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Chen AM. Management of unknown primary head and neck cancer with radiation therapy in the era of human papillomavirus (HPV): No longer cutting down the tree to get an apple. Radiother Oncol 2023; 189:109952. [PMID: 37844736 DOI: 10.1016/j.radonc.2023.109952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE Given the central role that radiation has in the management of head and neck squamous cell carcinoma of unknown primary origin, it is imperative to review how treatment paradigms have been refined and continue to evolve in the modern era. METHODS AND MATERIALS This study was designed based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement. A literature search of peer-reviewed publications was undertaken to identify works pertaining to the use of radiation for squamous cell carcinoma of unknown primary origin presenting as cervical lymph node metastases. Articles published from January 2002 to January 2023 with full text available on PubMed and restricted to the English language and human subjects were included. The full bibliographies of identified articles were reviewed and irrelevant studies were removed. RESULTS While such breakthroughs as intensity-modulated radiotherapy, positron emission tomography, biomarker testing with immune-histochemistry, and minimally invasive surgical techniques such as transoral robotic surgery have fundamentally changed the approach to this disease in recent decades, controversies still exist with respect to the manner in which radiation is delivered. Although the incidence of head and neck unknown primary cancer is relatively low, questions regarding the necessity of comprehensive radiation using the age-old standard method of targeting the bilateral necks and entire pharyngeal axis to encompass all putative sites of mucosal disease persist. CONCLUSIONS Prospective evidence is lacking, and the available studies have been complicated by such factors as the relatively limited sample sizes, as well as the variability in work-up, treatment, inclusion criteria, and follow-up. Regardless, advances in science and technology have ushered in more precise approaches with a high degree of customization, particularly given the increased proportion of patients presenting with human papillomavirus-related disease.
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Affiliation(s)
- Allen M Chen
- Department of Radiation Oncology, University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA 92868, USA.
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2
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Pouyiourou M, Regnery S, Bochtler T, Herfarth K, Krämer A. [Cancer of unknown primary (CUP)-single-site, oligometastatic, and in the head and neck region]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:358-365. [PMID: 36944857 DOI: 10.1007/s00117-023-01133-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION About 20% of all cancer of unknown primary (CUP) cases can be classified into favorable subgroups, which are defined by either obvious analogies to certain cancers with a known primary or amenability to local ablative treatment. In the updated European Society for Medical Oncology (ESMO) guidelines for diagnosis and treatment of CUP, the definition of favorable subgroups has been revised according to the latest scientific findings. In particular, the definition and treatment of oligometastatic CUP have undergone considerable changes in recent years. Thus, we delineate the current diagnostic and therapeutic standards for the two favorable CUP subtypes single-site/oligometastatic and head/neck CUP. METHODS The classification, diagnostic workup, and treatment of single-site and oligometastatic CUP are summarized based on the current ESMO and American Society of Clinical Oncology (ASCO) guidelines together with a literature review. CONCLUSIONS Single-site and oligometastatic CUP is defined by the presence of a maximum of five metastases that are amenable to local ablative treatment. Median overall survival is favorable and exceeds 4 years after local ablation of all detectable metastases. Lymph node metastases in the head and neck region represent a frequent scenario of single-site CUP. They usually originate from human papillomavirus (HPV)-associated squamous cell carcinoma in the oropharynx. Diagnostic workup comprises computed tomography (CT), magnetic resonance imaging (MRI) if necessary, and fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), followed by panendoscopy and biopsies of suspicious mucosal sites. Neck dissection, potentially followed by adjuvant radiotherapy, and definitive radiotherapy represent equally effective oncological treatment options with respect to a favorable prognosis.
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Affiliation(s)
- Maria Pouyiourou
- Klinische Kooperationseinheit Molekulare Hämatologie/Onkologie, Deutsches Krebsforschungszentrum (DKFZ) und Medizinische Klinik V, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland.
- Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - Sebastian Regnery
- Abteilung für Radioonkologie und Strahlentherapie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - Tilmann Bochtler
- Klinische Kooperationseinheit Molekulare Hämatologie/Onkologie, Deutsches Krebsforschungszentrum (DKFZ) und Medizinische Klinik V, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland
- Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
- Medizinische Onkologie, Nationales Centrum für Tumorerkrankungen (NCT) Heidelberg, Heidelberg, Deutschland
| | - Klaus Herfarth
- Abteilung für Radioonkologie und Strahlentherapie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - Alwin Krämer
- Klinische Kooperationseinheit Molekulare Hämatologie/Onkologie, Deutsches Krebsforschungszentrum (DKFZ) und Medizinische Klinik V, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland
- Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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3
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Pala M, Novakova P, Pechacova Z, Vesela L, Vrana A, Sukova J, Holeckova P, Drbohlavova T, Podlesak T, Petruzelka L. Long-term results of radio(chemo)therapy in metastatic carcinoma to cervical lymph nodes from an unknown primary. Adult Comorbidity Evaluation 27 score as a predictor of survival. Strahlenther Onkol 2023; 199:149-159. [PMID: 35943554 DOI: 10.1007/s00066-022-01983-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 07/10/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE To evaluate the effectiveness and toxicity of curative (chemo)radiotherapy in patients with metastatic carcinoma to cervical lymph nodes from an unknown primary. METHODS Retrospective study of 90 consecutive patients, treated with curative radiotherapy from 2003 to 2018 (median age 59 years; current/former smokers 76%) was conducted. The distribution of nodal staging was as follows: N1: 12%, N2a: 21%, N2b: 43%, N2c: 10%, N3: 13%. In 62% of patients, neck dissection was performed before radiotherapy. Concomitant chemotherapy was given to 64% of patients. RESULTS The median follow-up of surviving patients was 86 months. The median total radiotherapy dose achieved was 70 Gy. The 5‑ and 10-year locoregional control were 84% in both cases, while 5‑ and 10-year distant control were 90% and 89%, respectively. A primary tumor in the head and neck area was detected in only 2 patients. No patient had an initial failure in the pharyngeal axis or contralateral cervical nodes. The 5‑ and 10-year overall survival were 55% and 42%, respectively. Severe early toxicity occurred in 71%; severe late toxicity in 33% of patients. Multivariate analysis demonstrated N‑status (hazard ratio [HR] 2.424; 95% confidence interval [CI] 1.121-5.241; p = 0.024) and comorbidity scores assessed by ACE-27 (Adult Comorbidity Evaluation; HR 3.058; 95% CI 1.489-6.281; p = 0.002) as two independent prognostic factors for overall survival. CONCLUSION The results of our work study demonstrate the high effectiveness of curative (chemo)radiotherapy on the pharyngeal axis and bilateral cervical nodes with long-term locoregional and distant control in 3/4 of the treated patients. N‑status and comorbidity scores were shown as strong prognostic factors influencing overall survival.
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Affiliation(s)
- Miloslav Pala
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic.
| | - Pavla Novakova
- Radiophysics Department, Bulovka University Hospital, Prague, Czech Republic
| | - Zdena Pechacova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Lucie Vesela
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Antonin Vrana
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Jarmila Sukova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Petra Holeckova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Tereza Drbohlavova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Tomas Podlesak
- Department of Otorhinolaryngology, Bulovka University Hospital, Prague, Czech Republic
| | - Lubos Petruzelka
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
- Department of Oncology of the 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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4
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Ghatasheh H, Hui Huang S, Su J, Xu W, Bratman SV, Cho J, Giuliani M, Hahn E, Hope A, Kim J, O'Sullivan B, Ringash J, Waldron J, Chepeha DB, Irish JC, Goldstein DP, Spreafico A, Tong L, de Almeida JR, Hosni A. Evaluation of risk-tailored individualized selection of radiation therapy target volume for Head and Neck Carcinoma of Unknown Primary. Radiother Oncol 2022; 175:56-64. [PMID: 35905781 DOI: 10.1016/j.radonc.2022.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 07/12/2022] [Accepted: 07/18/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Intensity-modulated radiation therapy (IMRT) has enabled risk-tailored approach to elective mucosal and nodal clinical target volumes (CTVs) in treatment of head and neck carcinoma of unknown primary (HNCUP). This study report outcomes following such approach. METHODS HNCUP patients treated with definitive IMRT between 2005 and 2018 were reviewed. Local failure (LF), regional failure (RF), distant metastasis (DM), overall survival (OS) and grade ≥3 late toxicity (LT) were analyzed. Multivariable analysis (MVA) was used to identify OS predictors for entire cohort and cN2-3 subgroup. RESULTS A total of 203 patients were eligible: cN1 (7%), cN2a (14%), cN2b (46%), cN2c (14%) and cN3 (19%). Among 118 patients with known HPV status (by p16 staining), 81 (68%) were positive. IMRT target volume spared contralateral tonsil (55%), bilateral or contralateral sides of hypopharynx (72%), nasopharynx (72%), larynx (87%) and contralateral uninvolved neck (21%). Median follow-up was 5 years. Five-year LF, RF, DM, OS, and LT were 3%, 14%, 10%, 79%, and 7% respectively. Four patients developed mucosal recurrence: 3 within and 1 at the margin of the elective mucosal CTV. None of ipsilateral neck irradiation patients failed in the contralateral uninvolved neck. MVA identified cN2c-N3, HPV-negative status and older age as predictors for inferior OS. Within cN2-3 subgroup (n=189): cN2c-N3, HPV-negative status and older age predicted lower OS, while concurrent chemotherapy was associated with better OS. CONCLUSION Definitive IMRT with risk-adaptive radiation volume de-escalation for HNCUP resulted in high probability of tumor control with acceptable rate of late toxicity.
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Affiliation(s)
- Hamza Ghatasheh
- Department of Radiation Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada
| | - Shao Hui Huang
- Department of Radiation Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada; Department of Otolaryngology-Head & Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre / University of Toronto, Ontario, Canada
| | - Jie Su
- Biostatistics, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada
| | - Wei Xu
- Biostatistics, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada
| | - Scott V Bratman
- Department of Radiation Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada
| | - John Cho
- Department of Radiation Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada
| | - Meredith Giuliani
- Department of Radiation Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada
| | - Ezra Hahn
- Department of Radiation Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada
| | - Andrew Hope
- Department of Radiation Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada
| | - John Kim
- Department of Radiation Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada
| | - Brian O'Sullivan
- Department of Radiation Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada; Department of Otolaryngology-Head & Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre / University of Toronto, Ontario, Canada
| | - Jolie Ringash
- Department of Radiation Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada; Department of Otolaryngology-Head & Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre / University of Toronto, Ontario, Canada
| | - John Waldron
- Department of Radiation Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada; Department of Otolaryngology-Head & Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre / University of Toronto, Ontario, Canada
| | - Douglas B Chepeha
- Department of Otolaryngology-Head & Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre / University of Toronto, Ontario, Canada
| | - Jonathan C Irish
- Department of Otolaryngology-Head & Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre / University of Toronto, Ontario, Canada
| | - David P Goldstein
- Department of Otolaryngology-Head & Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre / University of Toronto, Ontario, Canada
| | - Anna Spreafico
- Department of Medical Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada
| | - Li Tong
- Department of Radiation Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada
| | - John R de Almeida
- Department of Otolaryngology-Head & Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre / University of Toronto, Ontario, Canada
| | - Ali Hosni
- Department of Radiation Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, Ontario, Canada.
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5
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Sherry AD, Pasalic D, Gunn GB, Fuller CD, Phan J, Rosenthal DI, Morrison WH, Sturgis EM, Gross ND, Gillison ML, Ferrarotto R, El-Naggar AK, Garden AS, Frank SJ. Proton Beam Therapy for Head and Neck Carcinoma of Unknown Primary: Toxicity and Quality of Life. Int J Part Ther 2021; 8:234-247. [PMID: 34285950 PMCID: PMC8270080 DOI: 10.14338/ijpt-20-00034.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/21/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose Proton radiation therapy (PRT) may offer dosimetric and clinical benefit in the treatment of head and neck carcinoma of unknown primary (HNCUP). We sought to describe toxicity and quality of life (QOL) in patients with HNCUP treated with PRT. Patients and Methods Toxicity and QOL were prospectively tracked in patients with HNCUP from 2011 to 2019 after institutional review board approval. Patients received PRT to the mucosa of the nasopharynx, oropharynx, and bilateral cervical lymph nodes with sparing of the larynx and hypopharynx. Patient-reported outcomes were tracked with the MD Anderson Symptom Inventory–Head and Neck Module, the Functional Assessment of Cancer Therapy–Head and Neck, the MD Anderson Dysphagia Inventory, and the Xerostomia-Related QOL Scale. Primary study endpoints were the incidence of grade ≥ 3 (G3) toxicity and QOL patterns. Results Fourteen patients (median follow-up, 2 years) were evaluated. Most patients presented with human papillomavirus–positive disease (n = 12, 86%). Rates of G3 oral mucositis, xerostomia, and dermatitis were 7% (n = 1), 21% (n = 3), and 36% (n = 5), respectively. None required a gastrostomy. During PRT, QOL was reduced relative to baseline and recovered shortly after PRT. At 2 years after PRT, the local regional control, disease-free survival, and overall survival were 100% (among 7 patients at risk), 79% (among 6 patients at risk), and 90% (among 7 patients at risk), respectively. Conclusion Therefore, PRT for HNCUP was associated with highly favorable dosimetric and clinical outcomes, including minimal oral mucositis, xerostomia, and dysphagia. Toxicity and QOL may be superior with PRT compared with conventional radiation therapy and PRT maintains equivalent oncologic control. Further prospective studies are needed to evaluate late effects and cost-effectiveness.
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Affiliation(s)
| | - Dario Pasalic
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neil D Gross
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maura L Gillison
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Renata Ferrarotto
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adel K El-Naggar
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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6
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De Leo AN, Mendenhall WM, Dagan R, Hitchcock KE, Dziegielewski PT, Morris CG, Amdur RJ. Sparing the Larynx and Hypopharynx With Radiation Therapy for Squamous Cell Carcinoma of Unknown Primary Site and Predominant Adenopathy in Level IIA. Pract Radiat Oncol 2021; 11:366-373. [PMID: 34175470 DOI: 10.1016/j.prro.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/04/2021] [Accepted: 06/16/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE There is controversy about the need to target the mucosa of the larynx and hypopharynx during radiation therapy (RT) for squamous cell carcinoma of an unknown primary site (SCCA-UP). By 1997, the policy in our department was to target only the oropharynx and nasopharynx in patients with SCCA-UP metastatic to the level II cervical nodes. The purpose of this study was to report the rate of cancer recurrence in the larynx or hypopharynx using an approach that excluded these areas from the RT target volumes. METHODS AND MATERIALS The inclusion criteria for this study were RT in our department for SCCA-UP between January 1, 1997, and December 31, 2019; no history of surgery that could disrupt the cervical lymphatics; predominant adenopathy in level IIA; and neck stage N1-2c. We excluded N3 because the incidental dose to the larynx and hypopharynx is usually high in patients with a >6-cm nodal conglomerate. RESULTS The study population was comprised of 50 patients with a median follow-up after RT of 7.1 years. No patient developed recurrent cancer in a mucosal site (0/50), 2% (1/50) developed a neck recurrence in a high-dose area with synchronous distant metastases, and 2% (1/50) developed distant metastases with no evidence of local or regional recurrence. CONCLUSIONS When delivering RT for SCCA-UP metastatic predominantly to level IIA, it is not necessary to target the mucosa of the larynx or hypopharynx. The extent to which the incidental RT dose to these areas contributes to cancer control is not evaluated in this study.
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7
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Axelsson L, Holmberg E, Nyman J, Högmo A, Sjödin H, Gebre-Medhin M, von Beckerath M, Ekberg T, Farnebo L, Talani C, Spak LN, Notstam I, Hammerlid E. Swedish National Multicenter Study on Head and Neck Cancer of Unknown Primary: Prognostic Factors and Impact of Treatment on Survival. Int Arch Otorhinolaryngol 2020; 25:e433-e442. [PMID: 34377181 PMCID: PMC8321641 DOI: 10.1055/s-0040-1712106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/25/2020] [Indexed: 12/05/2022] Open
Abstract
Introduction
Head and neck cancer of unknown primary (HNCUP) is a rare condition whose prognostic factors that are significant for survival vary between studies. No randomized treatment study has been performed thus far, and the optimal treatment is not established.
Objective
The present study aimed to explore various prognostic factors and compare the two main treatments for HNCUP: neck dissection and (chemo) radiation vs primary (chemo) radiation.
Methods
A national multicenter study was performed with data from the Swedish Head and Neck Cancer Register (SweHNCR) and from the patients' medical records from 2008 to 2012.
Results
Two-hundred and sixty HNCUP patients were included. The tumors were HPV-positive in 80%. The overall 5-year survival rate of patients treated with curative intent was 71%. Age (
p
< 0.001), performance status (
p
= 0.036), and N stage (
p
= 0.046) were significant factors for overall survival according to the multivariable analysis. Treatment with neck dissection and (chemo) radiation (122 patients) gave an overall 5-year survival of 73%, and treatment with primary (chemo) radiation (87 patients) gave an overall 5-year survival of 71%, with no significant difference in overall or disease-free survival between the 2 groups.
Conclusions
Age, performance status, and N stage were significant prognostic factors. Treatment with neck dissection and (chemo) radiation and primary (chemo) radiation gave similar survival outcomes. A randomized treatment study that includes quality of life is needed to establish the optimal treatment.
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Affiliation(s)
- Lars Axelsson
- Department of Otorhinolaryngology, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden.,Department of Otorhinolaryngology - Head and Neck Surgery, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Erik Holmberg
- Regional Cancer Center in Western Sweden, Gothenburg, Sweden.,Department of Oncology, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
| | - Jan Nyman
- Department of Oncology, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
| | - Anders Högmo
- Department of Otorhinolaryngology - Head and Neck Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Helena Sjödin
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Mathias von Beckerath
- Department of Otorhinolaryngology - Head and Neck Surgery, Örebro University Hospital, Örebro, Sweden
| | - Tomas Ekberg
- Department of Otorhinolaryngology - Head and Neck Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Lisa Farnebo
- Department of Otorhinolaryngology - Head and Neck Surgery, Linköping University Hospital, Linkoping, Sweden
| | - Charbel Talani
- Department of Oncology, Linköping University Hospital, Linkoping, Sweden
| | - Lena Norberg Spak
- Department of Otorhinolaryngology - Head and Neck Surgery, Norrlands University Hospital, Umea, Sweden
| | - Isak Notstam
- Department of Otorhinolaryngology, County Hospital Sundsvall-Harnosand, Sundsvall, Sweden
| | - Eva Hammerlid
- Department of Otorhinolaryngology, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden.,Department of Otorhinolaryngology - Head and Neck Surgery, Sahlgrenska University Hospital, Goteborg, Sweden
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8
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Abstract
Fluorine-18 (18F)-fluorodeoxyglucose (FDG) positron emission tomography fused with computed tomography (PET/CT) is a valuable tool in surgical planning for head and neck squamous cell carcinoma (HNSCC). If performed prior to biopsy or other surgical intervention, FDG-PET/CT has high sensitivity for the detection of the primary site in patients with cervical lymph node metastases from unknown primary origin and can be used to direct the surgical workup. FDG-PET/CT is superior to CT alone for detection of nodal metastases outside the expected pattern or distant metastases or second primary cancers and can greatly affect determination of appropriate management including surgical eligibility. Prior to the advent of PET/CT, many patients undergoing (chemo)radiation-based therapy had planned post-treatment neck dissection; FDG-PET/CT now has a proven role in the evaluation of recurrent or persistent disease amenable to salvage surgery and enables safe avoidance of planned postradiation neck dissection with a high negative predictive value. Specifically for this important application, two standardized reporting metrics may be used in the head and neck anatomic region: the "Hopkins criteria" and the "Neck Imaging Reporting and Data System"; both systems produce a formalized evaluation and recommendation based on PET/CT findings. The role of PET/CT as a replacement for elective neck dissection or examination under anesthesia remains controversial but deserves further study. FDG-PET/CT has a wide-ranging impact on the surgical management of patients with HNSCC and should be used routinely in patients with unknown primary nodal disease and those presenting with advanced-stage cancers at initial staging and to assess treatment response.
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Affiliation(s)
- Madeleine P Strohl
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA
| | - Patrick K Ha
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA
| | - Robert R Flavell
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA
| | - Sue S Yom
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA.
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9
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Finegersh A, Moss WJ, Saddawi-Konefka R, Faraji F, Coffey CS, Califano JA, Brumund KT, Orosco RK. Meta-analysis of risk of occult lymph node metastasis in the irradiated, clinically N0 neck. Head Neck 2020; 42:2355-2363. [PMID: 32432819 DOI: 10.1002/hed.26248] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 04/07/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Recurrent head and neck squamous cell carcinoma (HNSCC) after radiation is associated with poor survival, and management of the clinically negative (N0) neck during salvage surgery is controversial. METHODS Studies were selected according to preferred reporting items for systematic reviews and meta-analyses guidelines. Inclusion criteria were patients with HNSCC, prior radiation to the lateral neck nodal basin, undergoing salvage surgery for local recurrence, persistence or second primary, and N0 at time of salvage. Eleven studies with a total of 382 patients met inclusion criteria. RESULTS The rate of occult metastasis was 15.4%. The pooled rate of occult nodal metastasis was 16.2% for oral cavity, 12.9% for oropharynx, 23.7% for hypopharynx, and 27.3% for supraglottic or transglottic tumors. There was a significantly higher relative risk of occult metastasis for locally advanced tumors. CONCLUSION Elective neck dissection at time of salvage surgery should be considered based on subsite, T classification, and prior history of nodal metastasis.
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Affiliation(s)
- Andrey Finegersh
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California, San Diego, San Diego, California, USA
| | - William J Moss
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Commonwealth Health Center, Saipan, Northern Mariana Islands
| | - Robert Saddawi-Konefka
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California, San Diego, San Diego, California, USA
| | - Farhoud Faraji
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California, San Diego, San Diego, California, USA
| | - Charles S Coffey
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California, San Diego, San Diego, California, USA.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, VA San Diego Healthcare System, La Jolla, California, USA
| | - Joseph A Califano
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California, San Diego, San Diego, California, USA
| | - Kevin T Brumund
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California, San Diego, San Diego, California, USA.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, VA San Diego Healthcare System, La Jolla, California, USA
| | - Ryan K Orosco
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California, San Diego, San Diego, California, USA
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10
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Kamal M, Mohamed ASR, Fuller CD, Sturgis EM, Johnson FM, Morrison WH, Gunn GB, Hutcheson KA, Phan J, Volpe S, Ng SP, Phan J, Cardenas C, Ferrarotto R, Frank SJ, Rosenthal DI, Garden AS. Patterns of Failure After Intensity Modulated Radiation Therapy in Head and Neck Squamous Cell Carcinoma of Unknown Primary: Implication of Elective Nodal and Mucosal Dose Coverage. Adv Radiat Oncol 2020; 5:929-935. [PMID: 33083655 PMCID: PMC7557124 DOI: 10.1016/j.adro.2020.04.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 03/30/2020] [Accepted: 04/15/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose We evaluated the geometric and dosimetric-based distribution of mucosal and nodal recurrences in patients with metastatic head and neck squamous cell carcinoma to cervical lymph nodes of unknown primary after intensity modulated radiation therapy using validated typology-indicative taxonomy. Methods and Materials We reviewed the data of 260 patients who were irradiated between 2000 and 2015 and had a median follow-up time for surviving patients of 61 months. The mucosal and nodal recurrences were manually delineated on computed tomography images demonstrating the recurrences. The images were overlaid on the treatment plan using deformable image registration. The locations of the recurrences were determined relative to the original planning target volumes and doses using centroid-based approaches. Subsequently, the pattern of failures were classified into 5 types based on combined spatial and dosimetric criteria: A (central high dose), B (peripheral high dose), C (central elective dose), D (peripheral elective dose), and E (extraneous dose). For patients with type A failure with simultaneous nontype A lesions, the overall pattern of failures was defined as type A. Results Thirty-two patients had mucosal or nodal recurrences. The most common clinical nodal stage was N2b (66%). Preradiation therapy neck dissections were performed in 6 patients. The median dose delivered to clinical tumor volume 1 was 66 Gy. The majority (84%) had total/partial pharyngeal mucosa elective irradiation. Twenty-three patients had nodal recurrences, 8 had mucosal recurrences, and 1 had both nodal and mucosal recurrences. Twenty-one patients (91%) had type A nodal failure, and 7 of the mucosal failures (89%) were type C. Conclusions The majority of nodal recurrences occurred within the high-dose area, demanding the need for identification of radioresistant areas within malignant nodes. Future studies should focus on either dose escalation of high-risk volumes or novel radiosensitizers.
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Affiliation(s)
- Mona Kamal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Abdallah S R Mohamed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, University of Alexandria, Alexandria, Egypt.,MD Anderson Cancer Center/UTHealth Graduate School of Biomedical Sciences, Houston, Texas
| | - Clifton David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,MD Anderson Cancer Center/UTHealth Graduate School of Biomedical Sciences, Houston, Texas
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Faye M Johnson
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,The University of Texas Graduate School of Biomedical Sciences, Houston, Texas
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Katherine A Hutcheson
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stefania Volpe
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,European Institute of Oncology IRCCS, Division of Radiation Oncology, Milano, Italy
| | - Sweet Ping Ng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jae Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Rice University, Houston, Texas
| | - Carlos Cardenas
- Department of Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Renata Ferrarotto
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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11
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Maghami E, Ismaila N, Alvarez A, Chernock R, Duvvuri U, Geiger J, Gross N, Haughey B, Paul D, Rodriguez C, Sher D, Stambuk HE, Waldron J, Witek M, Caudell J. Diagnosis and Management of Squamous Cell Carcinoma of Unknown Primary in the Head and Neck: ASCO Guideline. J Clin Oncol 2020; 38:2570-2596. [PMID: 32324430 DOI: 10.1200/jco.20.00275] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To provide evidence-based recommendations to practicing physicians and other health care providers on the diagnosis and management of squamous cell carcinoma of unknown primary in the head and neck (SCCUP). METHODS The American Society of Clinical Oncology convened an Expert Panel of medical oncology, surgery, radiation oncology, radiology, pathology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 2008 through 2019. Outcomes of interest included survival, local and regional disease control, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS The literature search identified 100 relevant studies to inform the evidence base for this guideline. Four main clinical questions were addressed, which included subquestions on preoperative evaluations, surgical diagnostic and therapeutic procedures, appropriate pathology techniques, and adjuvant therapy. RECOMMENDATIONS Evidence-based recommendations were developed to address preoperative evaluation for patients with a neck mass, surgical diagnostic and therapeutic procedures, appropriate treatment options in unilateral versus bilateral SCCUP.Additional information is available at www.asco.org/head-neck-cancer-guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce Haughey
- Advent Health Medical Group, Otolaryngology, Head and Neck Surgery, Celebration, FL, and University of South Florida, Tampa, FL
| | - Doru Paul
- Weill Cornell Medical College, New York, NY
| | | | - David Sher
- University of Texas Southwestern, Dallas, TX
| | | | - John Waldron
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Matt Witek
- University of Wisconsin School of Medicine and Public Health, Madison, WI
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12
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Dou S, Li R, Zhang L, Wang Z, Xie L, Zhang C, Zhu G. Long-term results of elective mucosal irradiation for head and neck cancer of unknown primary in Chinese population: The EMICUP study. Cancer Med 2020; 9:1712-1720. [PMID: 31953927 PMCID: PMC7050068 DOI: 10.1002/cam4.2856] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 12/14/2019] [Accepted: 01/05/2020] [Indexed: 12/24/2022] Open
Abstract
Objective Controversy still exists regarding the volume of radiation for head and neck cancer of unknown primary (HNCUP). Theoretically, elective mucosal irradiation (EMI) should achieve a balance between survival and toxicity. This prospective study was conducted to evaluate the long‐term benefit of EMI in Chinese HNCUP patients. Methods A phase II, single‐arm trial was performed at two centers in China. HNCUP patients with pathologically confirmed metastatic squamous cell carcinoma or poorly differentiated carcinoma were enrolled. Patients with metastatic lymph nodes limited to level IV and/or the supraclavicular fossa were excluded. The EMI approach was specifically customized to Chinese patients by differentiating HNCUP as putative nasopharyngeal carcinoma (NPC) or non‐putative NPC. The primary endpoint was 3‐year mucosal recurrence‐free survival (MRFS). Results A total of 48 patients were enrolled between 02/02/2010 and 08/01/2018; 46 patients were analyzed, including 24 putative NPC and 22 non‐putative NPC patients. No primary recurrence was observed during a median follow‐up period of 70 months, and only 1 patient experienced out of field recurrence in the contralateral neck. The 3‐year MRFS was 90.6% (95%CI: 76.4%‐96.4%). The 5‐year MRFS, regional‐recurrence free survival (RRFS) and overall survival (OS) were 90.6% (95%CI: 76.4%‐96.4%), 86.0% (95%CI: 71.1%‐93.7%), and 90.6% (95%CI: 76.4%‐96.4%), respectively. No grade 4 acute or late toxicities occurred, and the most frequent grade 3 acute toxicity was oral mucositis (45.7%). Conclusion To the best of our knowledge, this is the first prospective study to evaluate the long‐term outcomes of EMI in Chinese HNCUP patients. Excellent MRFS and OS rates were observed. Further randomized studies are warranted.
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Affiliation(s)
- Shengjin Dou
- Radiotherapy Division, Department of Oral and Maxillofacial-Head Neck Oncology, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,National Clinical Research Center for Oral Diseases, Shanghai, China.,Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai, China
| | - Rongrong Li
- Radiotherapy Division, Department of Oral and Maxillofacial-Head Neck Oncology, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,National Clinical Research Center for Oral Diseases, Shanghai, China.,Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai, China
| | - Lin Zhang
- Radiotherapy Division, Department of Oral and Maxillofacial-Head Neck Oncology, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,National Clinical Research Center for Oral Diseases, Shanghai, China.,Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai, China
| | - Zhuoying Wang
- Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Li Xie
- Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chenping Zhang
- National Clinical Research Center for Oral Diseases, Shanghai, China.,Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai, China.,Department of Oral and Maxillofacial-Head Neck Oncology, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guopei Zhu
- Radiotherapy Division, Department of Oral and Maxillofacial-Head Neck Oncology, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,National Clinical Research Center for Oral Diseases, Shanghai, China.,Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai, China
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13
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Li H, Torabi SJ, Yarbrough WG, Mehra S, Osborn HA, Judson B. Association of Human Papillomavirus Status at Head and Neck Carcinoma Subsites With Overall Survival. JAMA Otolaryngol Head Neck Surg 2019; 144:519-525. [PMID: 29801040 DOI: 10.1001/jamaoto.2018.0395] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance Data are limited on the prognostic value of human papillomavirus (HPV) status for head and neck carcinoma subsites. Objective To determine whether HPV positivity at each head and neck subsite is associated with improved overall survival. Design, Setting, and Participants This retrospective population-based cohort study used the National Cancer Database to identify patients diagnosed with head and neck squamous cell carcinomas from January 1, 2010, to December 31, 2014. Patients were classified according to the location of their primary malignancy into 1 of the 6 main subsites of the upper aerodigestive tract: oral cavity, oropharynx, nasopharynx, hypopharynx, larynx, and sinonasal tract. Patients were also classified by their HPV status. Data collection for this study took place from January 1, 2010, to December 31, 2014. Data analysis was conducted from August 1, 2017, to September 30, 2017. Main Outcomes and Measures The difference in 5-year overall survival between patients with HPV-positive status and those with HPV-negative status in various head and neck carcinoma subsites; the role of HPV status in an unadjusted Cox multivariate regression model. Results Of the 175 223 total number of patients identified (129 634 [74.0%] male; 45 589 [26.0%] female; mean [SD] age, 63.1 [11.9] years), 133 273 (76.1%) were ineligible and 41 950 (23.9%) were included in the sample. This sample included 16 644 patients (39.7%) with HPV-positive tumors and 25 306 (60.3%) with HPV-negative tumors. Patients with an HPV-positive status were more likely to be younger, be white, be male, present with local T category tumors, and have poor differentiation on histologic examination. HPV-positive status was associated with survival at 4 tumor subsites: oral cavity (hazard ratio [HR], 0.76; 95% CI, 0.66-0.87), oropharynx (HR, 0.44; 95% CI, 0.41-0.47), hypopharynx (HR, 0.59; 95% CI, 0.45-0.77), and larynx (HR, 0.71; 95% CI, 0.59-0.85). The HPV status was the greatest factor in survival outcome between the HPV-positive and -negative cohorts at the oropharynx subsite (77.6% vs 50.7%; survival difference, 26.9%; 95% CI, 25.6%-28.2%) and hypopharynx subsites (52.2% vs 28.8%; survival difference, 23.4%; 95% CI, 17.5%-29.3%). For the nasopharynx (HR, 1.03; 95% CI, 0.75-1.42) and sinonasal tract (HR, 0.63; 95% CI, 0.39-1.01) subsites, HPV-positive status was not an independent prognostic factor. Conclusions and Relevance Human papillomavirus positivity was associated with improved survival in 4 subsites (oropharynx, hypopharynx, oral cavity, and larynx), and the largest survival difference was noted in the oropharynx and hypopharynx subsites. In the nasopharynx and sinonasal tract subsites, HPV positivity had no association with overall survival. Given these results, routine testing for HPV at the oropharynx, hypopharynx, oral cavity, and larynx subsites may be warranted.
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Affiliation(s)
- Hong Li
- Yale University School of Medicine, New Haven, Connecticut.,Section of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Sina J Torabi
- Yale University School of Medicine, New Haven, Connecticut.,Section of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Wendell G Yarbrough
- Yale University School of Medicine, New Haven, Connecticut.,Section of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.,Yale Cancer Center, New Haven, Connecticut.,Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Saral Mehra
- Yale University School of Medicine, New Haven, Connecticut.,Section of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.,Yale Cancer Center, New Haven, Connecticut
| | - Heather A Osborn
- Yale University School of Medicine, New Haven, Connecticut.,Section of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.,Yale Cancer Center, New Haven, Connecticut
| | - Benjamin Judson
- Yale University School of Medicine, New Haven, Connecticut.,Section of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.,Yale Cancer Center, New Haven, Connecticut
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14
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Wang M, Wu N, Han D, Zhao H, Cheng G. Image-guided high-dose-rate interstitial brachytherapy boost in the radical radiotherapy for a huge metastatic carcinoma of cervical lymph nodes from an unknown primary site. Cancer Radiother 2019; 23:426-431. [PMID: 31255579 DOI: 10.1016/j.canrad.2019.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 01/16/2019] [Accepted: 01/29/2019] [Indexed: 11/15/2022]
Abstract
The purpose of this article was to report the treatment effect of image-guided high-dose-rate interstitial brachytherapy boost in the radical radiotherapy for a huge metastatic carcinoma of cervical lymph nodes from an unknown primary site. The patient was a 75-year-old male. A diagnostic biopsy showed metastatic squamous cell carcinoma and the tumour size was 7.5×6.5×11.5cm3 before treatment (N3; AJCC 7th). After external beam radiotherapy with a dose of 60Gy in 30 fractions, the residual tumour (6.2×4.7×6.0cm3) was treated with image-guided high-dose-rate interstitial brachytherapy boost under ultrasound guidance. The brachytherapy dose was 16Gy in four fractions of 4Gy each. Removal of the huge metastatic tumour was securely achieved by high dose rate interstitial brachytherapy guided with ultrasound scanning. The refractory tumour in the patients healed uneventfully after image-guided high-dose-rate interstitial brachytherapy without recurrence during the 24 months of follow-up. The image-guided high-dose-rate interstitial brachytherapy boost may be a proposed treatment strategy for metastatic carcinoma of cervical lymph nodes from an unknown primary site with radical radiotherapy, especially for huge residual tumour.
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Affiliation(s)
- Minjie Wang
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Ning Wu
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Dongmei Han
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Hongfu Zhao
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Guanghui Cheng
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, China.
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15
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Abstract
In adult cervicofacial pathology, carcinoma of unknown primary is defined as lymph-node metastasis the anatomic origin of which is not known at the time of initial management. It constitutes up to 5% of head and neck cancers. Presentation may suggest benign pathology, delaying and confusing oncologic treatment. Diagnostic strategy in cervical lymph node with suspicion of neoplasia requires exhaustive work-up to diagnose malignancy and, in 45% to 80% of cases, depending on the series, to identify the primary site. Histologic types comprise squamous cell carcinoma, thyroid carcinoma, adenocarcinoma, neuroendocrine carcinoma and undifferentiated carcinoma. Association is sometimes found with human papilloma virus or Epstein Barr virus, guiding treatment. The objective of the present study was to provide clinicians with the necessary diagnostic tools, based on the current state of clinical, imaging and pathologic knowledge, and to detail treatment options.
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16
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Inter-observer variability of clinical target volume delineation in definitive radiotherapy of neck lymph node metastases from unknown primary. A cooperative study of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) Head and Neck Group. Radiol Med 2019; 124:682-692. [PMID: 30852793 DOI: 10.1007/s11547-019-01006-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 02/11/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND This study, promoted by Italian Association of Radiotherapy and Clinical Oncology (AIRO) Head and Neck Group, aimed to assess the current national practice of target volume delineation on a case of neck lymph node metastases from unknown primary evaluating inter-observer variability, in a setting of primary radiotherapy. MATERIALS AND METHODS A case of metastatic neck lymph node from occult primary was proposed to 17 radiation oncologists. A national reference RT center was identified and considered as benchmark. Participants were requested to delineate target volumes. A structured questionnaire was administered. A comparison between following parameters of the CTVs was performed: centroids distances, Dice similarity index (DSI), Jaccard index and mean distance to agreement (MDA). Volume expressed in cubic centimeters and CTVs cranio-caudal extension were evaluated. RESULTS Sixteen of 17 radiation oncologists recommended three CTVs dose levels. (CTV HD, CTV ID and CTV LD); CTV ID was not delineated by one of the participants and by the reference center. The distance between the reference centroid and the mean centroid of CTVs HD was 1.09 cm (0.36-3.99 cm); for CTV LD, a mean centroids distance of 2.45 (0.27-4.83 cm) was found, and for CTV HD, mean DSI is 0.48 and mean Jaccard index is 0.32 and MDA was 8.89 mm. CTV LD showed a mean DSI of 0.46, mean Jaccard index of 0.31 and MDA of 14.87 when compared to the reference. CONCLUSION Many aspects concerning treatment optimization of cervical nodes metastases from occult primary remain unclear, and we found a notable heterogeneity of global radiotherapy management reporting discordances both in target volume delineation and volume prescription.
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17
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LaVigne AW, Margalit DN, Rawal B, Puzanov M, Annino DJ, Goguen LA, Sher DJ, Schoenfeld JD, Chau NG, Lorch JH, Rabinowits G, Haddad RI, Tishler RB. IMRT‐based treatment of unknown primary malignancy of the head and neck: Outcomes and improved toxicity with decreased mucosal dose and larynx sparing. Head Neck 2019; 41:959-966. [DOI: 10.1002/hed.25531] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 07/26/2018] [Accepted: 09/28/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Anna W. LaVigne
- Johns Hopkins University School of Medicine Baltimore Maryland
| | - Danielle N. Margalit
- Department of Radiation OncologyDana‐Farber Cancer Institute/Brigham and Women's Hospital Boston Massachusetts
| | - Bhupendra Rawal
- Department of Biostatistics and Computational BiologyDana‐Farber Cancer Institute Boston Massachusetts
| | | | - Donald J. Annino
- Division of Otolaryngology, Department of SurgeryDana‐Farber Cancer Institute/Brigham and Women's Hospital Boston Massachusetts
| | - Laura A. Goguen
- Division of Otolaryngology, Department of SurgeryDana‐Farber Cancer Institute/Brigham and Women's Hospital Boston Massachusetts
| | - David J. Sher
- Department of Radiation OncologyUT Southwestern Medical Center Dallas Texas
| | - Jonathan D. Schoenfeld
- Department of Radiation OncologyDana‐Farber Cancer Institute/Brigham and Women's Hospital Boston Massachusetts
| | - Nicole G. Chau
- Department of Medical OncologyDana‐Farber Cancer Institute Boston Massachusetts
| | - Jochen H. Lorch
- Department of Medical OncologyDana‐Farber Cancer Institute Boston Massachusetts
| | | | - Robert I. Haddad
- Department of Medical OncologyDana‐Farber Cancer Institute Boston Massachusetts
| | - Roy B. Tishler
- Department of Radiation OncologyDana‐Farber Cancer Institute/Brigham and Women's Hospital Boston Massachusetts
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18
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Cheraghlou S, Torabi SJ, Husain ZA, Otremba MD, Osborn HA, Mehra S, Yarbrough WG, Burtness BA, Judson BL. HPV status in unknown primary head and neck cancer: Prognosis and treatment outcomes. Laryngoscope 2018; 129:684-691. [DOI: 10.1002/lary.27475] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Shayan Cheraghlou
- Division of Otolaryngology, Department of Surgery; New Haven Connecticut U.S.A
| | - Sina J. Torabi
- Division of Otolaryngology, Department of Surgery; New Haven Connecticut U.S.A
| | - Zain A. Husain
- Department of Therapeutic Radiology; New Haven Connecticut U.S.A
- Yale Cancer Center; New Haven Connecticut U.S.A
| | - Michael D. Otremba
- Division of Otolaryngology, Department of Surgery; New Haven Connecticut U.S.A
| | - Heather A. Osborn
- Division of Otolaryngology, Department of Surgery; New Haven Connecticut U.S.A
- Department of Medicine; Yale School of Medicine; New Haven Connecticut U.S.A
| | - Saral Mehra
- Division of Otolaryngology, Department of Surgery; New Haven Connecticut U.S.A
- Yale Cancer Center; New Haven Connecticut U.S.A
| | - Wendell G. Yarbrough
- Division of Otolaryngology, Department of Surgery; New Haven Connecticut U.S.A
- Department of Pathology; New Haven Connecticut U.S.A
- Yale Cancer Center; New Haven Connecticut U.S.A
| | - Barbara A. Burtness
- Department of Medicine; Yale School of Medicine; New Haven Connecticut U.S.A
- Yale Cancer Center; New Haven Connecticut U.S.A
| | - Benjamin L. Judson
- Division of Otolaryngology, Department of Surgery; New Haven Connecticut U.S.A
- Yale Cancer Center; New Haven Connecticut U.S.A
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19
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Cabrera Rodríguez J, Cacicedo J, Giralt J, García Miragall E, Lloret M, Arias F, González Ruiz MA, Contreras J. GEORCC recommendations on target volumes in radiotherapy for Head Neck Cancer of Unkown Primary. Crit Rev Oncol Hematol 2018; 130:51-59. [PMID: 30196912 DOI: 10.1016/j.critrevonc.2018.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/16/2018] [Accepted: 07/17/2018] [Indexed: 12/22/2022] Open
Abstract
Head Neck Cancer of Unknown Primary (HNCUP) is a rare condition, representing approximately 5-10% of all head neck cancers. Radiotherapy, adjuvant or radical, is usually employed in the treatment of those patients. To date, no specific guidelines for the optimal definition of the target volume to be irradiated have been published. In recent years, there have been advances in the knowledge of the molecular biology of HNCUP, its diagnostic imaging and the implementation of sophisticated radiotherapy techniques with enhanced precision in target localization and treatment delivery. These progresses have provided valuable information about the natural history of HNCUP that will allow for establishment of the best treatment for each patient, including standardized, consistent and reproducible target volumes definitions. Several recommendations regarding how to choose volumes when contouring HNCUP in clinical practice are reported, in order to achieve a high rate of loco-regional control while avoiding unnecessary toxicity.
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Affiliation(s)
- Joaquín Cabrera Rodríguez
- Radiation Oncology Department, Hospital Universitario Infanta Cristina, Avenida de Elvas, s/n, 06080 Badajoz, Spain.
| | - Jon Cacicedo
- Radiation Oncology Department, Hospital Universitario de Cruces, Plaza de Cruces, s/n, 48903 Baracaldo, Spain
| | - Jordi Giralt
- Radiation Oncololgy Deparment, Hospital General Vall D'Hebron, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - Enrique García Miragall
- Radiation Oncology Department, Hospital General Universitario Valencia- ERESA, Avenida Blasco Ibáñez, 17, 46010 Valencia, Spain
| | - Marta Lloret
- Radiation Oncology Department, Hospital Universitario Doctor Negrín, c/ Barranco de la ballena, s/n, 35010, Las Palmas de Gran Ganaria, Spain
| | - Fernando Arias
- Radiation Oncology Department, Complejo Hospitalario de Navarra, C/ Irunlarrea, 4, 31008 Pamplona, Spain
| | - María Angeles González Ruiz
- Radiation Oncology Department, Hospital Universitario Infanta Cristina, Avenida de Elvas, s/n, 06080 Badajoz, Spain
| | - Jorge Contreras
- Radiation Oncology Department, Complejo Hospitalario Carlos Haya, Avenida de Carlos Haya, s/n, 29010 Málaga, Spain
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20
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Müller von der Grün J, Bon D, Rödel C, Balermpas P. Patterns of care analysis for head & neck cancer of unknown primary site: a survey inside the German society of radiation oncology (DEGRO). Strahlenther Onkol 2018; 194:750-758. [DOI: 10.1007/s00066-018-1308-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 04/23/2018] [Indexed: 11/30/2022]
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21
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Troussier I, Klausner G, Blais E, Giraud P, Lahmi L, Pflumio C, Faivre JC, Geoffrois L, Babin E, Morinière S, Maingon P, Thariat J. [Advances in the management of cervical lymphadenopathies of unknown primary with intensity modulated radiotherapy: Doses and target volumes]. Cancer Radiother 2018; 22:438-446. [PMID: 29731331 DOI: 10.1016/j.canrad.2017.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 10/24/2017] [Indexed: 11/16/2022]
Abstract
The definition of nodal and/or mucosal target volumes for radiation therapy for lymphadenopathies of unknown primary is controversial. Target volumes may include all nodal areas bilaterraly and be pan-mucosal or unilateral, selective, including the sole oropharyngeal mucosa. This review presents current recommendations in light of changes in the TNM classification, Human papillomavirus status and therapeutic advances. We conducted a systematic review of the literature with the following keywords: lymphadenopathy; head and neck; unknown primary and radiation therapy. There are no direct comparative studies between unilateral or bilateral nodal irradiation or pan-mucosal and selective mucosal irradiation. Contralateral lymph node failure rates range from 0 to 6% after unilateral nodal irradiation and 0 and 31% after bilateral irradiation. Occurrence of a mucosal primary varies between 0 and 19.2%. Initial clinical presentation and Human papillomavirus status are critical to define mucosal target volumes. Intensity-modulated radiotherapy is recommended (rather than three-dimensional irradiation) to avoid toxicities. Systemic treatments have similar indications as for identified primary head and neck cancers. Failures do not appear superior in case of unilateral nodal irradiation but comparative studies are warranted due to major biases hampering direct comparisons. Human papillomavirus status should be incorporated into the therapeutic strategy and practice-changing TNM staging changes will need to be evaluated.
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Affiliation(s)
- I Troussier
- Radio-oncologie, hôpitaux universitaires de Genève, Avenue de la Roseraie 53 CH-1205 Genève
| | - G Klausner
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - E Blais
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - P Giraud
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - L Lahmi
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - C Pflumio
- Oncologie médicale, centre Alexis-Vautrin, 6, avenue de Bourgogne, 54511 Vandoeuvre-lès-Nancy cedex, France
| | - J-C Faivre
- Radiothérapie, centre Alexis-Vautrin, 6, avenue de Bourgogne, 54511 Vandoeuvre-lès-Nancy cedex, France
| | - L Geoffrois
- Oncologie médicale, centre Alexis-Vautrin, 6, avenue de Bourgogne, 54511 Vandoeuvre-lès-Nancy cedex, France
| | - E Babin
- Carcinologie cervicofaciale, CHRU de Caen, avenue de la Côte-de-Nacre, 14033 Caen, France
| | - S Morinière
- Carcinologie cervicofaciale, CHRU de Tours, 2, boulevard Tonnellé, 37000 Tours, France
| | - P Maingon
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - J Thariat
- Département de radiothérapie/Archade, centre François-Baclesse, 3, avenue General-Harris, 14000 Caen, France; Université Unicaen, 14000 Caen, France.
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22
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Wallis S, O'Toole L, Karsai L, Jose J. Transoral endoscopic base of tongue mucosectomy for investigation of unknown primary cancers of head and neck. Clin Otolaryngol 2018. [PMID: 29543400 DOI: 10.1111/coa.13096] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S Wallis
- Department of Ear, Nose & Throat, Castle Hill Hospital, Cottingham, UK
| | - L O'Toole
- Department of Oncology, Castle Hill Hospital, Cottingham, UK
| | - L Karsai
- Department of Cellular Pathology, Hull Royal Infirmary, Hull, UK
| | - J Jose
- Department of Ear, Nose & Throat, Castle Hill Hospital, Cottingham, UK
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Treatment for retropharyngeal metastatic undifferentiated squamous cell carcinoma from an unknown primary site: results of a prospective study with irradiation to nasopharyngeal mucosa plus bilateral neck. Oncotarget 2018; 8:42372-42381. [PMID: 28418897 PMCID: PMC5522073 DOI: 10.18632/oncotarget.16344] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 02/21/2017] [Indexed: 12/26/2022] Open
Abstract
Background and Objective To evaluate treatment outcomes for patients with retropharyngeal metastatic undifferentiated squamous cell carcinoma (SCC) from an unknown primary site. Methods From January 2005 to January 2015, patients who presented with enlarged retropharyngeal nodes underwent transoral sonography-guided fine-needle aspiration to confirm histology. Those with metastatic undifferentiated SCC with unknown primary tumors were treated with radical radiotherapy to nasopharyngeal mucosa plus bilateral neck. Chemotherapy was administered for patients staged N2-3. Endpoints included metastatic nodes control, the appearance of primary tumor, overall survival and treatment-related toxicities. Results A total of 49 patients were recruited into this study. Retropharyngeal and cervical nodal disease was controlled in 96% of all patients. The incidence of occult primary cancer appearance was 8%. No primary cancer other than of the nasopharynx was detected during the course of follow-up. Ten patients developed distant metastases. The 5-year overall survival, progression-free survival, regional relapse free survival, distant metastasis free survival were 79.6%, 61.1%, 83.4%, 73.8%, respectively. Common late adverse effects included xerostomia (57%) and hearing impairment (35%). Conclusion Radical radiotherapy to both the nasopharynx and bilateral neck can achieve excellent outcome with mild toxicities for patients with retropharyngeal metastatic undifferentiated squamous cell carcinoma from an unknown primary site.
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24
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Kamal M, Mohamed ASR, Fuller CD, Sturgis EM, Johnson FM, Morrison WH, Gunn GB, Hutcheson KA, Phan J, Volpe S, Ng SP, Ferrarotto R, Frank SJ, Skinner HD, Rosenthal DI, Garden AS. Outcomes of patients diagnosed with carcinoma metastatic to the neck from an unknown primary source and treated with intensity-modulated radiation therapy. Cancer 2018; 124:1415-1427. [PMID: 29338089 PMCID: PMC11362832 DOI: 10.1002/cncr.31235] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 12/01/2017] [Accepted: 12/06/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND There are few published studies to guide the treatment of carcinoma metastatic to the neck from an unknown primary (CUP). In this regard, the objective of the current study was to share the authors' current experience treating patients with CUP using intensity-modulated radiation therapy (IMRT), which principally targeted both sides of the neck, the nasopharynx, and the oropharynx. METHODS This was a retrospective study in which an institutional database search was conducted to identify patients with CUP who received IMRT. Data analysis included frequency tabulation, survival analysis, and multivariable analysis. RESULTS Two-hundred sixty patients met inclusion criteria. The most common lymph node category was N2b (54%). IMRT volumes included the entire pharyngolaryngeal mucosa in 78 patients, the nasopharynx and oropharynx in 167 patients, and treatment limited to the involved neck in 11 patients. Eighty-four patients underwent neck dissections. The 5-year overall survival, regional control, and distant metastases-free survival rates were 84%, 91%, and 94%, respectively. Over 40% of patients had gastrostomy tubes during therapy, and 7% patients were diagnosed with chronic radiation-associated dysphagia. Higher lymph node burden was associated with worse disease-related outcomes, and in subgroup analysis, patients with human papillomavirus-associated disease had better outcomes. No therapeutic modality was statistically associated with either disease-related outcomes or toxicity. CONCLUSIONS Comprehensive IMRT with treatment to both sides of the neck and to the oropharyngeal and nasopharyngeal mucosa results in high rates of disease control and survival. The investigators were unable to demonstrate that treatment intensification with chemotherapy or surgery added benefit or excessive toxicity. Cancer 2018;124:1415-27. © 2018 American Cancer Society.
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Affiliation(s)
- Mona Kamal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Abdallah S R Mohamed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Clifton David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Faye M Johnson
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- The University of Texas Graduate School of Biomedical Sciences, Houston, Texas
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Katherine A Hutcheson
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stefania Volpe
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- University of Milan, Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy
| | - Sweet Ping Ng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Renata Ferrarotto
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Heath D Skinner
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Tiong A, Rischin D, Young RJ, Herschtal A, Solomon B, D'Costa I, Fua T, Liu C, Coleman A, Kleid S, Dixon BJ, Corry J. Unilateral radiotherapy treatment for p16/human papillomavirus-positive squamous cell carcinoma of unknown primary in the head and neck. Laryngoscope 2018; 128:2076-2083. [PMID: 29481710 DOI: 10.1002/lary.27131] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 12/01/2017] [Accepted: 01/04/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS The outcomes of unilateral radiotherapy treatment for patients with p16/HPV-positive squamous cell carcinomas of unknown primary (SCCUP) affecting cervical lymph nodes are under-reported. Compared to radiating large volumes of the pharyngeal axis (the more common approach), this is potentially a much less toxic treatment for a good prognosis group. STUDY DESIGN Retrospective cohort study. METHODS We identified patients with SCCUP who were treated radically at our center and did not have parotid or isolated level IV or V nodal involvement. Failure-free and overall survivals were calculated using Kaplan-Meier methods. RESULTS From 2004 to 2012, there were 49 radically treated patients with SCCUP. Fourteen patients had bilateral neck treatment (they had bilateral nodal disease or suspected lesions in the base of tongue, though not proven with biopsy), two had surgery alone, whereas 33 had unilateral radiotherapy (after neck dissection, excisional biopsy, or definitively with concurrent chemotherapy). Of the 33 patients, 21 tested positive to p16/HPV and had median follow-up of 57 months. In this group, no isolated contralateral neck failures or putative primaries emerged. There was 1/21 (4.3%) ipsilateral neck failure, 1/21 (4.3%) concurrent contralateral neck and distant failure, and 1/21 (4.3%) patient with distant failure. The 5-year freedom from failure was 78% (95% confidence interval [CI]: 56%-100%) and overall survival was 90% (95% CI: 79%-100%). CONCLUSIONS With no emergence of putative primaries and no isolated contralateral neck failures, this single-institution experience in p16/HPV-positive SCCUP patients suggests that unilateral radiotherapy may be an underutilized management strategy. LEVELS OF EVIDENCE 4 Laryngoscope, 128:2076-2083, 2018.
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Affiliation(s)
- Albert Tiong
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Danny Rischin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Parkville, Victoria, Australia
| | - Richard J Young
- Molecular Therapeutics and Biomarkers Laboratory, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alan Herschtal
- Department of Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Ben Solomon
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Parkville, Victoria, Australia
| | - Ieta D'Costa
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Tsien Fua
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Chen Liu
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Andrew Coleman
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Stephen Kleid
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Benjamin J Dixon
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, St. Vincent's Hospital, Fitzroy, Victoria, Australia
| | - June Corry
- University of Melbourne, Parkville, Victoria, Australia.,GenesisCare Radiation Oncology Centre, St Vincent's Hospital, Fitzroy, Victoria, Australia
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Chen AM, Meshman J, Hsu S, Yoshizaki T, Abemayor E, John MS. Oropharynx-directed ipsilateral irradiation for p16-positive squamous cell carcinoma involving the cervical lymph nodes of unknown primary origin. Head Neck 2017; 40:227-232. [PMID: 29247568 DOI: 10.1002/hed.24906] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 05/13/2017] [Accepted: 06/28/2017] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The purpose of this study was to present our findings on the use of limited-field, oropharynx-directed ipsilateral irradiation for p16-positive squamous cell carcinoma of unknown primary origin. METHODS Between April 2011 and January 2016, 25 patients with a histological diagnosis of p16-positive squamous cell carcinoma were selectively irradiated to the ipsilateral oropharynx and cervical neck for tumors of unknown primary origin. The dose to the oropharynx ranged from 54-60 Gy (median 60 Gy) in 30-33 fractions. Concurrent cisplatin-based chemotherapy was administered to 8 patients (32%). RESULTS The actuarial 2-year estimates of locoregional control, progression-free survival, and overall survival were 91%, 87%, and 92%, respectively. One patient failed in the contralateral neck. There was no grade 3 + toxicity in either the acute or late setting. CONCLUSION Oropharynx-directed, ipsilateral radiation results in disease control that compares favorably with historical controls treated by comprehensive mucosal and bilateral neck radiation.
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Affiliation(s)
- Allen M Chen
- Department of Radiation Oncology, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Jessica Meshman
- Department of Radiation Oncology, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Sophia Hsu
- Department of Radiation Oncology, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Taeko Yoshizaki
- Department of Radiation Oncology, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Elliot Abemayor
- Department of Otolaryngology - Head and Neck Surgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Maie St John
- Department of Otolaryngology - Head and Neck Surgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
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27
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Ross RB, Koyfman SA, Reddy CA, Houston N, Geiger JL, Woody NM, Joshi NP, Greskovich JF, Burkey BB, Scharpf J, Lamarre ED, Prendes B, Lorenz RR, Adelstein DJ, Ward MC. A matched comparison of human papillomavirus-induced squamous cancer of unknown primary with early oropharynx cancer. Laryngoscope 2017; 128:1379-1385. [PMID: 29086413 DOI: 10.1002/lary.26965] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 09/01/2017] [Accepted: 09/19/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVES/HYPOTHESIS Patients with human papillomavirus (HPV)-induced cancer of unknown primary (CUP) are generally excluded from clinical trials, despite surgical series reporting detection rates of occult oropharynx primaries of >80%. We performed a matched-pair analysis to compare outcomes between T0N1-3M0 HPV+ CUP and T1-2N1-3M0 HPV+ oropharynx known primary (OPX). STUDY DESIGN Retrospective cohort study at a single institution. METHODS Patients with early T stage, node positive HPV+ OPX or CUP treated with curative intent between 1998 and 2016 were identified. For a subgroup of CUP patients with an unknown HPV status, we imputed HPV status and included patients with a >80% probability of being HPV+. Cohorts were matched based on patient demographics using a nearest neighbor propensity technique. After matching, patients were grouped according to either a favorable or unfavorable risk stratification designations per current NRG Oncology clinical trial enrollment criteria. Disease-free survival (DFS) and overall survival (OS) were calculated using Kaplan-Meier analysis. RESULTS Of 298 patients with T1-2N1-3 OPX, 48 were matched to 48 HPV+ CUP patients (32 with confirmed and 16 imputed HPV status). Median follow-up for CUP (34.1 months) and OPX (27.8 months) patients were similar (P = .23).There were no significant differences between the CUP and OPX groups for 3-year DFS (89% vs. 85%, P = .44), and 3-year OS (91% vs. 91%, P = .11), respectively. CONCLUSIONS Patients with T0N+M0 HPV-induced CUP have similar survival outcomes to matched patients with T1-2N+M0 HPV+ OPX. These patients can reasonably be included in clinical trials investigating the role of treatment deintensification and risk stratified similar to patients with early-stage known primary OPX cancer. LEVEL OF EVIDENCE 4. Laryngoscope, 128:1379-1385, 2018.
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Affiliation(s)
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Narcissa Houston
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jessica L Geiger
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Neil M Woody
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nikhil P Joshi
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - John F Greskovich
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian B Burkey
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Joseph Scharpf
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Eric D Lamarre
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Brandon Prendes
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Robert R Lorenz
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - David J Adelstein
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Matthew C Ward
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
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29
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Axelsson L, Nyman J, Haugen-Cange H, Bove M, Johansson L, De Lara S, Kovács A, Hammerlid E. Prognostic factors for head and neck cancer of unknown primary including the impact of human papilloma virus infection. J Otolaryngol Head Neck Surg 2017; 46:45. [PMID: 28601094 PMCID: PMC5466757 DOI: 10.1186/s40463-017-0223-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 05/26/2017] [Indexed: 01/03/2023] Open
Abstract
Background Head and neck cancer of unknown primary (HNCUP) is rare and prospective studies are lacking. The impact of different prognostic factors such as age and N stage is not completely known, the optimal treatment is not yet established, and the reported survival rates vary. In the last decade, human papilloma virus (HPV) has been identified as a common cause of and important prognostic factor in oropharyngeal cancer, and there is now growing interest in the importance of HPV for HNCUP. The aim of the present study on curatively treated HNCUP was to investigate the prognostic importance of different factors, including HPV status, treatment, and overall survival. Methods A search for HNCUP was performed in the Swedish Cancer Registry, Western health district, between the years 1992–2009. The medical records were reviewed, and only patients with squamous cell carcinoma or undifferentiated carcinoma treated with curative intent were included. The tumor specimens were retrospectively analyzed for HPV with p16 immunostaining. Results Sixty-eight patients were included. The mean age was 59 years. The majority were males, and had N2 tumors. Sixty-nine percent of the tumors were HPV positive using p16 staining. Patients who were older than 70 years, patients with N3-stage tumors, and patients with tumors that were p16 negative had a significantly worse prognosis. The overall 5-year survival rate for patients with p16-positive tumors was 88% vs 61% for p16-negative tumors. Treatment with neck dissection and postoperative radiation or (chemo) radiation had 81 and 88% 5-year survival rates, respectively. The overall and disease-free 5-year survival rates for all patients in the study were 82 and 74%. Conclusions Curatively treated HNCUP had good survival. HPV infection was common. Independent prognostic factors for survival were age over 70 years, HPV status and N3 stage. We recommend that HPV analysis should be performed routinely for HNCUP. Treatment with neck dissection and postoperative radiation or (chemo) radiation showed similar survival rates.
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Affiliation(s)
- Lars Axelsson
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden.
| | - Jan Nyman
- Department of Oncology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Hedda Haugen-Cange
- Department of Oncology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Mogens Bove
- Department of Otorhinolaryngology, Norra Älvsborgs Hospital, Trollhättan, Sweden
| | - Leif Johansson
- Department of Otorhinolaryngology, Central Hospital Skövde, Skövde, Sweden
| | - Shahin De Lara
- Department of Clinical Pathology and Genetics, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Anikó Kovács
- Department of Clinical Pathology and Genetics, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Eva Hammerlid
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
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30
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Hu KS, Mourad WF, Gamez ME, Lin W, Jacobson AS, Persky MS, Urken ML, Culliney BE, Li Z, Tran TN, Schantz SP, Chadha J, Harrison LB. Five-year outcomes of an oropharynx-directed treatment approach for unknown primary of the head and neck. Oral Oncol 2017. [PMID: 28622886 DOI: 10.1016/j.oraloncology.2017.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Squamous cell carcinoma of unknown primary (SCCHNUP) is commonly treated with comprehensive radiation to the laryngopharynx and bilateral necks. In 1998, we established a departmental policy to treat SCCHNUP with radiation directed to the oropharynx and bilateral neck. METHODS From 1998-2011, 60 patients were treated - N1: 18%, N2: 75% and N3: 7%. 82% underwent neck dissection. 55% received IMRT and 62% underwent concurrent chemoradiotherapy. RESULTS At median follow-up of 54months, 5 patients failed regionally and 4 emerged with a primary (tongue base, hypopharynx and thoracic esophagus). Five-year rates of regional control, primary emergence, distant metastasis, disease-free survival and overall survival were 90%, 10%, 20%, 72% and 79%, respectively. The 5year rate of primary emergence in a non-oropharynx site was 3%. CONCLUSION This is the first demonstration that an oropharynx-directed approach yields low rates of primary emergence in SCCHNUP with excellent oncologic outcomes.
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Affiliation(s)
- Kenneth Shung Hu
- Dept of Radiation Oncology, New York University Langone Medical Center, New York, NY, United States.
| | - Waleed Fouad Mourad
- Dept of Radiation Oncology, Georgia Regents University, Augusta, GA, United States
| | - Mauricio E Gamez
- Dept of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, United States.
| | - Wilson Lin
- Dept of Radiation Oncology, Mount Sinai at Beth Israel Medical Center, New York, NY, United States
| | - Adam Saul Jacobson
- Dept of Otolaryngology, New York University Langone Medical Center, New York, NY, United States
| | - Mark Stephen Persky
- Dept of Otolaryngology, New York University Langone Medical Center, New York, NY, United States
| | - Mark L Urken
- Dept of Otolaryngology, Mount Sinai at Beth Israel, New York, NY, United States
| | - Bruce E Culliney
- Dept of Medicine, Mount Sinai at Beth Israel, New York, NY, United States
| | - Zujun Li
- Dept of Medicine, New York University Langone Medical Center, New York, NY, United States
| | - Theresa Nguyen Tran
- Dept of Otolaryngology, New York University Langone Medical Center, New York, NY, United States
| | | | - Juskaran Chadha
- Dept of Medicine, Mount Sinai at Roosevelt Hospital, New York, NY, United States
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Müller von der Grün J, Tahtali A, Ghanaati S, Rödel C, Balermpas P. Diagnostic and treatment modalities for patients with cervical lymph node metastases of unknown primary site - current status and challenges. Radiat Oncol 2017; 12:82. [PMID: 28486947 PMCID: PMC5424363 DOI: 10.1186/s13014-017-0817-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 05/03/2017] [Indexed: 11/29/2022] Open
Abstract
Background and Purpose This review aims to provide a comprehensive overview of the literature and elucidate open questions for future clinical trials concerning diagnostics and treatment modalities for cervical cancer of unknown primary (CUP). Methods A literature search for head and neck CUP was performed with focus on diagnostics and therapies as well as molecular markers. Results High level evidence on CUP is limited. However, it seems that a consensus exists regarding the optimal diagnostic procedures. The correct implementation of biomarkers for patient stratification and treatment remains unclear. An even greater dispute dominates about the ideal treatment with publications ranging from sole surgery to surgery with postoperative bilateral radiotherapy with inclusion of the mucosa and concomitant chemotherapy. Conclusions Cervical CUP represents a very heterogeneous malignant disease. On this account many aspects concerning treatment optimization remain unclear, despite a considerable number of publications in the past. Future research in form of prospective randomized trials is needed in order to better define patient stratification criteria and enable tailored treatment.
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Affiliation(s)
- Jens Müller von der Grün
- Department of Radiation Oncology, University Hospital, Johann Wolfgang Goethe University, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Aykut Tahtali
- Department of Otolaryngology and Head and Neck Surgery, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Shahram Ghanaati
- Department of Maxillofacial Surgery, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Claus Rödel
- Department of Radiation Oncology, University Hospital, Johann Wolfgang Goethe University, Theodor Stern Kai 7, 60590, Frankfurt, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Frankfurt, Germany
| | - Panagiotis Balermpas
- Department of Radiation Oncology, University Hospital, Johann Wolfgang Goethe University, Theodor Stern Kai 7, 60590, Frankfurt, Germany. .,German Cancer Research Center (DKFZ), Heidelberg, Germany. .,German Cancer Consortium (DKTK), Frankfurt, Germany.
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de Ridder M, Klop M, Hamming-Vrieze O, de Boer J, Jasperse B, Smit L, Vogel W, van den Brekel M, Al-Mamgani A. Unknown primary head and neck squamous cell carcinoma in the era of fluorodeoxyglucose-positron emission tomography/CT and intensity-modulated radiotherapy. Head Neck 2017; 39:1382-1391. [PMID: 28370570 DOI: 10.1002/hed.24762] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The diagnosis and treatment of head and neck carcinoma of unknown primary (CUP) have changed with the introduction of fluorodeoxyglucose-positron emission tomography (FDG-PET)/CT and intensity-modulated radiotherapy (IMRT), with potential implications for outcome. METHODS We conducted a retrospective analysis of 80 patients with head and neck CUP who were PET-staged and treated with curative intention using IMRT between 2006 and 2016 in the Netherlands Cancer Institute. Patient, tumor, and treatment demographics were recorded and oncologic outcomes were analyzed. RESULTS Local control was 100% in mucosal irradiated patients. Regional control was 90%. Ten patients developed distant metastases, which were associated with N3, extracapsular extension (ECE) and lower neck positive lymph nodes. Overall survival (OS) at 5 years was 62% and disease-specific survival was 78%. ECE, N3 neck, multiple levels of positive lymph nodes, and positive lymph nodes in the lower neck were associated with worse prognosis. CONCLUSION Locoregional outcome of head and neck CUP managed with modern techniques is good. Future research needs to focus on reducing toxicity and patients prone for distant metastasis.
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Affiliation(s)
- Mischa de Ridder
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Martin Klop
- Department of Head and Neck Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Olga Hamming-Vrieze
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - JanPaul de Boer
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Bas Jasperse
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Laura Smit
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wouter Vogel
- Department of Nuclear Medicine, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michiel van den Brekel
- Department of Head and Neck Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Abrahim Al-Mamgani
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Investigation and management of the unknown primary with metastatic neck disease: United Kingdom National Multidisciplinary Guidelines. The Journal of Laryngology & Otology 2017; 130:S170-S175. [PMID: 27841129 PMCID: PMC4873921 DOI: 10.1017/s0022215116000591] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It discusses the evidence base pertaining to the management of metastatic neck disease in the setting of an unknown primary and provides recommendations on the work up and management for this group of patients receiving cancer care.
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Arosio AD, Pignataro L, Gaini RM, Garavello W. Neck lymph node metastases from unknown primary. Cancer Treat Rev 2016; 53:1-9. [PMID: 28027480 DOI: 10.1016/j.ctrv.2016.11.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/23/2016] [Accepted: 11/29/2016] [Indexed: 11/18/2022]
Abstract
Metastatic cervical carcinoma from unknown primary is a metastatic disease in the lymph nodes of the neck without any evidence of a primary tumour after appropriate investigation. The condition is rare and definite evidence is lacking for both diagnosis and treatment. In this review of the literature, we tried to draw some clinical indications based on the few available studies. We ultimately came to the following conclusions: (1) a thorough and accurate diagnostic work-up should be systematically offered. It includes accurate inspection with fibroscopy, CT or MRI, fine needle aspiration, panendoscopy and positron emission tomography, (2) Patients with low-volume neck disease, N1 and N2a stage and without extracapsular extension on histopathological examination should receive single modality treatment. Radiotherapy and surgery may be similarly effective but, if possible, surgery (excisional biopsy, neck dissection and tonsillectomy) should be favoured because it consents a more precise staging, (3) patients with more advanced conditions require combined treatment in the form of either resection followed by adjuvant radiation (±chemotherapy) or primary chemoradiation (±post-therapy neck dissection).
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Affiliation(s)
- Alberto Daniele Arosio
- Department of Otorhinolaryngology, School of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Lorenzo Pignataro
- Department of Otorhinolaryngology, Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Renato Maria Gaini
- Department of Otorhinolaryngology, School of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Werner Garavello
- Department of Otorhinolaryngology, School of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy.
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35
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Su YY, Chen SS, Hsieh CH, Liao CT, Lin CY, Kang CJ, Yen TC. Defining risk groups of patients with cancer of unknown primary site and cervical nodal metastases by F-18 fluorodeoxyglucose positron emission tomography and computed tomography imaging. Kaohsiung J Med Sci 2016; 32:407-13. [DOI: 10.1016/j.kjms.2016.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/15/2016] [Accepted: 07/06/2016] [Indexed: 12/31/2022] Open
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Total Mucosal Irradiation with Intensity-modulated Radiotherapy in Patients with Head and Neck Carcinoma of Unknown Primary: A Pooled Analysis of Two Prospective Studies. Clin Oncol (R Coll Radiol) 2016; 28:e77-e84. [PMID: 27180092 DOI: 10.1016/j.clon.2016.04.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 03/02/2016] [Accepted: 03/03/2016] [Indexed: 11/23/2022]
Abstract
AIMS To determine the clinical outcomes of an intensity-modulated radiotherapy technique for total mucosal irradiation (TM-IMRT) in patients with head and neck carcinoma of unknown primary (HNCUP). MATERIALS AND METHODS A single-centre prospective phase II trial design was used in two sequential studies to evaluate TM-IMRT for HNCUP. Patients were investigated for primary tumour site using examination under anaesthetic and biopsies, computed tomography ± magnetic resonance imaging (MRI) or 18-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT). Patients received IMRT to the potential primary tumour sites and elective cervical nodes. Concomitant chemotherapy was used in patients who received primary radiotherapy or those with nodal extracapsular extension. RESULTS Thirty-six patients with HNCUP were recruited; 72% male. Twenty-five patients (69.4%) had p16-positive disease. Two year mucosal and local nodal control rates were 97.1% (95% confidence interval 91.4-100) and 89.8% (78.4-100), respectively. One mucosal primary was detected 7.3 months after TM-IMRT and three patients died from recurrent/metastatic squamous cell carcinoma of the head and neck. Twelve patients (33%) developed grade 3 (Late Effects in Normal Tissue-Subjective, Objective, Management and Analytical; LENT-SOMA) dysphagia with a 1 year enteric tube feeding rate of 2.7%. The high-grade subjective xerostomia rate (LENT-SOMA) at 24 months after IMRT was 15%. CONCLUSIONS At a median follow-up of 36.1 months, the use of TM-IMRT was associated with good local control. Toxicity was comparable with previously reported TM-IMRT regimens encompassing similar mucosal volumes.
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Galloway TJ, Ridge JA. Management of Squamous Cancer Metastatic to Cervical Nodes With an Unknown Primary Site. J Clin Oncol 2015; 33:3328-37. [PMID: 26351351 DOI: 10.1200/jco.2015.61.0063] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Squamous cell carcinoma of an unknown primary (SCCUP) of the head and neck is a rare disease. As a diagnosis of exclusion, the manner in which it is assigned merits consideration. Despite the development and refinement of several techniques designed to locate an occult tumor, including cross-sectional anatomic imaging, functional imaging, and transoral surgical techniques, delineating SCCUP remains an active clinical problem. Its relative rarity has prevented prospective study of the entity. Hence, investigators must rely on retrospective analyses to understand the disease and its appropriate treatment. The current understanding of SCCUP differs substantially from when it was initially described decades ago. The most common site of a small primary tumor initially thought to represent SCCUP is the tonsil or base of the tongue, and an increasing percentage are associated with human papilloma virus. Modern treatment of SCCUP by neck dissection alone, neck dissection followed by radiation with or without concurrent chemotherapy, or primary chemoradiation according to initial nodal disease burden produces extraordinarily low recurrence rates. Whether the potential mucosal primary site and/or the contralateral neck should be electively treated is controversial. Efficacy data seem to be similar; therefore, an evaluation of the toxicity of both treatment paradigms is warranted.
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Affiliation(s)
| | - John A Ridge
- All authors: Fox Chase Cancer Center, Philadelphia, PA.
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38
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Cuaron J, Rao S, Wolden S, Zelefsky M, Schupak K, Mychalczak B, Lee N. Patterns of failure in patients with head and neck carcinoma of unknown primary treated with radiation therapy. Head Neck 2015; 38 Suppl 1:E426-31. [PMID: 25581274 DOI: 10.1002/hed.24013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2015] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The purpose of this study was to examine patterns of failure and the relationship to radiation doses in patients with head and neck carcinoma of unknown primary (HNCUP). METHODS We reviewed 85 patients with HNCUP treated with curative-intent radiation therapy (RT) during 1995 to 2012. RESULTS There have been no failures in the pharyngeal axis. Relapse at initial neck sites of disease developed in 7 patients (8.2%). The median dose to these sites was 70 Gy (range, 63-70 Gy). Failure at neck sites without initial disease occurred in 4 patients (4.7%). The median dose was 54 Gy (range, 50-58.8 Gy). There were no contralateral failures in a small cohort of patients receiving unilateral treatment (n = 6). Percutaneous endoscopic gastrostomy (PEG) tube dependence at 12 months was 7.4%, and 2.5% at 3 years. Esophageal stricture developed in 5 patients (5.9%). CONCLUSION RT for HNCUP produces excellent locoregional control rates with acceptably low levels of late toxicity. Doses prescribed to sites of eventual failure did not vary significantly from those sites that were treated and remain in control. © 2015 Wiley Periodicals, Inc. Head Neck 38: E426-E431, 2016.
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Affiliation(s)
- John Cuaron
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Shyam Rao
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Michael Zelefsky
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Karen Schupak
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Borys Mychalczak
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Nancy Lee
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
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39
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Martin JM, Galloway TJ. Evaluation and management of head and neck squamous cell carcinoma of unknown primary. Surg Oncol Clin N Am 2015; 24:579-91. [PMID: 25979401 DOI: 10.1016/j.soc.2015.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The diagnostic evaluation and therapeutic management of a patient with squamous cell carcinoma of an unknown primary (SCCUP) has considerably evolved over recent decades and will likely continue to change as a result of the improving ability to identify small primary tumors and better tailor the implementation of multimodality therapy. By application of the general principles of head and neck oncology, physicians and surgeons are often able to achieve satisfactory control of the disease in patients with SCCUP.
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Affiliation(s)
- Jeffrey M Martin
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Thomas J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA.
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40
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Merlotti A, Alterio D, Vigna-Taglianti R, Muraglia A, Lastrucci L, Manzo R, Gambaro G, Caspiani O, Miccichè F, Deodato F, Pergolizzi S, Franco P, Corvò R, Russi EG, Sanguineti G. Technical guidelines for head and neck cancer IMRT on behalf of the Italian association of radiation oncology - head and neck working group. Radiat Oncol 2014; 9:264. [PMID: 25544268 PMCID: PMC4316652 DOI: 10.1186/s13014-014-0264-9] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 11/17/2014] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Anna Merlotti
- Radioterapia AO Ospedale di Circolo-Busto Arsizio (VA), Piazzale Professor G. Solaro, 3, 21052, Busto Arsizio, VA, Italy.
| | | | | | | | | | - Roberto Manzo
- Radioterapia Azienda Ospedaliera ASL Napoli 1-Napoli, Napoli, Italy.
| | | | - Orietta Caspiani
- Radioterapia Ospedale Fatebenefratelli, Isola Tiberina-Roma, Roma, Italy.
| | | | - Francesco Deodato
- Radioterapia Università Cattolica del S. Cuore -Campobasso, Roma, Italy.
| | - Stefano Pergolizzi
- Dipartimento SBIMOF Sezione di Scienze Radiologiche, Università di Messina, Piazza Pugliatti Salvatore, 1, 98122, Messina, ME, Italy.
| | - Pierfrancesco Franco
- Dipartimento di Oncologia, Radioterapia Oncologica, Università di Torino, Turin, Italy.
| | - Renzo Corvò
- Oncologia Radioterapica, IRCS S. Martino-IST- Istituto Nazionale per la Ricerca sul Cancro, Università Genova, Genova, Italy.
| | - Elvio G Russi
- Radioterapia Az. Ospedaliera S. Croce e Carle-Cuneo, via M. Coppino 26 12100, Cuneo, Italy.
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41
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[Lymph node metastases from squamous cell carcinoma of unknown primary site. Is it time to change of paradigm?]. Bull Cancer 2014; 101:455-60. [PMID: 24886896 DOI: 10.1684/bdc.2014.1965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The diagnosis of carcinoma of unknown primary (CUP) is made after exclusion of the presence of a mucosal primary. There are two mains options for the primary treatment of CUP, either a neck node dissection followed by postoperative radiotherapy or chemo-radiotherapy, or a primary radiotherapy or chemo-radiotherapy depending on the nodal stage followed in case of residual neck disease by a selective neck dissection. There is no data to suggest the superiority of one over the other. For radiotherapy, unilateral neck or bilateral neck, including the upper aerodigestive tract mucosa are possible options. There is no definite data to demonstrate the superiority of one over the other, but owing the reduced toxicity of unilateral irradiation, and the possibility of salvage treatment in case of emergence of a mucosal primary and/or a contralateral neck node development, the former may be the preferred option. Advances in radiotherapy such as intensity modulated radiation therapy have the potential to spare organs at risk and reduce late toxicity rates. A selective irradiation approach customized on "major" criteria, such as nodal stage and level, HPV and EBV status and accessory criteria, such as histological variants, is under investigation.
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Troussier I, Bensadoun RJ, Chamorey E, Lapeyre M, Baujat B, Leysalle A, Sun XS, Pointreau Y, Calugaru V, Pan Q, Ovidiu V, Schultz P, Malard O, Bujor L, Morinière S, Chamois J, Coutte A, Michel X, Huguet F, Fouillet B, Roth V, Vernat SS, Meert N, Gallocher O, Drouet F, Lang P, Thariat J. Cervical node of unknown primary: patterns of care and factors influencing the choice of clinical target volumes. Oral Oncol 2014; 50:e25-6. [PMID: 24630259 DOI: 10.1016/j.oraloncology.2014.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 02/05/2014] [Accepted: 02/16/2014] [Indexed: 10/25/2022]
Affiliation(s)
| | - René-Jean Bensadoun
- Oncologie Radiothérapie, PRC, CHU Poitiers, France; Oncologie Radiothérapie, CHRU Carémeau Nimes, France
| | | | - Michel Lapeyre
- Oncologie Radiothérapie, Centre Jean Perrin, CLCC d'Auvergne, France
| | | | - Axel Leysalle
- Oncologie Radiothérapie, Centre Antoine Lacassagne, Nice, France
| | - Xu Shan Sun
- Oncologie Radiothérapie CHRU Besançon, France
| | - Yoann Pointreau
- Oncologie Radiothérapie, Clinique Victor Hugo, Le Mans, France
| | | | - Quiong Pan
- Oncologie Radiothérapie, APHP Hôpital Henri Mondor, Créteil, France
| | | | | | | | - Laurentiu Bujor
- Oncologie Radiothérapie, Centro Hospitalar Lisboa Norte, Lisbonne, Portugal
| | | | - Jérome Chamois
- Oncologie Radiothérapie, Centre Hospitalier Privé Saint Grégoire, France
| | - Alexandre Coutte
- Oncologie Radiothérapie, Hôpital Sud Avenue René Laënnec Amiens, France
| | - Xavier Michel
- Oncologie Radiothérapie, CHR Metz-Thionville, France
| | | | | | | | | | - Nicolas Meert
- Oncologie Radiothérapie, GHdC, Site St Joseph, Gilly, Charleroy, Belgique
| | - Olivier Gallocher
- Oncologie Radiothérapie, Capio Polyclinique du Parc, Toulouse, France
| | | | - Philippe Lang
- Oncologie Radiothérapie, CHRU Carémeau Nimes, France
| | - Juliette Thariat
- Oncologie Radiothérapie, Centre Antoine Lacassagne, Institut Universitaire de la Face et du Cou, Nice, France
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Janssen S, Glanzmann C, Huber G, Studer G. Individualized IMRT treatment approach for cervical lymph node metastases of unknown primary. Strahlenther Onkol 2014; 190:386-93. [DOI: 10.1007/s00066-013-0508-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 11/08/2013] [Indexed: 01/08/2023]
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Keller LM, Galloway TJ, Holdbrook T, Ruth K, Yang D, Dubyk C, Flieder D, Lango MN, Mehra R, Burtness B, Ridge JA. p16 status, pathologic and clinical characteristics, biomolecular signature, and long-term outcomes in head and neck squamous cell carcinomas of unknown primary. Head Neck 2014; 36:1677-84. [PMID: 24115269 DOI: 10.1002/hed.23514] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2013] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The purpose of this study was to report associations between p16 status, clinicopathologic characteristics, and outcomes for head and neck squamous cell carcinoma of unknown primary (CUP). METHODS Specimens of squamous cell CUP were reanalyzed. Human papillomavirus (HPV) status was determined by p16 stain. A tissue microarray (TMA) was constructed to evaluate biomarkers potentially prognostic in head and neck squamous cell carcinoma (HNSCC). RESULTS A majority of the population (n = 26; 74%) was p16 positive (+). Prognostic factors benefiting survival were p16+ status (p < .0001), absence of macroscopic extracapsular extension (ECE; p = .004), younger age (p = .01), and higher grade (p = 0.007). The prognostic implication of worse overall survival (OS) with macroscopic ECE (p = .009) remained significant when limited to patients who were p16+ (p = .002). Exploratory TMA between unknown primary and controls suggested a biomolecular difference between squamous cell CUP and known-primary cancer. CONCLUSION The majority of patients with squamous cell CUP were p16+, indicative of HPV association. P16 staining and ECE seem to be the most prognostic features in squamous cell CUP.
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Affiliation(s)
- Lanea M Keller
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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Abstract
BACKGROUND The term cancer of unknown primary (CUP) encompasses a group of entities which differ to a great extent regarding etiology, prognosis and therapeutic management. OBJECTIVES The aim of the study was an elaboration of the role of radiotherapy in CUP syndrome. MATERIAL AND METHODS Systematic literature search and specification of the available treatment options. RESULTS Radiotherapy is an integral part of interdisciplinary management approaches for patients with CUP in both curative and palliative situations. Radio-oncological techniques, such as intensity-modulated radiotherapy and stereotactic body radiotherapy increase the therapeutic window. Modern diagnostic modalities from radiology and nuclear medicine are the cornerstone of radiotherapeutic interventions, especially in terms of target volume definition and pretherapeutic staging. In the interdisciplinary setting radiation oncology offers the possibility of curative and often organ preserving approaches in patients with axillary and cervical CUP. In addition, improvement and preservation of quality of life can be achieved in patients with metastatic disease. CONCLUSION Radiation oncology is a crucial component of the interdisciplinary management of patients with CUP. Therapeutic decisions in patients with CUP should be made in an interdisciplinary setting.
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46
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Demiroz C, Vainshtein JM, Koukourakis GV, Gutfeld O, Prince ME, Bradford CR, Wolf GT, McLean S, Worden FP, Chepeha DB, Schipper MJ, McHugh JB. Head and neck squamous cell carcinoma of unknown primary: neck dissection and radiotherapy or definitive radiotherapy. Head Neck 2013; 36:1589-1595. [PMID: 23996575 DOI: 10.1002/hed.23479] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 07/13/2013] [Accepted: 08/23/2013] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Management of head and neck carcinoma from unknown primary (HNCUP) remains controversial, with neck dissection and radiotherapy (RT) or definitive RT both commonly used. The purpose of this study was to characterize HNCUP and retrospectively compare outcomes for patients treated with neck dissection + RT versus definitive RT. METHODS From 1994 to 2009, 41 patients with HNCUP underwent either neck dissection + RT (n = 22) or definitive RT ± concurrent chemotherapy (n = 19) at our institution. Treatment outcomes were compared using Kaplan-Meier methods and log-rank test. RESULTS There were no differences between patients treated with neck dissection + RT and definitive RT in overall survival (OS), progression-free survival (PFS), locoregional relapse-free survival (LRFS), freedom from locoregional failure (FFLRG), or freedom from distant failure (FFDF). Among 17 patients who underwent neck dissection + RT for whom human papillomavirus (HPV) status could be determined, HPV(+) patients trended toward improved OS (p = .06) and PFS (p = .15). CONCLUSION Neck dissection and postoperative RT resulted in similar outcomes as definitive RT. The prognostic implications of HPV(+) nodes in HNCUP are similar to those in oropharyngeal primary cancers.
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Affiliation(s)
- Candan Demiroz
- Department of Radiation Oncology, Uludag University Faculty of Medicine, Bursa, Turkey; Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | | | - Georgios V Koukourakis
- Department of Radiation Oncology, Saint Savvas Anticancer Institute of Athens, Greece; Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Orit Gutfeld
- Division of Oncology, Institute of Radiation Therapy, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Mark E Prince
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI
| | - Carol R Bradford
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI
| | - Gregory T Wolf
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI
| | - Scott McLean
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI
| | - Francis P Worden
- Division of Hematology Oncology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Douglas B Chepeha
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI
| | | | - Jonathan B McHugh
- Department of Pathology, University of Michigan, Ann Arbor, MI Avraham Eisbruch, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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Troussier I, Barry B, Baglin AC, Leysalle A, Janot F, Baujat B, Fakhry N, Sun XS, Marcy PY, Dufour X, Bensadoun RJ, Thariat J. [Target volumes in cervical lympadenopathies of unknown primary: toward a selective customized approach? On behalf of REFCOR]. Cancer Radiother 2013; 17:686-94. [PMID: 24095636 DOI: 10.1016/j.canrad.2013.07.132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 06/27/2013] [Accepted: 07/03/2013] [Indexed: 11/25/2022]
Abstract
The treatment of carcinomas of unknown primary revealed by cervical lymphadenopathy is based on neck dissection and nodal and pan-mucosal irradiation to control the neck and avoid the emergence of a metachronous primary. The aim of this review was to assess diagnostic and therapeutic approaches and criteria that may be used for a customized selective approach to avoid severe toxicities of pan-mucosal irradiation. A literature search was performed with the following keywords: cervical lymphadenopathy, unknown primary, upper aerodigestive tract, cancer, radiotherapy, squamous cell carcinoma, variants. The diagnostic workup includes a head and neck scanner or MRI, ((18)F)-FDG PET CT, a panendoscopy and tonsillectomy. Squamous cell carcinoma represents over two thirds of cases. The number of metastatic cervical nodes, nodal level, and histological variant (associated with HPV/EBV status) may determine the primary site origin and might be weighted for the determination of radiation target volumes on a multidisciplinary basis. A selective customized approach is relevant to decrease radiation toxicity only if neck and mucosal control is not impaired. Although no recommendation can yet be made in the absence of sufficient level of evidence, the relevance of systematic pan-mucosal irradiation appears questionable in a number of clinical situations. Accordingly, a customized selective redefinition of target volumes may be discussed and be prospectively evaluated in relation to the therapeutic index obtained.
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Affiliation(s)
- I Troussier
- Service d'oncologie radiothérapie, PRC, CHU de la Milétrie, 2, rue de la Milétrie, BP 557, 86021 Poitiers cedex, France
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Gani C, Eckert F, Müller AC, Mauz PS, Thiericke J, Bamberg M, Weinmann M. Cervical squamous cell lymph node metastases from an unknown primary site: survival and patterns of recurrence after radiotherapy. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2013; 7:173-80. [PMID: 23943661 PMCID: PMC3738379 DOI: 10.4137/cmo.s12169] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction The purpose of the present retrospective study was to review outcome and patterns of failure of patients who were treated with radiotherapy for cervical lymph node metastases from an unknown primary site (CUP). Patients and Methods Between 2000 and 2009, 34 patients diagnosed with squamous cell CUP were admitted to radiotherapy in curative intent. In 26 of 34 patients (76%) neck dissection was performed prior to radiotherapy, extracapsular extension (ECE) was seen in 20 of 34 patients (59%). Target volumes included the bilateral neck and panpharyngeal mucosa. Concomitant chemotherapy was applied in 14 of 34 patients (41%). Results After a median follow-up of 45 months for the entire group, 2 of 34 patients (6%) presented with an isolated regional recurrence, another 2 of 34 patients (6%) developed both local and distant recurrence, and 6 of 34 patients (18%) had distant failure only. Estimated overall survival after 2- and 5 -years was 78% and 63%. All patients with N1 or N2a disease (n=6) were disease free after 5 years. ECE, concomitant chemotherapy and involvement of neck levels 4 and 5 were associated with worse overall survival on univariate analysis. Conclusion Radiotherapy of the panpharynx and bilateral neck leads to excellent local control while distant metastases are the most frequent site of failure and prognostically limiting. Therefore intensified concomitant or sequential systemic therapies should be evaluated in future trials.
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Affiliation(s)
- Cihan Gani
- Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
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Dragan AD, Nixon IJ, Guerrero-Urbano MT, Oakley R, Jeannon JP, Simo R. Selective neck dissection as a therapeutic option in management of squamous cell carcinoma of unknown primary. Eur Arch Otorhinolaryngol 2013; 271:1249-56. [DOI: 10.1007/s00405-013-2643-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 07/15/2013] [Indexed: 10/26/2022]
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Gunn GB, Frank SJ. Advances in radiation oncology for the management of oropharyngeal tumors. Otolaryngol Clin North Am 2013; 46:629-43. [PMID: 23910474 DOI: 10.1016/j.otc.2013.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The major benefits of modern radiation therapy (eg, intensity-modulated [x-ray] radiation therapy [IMRT]) for oropharyngeal cancer are reduced xerostomia and better quality of life. Intensity-modulated proton therapy may provide additional advantages over IMRT by reducing radiation beam-path toxicities. Several acute and late treatment-related toxicities and symptom constellations must be kept in mind when designing and comparing future treatment strategies, particularly because currently most patients with oropharyngeal carcinoma present with human papillomavirus-positive disease and are expected to have a high probability of long-term survival after treatment.
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Affiliation(s)
- G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Unit 97, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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