Cutaneous Squamous Cell Carcinoma of the Head and Neck

Surgical Management of Patients with Parotid Involvement from Non-Melanoma Skin Cancer of the Head and Neck

We conducted a retrospective, longitudinal study on a single-center series of patients who underwent parotidectomy in the management of advanced head and neck non-melanoma skin cancer (hnNMSC). The aim of this study was to identify prognostic factors associated with worse outcomes. Forty-one men and nine women were included. The mean age at the time of surgery was 78.9 years. The 5-year overall survival, disease-specific survival, locoregional recurrence-free survival, and distant metastasis-free survival calculated with Kaplan-Meier curves were 39.9%, 56.3%, 58.6%, and 82.1%, respectively. A univariate analysis showed that the status of the margins, facial nerve direct involvement, lymph vascular invasion, and histological grading were associated with worse outcomes (p < 0.05). Positive margins were associated with worse disease-specific survival also in a multivariate analysis (p = 0.001, HR = 32.02, and CIs 4.338 to 351.3). Because the resection in free margins is the most important prognostic factor, early diagnosis or, in the case of advanced disease, extensive surgical resection with concomitant reconstruction is needed. Adjuvant therapy is indicated in selected cases.

The Role of Radiation Therapy in the Treatment of Non-Melanoma Skin Cancer

Non-melanoma skin cancer (NMSC) is the most common malignancy in the United States. While surgery is considered as the main treatment modality for both cutaneous basal cell carcinoma (cBCC) and cutaneous squamous cell carcinoma (cSCC), radiotherapy plays an important role in the treatment of NMSC, both in the adjuvant setting for cases considered high-risk for recurrence, and in the definitive setting, when surgery is not feasible or desired by the patient. The last years have seen the emergence of immunotherapy treatment for cases of advanced cSCC in the palliative, and possibly neoadjuvant settings, making the treatment paradigm more complex. In this review, we attempt to describe the different radiation modalities available for the treatment of NMSC, the indications for adjuvant post-operative treatment with radiotherapy for cSCC, the role of radiotherapy in elective neck treatment, and the efficacy, safety, and toxicity profile of this treatment in these different settings. Furthermore, we aim to describe the efficacy of radiotherapy combined with immunotherapy as a promising horizon for treating advanced cSCC. We also aim to describe the ongoing clinical studies that attempt to examine future directions for the role of radiation treatment in NMSC.

Elective neck dissection versus observation in patients with head and neck cutaneous squamous cell carcinoma

BACKGROUND

The survival benefit of elective neck dissection (END) for patients with cutaneous squamous cell carcinoma (cSCC) of the head and neck and no evidence of regional metastasis (cN0) has never been reported. The aim of this study was to determine the effect of END on patient survival.

METHODS

The authors included patients with head and neck cSCC who had undergone primary surgery from 1995 to 2017. The primary end point was survival, and the secondary end points were the incidence of occult regional disease and regional disease control. To assess the impact of END on survival, the authors used multivariable Cox proportional hazards models with propensity score and matching techniques for internal validation.

RESULTS

A total of 1111 patients presented with no evidence of nodal disease; 173 had END, and 938 were observed. Adjuvant radiotherapy to the neck was administered to 101 patients (9%). END resulted in a 5-year overall survival rate of 52%, whereas the rate was 63% in the observation group (P = .003 [log-rank]). The 5-year disease-free survival rate for patients undergoing END was similar to that for the observation group (73% vs 75%; P = .429). A multivariate regression model showed that the performance of END was not associated with improved rates of overall, disease-specific, or disease-free survival; similarly, among patients with advanced disease (T3-4), those who underwent END did not have improved survival rates.

CONCLUSIONS

Among patients with cSCC of the head and neck, observation of the neck nodes resulted in noninferior survival rates in comparison with END at the time of primary surgery. Further studies are required to elucidate the role of END in patients with advanced disease.

Outcome in Patients with Partial and Full-Thickness Cheek Defects following Free Flap Reconstruction-A Multicentric Analysis of 47 Cases

The objective of this study was to evaluate whether the extent of tumor resection and free flap reconstruction influences functional outcome and complications in patients with solid malignancies of the cheek. Therefore, we retrospectively assessed recipient site complications and functional outcomes in 47 patients with solid malignancies of the cheek who underwent either partial (n = 30; 63.8%) or full-thickness (n = 17; 36.2%) cheek resection with free flap reconstruction. Complications occurred in 12 (70.6%) patients after full thickness resections with creation of through-and-through defects compared to 14 (70.6%) patients with partial defects (p = 0.138). Among those 26 patients (55.3%), major recipient site complications, like development of salivary fistula or free flap loss, were observed in 10 (21.3%) and 2 (4.3%) cases, respectively, while minor complications, like wound dehiscence and local infections, were found in 14 (29.8%) and 9 (19.1%) patients. Complications were noticed particularly after reconstruction of suborbital defects (69.2%; p = 0.268), of which occurrence of salivary fistulae was the most common (46.2%; p = 0.035). Similarly, functional outcomes including oral incompetence, ectropion, and trismus were not affected by the extent of resection (p = 0.766). However, oral incompetence was higher in patients with tumors originating from the oral cavity (p = 0.020) and after the performance of mandibulectomy (p = 0.003). Overall, there was no difference in functional outcome or recipient site morbidity between tumor resections resulting in full-thickness and partial defects.

Non-primary salivary malignancies: A 22-year retrospective study

PURPOSE

Most salivary gland malignancies are primary tumors, but in our medical center one of six is non-primary. The relative scarcity of such reports justifies studying them.

SUBJECTS & METHODS

We studied patients' demographic and clinical parameters, salivary tumors/metastasis, diagnosis and treatment, and survival rates.

RESULTS

Of all our salivary malignancy patients over the last 22 years, 15% (18/119) had non-primary malignant tumors, all located in the parotid glands. Of these, nine had skin cancer (SCC), 3 malignant solid tumors and 6 hematological systemic malignancies. Four had concomitant second malignancy. Mean age was 70.2 ± 13.8 years, 66.7% of the patients were males, 27.8% were smokers, none reported alcohol use. The most prevalent diagnostic tools used were CT (16 patients), FNA (13) and PET-CT (12). Eleven of 18 patients died from the disease despite receiving therapy: 6 SCC patients, 2 CLL patients and all 3 with solid tumors. All four lymphoma patients survived as did another three SCC patients.

CONCLUSIONS

Chemotherapy and radiotherapy for systemic disease prolonged life rather than surgery. Patients with poor prognosis non-primary salivary tumors should be treated conservatively; surgery should be for those without widespread metastases or systemic disease. Sometimes a palliative patient may benefit from tumor debulking.

Cancers of the Major Salivary Gland

Salivary gland malignancies are rare tumors that comprise multiple histologic entities with diverse clinical behavior. Mucoepidermoid carcinoma is the most frequent primary salivary malignancy, followed by adenoid cystic and acinic cell carcinoma. Although most salivary malignancies are asymptomatic, presentation with a rapidly enlarging mass may be accompanied by pain, functional neurologic deficits, soft-tissue invasion, or nodal enlargement. Assessment of clinical behavior and physical exam greatly contributes to diagnostic workup. Preoperative imaging, to include ultrasound, computed tomography, or magnetic resonance imaging, may assist with surgical planning. Limitations of preoperative fine-needle aspiration cytology mean that, in some cases, definitive histologic diagnosis may not be established until therapeutic surgery is undertaken. Treatment strategies rely on oncologic resection of the primary site with negative margins as well as adjuvant radiotherapy in patients with high-risk features, such as high-grade histology, advanced T class, or perineural invasion. Regional lymphadenectomy is recommended for involved nodal basins. Patients with clinically node-negative disease at high risk for occult nodal metastases may be considered for elective lymphadenectomy or radiotherapy. Use of chemotherapy in the adjuvant setting, in combination with radiotherapy, remains controversial. The rate of objective response to palliative chemotherapy in recurrent or metastatic salivary gland malignancy remains low. In studies that include a significant proportion of adenoid cystic carcinomas, whether disease stability represents an indolent disease process or the true effect of a therapeutic drug may be difficult to discern. Recognition of genetic alterations and protein expression unique to salivary malignancies presents exciting new opportunities for molecularly targeted therapy, although the response to molecularly targeted therapy in studies has been modest thus far.

Comparison between wait-and-see policy and elective neck dissection in clinically N0 cutaneous squamous cell carcinoma of head and neck

To analyze the superiority of wait-and-see policy and elective neck dissection in treating cN0 patients with facial cutaneous cell carcinoma (cSCC).Patients with clinically negative parotid and neck metastasis disease were prospectively enrolled. Three groups were divided based on whether the patient received an operation of superficial parotidectomy or/and elective dissection, and regional control and disease-specific survival rates were compared.The occult parotid and neck metastasis rate was 20% and 16%, respectively. There was neck node metastasis without parotid metastasis in only 1 patient. All the node metastasis occurred in level II. Regional recurrence was noted in 16 (16%) patients, and 6 patients died of the disease. In the group undergoing superficial parotidectomy and elective neck dissection, 2 patients had neck node metastasis, and there was no disease-related death, further survival analysis indicated it had better regional control and disease-specific survival rates compared with the other 2 groups.Superficial parotidectomy and elective neck dissection are suggested for patients with T3-4 facial cutaneous squamous cell carcinoma.

Cancers of major salivary glands

Major salivary gland malignancies are a rare but histologically diverse group of entities. Establishing the diagnosis of a malignant salivary neoplasm may be challenging because of the often minimally symptomatic nature of the disease, and limitations of imaging modalities and cytology. Treatment is centered on surgical therapy and adjuvant radiation in selected scenarios. Systemic therapy with chemotherapeutic agents and monoclonal antibodies lacks evidence in support of its routine use.