Summary of Japanese clinical practice guidelines for head and neck cancer - 2022 update edited by the Japan society for head and neck cancer

Impact of preceding treatment for head and neck squamous cell carcinoma on synchronous superficial esophageal squamous cell carcinoma

BACKGROUND

Patients with esophageal squamous cell carcinoma (ESCC) frequently develop synchronous head and neck squamous cell carcinoma (HNSCC). With advances in endoscopic technology and widespread screening of synchronous cancers, the detection of synchronous HNSCC and superficial ESCC (SESCC) is increasing. We aimed to evaluate the impact of preceding HNSCC treatment on synchronous SESCC.

METHODS

This single-center retrospective study enrolled patients with synchronous HNSCC and SESCC who were treated between January 2010 and December 2023. Tumor size and depth of SESCC before and after HNSCC treatment were evaluated. The factors associated with SESCC progression were investigated.

RESULTS

Of the 299 patients with synchronous HNSCC and SESCC, 134 who underwent preceding HNSCC treatment with follow-up esophagogastroduodenoscopy (EGD) for SESCC were evaluated. Chemoradiotherapy was the most common treatment for HNSCC (56.0%), followed by surgery (17.2%), radiotherapy (14.9%), local resection (7.5%), and chemotherapy (4.5%). The tumor size of SESCC increased after HNSCC treatment in 18 patients (13.4%). Multivariate analysis revealed that an EGD interval of ≥ 120 days was significantly associated with increased tumor size in SESCC (odds ratio, 6.64; 95% confidence interval, 1.91-23.1). Tumor regrowth was observed in 70.6% of SESCCs that shrank with HNSCC treatment, mostly within six months. Tumor depth aggravation was rare (2.2%), but progression to advanced ESCC was observed in two patients.

CONCLUSIONS

Timely endoscopic follow-up, preferably within 120 days, is crucial for managing synchronous SESCC after HNSCC treatment to prevent tumor progression. Tumor regrowth should be monitored when SESCC shrinks with HNSCC treatment.

Clinical practice guidelines for the treatment of squamous cell carcinoma of the head and neck: an assessment based on the AGREE II, AGREE-REX tools and the RIGHT checklist

Objective

The aim of this study was to obtain several published clinical practice guidelines (CPGs) for Head and neck squamous cell carcinoma (HNSCC) and critically assess and compare their quality by using three guideline quality evaluation tools, namely, AGREE II, AGREE-REX, and RIGHT, to support the development of future CPGs for HNSCC.

Methods

Clinical practice guidelines related to the diagnosis and treatment of HNSCC were screened through a comprehensive systematic literature search. Data were extracted from the guidelines which met the inclusion criteria, and two experienced head and neck oncology surgeons were trained to act as independent reviewers. The quality of the retrieved guidelines that met the inclusion and exclusion criteria was evaluated by using the AGREE II, AGREE-REX, and RIGHT tools. Then, the quality of the guidelines that met the criteria was assessed. Finally, conclusions and recommendations were drawn based on the scoring results.

Results

A total of eight guidelines met the inclusion criteria. Four guidelines(written by ASCO, NCCN, CCO and KCE) scored > 60% in five or more AGREE II quality domains, two guidelines(written by ASCO and KCE) scored > 60% in all AGREE-REX quality domains, and two guidelines(written by ASCO and KCE) scored > 60% in all quality domains on the RIGHT checklist and were considered "recommendable".

Conclusions

The authors recommend consulting the American Society of Clinical Oncology guidelines for HNSCC and suggest that future guideline development groups refer to the guideline evaluation framework for guideline writing to enhance the applicability and effectiveness of clinical practice guidelines.

Endoscopic submucosal dissection for lesions developing in the irradiated area of head and neck cancer

BACKGROUND AND AIM

Effective treatment of lesions that develop in the irradiated area of head and neck squamous cell carcinoma is a major concern. This study aimed to clarify the efficacy and safety of endoscopic resection for such lesions.

METHODS

Among consecutive patients who underwent endoscopic resection for histologically proven head and neck squamous cell carcinoma between January 2014 and December 2021, those who received definitive radiotherapy/chemoradiotherapy before endoscopic resection were included in this single-center, retrospective study. Short- and long-term outcomes were evaluated.

RESULTS

Among 422 patients who underwent endoscopic resection for 615 lesions, 43 patients with 57 lesions were eligible. All 57 lesions were treated with endoscopic submucosal dissection and en bloc resection was achieved in all lesions. Grade 3 of Common Toxicity Criteria for Adverse Events v5.0 occurred in eight (19%) patients (dysphagia, seven; stricture, three; aspiration pneumonia, two; and pharyngeal necrosis, one [some cases overlapped]), but no grade ≥ 4 events occurred. Enteral nutrition by gastrostomy was temporarily required in two patients owing to dysphagia and laryngeal necrosis. During the median follow-up of 40 (interquartile range, 29.5-61) months after endoscopic submucosal dissection for the lesions developed in the irradiated area, local recurrence and metachronous lesions developed in two (5%) and nine (21%) patients, respectively. However, total laryngectomies and tracheostomies were avoided in all patients. The 3-year overall and disease-specific survivals were 81% (95% confidence interval, 64%-91%) and 94% (95% confidence interval, 79%-99%), respectively.

CONCLUSIONS

Favorable local control and safety of endoscopic submucosal dissection were demonstrated.

Preserving Laryngo-Esophageal Function in Patients With Hypopharyngeal Cancer Treated With Radiotherapy: Predictive Factors and Long-Term Outcomes

BACKGROUND

Functional outcomes after hypopharyngeal cancer (HPC) treatment have a significant effect on patients' quality of life and prognosis. This study aimed to identify the predictive factors associated with laryngo-esophageal dysfunction in patients with HPC who received definitive radiotherapy.

METHODS

Patients with HPC treated with definitive intensity-modulated radiotherapy between 2007 and 2019 at our institution were retrospectively evaluated. Laryngo-esophageal dysfunction-free survival (LDFS) events were defined as local recurrence, laryngo-esophageal dysfunction (defined as tracheostomy or feeding tube dependence), or death from any cause.

RESULTS

The median follow-up period was 61 months for the 80 patients included in the study. The 5-year LDFS rate was 47%. A clinical T4 stage and lower pretreatment prognostic nutritional index (PNI) were independently associated with a lower LDFS.

CONCLUSION

A clinical T4 stage and lower pretreatment PNI were identified as predictors of a lower LDFS after definitive radiotherapy for HPC.

Emergency Management and Nursing Considerations of Carotid Blowout Syndrome

INTRODUCTION

Carotid blowout syndrome is a rare but fatal complication often witnessed secondary to treating patients with head and neck cancer. It occurs when damage and necrosis lead to the carotid artery wall rupture. The symptoms encountered in these patients range from asymptomatic to cardiac arrest. Here, we present 5 cases of carotid blowout syndrome in the emergency department.

CASE PRESENTATIONS

Patients demonstrated symptoms ranging from subtle bleeding to hemodynamic instability, highlighting the diverse nature of carotid blowout syndrome in this population. Notably, while all patients had a history of radiotherapy, some had additional risk factors for carotid blowout syndrome, including prior surgery (n = 2), malnutrition (n = 3), and tracheostomies (n = 2). Definitive diagnoses were established through clinical evaluation and computed tomography angiography. Immediate interventions included bleeding control, resuscitation, and consultations with relevant specialties. Four patients underwent interventional radiology procedures, and 1 patient received otolaryngology care. While 2 patients recovered completely, 1 died in the emergency department, and 1 in the intensive care unit. One patient's clinical course was complicated by a stroke.

CONCLUSION

The approach to the carotid blowout syndrome patient includes complex steps that proceed in a multidisciplinary manner, starting from triage until discharge. Emergency nurses play crucial roles at every stage. They should be aware of carotid blowout syndrome when evaluating patients with head and neck cancer presenting with bleeding. When treating these patients, emergency nurses should be ready for airway interventions, bleeding control, and massive transfusion protocol. In this context, the multifaceted approaches made by nurses contribute significantly to carotid blowout syndrome management in the emergency department.

Frequency of use and cost in Japan of first-line palliative chemotherapies for recurrent or metastatic squamous cell carcinoma of the head and neck

BACKGROUND

Over the last decade, novel anticancer drugs have improved the prognosis for recurrent or metastatic squamous cell carcinoma of the head and neck (RM-SCCHN). However, this has increased healthcare expenditures and placed a heavy burden on patients and society. This study investigated the frequency of use and costs of select palliative chemotherapy regimens in Japan.

METHODS

From July 2021 to June 2022 in 54 healthcare facilities, we gathered data of patients diagnosed with RM-SCCHN and who had started first-line palliative chemotherapy with one of eight commonly used regimens. Patients with nasopharyngeal carcinomas were excluded. The number of patients receiving each regimen and the costs of each regimen for the first month and per year were tallied.

RESULTS

The sample comprised 907 patients (674 were < 75 years old, 233 were ≥ 75 years old). 330 (36.4%) received Pembrolizumab monotherapy, and 202 (22.3%) received Nivolumab monotherapy. Over 90% of patients were treated with immune checkpoint inhibitors as monotherapy or in combination with chemotherapy. Treatment regimens' first-month costs were 612 851-849 241 Japanese yen (JPY). The cost of standard palliative chemotherapy until 2012 was about 20 000 JPY per month. The incremental cost over the past decade is approximately 600 000-800 000 JPY per month, a 30- to 40-fold increase in the cost of palliative chemotherapy for RM-SCCHN.

CONCLUSION

First-line palliative chemotherapy for RM-SCCHN exceeds 600 000 JPY monthly. Over the last decade, the prognosis for RM-SCCHN has improved, but the costs of palliative chemotherapy have surged, placing a heavy burden on patients and society.

Oncological Outcomes of Concurrent Chemoradiotherapy and Surgical Treatment for Patients With T3 Hypopharyngeal Cancer: A Single-Center Retrospective Analysis

Background Since the larynx and pharynx are vital for respiration, swallowing, and speech, chemoradiotherapy (CRT) has been widely applied for T3 hypopharyngeal cancer (HPC) as an organ-preserving treatment. However, CRT can lead to severe late adverse events such as dysphagia and aspiration pneumonia, especially in patients who have difficulty swallowing and/or aspiration at the time of initial diagnosis. Patients and methods Between 2012 and 2020, 86 patients with T3 HPC treated with curative intent at Kobe University Hospital were included in this study. The average age was 69 years old, ranging from 43 to 89. Diseases were classified as Stage III in 29 patients, Stage IVA in 52 patients, and Stage IVB in five patients. Thirty-five (41%) patients were treated by CRT, and 51 (59%) patients were treated by surgery. Patients were followed up for at least two years, and the follow-up period ranged from four to 128 months (median: 45 months). Results Three-year progression-free survival (PFS) rates of patients treated by CRT and patients treated by surgery were 56.2% and 60.3%, respectively. Three-year disease-specific survival (DSS) rates of patients treated by CRT and surgically treated patients were 79.0% vs. 70.8%, respectively. Three-year overall survival (OS) rates of patients treated by CRT and surgically treated patients were 64.5% and 69.0%, respectively. Of note, a significant difference was observed between three-year DSS and three-year PFS (79.0% vs. 56.2%, p = 0.0014) in the patients treated by CRT but not in the patients treated by surgery. Conclusions No significant differences were observed between the PFS, DSS, and OS rates of patients treated by CRT and those of surgically treated patients. Locoregional recurrences after CRT were significantly successfully salvaged by surgical intervention. These results suggest that CRT can be applied as an alternative to surgery without reducing survival, especially for patients without severe clinical symptoms. Meticulous follow-up is mandatory for early detection of recurrence to salvage by surgery and for the management of late adverse events.

Analyzing the challenges faced by recently qualified nurses in radiation therapy nursing at Japan's National University Hospitals: Uncovering the determinants of difficulty

Objective

Newly graduated nurses embarking on careers in radiation therapy nursing at Japan's National University Hospitals face a spectrum of challenges, many of which have received limited attention in existing literature. This study aimed to uncover the primary difficulties encountered by these nurses, with a specific focus on their implications for training and systematic education.

Methods

Employing a survey involving nurses from five prestigious medical institutions in Japan, we explored the real-time experiences and challenges within radiation therapy nursing. Our investigation concentrated on adverse events and the requisite knowledge for effective symptom management. The results illuminated a notable divergence in experiences among nurses, with particular challenges emerging in the treatment of head and neck cancers, especially when combined with chemotherapy. The data emphasized the pivotal role of certified nurses in offering support and knowledge transfer in complex cases, underscoring the importance of peer support and consultations.

Results

The findings underscored a significant variance in experiences among nurses, with specific difficulties encountered in the management of head and neck cancers, particularly in conjunction with chemotherapy. The data highlighted the essential role of certified nurses in providing support and knowledge dissemination in challenging scenarios, underscoring the significance of peer support and consultations.

Conclusions

This study provides an overview of the landscape, highlighting the critical role of peer consultation and the need for advancements in the educational framework for radiation therapy nurses.

Definitive radiotherapy for nasopharyngeal carcinoma in Japan: analysis of cases in the National Head and Neck Cancer Registry from 2011 to 2014

OBJECTIVE

This study aimed to analyze the nationwide prognosis of patients with nasopharyngeal carcinoma who underwent definitive radiotherapy in Japan, utilizing the National Head and Neck Cancer Registry data.

METHODS

A total of 741 patients diagnosed with primary nasopharyngeal carcinoma were screened from 2011 to 2014. The inclusion criteria were histologically proven nasopharyngeal squamous cell carcinoma, receiving definitive radiotherapy, and no distant metastases. Patients with unclear prognoses or unknown staging were excluded. The primary endpoint was 5-year overall survival, and secondary endpoints were 5-year progression-free survival and survival by stage.

RESULTS

A total of 457 patients met the inclusion criteria. The median age was 60 years, and 80% were male. The proportions of patients with performance status 0, 1, 2 and 3 were 69, 10, 1 and 1%, respectively. Chemoradiotherapy was administered to 84.7%. Radiotherapy modalities were recorded only for 29 patients (three received intensity-modulated radiotherapy and 26 received two/three-dimensional radiotherapy). Of those included, 7.4, 24.7, 35.7, 24.5 and 7.7% had Stage I, II, III, IVA and IVB disease, respectively. The 5-year overall survival was 72.5% for all patients: 82.6, 86.6, 76.0, 51.4 and 66.5% for Stage I, II, III, IVA and IVB disease, respectively. The 5-year progression-free survival was 58.6%: 75.6, 66.8, 61.5, 43.7 and 46.5% for Stage I, II, III, IVA and IVB disease, respectively.

CONCLUSIONS

This nationwide survey demonstrated favorable prognoses and provided valuable foundational data for similar future surveys to monitor the penetration of appropriate treatment and changes in clinical structures based on new evidence.