Chemoradiation therapy with or without salvage surgery for early squamous cell carcinoma of the hypopharynx

Technical guidelines for head and neck cancer IMRT on behalf of the Italian association of radiation oncology - head and neck working group

Performing intensity-modulated radiotherapy (IMRT) on head and neck cancer patients (HNCPs) requires robust training and experience. Thus, in 2011, the Head and Neck Cancer Working Group (HNCWG) of the Italian Association of Radiation Oncology (AIRO) organized a study group with the aim to run a literature review to outline clinical practice recommendations, to suggest technical solutions and to advise target volumes and doses selection for head and neck cancer IMRT. The main purpose was therefore to standardize the technical approach of radiation oncologists in this context. The following paper describes the results of this working group. Volumes, techniques/strategies and dosage were summarized for each head-and-neck site and subsite according to international guidelines or after reaching a consensus in case of weak literature evidence.

Function and organ preservation in adult cancers of the head and neck

Treatment for primary head and neck cancer has evolved from the use of radical approaches to therapies preserving important functions. Essential to this concept is the maintenance of therapeutic efficacy. The advances of organ-sparing surgery, improved radiation techniques and fractionation, and the addition of chemotherapy and targeted systemic agents, have added to the number of patients who undergo organ-preservation therapy. Crucial functions that can be spared include speech, swallowing, vision, salivation and cosmesis. This paper examines advances in therapy that allow the preservation of these important functions, scenarios where organ and function preservation is indicated, given current technology and agents, and where there might be future improvements.

Transoral treatment strategies for head and neck tumors

The introduction of transoral endoscopic surgery has initiated a fundamental change in the treatment of head and neck cancer. The endoscopic approach minimizes the intraoperative trauma. Due to the lower burden for the patient and the savings potential these methods have gained wide acceptance. These transoral accesses routes allow experienced surgeons to reduce the morbidity of surgical resection with no deterioration of oncologic results. This suggests a further extension of the indication spectrum and a high growth potential for these techniques and equipment in the coming years. For selected patients with selected tumors the minimally invasive transoral surgery offers improved oncological and functional results. In the present paper, different surgical access routes are presented and their indications discussed.

Radiotherapy for stage I or II hypopharyngeal carcinoma

Hypopharyngeal squamous cell carcinoma (HPSCC) is usually diagnosed at an advanced stage, and early-stage HPSCC is relatively rare. Because of the rarity of early-stage HPSCC, few reports have been published on the efficacy of radiotherapy (RT) in its treatment. We retrospectively reviewed the clinical records of 45 consecutive patients with Stage I and II HPSCC from May 1991 to June 2010. Patient characteristics were as follows: median age, 66 years (range, 44-90 years); male/female, 39/6; and T1/T2, 27/18. The irradiation dose ranged from 60 to 72 Gy (median: 70 Gy). Of the 45 patients, 21 underwent concurrent chemotherapy. With a median follow-up period of 62 months, the 5-year overall survival rate was 81%. Local failure occurred in 5 patients, and the 5-year local control rate was 83%. All local recurrences were successfully salvaged by surgery. The 5-year functional larynx preservation rate was 92%. Acute toxicity was manageable. Grade 3 laryngeal edema and Grade 3 hypothyroidism occurred in 1 patient each. No other late adverse events of Grade 3 or greater were observed. Based on these results, RT seemed to be an effective treatment modality for early HPSCC, with favorable organ preservation and acceptable adverse events. Early detection and accurate management of local recurrence and second malignancy was deemed to be critical.

[T1-T2 NO hypopharyngeal cancers treated with surgery alone. A GETTEC study (French Neck Study Group)]

OBJECTIVE

Consider whether surgery alone in the treatment of early cancers of the hypopharynx can give identical or better results in terms of survival and local control than radiotherapy.

METHODS

Forty-five patients were operated on during the years 1991-2004. Surgical treatment consisted in a resection by the transoral approach in four patients and 41 patients had a partial pharyngolaryngectomy. An elective neck dissection was performed on 43 patients.

RESULTS

The 1-, 3-, and 5-year overall survival rates were 100, 95, and 75%. The 1-, 3-, and 5-year locoregional control rates were 93, 88, and 82% and were influenced by the presence of dysplasia on surgical margins (p=0.027). The oncological occurrences observed were five local recurrences, two nodal recurrences, ten second primary cancers, and two metastases. Five locoregional failures out of seven were controlled after a second treatment.

CONCLUSION

Surgery alone gives completely satisfactory results in terms of survival and locoregional control. In case of recurrence, this makes it possible to operate on patients in nonirradiated areas with lower morbidity and mortality and better results. These results must be confirmed by a randomized trial.

Accelerated Radiotherapy and Larynx Preservation in Favorable-risk Patients with T2 or Worse Hypopharyngeal Cancer

OBJECTIVE

To evaluate the advantage of accelerated fractionation radiotherapy for patients with hypopharyngeal cancer requiring total laryngectomy.

METHODS

Seventy patients with previously untreated, technically resectable hypopharyngeal cancer who received larynx-preserving treatment with radiotherapy between April 1992 and June 2004 were analyzed. No patients had previous history of other malignancy or poor performance status that would possibly affect the outcomes. A total RT dose of > or = 60 Gy/6 weeks was determined depending on the tumor clearance during treatment before December 1998, and fixed to 70 Gy in all patients thereafter. Accelerated fractionation (70 Gy/<49 days) was completed in 35 patients during the latter period. Concomitant platinum-based chemotherapy was used in 41 patients after May 1998.

RESULTS

Local control rates at 2 years were 72 and 68% for patients with T2 and T3/T4 disease, respectively. Patients who had received 70 Gy/<49 days achieved a better local control rate than those who had received other, more conservative total dose/overall treatment time with statistical significance (91% versus 50% at 2 years, P < 0.001). Multivariate analysis involving 70 Gy/<49 days of radiotherapy, T-classification (T2 versus T3/4), and use of chemotherapy revealed that administering 70 Gy/<7 weeks was the only independent prognostic factor (P = 0.007) for better local control.

CONCLUSIONS

Our experience in radiotherapy for hypopharyngeal cancer mirrored the results of previously conducted large randomized trials for various head and neck cancers. Encouraging local control in this study warrants prospective study to test the long-term oncological and functional outcome of larynx-preserving treatment in patients with advanced but resectable volume of this disease.

Multi-institutional analysis of early squamous cell carcinoma of the hypopharynx treated with radical radiotherapy

PURPOSE

To analyze the outcomes of patients with early hypopharyngeal cancer treated with radical radiotherapy (RT).

METHODS AND MATERIALS

Ten institutions combined the data from 115 patients with Stage I-II hypopharyngeal squamous cell carcinoma treated with definitive RT between 1990 and 2001. The median patient age was 67 years; 99 patients were men and 16 were women. Of the 115 patients, 39 had Stage I and 76 had Stage II disease. Conventional fractionation was used in 98 patients and twice-daily RT in 17 patients; chemotherapy was combined with RT in 57 patients. The median follow-up period was 47 months.

RESULTS

The overall and disease-specific 5-year survival rate for 95 patients without synchronous malignancies was 66.0% and 77.4%, respectively. The 5-year disease-specific survival rate by T stage was 95.8% for patients with T1 disease and 70.1% for patients with T2 disease (p=0.02). Of the 115 patients, local control with laryngeal voice preservation was achieved in 34 of 39 patients with T1 lesions, including 7 patients successfully salvaged, and in 56 of 76 patients with T2 lesions. Sixty-five patients (56.5%) had synchronous or metachronous cancers. Of the 115 patients, 19 died of hypopharyngeal cancer, 10 died of second primary cancers, and 14 died of other causes during the study and follow-up periods.

CONCLUSIONS

Patients with early hypopharyngeal cancer tended to have a good prognosis after RT. However, second malignancies had an adverse effect on the overall outcomes of patients with early hypopharyngeal cancer.

Radiotherapy for Head and Neck Cancer

The length and quality of head and neck cancer survivorship continues to improve. Radiotherapy has been central to this process through advances in treatment technology, fractionation schemas, radiosensitizing chemotherapy, and surgical technique. The future of head and neck radiotherapy looks brighter still with progress in radiosensitizing biologic therapy, molecular characterization, functional imaging, and rehabilitative strategies fast approaching. Head and neck cancer, a disease once fraught with nihilism and failure, is evolving into a major success story of multidisciplinary solid tumor management. Continued dedication and work on the part of provider and patient alike will be required to make this promise a reality.