The effectiveness of treatment of lymph nodes in cancers of the pyriform sinus and supraglottis

Nodal downstaging predicts survival following induction chemotherapy for stage IIIA (N2) non-small cell lung cancer in CALGB protocol #8935

BACKGROUND AND OBJECTIVES

CALGB 8935 was a phase II protocol for mediastinoscopically staged IIIA (N2) non-small cell lung cancer. Induction cisplatin/vinblastine chemotherapy was followed by surgical resection, adjuvant cisplatin/vinblastine, and radiotherapy. We now evaluate the prognosis of pathologic nodes.

METHODS

Failure-free survival was calculated from a landmark 3 months after resection to account for heterogeneity in adjuvant therapy.

RESULTS

Nine of 42 (21%) resected patients had no residual N2 disease. This subset of 9 had a median failure-free interval of 47.8 months from landmark, whereas the 33 patients (79%) with persistent N2 disease had a median failure-free survival of 8.2 months from landmark (P=0.01). Although 21/42 (50%) had an incomplete resection (positive highest resected node and/or margin), completeness of resection did not influence failure-free survival. There were 3 distant and no local recurrences among the N2 negative group, and 12 local recurrences among patients with residual N2 disease (P=0.041).

CONCLUSIONS

These data suggest: (1) persistent N2 disease following induction chemotherapy is unfavorable; (2) patients downstaged to N2 negative may benefit from surgical resection; however, (3) 33% of N2 negative patients suffered disease relapse.

Stereotactic radiosurgery plus intracavitary irradiation in the salvage of nasopharyngeal carcinoma

BACKGROUND

We sought to assess the efficacy and complications of linear accelerator-based stereotactic radiosurgery (SRS) plus intracavitary irradiation (ICI) as salvage treatment for local persistent and recurrent nasopharyngeal carcinoma (NPC) after primary external beam radiotherapy (EBRT).

METHODS

Between July 1995 and June 2003, 36 patients (25 men and 11 women; median age, 48 years; range, 22-66 years) with local recurrent NPC confined to the nasopharynx (rT1) or limited extension to the parapharynx and nasal cavity (rT2) were treated with SRS plus ICI. Nineteen patients had rT1 and 17 had rT2 disease. Five patients (13.8%) had persistent disease, and 31 patients (86.1%) had recurrent disease using the definition of >4 months after the primary treatment as recurrent relapse. The median target volume was 36.3 cm(3) (range, 10.3-56.2 cm(3)) for the SRS treatment. All patients received 18 Gy to the 90% isodose line followed by two separate ICI 6 Gy each to 0.5 cm from the surface of the endotracheal balloon. Patients were assessed with serial nasoendoscopy and repeat scans (CT or MRI) at 3 months, and suspicious lesions were rebiopsied.

RESULTS

The median follow-up for surviving patients was 4.24 years (range, 0.73-8.81 years). Twenty-two of 36 (61%) patients were alive at the time of reporting. Twenty patients were free of disease, and two patients were alive with disease. Fourteen of 36 (39%) patients had died (five of distant metastases, six of local recurrences, two of both local disease and distant metastases, and one of unrelated cause). Patients with rT1 disease (median survival not reached) fared better that patients with rT2 disease (median survival, 4.6 years). The actuarial 5-year disease-free survival and overall survival (OS) were 57% (rT1 78%, rT2 39%) and 62% (rT1 80%, rT2 48%), respectively. The actuarial 5-year local control was 65% (rT1 82%, rT2 49%). The treatment was well tolerated with no significant acute complications. Sixteen patients (44%) had late complications, including palatal fibrosis in six patients (17%), trismus in seven patients (20%), cranial nerve palsies in seven patients (20%), temporal lobe necrosis in two patients (8%), and osteoradionecrosis of the skull base in six patients (17%). The complication-free survival rates at 2 and 5 years were 70% (95% confidence interval [CI], 56% to 87%) and 31% (95% CI, 17% to 56%), respectively. No patient died as a direct result of the late complication.

CONCLUSION

Although our series is small, the combination of SRS and ICI seems to be an effective salvage treatment for early-stage recurrent NPC. The OS of 62% at 5 years is very encouraging and favorable compared with reported reirradiation or surgical series. The late complications are considerable but expected because of the high doses of radiation previously delivered. The ideal dose fractionation for SRS and ICI is unknown and remains to be defined.

Horizontal partial laryngectomy for supraglottic squamous cell carcinoma

Between 1981-1999, 75 patients treated for supraglottic SCC with horizontal supraglottic laryngectomy (HSL) at the Otolaryngology Head and Neck Surgery Department of Lausanne University Hospital were retrospectively studied. There were 16 patients with T1, 46 with T2 and 13 with T3 tumors. Among these, 16 patients (21%) had clinical neck disease corresponding to stage I, II, III and IV in 12, 39, 18 and 6 patients, respectively. All patients had HSL. Most patients had either elective or therapeutic bilateral level II-IV selective neck dissection. Six patients (8%) with advanced neck disease had ipsilateral radical and controlateral elective II-IV selective neck dissections. Adjuvant radiotherapy was given to 25 patients (30%) for either positive surgical margins (n=8), pathological nodal status (n=14) or both (n=3). Median follow-up was 48 months (range, 24-199). Five-year disease-specific survival and locoregional and local control were 92, 90 and 92.5%, respectively. Among five patients who were diagnosed with local recurrence, one had a total laryngectomy (1.4%); the others were treated by endoscopic laser surgery. Two patients had both a local and regional recurrence. They were salvaged with combined surgery and radiotherapy, but eventually died of their disease. Cartilage infiltration seems to influence both local control (P=0.03) and disease-specific survival (P=0.06). There was a trend for worse survival with pathological node involvement (P=0.15) and extralaryngeal extension of the cancer (P=0.1). All patients except one recovered a close to normal function after the treatment. Aspiration was present in 16 patients (26%) in the early postoperative period. A median of 16 days (7-9) was necessary to recover a close to normal diet. Decannulation took a median of 17 days (8-93). Seven patients kept a tracheotomy tube for up to 3 months because of persistent aspiration. There was no permanent tracheostomy or total laryngectomy for functional purposes. Horizontal supraglottic laryngectomy remains an adequate therapeutic alternative for supraglottic squamous cell carcinoma, offering an excellent oncological outcome. The postoperative functional morbidity is substantial, indicating the need for careful patient selection, but good laryngeal function recovery is the rule. The surgical alternative is endoscopic laser surgery, which may offer comparable oncological results with less functional morbidity. Nevertheless, these two different techniques need to be compared prospectively.

Subclinical disease revisited

It has become commonplace to treat postoperative patients with adjuvant radiotherapy to increase local control. The reduction in local recurrences seen in patients with head and neck cancer following radiotherapy led to coining of the term "subclinical disease" to describe the presumed presence of small, clinically undetectable, nests of tumor cells which remain even after the most aggressive of surgeries. The basic assumption fundamental to the concept of subclinical disease is that any patient with residual disease will suffer a local failure if left untreated. For example, lymph node involvement, either clinically evident or pathologically proven, is considered an absolute indication for adjuvant therapy. A positive or "close" or "microscopically positive" margin is also considered grounds for further treatment. The purpose of this communication is to critically discuss recent reports that challenge this assumption.

Comprehensive analysis of nodal recurrence of advanced laryngeal carcinoma following surgery

The problems of nodal recurrence after surgical treatment of T3-4 laryngeal carcinoma were analysed. There were 133 N0 and 66 N+ patients. The 5-year actuarial nodal recurrence rate of N0 patients was 18% and N+ patients was 31%. Nodal recurrence was the commonest site of recurrence. The sites of nodal recurrence of N0 patients were at the level II, III, and IV nodes. Both ipsilateral and contralateral nodal recurrences were common. Of those patients who developed nodal recurrence, 63% patients were feasible for surgical salvage. Surgical salvage with radical neck dissection was the preferred treatment for nodal recurrence with 38% 5-year survival rate. The 'watchful waiting policy' in the management of N0 neck is an acceptable option with eventual nodal failure rate of 10% after surgical salvage. Close follow-up of patients is mandatory for the early detection of surgically salvageable nodal recurrence.

Adjuvant therapy with chemotherapy and radiation therapy in the management of carcinoma of the pancreatic head

Surgical resection remains the backbone of the curative management of carcinoma of the pancreatic head. The primary cause of recurrence appears to be residual locoregional subclinical disease. Data supporting the use and continued study of adjuvant chemotherapy and radiation therapy are summarized.

Squamous cell carcinomas of the aryepiglottic fold: therapeutic results and long-term follow-up

Three hundred fifteen patients with squamous cell carcinomas involving the aryepiglottic (A-E) folds were treated between January 1964 and December 1991. The age ranged from 39 to 87 years (mean, 62.4 years; median, 61.3 years) and the male-to-female ratio was 5:1 (54 women and 261 men). Symptom duration prior to diagnosis was 4.8 months. Eighty percent of patients had T3 and T4 lesions and 56.3% had neck metastases at presentation. Six patients (1.8%) had distant metastases and were excluded from this study. Clinically the tumors presented as either exophytic infiltrating lesions which were confined to the A-E fold (n = 57) or mucosally spreading tumors which extended to the lateral supraglottis or pyriform sinus (n = 258). Prior to 1978 preoperative radiation (3000 to 5000 cGy) was used. Higher doses of postoperative radiation (5000 to 6000+ cGy) were used thereafter. After 1982 the use of myocutaneous flaps for closure of partial laryngopharyngectomy defects was routine. Almost all N0 neck disease was treated by radiation or surgery. Combined therapy was used in N1-N3 disease. One quarter of the patients had single-modality therapy (25.7%; 81 patients) with a cumulative 5-year disease-free survival of 53%. The remainder of the patients (n = 234) had combined therapy with a cumulative 5-year survival of 67.2%. The latter group had 163 conservation surgeries and 121 total laryngectomy resections. The 5-year disease-free survival for preoperative radiation with surgery (68%) and postoperative radiation with surgery (64%) was similar. Those treated by radiation alone had a 34% 5-year disease-free survival and those treated with surgery alone had a 61% 5-year disease-free survival. The cumulative locoregional control rate was 77%. The cumulative disease-free survival at 5, 10, 15, and 20 years is 66%, 57%, 55%, and 55%, respectively. Infiltrating tumors had a better disease-free survival (by more than 10%) than spreading tumors. The 5-year survival rates were separated well by clinical stages of tumors. In patients with T1 tumors the 5-year survival was 87%; in those with T2 tumors, 80%; in those with T3 tumors, 78%; and in those with T4 tumors, 41%. The survival rate was greater in those with N0 tumors than in those with N+ tumors by 25% and greater in those with N1 tumors than in those with N2 + N3 tumors by an additional 18%. The overall complication rate was 26% and in 7.7% these were fatal.(ABSTRACT TRUNCATED AT 400 WORDS)

Squamous cell carcinoma of the pyriform sinus: a nonrandomized comparison of therapeutic modalities and long-term results

From January 1964 through December 1991, 408 patients with squamous cell carcinomas involving the pyriform sinus were treated at Washington University Medical Center. Their ages ranged from 29 to 83 years (mean, 62.3; median 59) and the male to female ratio was 5:1. The mean duration of symptoms prior to diagnosis was 3.9 months (range 1 to 32 months) and 89% had a smoking or ethanol history. Sixty-seven percent had T3 or T4 lesions and 87% were stage III or IV at presentation. Sixty-nine percent had neck metastases. The treatment strategy varied with respect to radiation and reconstruction. Prior to 1978, preoperative radiation (3.5 to 5000 cGy) was used. Postoperative radiation was given thereafter (600+ Gy). Since 1982, flap reconstruction (usually pectoralis major myocutaneous) has been used to close the partial laryngopharyngectomy (PLP) defect. Almost all N0 necks were treated by radiation or surgery and all N1-N3 lesions were treated by combined therapy. Pyriform tumors were subdivided into three groups: 1. one-wall lesions (n = 48), 2. medial-wall lesions which involved the aryepiglottic fold or supraglottis (N = 267), and 3. two- or three-wall lesions which extended to the pyriform apex or post-cricoid region (N = 93). Ninety-five patients had single-modality therapy and 302 had combined treatment. Two hundred seven patients had conservation surgery (PLP) and 157 had total laryngopharyngectomy alone or in combination with radiation. Thirty-three patients were treated by radiation alone. Eleven patients were excluded from the study because of distant metastases (TxNxM1) at presentation. The cumulative survival (NED) at 5, 10, 15, and 20 years was 56%, 35%, 31%, and 20%, respectively. The cumulative locoregional control rate was 71%. At 5 years (NED), the cure rates for one-wall lesions (73%) were better than for medial-wall lesions (63%) or 2- and 3-wall lesions (49%). One-wall lesions were smaller, medial-wall lesions behaved similar to supraglottic tumors, and two- or three-wall tumors behaved as hypopharyngeal tumors. The cure rates were related to T stage with T1 + T2 > T3 + T4 (28%). Neck metastases reduced the cure rate by 26% and N1 > N2-N3 by an additional 12%. Other factors contributing to therapeutic failure were distant metastases (17.7%), second primary tumors (6.2%; oropharynx and lung were most common), and intercurrent disease fatalities (9.5%). The secondary therapeutic salvage rate was 44% for surgery and 32% for radiation therapy. The therapeutic complication rate was 19% with 3.6% leading to fatality.(ABSTRACT TRUNCATED AT 400 WORDS)

Control of neck nodes in squamous cell carcinoma of the head and neck by radiotherapy: prognostic factors

313 patients with cervical metastases from a squamous carcinoma of the head and neck treated with radiotherapy, were studied by means of a multivariant analysis in order to determine the prognostic factors for cure. These were: lymph node response to irradiation (P = 0.0000), size of node (P = 0.0000), radiotherapy dose (P = 0.0037), condition of the primary (controlled vs non-controlled) (P = 0.0015), recurrent cervical metastases post-surgery (P = 0.0286).

Prognostic factors for survival and tumor control in cervical lymph node metastases from head and neck cancer. A multivariate study of 492 cases

A multivariate analysis was carried out in 492 patients with metastatic neck disease from squamous cell carcinoma to determine the influence of clinical and therapeutic factors on survival, local and regional control, and distant metastases. After radiation treatment with radical intent, recurrence at the primary site was the most frequent site of treatment failure (20% of cases), followed by distant metastases (14% of the cases), whereas isolated neck recurrences occurred in only 7% of the patients. The most significant factors influencing survival were primary tumor site, node fixation, N-stage, T-stage, and number of lymphatic chains. The most significant factors influencing local control were primary site, T-stage, and node fixation. Significant factors influencing regional control were radiation therapy volume, primary tumor site, node fixation, and node location (upper and lower neck). Significant factors influencing distant control were N-stage, number of nodes, and number of involved lymphatic chains.

The influence of dose and time on wound complications following post-radiation neck dissection

Data on 205 patients who were treated with a planned unilateral neck dissection following radiation therapy were analyzed with the purpose of understanding how treatment factors affect the incidence of wound complications. There were 27 occurrences of wound complication in the patient series. Logistic regression was used to analyze the data. We found that the surgical technique of flap reconstruction gave a significant increase in wound complications. There was a suggestion, although not statistically significant, that higher total doses increased the complication rate, that lower fraction sizes reduced the complication rate, and that longer overall radiotherapy treatment times were associated with higher complication rates. There was no association between the incidence of complications and the time interval between the end of radiotherapy and surgery.

Cervical metastases from unknown primaries: radiotherapeutic management and appearance of subsequent primaries

Between 1964 and 1986, 72 patients who presented with squamous or undifferentiated metastatic carcinoma to neck nodes, where the primary tumor could not be found by standard clinical procedures, were treated at the Mallinckrodt Institute of Radiology. These cases were managed in the following manner: biopsy and radiotherapy in 46 out of 72 patients, radiotherapy (RT) and a planned neck dissection in 14 out of 72, and neck dissection after failure to achieve a complete response (CR) with RT in 12 out of 72. Minimum follow-up was 2 years. The initial CR rates for stages N1, N2a, N2b, N3a, and N3b were 83%, 93%, 61%, 50%, and 33%, respectively. The long-term neck tumor control for the same stages was 83%, 71%, 67%, 44%, and 50%, respectively. One patient had soft tissue necrosis and two had carotid artery ruptures, one of which left no symptomatic sequelae. Twenty-one out of 72 patients developed subsequent primary tumor. Only one of these patients survived. This incidence was not affected significantly by prophylactic treatment of the mucosal areas except in patients with bilateral neck nodes, undifferentiated or poorly differentiated histologies, and/or posterior cervical node involvement. A multivariate analysis showed that prognosticators of an improved disease-free survival were: a complete clearance of tumor by the end of radiotherapy (p less than 0.0009) and no appearance of a subsequent primary tumor (p = 0.035). The only factor that correlated with an increased loco-regional control was having a complete response by the end of radiotherapy (p less than 0.00009). The recommended management and possible ways of preventing the appearance of subsequent primaries will be discussed.

Partial laryngectomy and radiotherapy for supraglottic cancer: a conservative approach

This is a retrospective study of 33 patients with supraglottic cancer treated with partial laryngectomy and moderate-dose radiotherapy at the University of Virginia from 1967 through 1986. All patients had a 2-year minimum follow-up. Ten patients received preoperative radiotherapy, and 23, postoperative radiotherapy. The 2-year adjusted survival rate was impressive at 97%. Local control at 2 years was 96%, including one patient who was salvaged with total laryngectomy. Control of the neck was 90% at 2 years. Ninety percent of the patients alive at 2 years had a functional voice. One patient required a completion laryngectomy for chronic aspiration. Conservation surgery with radiotherapy provides excellent survival as well as locoregional control rates with preservation of function in selected patients with supraglottic cancer. This approach may be especially helpful in the management of bulky T2 lesions as well as T4 lesions with minimal vallecula or base of tongue involvement.