Neck dissection with and without radiotherapy: prognostic factors, patterns of recurrence, and survival

Depth of invasion in early oral cancers- is it an independent prognostic factor?

INTRODUCTION

Depth of invasion (DOI) has been incorporated into oral cancer staging. Increasing DOI is known to be associated with an increased propensity to neck metastasis and adverse tumor factors and hence may not be an independent prognosticator but a surrogate for a biologically aggressive tumor.

METHODS

570 patients, median follow up 79.01 months from a previously reported randomized trial (NCT00193765) designed to establish appropriate neck treatment [elective neck dissection (END) vs therapeutic neck dissection (TND)] in clinically node-negative early oral cancers were restaged (nT) according to AJCC TNM 8th edition. Overall survival (OS) was estimated for the entire cohort, END, and TND arms. Multivariate analysis performed for stratification and prognostic factors, and interaction term between revised T-stage and neck treatment, for tumours with DOI≤10mm. Presence of adverse factors was compared between nT3 (DOI>10 mm) and those with DOI≤10 mm.

RESULTS

Stage migration occurred in 44.38% of patients. 5-Year OS was nT1-79%, nT2-69.4% and nT3-53.8%, (p < 0.001). In TND arm 5-year OS was nT1-81.1% versus nT2-65%,p = 0.004, while that in END arm was nT1 -76.9% versus nT2 -73.7%,p = 0.73. There was a significant interaction between T stage and neck treatment (p = 0.03). T3 tumors (>10 mm) were associated with a higher proportion of adverse factors (occult nodal metastasis, p = 0.035; LVE/PNI, p = 0.001).

CONCLUSION

Elective neck treatment negates the prognostic impact of DOI for early oral cancers (T1/T2 DOI≤10 mm). T3 tumors with DOI>10 mm have a higher association with other adverse risk factors resulting in poorer outcomes in spite of elective neck dissection.

Evaluation of Anti-Tumor Effects of Whole-Body Low-Dose Irradiation in Metastatic Mouse Models

Low-dose irradiation (LDI) has recently been shown to have various beneficial effects on human health, such as on cellular metabolic activities, DNA repair, antioxidant activity, homeostasis potency, and immune activation. Although studies on the immunogenic effects of LDI are rapidly accumulating, clinical trials for cancer treatment are considered premature owing to the lack of available preclinical results and protocols. Here, we aim to investigate anti-tumor and anti-metastatic effects of whole-body LDI in several tumor-bearing mouse models. Mice were exposed to single or fractionated whole-body LDI prior to tumor transplantation, and tumor growth and metastatic potential were determined, along with analysis of immune cell populations and expression of epithelial-mesenchymal transition (EMT) markers. Whole-body fractionated-LDI decreased tumor development and lung metastasis not only by infiltration of CD4⁺, CD8⁺ T-cells, and dendritic cells (DCs) but also by attenuating EMT. Moreover, a combination of whole-body LDI with localized high-dose radiation therapy reduced the non-irradiated abscopal tumor growth and increased infiltration of effector T cells and DCs. Therefore, whole-body LDI in combination with high-dose radiation therapy could be a potential therapeutic strategy for treating cancer.

Prognostic indicators of improved survival and quality of life in surgically treated oral cancer

OBJECTIVE

No published study has analyzed the prognostic factors of surgically treated oral squamous cell carcinoma (OSCC) in relation to both survival and quality of life (QoL). The aim of this study was to analyze postoperative QoL in relation to survival to identify which parameters can predict the long-term outcome allowing the best QoL.

STUDY DESIGN

This retrospective cohort study considered 167 patients affected by OSCC treated surgically at the Otolaryngology Department of Cattinara Hospital (Trieste, Italy) by a single surgeon. We collected data about the main prognostic factors and the postoperative QoL 12 month after surgery.

RESULTS

The 5-year overall survival rate was equal to 68.1%, and the 5-year disease-specific survival was 77.8%. In this sample, 32% of patients also underwent adjuvant chemoradiotherapy. On stepwise Cox regression, the best predictors of disease-specific survival were the N stage (P < .001) and tumor depth of invasion (P < .001). QoL was affected by N stage, depth of invasion, invasive surgical approach, radiotherapy, and neck dissection (P < .05).

CONCLUSION

The prognostic factors that affect both survival rates and residual QoL are the surgical approach, the neck stage, and the depth of invasion, all of which can be minimized by early diagnosis.

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.

Metastatic genes targeted by an antioxidant in an established radiation- and estrogen-breast cancer model

Breast cancer remains the second most common disease worldwide. Radiotherapy, alone or in combination with chemotherapy, is widely used after surgery as a treatment for cancer with proven therapeutic efficacy manifested by reduced incidence of loco-regional and distant recurrences. However, clinical evidence indicates that relapses occurring after radiotherapy are associated with increased metastatic potential and poor prognosis in the breast. Among the anticarcinogenic and antiproliferative agents, curcumin is a well-known major dietary natural yellow pigment derived from the rhizome of the herb Curcuma longa (Zingiberaceae). The aim of the present study was to analyze the differential expression of metastatic genes in radiation- and estrogen-induced breast cancer cell model and the effect of curcumin on such metastatic genes in breast carcinogenesis. Expression levels of TGF-α and TGFβ1 genes were upregulated in MCF-10F and downregulated in Tumor2 cell lines treated with curcumin. Expression levels of other genes such as caspase 9 and collagen 4 A2 were upregulated in both MCF-10F and Tumor2-treated cell lines. Integrin α5 and cathepsin B and D decreased its expression in Tumor2, whereas E-Cadherin, c-myc and CD44 expressions were only increased in MCF-10F. It can be concluded that metastatic genes can be affected by curcumin in cancer progression and such substance can be used in breast cancer patients with advanced disease without side-effects commonly observed with therapeutic drugs.

Prognosis of oral squamous cell carcinoma patients with level IV/V metastasis: An observational study

PURPOSE

The objectives of this study were to retrospectively describe the characteristics and outcomes of patients with oral squamous cell carcinoma (OSCC) with level IV/V metastases, and to evaluate the multivariate relationships among potential risk factors for metastasis and prognosis.

MATERIALS AND METHODS

We evaluated 291 patients (178 men and 113 women; mean age, 65.9 ± 13.5 years). Clinicopathological data, time of development of level IV/V metastases, and clinical course were investigated.

RESULTS

Twenty-three patients (7.9%) developed level IV/V metastases. The 3-year overall survival rates when level IV/V metastasis first developed were 27.3% upon initial treatment, 57.1% when metachronous neck metastasis developed, and 40.0% when the tumor recurred. Oral tongue tumor subsite, high N staging, neck dissection when metachronous neck metastasis developed, as well as recurrence were independent risk factors for level IV/V metastasis.

CONCLUSION

We demonstrate here the multivariate relationships among the risk factors indicated above for level IV/V metastasis and their prognostic significance for patients with OSCC. Oral tongue tumors, high N staging, and neck dissection upon the occurrence of metachronous neck metastasis or recurrence were risk factors for level IV/V metastasis and positive extracapsular spread, presence of multiple lymph metastases, and moderate or poor differentiation were poor prognostic factors.

PET/MR in cancers of the head and neck

One early application of PET/MRI in clinical practice may be the imaging of head and neck cancers. This is because the morphologic imaging modalities, CT and MR, are recognized as similarly effective tools in cross-sectional oncological imaging of the head and neck. The addition of PET with FDG is believed to enhance the accuracy of both modalities to a similar degree. However, there are a few specific scenarios in head and neck cancer imaging where MR is thought to provide an edge over CT, including perineural spread of tumors and the infiltration of important anatomical landmarks, such as the prevertebral fascia and great vessel walls. Here, hybrid PET/MR might provide higher diagnostic certainty than PET/CT or a separate acquisition of PET/CT and MR. Another advantage of MR is the availability of several functional techniques. Although some of them might enhance the imaging of head and neck cancer with PET/MR, other functional techniques actually might prove dispensable in the presence of PET. In this overview, we discuss current trends and potential clinical applications of PET/MR in the imaging of head and neck cancers, including clinical protocols. We also discuss potential benefits of implementing functional MR techniques into hybrid PET/MRI of head and neck cancers.

Cervical: Lymphadenopathy

The neck region contains around 300 lymph nodes (LNs) out of 800 LNs in the whole body. The detailed study of LNs by Rouviere in 1932 [1] and the later illustration of metastatic predilection of head and neck malignancies to certain LN regions by Lindberg et al. [2] paved the road to a clinically sound classification. The American Academy of Otolaryngology and Head and Neck Surgery (AAO-HNS) and the American Joint Committee on Cancer (AJCC) developed the currently widely accepted levels classification of the cervical LNs (Table 8.1, Figs. 8.1 and 8.2).

Copy number increase of oncoprotein CIP2A is associated with poor patient survival in human head and neck squamous cell carcinoma

BACKGROUND

CIP2A, an inhibitor of PP2A tumour suppressor function, is a widely overexpressed biomarker of aggressive disease and poor therapy response in multiple human cancer types.

METHODS

CIP2A and DPPA4 copy number alterations and expression were analysed by fluorescence in situ hybridisation (FISH) and immunohistochemistry (IHC) in different cell lines and a tissue microarray of 52 HNSCC patients. Results were correlated with patient survival and other clinicopathological data.

RESULTS

CIP2A and DPPA4 copy number increase occurred at a relatively high frequency in human HNSCC patient samples. CIP2A but not DPPA4 FISH status was significantly associated with patient survival. CIP2A detection by combining IHC with FISH yielded superior resolution in the prognostication of HNSCC.

CONCLUSIONS

CIP2A copy number increase is associated with poor patient survival in human HNSCC. We suggest that the reliability and prognostic value of CIP2A detection can be improved by performing FISH analysis to CIP2A IHC positive tumours.

Contralateral neck failure in lateralized oral squamous cell carcinoma

BACKGROUND

Elective treatment of the contralateral clinically node-negative (cN0) neck is not routinely recommended for lateralized oral cavity squamous cell carcinoma (SCC). We sought to determine the failure rate in the untreated contralateral neck in patients with lateralized oral SCC undergoing treatment of the primary and ipsilateral neck and to identify any features placing patients at sufficient risk of contralateral regional failure to justify elective treatment.

METHODS

We identified 688 patients with oral SCC undergoing curative surgery ± adjuvant therapy between 1985 and 2012 from a prospectively collected database. Patients with midline primaries and those undergoing bilateral neck treatment were excluded. The primary endpoint was isolated contralateral neck failure.

RESULTS

Of 481 patients, 14 (2.9%) developed isolated contralateral neck recurrence, with median time to recurrence of 8 months. Patients with poorly differentiated tumours or pathologically proven ipsilateral nodal metastases were at significantly higher risk of contralateral failure (hazard ratio (HR) 3.6, 95% confidence interval (CI) 1.1-11.9, P = 0.037 and HR 4.6, 95% CI 1.5-13.8, P = 0.006 respectively). Presence of both of these factors conferred a 10% risk of contralateral failure.

CONCLUSION

Patients with lateralized oral SCC undergoing treatment of the primary tumour and ipsilateral neck have a low rate of isolated contralateral neck failure. Although poorly differentiated primaries and ipsilateral nodal metastases were predictors of contralateral recurrence, the risk remains relatively modest in this subset of patients suggesting close observation may be more appropriate than elective treatment. Our results support current recommendations for observation of the cN0 contralateral neck in lateralized oral SCC.

Mechanism of irradiation-induced mammary cancer metastasis: A role for SAP-dependent Mkl1 signaling

Radiotherapy is a standard treatment after conservative breast cancer surgery. However, cancers relapsing within a previously irradiated area have an increased probability to metastasize. The mechanisms responsible for this aggressiveness remain unclear. Here, we used the clinically relevant 4T1 breast cancer model mimicking aggressive local relapse after radiotherapy to identify differences between tumors grown in untreated versus preirradiated mammary glands. Tumors grown within preirradiated beds were highly enriched in transcripts encoding collagens and other proteins building or modifying the extracellular matrix, such as laminin‐332, tenascins, lysyl oxidases and matrix metalloproteinases. Type I collagen, known to directly contribute to tissue stiffening, and the pro‐metastatic megakaryoblastic leukemia‐1 (Mkl1) target gene tenascin‐C were further investigated. Mammary tissue preirradiation induced Mkl1 nuclear translocation in the tumor cells in vivo, indicating activation of Mkl1 signaling. Transcript profiling of cultured 4T1 cells revealed that the majority of the Mkl1 target genes, including tenascin‐C, required serum response factor (SRF) for their expression. However, application of dynamic strain or matrix stiffness to 4T1 cells converted the predominant SRF/Mkl1 action into SAP domain‐dependent Mkl1 signaling independent of SRF, accompanied by a switch to SAP‐dependent tumor cell migration. 4T1 tumors overexpressing intact Mkl1 became more metastatic within preirradiated beds, while tumors expressing Mkl1 lacking the SAP domain exhibited impaired growth and metastatic spread, and decreased Mkl1 target gene expression. Thus, we identified SAP‐dependent Mkl1 signaling as a previously unrecognized mediator of aggressive progression of mammary tumors locally relapsing after radiotherapy, and provide a novel signaling pathway for therapeutic intervention.

Stroma irradiation results in tumors with increased extracellular matrix deposition.

Irradiation induces Mkl1 nuclear translocation, tumor growth and lung metastases.

Matrix stiffness and cyclic mechanical strain trigger SAP‐dependent Mkl1 signaling.

Strain and irradiation induce SAP‐dependent cell migration and tumor progression.

Radiation‐induced SAP‐dependent Mkl1 action: a new target for breast cancer therapy.

Surgically treated oropharyngeal cancer: risk factors and tumor characteristics

PURPOSE

To assess risk factors of patients with oropharyngeal squamous cell carcinoma in the Munich area of Southern Germany in relation to human papillomavirus (HPV) association of the tumors. To demonstrate differences in tumor characteristics and their impact on adjuvant treatment.

METHODS

Between November 2010 and July 2013, patients were prospectively interviewed for risk factors before they underwent surgical resection of their tumors. HPV association was evaluated by p16 immunohistochemistry; tumor characteristics and type of adjuvant treatment were recorded. Follow-up data were collected after a median follow-up of 12.1 month.

RESULTS

In contrast to many recent studies, we could not detect any difference in overall age and age at sexual debut between p16-positive and p16-negative patients. P16-negative patients are characterized by a more intensive tobacco and alcohol use, a more abusive way of consumption, less nonoral and less oral sex partners. P16-positive patients had a significantly higher risk of lymph node metastases, but nevertheless a significant lower risk to recur or to die. No difference in the incidence of synchronous second primary tumors was seen. P16-positive patients generally received a more aggressive adjuvant treatment because of more frequently involved lymph nodes.

CONCLUSION

Lifestyle risk factors such as smoking, drinking, and sexual habits were independent from age, but showed marked differences between the p16-positive and p16-negative group. Since p16-positive patients were treated more aggressively, it is not possible to distinguish whether the better outcome of HPV-positive patients is a result of less aggressive cancers or more aggressive treatment. With regard to the ongoing debate about treatment deintensification, we should keep in mind that the survival of HPV-positive cancer patients is not 100 %.

Clinicobiological progression and prognosis of oral squamous cell carcinoma in relation to the tumor invasive front: impact on prognosis

CONCLUSION

There are several factors that influence the final outcome when treating oral squamous cell carcinoma (OSCC). Invasive front phenomena and more importantly their clinicopathological translation can have a direct impact on survival, and subsequently on the decision for an adjuvant treatment.

OBJECTIVES

In recent years, the concept of tumor-host interaction has been the subject of substantial efforts in cancer research. Tumoral behavior may be better understood when studying the changes occurring at the tumor-host interface. This study evaluated the influence of several clinicopathological features on the outcome of OSCCs.

METHODS

The clinical records and pathology specimens of 54 patients with OSCC treated by primary resection were reviewed retrospectively. The pathologic features reviewed were: invasive front grading (IFG), stromal reaction, lymphovascular invasion (LVI), perineural invasion (PNI), margin status, and depth of invasion.

RESULTS

High IFGs had a significant relationship with pT status and pN status. High IFGs were strongly correlated with nodal metastases (odds ratio (OR) = 4.77; confidence interaval (CI) = 1.37-16.64). Concerning survival, IFG had a strong impact on disease-free survival in patients treated unimodally, as did the depth of invasion in the same group. Lymphovascular involvement was found to have a negative impact on overall survival in patients treated multimodally.

Treatment results and prognostic factors of patients undergoing postoperative radiotherapy for laryngeal squamous cell carcinoma

Postoperative radiotherapy (PRT) is widely advocated for patients with squamous cell carcinomas of the head and neck that are considered to be at high risk of recurrence after surgical resection. The aims of this study were to evaluate the treatment outcomes of PRT for patients with laryngeal carcinoma and to identify the value of several prognostic factors. We reviewed the records of 256 patients treated for laryngeal squamous cell carcinoma between January 1993 and December 2005. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Log-rank test was employed to identify significant prognostic factors for DFS and OS. The Cox proportional hazards model was applied to identify covariates significantly associated with the aforementioned endpoints. Our results showed the 3-, 5-, and 10-year DFS for all patients were 69.9%, 59.5%, and 34.9%, respectively. The 3-, 5-, and 10-year OS rates were 80.8%, 68.6%, and 38.8%, respectively. Significant prognostic factors for both DFS and OS on univariate analysis were grade, primary site, T stage, N stage, overall stage, lymph node metastasis, overall treatment times of radiation, the interval between surgery and radiotherapy, and radiotherapy equipment. Favorable prognostic factors for both DFS and OS on multivariate analysis were lower overall stage, no cervical lymph node metastasis, and using 60Co as radiotherapy equipment. In conclusion, our data suggest that lower overall stage, no cervical lymph node metastasis, and using 60Co as radiotherapy equipment are favorable prognostic factors for DFS and OS and that reducing the overall treatment times of radiation to 6 weeks or less and the interval between surgery and radiotherapy to less than 3 weeks are simple measures to remarkably improve treatment outcome.

The treatment of oral cancer: an overview for dental professionals

Oral cancer is a serious life-threatening disease. Dental professionals may be the first individuals to identify/suspect these lesions before referring to oral and maxillofacial surgeons and oral medicine specialists. Because the general dentist will likely follow on with the patient's future oral health, it is important that he or she has a basic understanding of the various treatments involved in treating oral malignancies and their respective outcomes. The four main modalities discussed in this review include surgery alone, radiotherapy alone, surgery with radiotherapy, and chemotherapy with or without surgery and radiotherapy. Chemotherapy has become an area of great interest with the introduction of new 'targeted therapies' demonstrating promising results in conjunction with surgery. Despite these results, the toxicities associated with chemotherapy regimens are frequent and can be severe, and therefore may not be suitable for all patients. Treatment modalities have improved significantly over the decades with overall decreases in recurrence rates, improved disease-free and overall survival, and an improved quality of life. Prognosis, however, is still ultimately dependent on the clinical stage of the tumour at the initial diagnosis with respect to size, depth, extent, and metastasis as recurrence rates and survival rates plummet with disease progression.

Two distinct routes to oral cancer differing in genome instability and risk for cervical node metastasis

PURPOSE

Problems in management of oral cancers or precancers include identification of patients at risk for metastasis, tumor recurrence, and second primary tumors or risk for progression of precancers (dysplasia) to cancer. Thus, the objective of this study was to clarify the role of genomic aberrations in oral cancer progression and metastasis.

EXPERIMENTAL DESIGN

The spectrum of copy number alterations in oral dysplasia and squamous cell carcinomas (SCC) was determined by array comparative genomic hybridization. Associations with clinical characteristics were studied and results confirmed in an independent cohort.

RESULTS

The presence of one or more of the chromosomal aberrations +3q24-qter, -8pter-p23.1, +8q12-q24.2, and +20 distinguishes a major subgroup (70%-80% of lesions, termed 3q8pq20 subtype) from the remainder (20%-30% of lesions, non-3q8pq20). The 3q8pq20 subtype is associated with chromosomal instability and differential methylation in the most chromosomally unstable tumors. The two subtypes differ significantly in clinical outcome with risk for cervical (neck) lymph node metastasis almost exclusively associated with the 3q8pq20 subtype in two independent oral SCC cohorts.

CONCLUSIONS

Two subtypes of oral lesions indicative of at least two pathways for oral cancer development were distinguished that differ in chromosomal instability and risk for metastasis, suggesting that +3q,-8p, +8q, and +20 constitute a biomarker with clinical utility for identifying patients at risk for metastasis. Moreover, although increased numbers of genomic alterations can be harbingers of progression to cancer, dysplastic lesions lacking copy number changes cannot be considered benign as they are potential precursors to non-3q8pq20 locally invasive, yet not metastatic oral SCC.

Clinicopathologic analysis and predictive factors for distant metastases in patients with head and neck squamous cell carcinomas

BACKGROUND

The recognition of patients at high risk for the development of distant metastasis (DM) is required to recognize a subset of patients who may benefit from systemic therapy.

METHODS

In a retrospective analysis of patients treated between 1995 and 2006, 443 patients with surgically treated primary head and neck squamous cell carcinoma were included. The frequency and clinicopathologic risk factors for DM were evaluated.

RESULTS

A total of 60 patients (13.5%) developed DM. In a univariate analysis, tumor site (pharynx), pN classification (pN2-N3), differentiation grade (poorly differentiated), disease stage (stage IV), number (3 or more nodes), and site (bilateral nodes) of nodal metastasis were found to be significantly associated with the risk of DM. In a multivariate analysis, the only significant risk factors were the differentiation grade and the number and site of nodal metastasis.

CONCLUSIONS

Patients with pharyngeal poorly differentiated tumors, with multiple or bilateral nodal metastases, are at greater risk of DM and should be considered for systemic therapy.

Low doses of ionizing radiation promote tumor growth and metastasis by enhancing angiogenesis

Radiotherapy is a widely used treatment option in cancer. However, recent evidence suggests that doses of ionizing radiation (IR) delivered inside the tumor target volume, during fractionated radiotherapy, can promote tumor invasion and metastasis. Furthermore, the tissues that surround the tumor area are also exposed to low doses of IR that are lower than those delivered inside the tumor mass, because external radiotherapy is delivered to the tumor through multiple radiation beams, in order to prevent damage of organs at risk. The biological effects of these low doses of IR on the healthy tissue surrounding the tumor area, and in particular on the vasculature remain largely to be determined. We found that doses of IR lower or equal to 0.8 Gy enhance endothelial cell migration without impinging on cell proliferation or survival. Moreover, we show that low-dose IR induces a rapid phosphorylation of several endothelial cell proteins, including the Vascular Endothelial Growth Factor (VEGF) Receptor-2 and induces VEGF production in hypoxia mimicking conditions. By activating the VEGF Receptor-2, low-dose IR enhances endothelial cell migration and prevents endothelial cell death promoted by an anti-angiogenic drug, bevacizumab. In addition, we observed that low-dose IR accelerates embryonic angiogenic sprouting during zebrafish development and promotes adult angiogenesis during zebrafish fin regeneration and in the murine Matrigel assay. Using murine experimental models of leukemia and orthotopic breast cancer, we show that low-dose IR promotes tumor growth and metastasis and that these effects were prevented by the administration of a VEGF receptor-tyrosine kinase inhibitor immediately before IR exposure. These findings demonstrate a new mechanism to the understanding of the potential pro-metastatic effect of IR and may provide a new rationale basis to the improvement of current radiotherapy protocols.

Effectiveness of modified radical neck dissection and postoperative radiotherapy

BACKGROUND AND OBJECTIVE

The aim of this study was to evaluate the effectiveness of a modified radical neck dissection with preservation of non-lymphatic structures usually removed in advanced-stage head and neck epidermoid carcinoma associated with postoperative radiotherapy (PORT).

METHODS

We analyzed retrospectively the files of 109 patients, presenting with epidermoid carcinoma of the upper digestive/respiratory tract staged N2 or N3, over a 6-year period. The rates of regional control, mortality, and recurrence were analyzed and linked to the kind of neck-dissection (usual radical neck dissection [RND], modified radical neck dissection [MRND], selective neck-dissection [SND]) performed.

RESULTS

Forty-three neck dissections were RND, 92 were MRND, and 21 were SND. PORT was used in all cases. The mean follow-up was 57.3 months. The overall rate of regional control was 93.6% (97.7% for RND and 93.5% for MRND; p=0.35). Patients having undergone MRND had a better prognosis and less recurrence then patients having undergone RND (respectively p=0.007, and p=0.0004).

DISCUSSION

MRND in association with PORT is an effective treatment in patients with advanced head and neck epidermoid carcinoma staged N2 and N3.

Postoperative radiotherapy for head and neck cancer with single positive node

The essential need for postoperative irradiation in people with carcinoma of the upper aerodigestive tract and limited metastatic nodal spread is controversial. An experience with postoperative radiotherapy in head and neck cancer (HNC) patients with one histologically positive cervical node is presented. Between 1976 and 2000, 37 individuals with confirmed metastatic disease in a single neck node underwent postoperative radiotherapy. The median follow-up period was 24 months. Among the 35 evaluable patients, the observed failure rates at the primary site, neck and distant location were 11%, 15% and 6%, respectively. The overall 5-year relapse-free survival rate was 60%. The relapse-free survival rate at 5 years was 86% in individuals who did not have additional histopathological risk factors and 55% in those patients who did (p = 0.46). The precise role of postoperative radiotherapy in people with HNC and documented metastasis in a single cervical lymph node remains to be defined including the identification of select individuals who may truly benefit from the combined therapy program.

The Influence of Lymph Node Metastasis in the Treatment of Squamous Cell Carcinoma of the Oral Cavity, Oropharynx, Larynx, and Hypopharynx: N0 Versus N+

OBJECTIVES/HYPOTHESIS

Management of the N0 neck is a continuing controversy. The study compares the influence of N0 and N+ disease on the results of treating squamous cell carcinoma (SCCA) of the oral cavity (OC), oropharynx (OP), larynx (LX), and hypopharynx (HP) with five different treatment modalities. The study also compares the results of four different approaches to the treatment of the N0 neck.

STUDY DESIGN

A retrospective study of 3887 patients.

METHODS

Patients in the Tumor Research Project of the Department of Otolaryngology-Head and Neck Surgery of the Washington University School of Medicine (St. Louis, MO) with biopsy-proven previously untreated SCCA of one of the four above-mentioned regions who were treated with curative intent by one of five modalities and who were eligible for 5-year follow-up were included in the study. The treatment modalities included local resection of primary alone (LR), composite resection (primary with neck dissection) (CR), radiation therapy alone (RT), local resection with radiation therapy (LR/RT), and composite resection with radiation therapy (CR/RT). The N0 neck was treated with one of four approaches: observation with close follow-up reserving treatment only for subsequent neck disease, neck dissection, RT to the neck region, and a combination of neck dissection with RT. Multiple diagnostic, treatment, and follow-up parameters were studied using standard statistical analyses to determine statistical significance.

RESULTS

The 5-year disease-specific survival (DSS) for the all-sites group (ASG) was 59%. The DSS for the subsites included the following: OC, 53%; OP, 47%; LX, 70%; and HP, 42%. Patients with N0 disease had significantly better DSS than patients with N+ disease at all sites. Occult neck disease in N0 patients was low with 4% pN1 for ASG, OC, and LX and with 11% pN1 for OP and HP. There was 3% pN2 for LX, 4% pN2 for ASG and OC, and 6% pN2 for OP and HP. The DSS for patients with occult neck disease was statistically similar to that of N+ patients. Prognostic survival indicators included age, decade of treatment, T stage, N stage, TN stage, treatment modality, and recurrence. Patients over 65 years of age had poorer DSS than younger patients. Staging T, N, and TN affected survival at all sites. Local resection produced better DSS for ASG, OC, LX, and HP patients. Local resection with radiation therapy produced increased DSS for ASG and OC patients. There was no survival advantage for HP patients related to treatment modality. Treatment of the N0 neck with observation and later treatment for subsequent neck disease produced a survival advantage for patients in the ASG. This advantage was specific for ASG and LX patients staged T1N0. For patients staged T2N0, T3N0, and T4N0 at all four subsites there was no survival advantage for any of the four neck approaches.

CONCLUSION

Lymph node metastasis significantly and negatively affects DSS in patients with SCCA of the OC, OP, LX and HP. The rate of occult neck disease (pN+) in N0 patients receiving meticulous workup is low. When present, it produces DSS rates similar to those found in N+ patients. In the study series, there was decreased survival in patients older than 65 years of age, in patients with advanced tumor (T, N, TN), and in patients with recurrent disease. None of the four current approaches to treatment of the N0 neck produces a significant survival advantage. Close observation with later treatment reserved for subsequent neck disease produces statistically similar survival (DSS) to the three elective (prophylactic) treatments and is a valid form of treatment. It may preclude unnecessary treatment of the neck with its attendant risks and complications.

Effectiveness of selective neck dissection in the treatment of the clinically positive neck

BACKGROUND

The aim of this work was to determine whether or not patients treated with therapeutic selective neck dissection for head and neck squamous cell carcinoma were oncologically disadvantaged compared with those having comprehensive procedures.

METHODS

The study involves a retrospective review of 232 therapeutic neck dissections with a minimum of 2 years follow-up.

RESULTS

Patients having selective neck dissection had fewer adverse prognostic factors compared with patients having comprehensive dissection (pN2/3, p = .001; and extracapsular spread, p = .001). There were trends toward improved control in the dissected neck (96% vs 86%, p = .06), and disease-specific survival (59% vs 43%, p = .06) following selective neck dissection. Disease-specific survival for all patients was adversely affected by pN classification (p <.001) and extracapsular spread (p <.001).

CONCLUSIONS

Patients undergoing aggressive neck surgery had more extensive disease. Selective neck dissection can be used to effectively treat clinically positive nodal disease in selected patients.

The tumor microenvironment and its contribution to tumor evolution toward metastasis

Cancer cells acquire cell-autonomous capacities to undergo limitless proliferation and survival through the activation of oncogenes and inactivation of tumor suppressor genes. Nevertheless, the formation of a clinically relevant tumor requires support from the surrounding normal stroma, also referred to as the tumor microenvironment. Carcinoma-associated fibroblasts, leukocytes, bone marrow-derived cells, blood and lymphatic vascular endothelial cells present within the tumor microenvironment contribute to tumor progression. Recent evidence indicates that the microenvironment provides essential cues to the maintenance of cancer stem cells/cancer initiating cells and to promote the seeding of cancer cells at metastatic sites. Furthermore, inflammatory cells and immunomodulatory mediators present in the tumor microenvironment polarize host immune response toward specific phenotypes impacting tumor progression. A growing number of studies demonstrate a positive correlation between angiogenesis, carcinoma-associated fibroblasts, and inflammatory infiltrating cells and poor outcome, thereby emphasizing the clinical relevance of the tumor microenvironment to aggressive tumor progression. Thus, the dynamic and reciprocal interactions between tumor cells and cells of the tumor microenvironment orchestrate events critical to tumor evolution toward metastasis, and many cellular and molecular elements of the microenvironment are emerging as attractive targets for therapeutic strategies.

CYR61 and alphaVbeta5 integrin cooperate to promote invasion and metastasis of tumors growing in preirradiated stroma

Radiotherapy is widely used to treat human cancer. Patients locally recurring after radiotherapy, however, have increased risk of metastatic progression and poor prognosis. The clinical management of postradiation recurrences remains an unresolved issue. Tumors growing in preirradiated tissues have an increased fraction of hypoxic cells and are more metastatic, a condition known as tumor bed effect. The transcription factor hypoxia inducible factor (HIF)-1 promotes invasion and metastasis of hypoxic tumors, but its role in the tumor bed effect has not been reported. Here, we show that tumor cells derived from SCCVII and HCT116 tumors growing in a preirradiated bed, or selected in vitro through repeated cycles of severe hypoxia, retain invasive and metastatic capacities when returned to normoxia. HIF activity, although facilitating metastatic spreading of tumors growing in a preirradiated bed, is not essential. Through gene expression profiling and gain- and loss-of-function experiments, we identified the matricellular protein CYR61 and alphaVbeta5 integrin as proteins cooperating to mediate these effects. The anti-alphaV integrin monoclonal antibody 17E6 and the small molecular alphaVbeta3/alphaVbeta5 integrin inhibitor EMD121974 suppressed invasion and metastasis induced by CYR61 and attenuated metastasis of tumors growing within a preirradiated field. These results represent a conceptual advance to the understanding of the tumor bed effect and identify CYR61 and alphaVbeta5 integrin as proteins that cooperate to mediate metastasis. They also identify alphaV integrin inhibition as a potential therapeutic approach for preventing metastasis in patients at risk for postradiation recurrences.

Multicenter validation of recursive partitioning analysis classification for patients with squamous cell head and neck carcinoma treated with surgery and postoperative radiotherapy

PURPOSE

To validate the recursive partitioning analysis (RPA) classification system for squamous cell head and neck cancer as recently reported by the VU University Medical Center.

METHODS AND MATERIALS

In eight Dutch head and neck cancer centers, data necessary to classify patients according to the RPA system were retrospectively collected from the charts of a group of 780 patients treated between 1989 and 2003. The patients in this validation group were classified according to the RPA classification system. For each endpoint, the 5-year values and hazard ratios were calculated and compared with the results of the VU University Medical Center. The RPA classification system was considered valid if the hazard ratio of the validation population was within the 95% confidence interval of the VU University Medical Center study population.

RESULTS

The locoregional control rate was 82%, 75%, and 63% at 5 years for those with class I, II, and III, respectively (p < 0.0001). The hazard ratio for the locoregional control rate relative to class I was 1.44 (95% confidence interval, 0.97-2.16) for class II and 2.37 (95% confidence interval, 1.57-3.57) for class III. Similar results were found for the distant metastasis, overall survival, and disease-free survival rates.

CONCLUSION

The RPA classification system for head and neck squamous cell carcinoma in the postoperative setting, which was originally designed at one center, proved to be valid in a multicenter setting among patients included in a national multicenter study. This validated RPA classification scheme can be used to assess standard treatment strategies for head and neck squamous cell carcinoma in the postoperative setting, as well as in the design of future prospective studies.

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.

Surgery and Postoperative Radiotherapy for Squamous Cell Carcinoma of the Larynx and Pharynx

OBJECTIVE

To determine the rates of local-regional control, survival, and complications for patients treated with postoperative radiation for squamous carcinomas of the larynx, hypopharynx, and oropharynx.

METHODS

There were 295 patients with previously untreated squamous cell carcinomas of the larynx (n = 199), hypopharynx (n = 80), and oropharynx (n = 16) treated postoperatively with radiotherapy (RT).

RESULTS

Five-year local-regional control rates according to site and pathologic American Joint Committee on Cancer (AJCC) stage were: stage III larynx, 89% versus stage IVA larynx, 85% (P = 0.33); stage III oropharynx/hypopharynx, 76% versus stage IVA oropharynx/hypopharynx, 79% (P = 0.72). Local-regional control rates steadily declined as the number of indications for administering postoperative RT increased. Five-year absolute survival rates versus pathologic AJCC stage for the entire group were: stage III 59% and stage IVA 40% (P = 0.40).

CONCLUSION

Rates of local-regional control, survival, and complications support the use of postoperative radiation in selected patients. Tumor control and survival will hopefully improve further with the addition of chemotherapy to postoperative radiation.

The importance of immunohistochemical expression of EGFr in squamous cell carcinoma of the oral cavity treated with surgery and postoperative radiotherapy

PURPOSE

The aim of this study was to investigate the prognostic significance of epidermal growth factor (EGFr) expression in oral cavity squamous cell carcinoma (OCSCC) treated with curative surgery and postoperative radiotherapy.

METHODS AND MATERIALS

This retrospective study included 165 OCSCC patients. The expression of EGFr was assessed on paraffin-embedded tissue of the primary tumor by immunohistochemistry using a monoclonal antibody directed against EGFr. Intensity of the EGFr expression was scored by two authors blinded for the clinical outcome.

RESULTS

In the univariate analysis, locoregional control at 3 years (LRC) in the EGFr-negative cases was 69% compared with 77% in the EGFr-positive cases (p = 0.22). In the multivariate analysis for local control, a significant interaction was found between EGFr and overall treatment time of radiation (OTT). After stratification for EGFr expression, the OTT was of no importance in the EGFr-negative cases, whereas a significant difference in LRC was found in the EGFr-positive cases, in which the LRC after 3 years was 69% and 94% in case of an OTT of 0-42 days and >42 days, respectively (p = 0.009; hazard ratio = 3.42; 95% confidence interval, 1.28-8.96). No significant association was found between EGFr expression and overall survival.

CONCLUSIONS

In the present study, no association was found between EGFr expression and outcome regarding locoregional control and overall survival. However, the results of the present study suggest that patients with squamous cell carcinoma of the oral cavity with high EGFr expression benefit more from a reduction of the overall treatment time of postoperative radiation than those with low EGFr expression.

Results of postoperative reirradiation for recurrent or second primary head and neck carcinoma

BACKGROUND

In this prospective study, the effects of a second course of postoperative radiation therapy on locoregional control, survival, toxicity, and quality of life were investigated in patients who underwent resection of a second primary or locoregional recurrent head and neck tumor in a previously irradiated area.

METHODS

In total, 39 patients who underwent surgery for second primary tumors (n = 19 patients) or for recurrent locoregional tumors (n = 20 patients) were retreated with postoperative radiotherapy (RE-PORT). Indications for RE-PORT were extranodal spread (49%), positive surgical margins (44%), and/or other risk factors (8%). The target volume for RE-PORT was confined to the high-risk area. No elective radiotherapy was applied in regions that were situated in the formerly high-dose area. A total dose of 46 grays (Gy) was given to elective areas with boosts from 60 Gy to 66 Gy to the high-risk region with conventional fractionation. The results of RE-PORT were compared with the results from patients who were treated in the same period with primary adjuvant radiotherapy (PRI-PORT) at the authors' institution.

RESULTS

The mean follow-up was 32 months (range, 3-84 mos). The locoregional control rate after 3 years in the RE-PORT group was 74%, and the 3-year overall survival rate was 44%. This did not differ significantly compared with survival rates in the PRI-PORT group. Although a higher rate of late radiation-induced morbidity and more head and neck symptoms were observed in the RE-PORT group compared with the PRI-PORT group, no differences were observed with regard to the more general dimensions of quality of life.

CONCLUSIONS

RE-PORT after surgery for recurrent locoregional tumors and/or second primary tumors should be considered in patients who have high-risk histopathologic features.

The current status of positron-emission tomography scanning in the evaluation and follow-up of patients with head and neck cancer

PURPOSE OF REVIEW

Functional imaging has increasingly become an important diagnostic tool for head and neck cancer and as its availability increases so will its utilization. Positron-emission tomography using the radiotracer [18F]fluoro-2-deoxy--glucose is the most commonly used functional imaging technology and it has the potential to improve the staging and detection of head and neck tumors compared with conventional imaging techniques such as computed tomography or magnetic resonance imaging.

RECENT FINDINGS

The combination of [18F]fluoro-2-deoxy--glucose and positron-emission tomography contributes valuable information in localizing a primary tumor in patients with an unknown primary and neck metastases, in the staging of primary head and neck cancer, in the detection of residual disease following definitive chemoradiation, and in the detection of recurrent disease. New technologies have been recently introduced using the combination of computed tomography and positron-emission tomography that allows exact anatomical correlation with areas of increased tracer uptake. In addition, new tracers may allow quantification of important cellular processes related to tumor proliferation or identification of tumors that may respond to certain targeted therapies.

SUMMARY

[18F]Fluoro-2-deoxy--glucose and positron-emission tomography are increasingly being used as a clinical imaging modality in the complex management of head and neck cancer. In particular, its clinical value in the evaluation of the unknown primary, and the evaluation of recurrent or residual disease, is well established and has shown to be more accurate than conventional imaging modalities.

Prognostic indicators for survival in head and neck squamous cell carcinomas: analysis of a series of 621 cases

BACKGROUND

We sought to study the influence of pT classification, pN status, tumor volume, and number of lymph nodes invaded on survival of patients with head and neck cancers to improve therapeutic indications.

METHODS

This was a retrospective study of 621 consecutive patients treated from 1990 to 1997 by a single team.

RESULTS

In univariate analysis, pT classification (p < .0001), pN status (p < .0001), capsule rupture (p < .0001), the number of lymph nodes invaded (0, 1-3, 4-9, > or =10) (p < .0001), and the tumor volume (p < .0001) were significantly associated with overall survival. A Cox model identified as independent prognostic indicators age (p < .0001), pT classification (p < .0001), and pN status (p < .0001).

CONCLUSIONS

Not only pT classification and pN status but also the number of the lymph nodes invaded and the tumor volume should be considered as essential prognostic indicators, and any clinical trial developed should stratify accordingly.

What the clinician wants to know: surgical perspective and ultrasound for lymph node imaging of the neck

Imaging of lymph node metastases in the neck can have two major indications: (1) prognosis and assisting with choice of treatment; (2) staging and detection of clinically occult metastases in different levels of the neck. Both indications are discussed. The role and limitations of US and US-guided fine-needle aspiration cytology are also reviewed.

Risk-group definition by recursive partitioning analysis of patients with squamous cell head and neck carcinoma treated with surgery and postoperative radiotherapy

BACKGROUND

The objective of this study was to define different prognostic groups with regard to locoregional control (LRC) derived from recursive partitioning analysis (RPA).

METHODS

Eight hundred one patients with squamous cell head and neck carcinoma underwent with primary surgery and received postoperative radiotherapy. For the definition of prognostic groups, the method of classification and regression trees was performed, including a large number of well known prognostic factors.

RESULTS

The final model was composed of six prognostic factors for LRC, resulting in seven terminal nodes. RPA Class I (intermediate risk) consisted of 381 patients who had no N3 lymph nodes, free surgical margins (> 5 mm), and no extranodal spread (ENS). RPA Class II (high risk) consisted of 189 patients who had 1 positive lymph node with ENS or had T1, T2, or T4 tumors with close or positive surgical margins. RPA Class III (very high risk) consisted of 231 patients who had a N3 neck, > or = 2 positive lymph nodes with ENS, or a T3 tumor with close or positive surgical margins. The 5-year LRC rate was 88%, 73% and 58%, in RPA Class I, II, and III, respectively (P < 0.0001). The hazard ratio (HR) relative to RPA Class I was 2.3 (95% confidence interval [95%CI], 1.5-3.6) for RPA Class II and 4.2 (95%CI, 2.8-6.1) for RPA Class III.

CONCLUSIONS

The RPA classification scheme studied allowed for the clear definition of three prognostic groups with regard to LRC and OS. These groups may be useful in the design of future prospective, randomized studies investigating new treatment modalities.

Outcome of treatment for advanced cervical metastatic squamous cell carcinoma

BACKGROUND

Patients with advanced cervical metastases from mucosal squamous cell carcinoma have a poor prognosis because of their high risk of regional and distal failure. This study aims to evaluate the outcomes of patients with clinical N2 or N3 disease managed with surgery and postoperative radiotherapy.

METHODS

From a comprehensive computerized database, 181 entered patients who had neck dissection for N2 or N3 disease between 1988 and 1999 were evaluated. The mean age was 62 years, and minimum follow-up was 3 years.

RESULTS

A total of 233 neck dissections were performed in 181 patients, including 163 comprehensive and 70 selective dissections. Postoperative radiotherapy was given in 82% of cases. The local control rate was 75% at 5 years, and control of disease in the treated neck was achieved in 86%. Macroscopic extracapsular spread (ECS) significantly increased regional recurrence (p = .001). Adjuvant radiotherapy significantly improved neck control (p = .004) but did not alter survival. Patients with ECS (both microscopic and macroscopic) who received radiotherapy had a significantly better survival than did patients with ECS who did not receive radiotherapy. Disease-specific survival for the entire group was 39% at 5 years. By use of multivariate analysis, macroscopic ECS and N2c neck disease were independent adverse prognostic factors for survival (p = .001).

CONCLUSIONS

Despite a high rate of control in the treated neck, the poor survival (39%) in this patient group indicates that adjuvant therapeutic strategies need to be considered.

Functional imaging in head and neck cancer

Functional imaging has become an increasingly important diagnostic tool for head and neck cancer, and as its availability increases so will its utilization. Positron emission tomography (PET) with the radiotracer 18-fluorodeoxyglucose (18FDG) is the most commonly used functional imaging technology, and it has the potential to improve the staging and detection of head and neck tumors compared with conventional cross-sectional imaging techniques such as CT or magnetic resonance imaging. Specifically, PET contributes valuable information for localizing a primary tumor in patients with an unknown primary and neck metastasis, in the staging of untreated head and neck cancer, in the detection of residual disease after definitive radiotherapy or chemoradiotherapy, and in the detection of recurrent disease. New technologies have been introduced using the combination of CT and PET, which allows exact anatomic correlation with areas of increased tracer uptake. In addition, new tracers may allow quantification of important cellular processes related to tumor proliferation or identification of tumors that may respond to certain targeted therapies. This strategy will eventually enable physicians to tailor therapy to molecular characteristics and therefore improve outcomes for patients with head and neck cancer.

Radiation therapy following lymph node dissection in melanoma patients: treatment, outcome and complications

Adjuvant radiation treatment following lymph node dissection in the melanoma patient has been suggested and investigated in an attempt to gain regional control and improve survival. In this review we discussed the treatment, the loco-regional control, disease-free and survival rates and complications. Historically melanoma has been thought of as a relatively radioresistant tumour. Nowadays, radiation delivered according to the hypofractionated schedule is the most used, although there are no data to confirm that this schedule improves the therapeutic impact. Almost all the reviewed studies were retrospective, which could have led to an underestimation of the true incidence of the treatment toxicity and morbidity. Adjuvant radiotherapy after lymph node dissection for metastases of melanoma seems to improve loco-regional control without improving overall survival. The available data indicate the need for improved regional control rates in patients with extranodal extension, multiple involved nodes (more than three) and patients with large involved nodes (larger than 3 cm). The complications seem manageable and consist mainly of fibrosis and edema.

Postoperative irradiation for squamous cell carcinoma of the oral cavity: 35-year experience

BACKGROUND

The purpose of this study was to analyze factors influencing outcome in patients who received postoperative irradiation for advanced squamous cell carcinoma of the oral cavity.

METHODS

Between October 1964 and November 2000, 226 patients with 230 previously untreated primary invasive squamous cell carcinomas of the oral cavity were treated postoperatively with continuous-course external beam irradiation. All patients had a minimum follow-up of 2 years (analysis, November 2002). No patient was lost to follow-up.

RESULTS

The 5-year actuarial rates of locoregional control by pathologic American Joint Committee on Cancer stage were: stage I, 100%; stage II, 84%; stage III, 78%; and stage IV, 66%. Recurrence of cancer above the clavicles developed in 55 patients (24%). In multivariate analysis of locoregional control, positive margins, vascular invasion, perineural invasion, extracapsular extension, and T classification remained significant.

CONCLUSIONS

This article provides additional data defining relatively favorable and unfavorable groups of patients in the postoperative setting. Dose recommendations are re-examined and selectively increased for high-risk patients.

Positron emission imaging of head and neck cancer, including thyroid carcinoma

Most positron emission tomography (PET) imaging studies in head and neck cancer are performed using the radiotracer 18-fluorodeoxyglucose ((18)FDG). PET with FDG has become a standard clinical imaging modality in patients with head and neck cancer. It contributes valuable information in localizing a primary tumor in patients with neck nodal metastases from an unknown primary, in the staging of primary head and neck cancer, and in the detection of recurrent disease. In addition, FDG-PET provides independent prognostic information in patients with newly diagnosed and recurrent head and neck cancer. PET/CT improves lesion localization and accuracy of FDG-PET and is strongly recommended in patients with head and neck cancer. After thyroidectomy, FDG-PET has proven useful in patients with clinical or serological evidence of recurrent or metastatic thyroid carcinoma but negative whole body iodine scan. PET shows metastatic disease in up to 90% of these patients, thereby providing a rational basis for further studies and therapy. In patients with medullary thyroid cancer with elevated calcitonin levels following thyroidectomy, FDG-PET has a sensitivity of 70-75% for localizing metastatic disease. Occasionally incidental intense FDG uptake is observed in the thyroid gland on whole body PET studies performed for other indications. Although diffuse FDG uptake usually indicates thyroiditis, focal uptake has been related to thyroid cancer in 25-50% of cases and should therefore be evaluated further if a proven malignancy would cause a change in patient management.

Cervical lymphadenopathy: what radiologists need to know

Metastatic cervical lymphadenopathy is a common problem in head and neck oncology. The appropriate management of the cervical lymph nodes requires a good understanding of the incidence, patterns, and prognostic implications of nodal metastasis. This paper correlates the anatomical and the simplified level classification systems of cervical lymph nodes, examines the clinical significance of nodal metastasis, and evaluates the criteria for nodal metastasis.

Postoperative radiotherapy in squamous cell carcinoma of the oral cavity: The importance of the overall treatment time

PURPOSE

To test the hypothesis that (1) the distinction between intermediate- and high-risk patients by clustering different prognostic factors results in a significant difference in treatment outcome and (2) a shorter interval between surgery and radiotherapy and shorter overall treatment times of radiation (OTTRT) result in higher rates of locoregional control (LRC).

METHODS AND MATERIALS

Included were patients (n = 217) with previously untreated squamous cell carcinoma of the oral cavity treated with radical surgery and postoperative radiotherapy. Patients with extranodal spread or microscopic residual disease and patients with two or more other risk factors (i.e., N2b-N3, >1 nodal level involved, perineural growth, or stage T3-T4) were classified as high-risk patients. Patients with only one other risk factor were classified as intermediate risk.

RESULTS

In the intermediate-risk group, the 3-year LRC was 87% as compared with 66% in the high-risk group (p = 0.0005). No association was found between interval and LRC. However, the OTTRT was significantly associated with LRC. The 3-year LRC was 87%, 75%, 69%, and 51% when the OTT was <6 weeks, 6-7 weeks, 7-8 weeks, and >8 weeks, respectively (p = 0.0004). The 3-year overall survival (OS) in the intermediate risk patients was 74% compared with 50% in the high-risk group (p = 0.0014). A significant association was also found between the OS and OTTRT. The OS increased from 50% when the OTTRT was >8 weeks to 74% when the OTT was <6 weeks (p = 0.006). Similar results were found with regard to the disease-free survival (DFS). In the multivariate analysis, both risk group and OTT were significantly associated with LRC, DFS, and OS. No significant interaction term was present between these two factors, which means that the OTT was of importance both for the high-risk and the intermediate-risk patients.

CONCLUSION

In the subset of patients with carcinoma of the oral cavity, the classification of high- and intermediate-risk patients by clustering a number of prognostic factors provides important prognostic information regarding LRC, DFS, and OS. The OTT was the most important prognostic factor both in the high-risk and intermediate-risk patients. Reducing the OTT to 6 weeks or less is a rather simple measure to achieve a considerable improvement of the outcome of treatment in this category of patients.

Immunosuppressive effects of soluble factors secreted by head and neck squamous cell carcinoma on dendritic cells and T lymphocytes

Recent observations suggest that the inability of the immune system to mount an effective immune response against head and neck squamous cell carcinoma (HNSCC) could be a result of the immunosuppression mediated through soluble factors that are secreted by tumour cells. Therefore, we investigated the effects of conditioned medium obtained from cultures of HNSCC cell lines (HNSCC-CM) on the function of dendritic cells (DC) and T cell immune response. In our study, we could not observe any inhibitory effect of HNSCC-CM on the maturation and the cytokine secretion pattern of DC. On the contrary, HNSCC-CM from two of three cell lines consistently decreased the quantity of IFN-gamma- and IL-4-secreting T cells upon restimulation in vitro. In conclusion, our data suggest that soluble factors secreted by HNSCC cells directly inhibit the function of effector T cells, rather than impeding the process of antigen presentation.

Prognostic value of genomic alterations in head and neck squamous cell carcinoma detected by comparative genomic hybridisation

A total of 45 primary head and neck squamous cell carcinomas were analysed by comparative genomic hybridisation to identify regions of chromosomal deletion and gain. Multiple regions of copy number aberration were identified including gains affecting chromosomes 3q, 8q, 5p, 7q, 12p and 11q and deletion of material from chromosomes 3p, 11q, 4p, 5q, 8p, 10q, 13q and 21. Kaplan-Meier survival analysis revealed significant correlations between gain of 3q25-27 and deletion of 22q with reduced disease-specific survival. In addition, gain of 17q and 20q, deletion of 19p and 22q and amplification of 11q13 were significantly associated with reduced disease-free survival. A Cox proportional hazards regression model identified deletion of 22q as an independent prognostic marker. The data presented here provide further evidence that the creation of a genetically based tumour classification system will soon be possible, complementing current histopathological characterisation.

Disparity in pathologic and clinical lymph node staging in oral tongue carcinoma. Implication for therapeutic decision making

BACKGROUND

Regional lymph node metastasis is the most reliable predictor of treatment outcomes for patients with squamous cell carcinoma of the oral tongue (SCCOT). A recent American Joint Committee on Cancer staging update of malignant melanoma has incorporated pathologic lymph node staging. The authors hypothesized that pathologic lymph node staging (pN) would be a more reliable predictor of treatment outcomes than clinical lymph node staging (cN).

METHODS

The authors retrospectively reviewed 266 patients who received primary surgical treatment for SCCOT, including a neck dissection, from January 1980 to December 1995. Overall and disease-specific survival and disease-free interval were compared with respect to clinical and pathologic lymph node stages.

RESULTS

Statistically significant survival differences were identified for both clinical (cN0-cN2) and pathologic lymph node stages (pN0-pN2). However, survival and disease-free interval differences for pathologic lymph node staging reached higher statistical significance (P < 0.0001) than for clinical lymph node staging (P < 0.002). This disparity can be explained by stage migration (i.e., patients with cN0-1 disease have a more advanced lymph node stage at the time of pathologic review compared with patients without cN0-1 disease). The authors found a 34% rate of occult lymph node disease in the cN0 group (19% of occult lymph nodes had extracapsular spread [ECS]). Similarly, 43% of cN1 patients had a higher stage than pN2b disease and 50% had ECS.

CONCLUSIONS

Pathologic lymph node staging, based on a staging or therapeutic neck dissection, should be considered for patients treated for SCCOT to identify high-risk patients who may benefit from additional adjuvant therapy. Prospective studies are essential to validate these findings before pathologic lymph node staging is included in standard staging criteria.