Prognostic factors of unknown primary head and neck squamous cell carcinoma

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

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.

Swedish National Multicenter Study on Head and Neck Cancer of Unknown Primary: Prognostic Factors and Impact of Treatment on Survival

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.

Optimization of radiotherapy for neck carcinoma metastasis from unknown primary sites: a meta-analysis

This meta-analysis was designed to evaluate radiotherapy (RT) options preferable for neck cancer metastases from unknown primary sites (NCUP). Relevant articles published up through September 2015 were selected from EMBASE, Cochrane, PubMed and Web of Science. Thirty-three articles were identified, and relative risks (RRs) and 95% CIs for all pre-specified endpoints were calculated. Surgery plus RT showed an advantage for 5-year overall survival (OS) (RR 0.66, 95% CI 0.52-0.83, p = 0.0004) and neck recurrence (NR) (RR = 0.74, 95% CI 0.59-0.92, p = 0.008) compared to RT alone. The RRs for NR, primary tumor emergence (PTE), and 5-year disease free survival (DFS) for bilateral neck compared to ipsilateral neck irradiation were 0.61 (95% CI 0.41-0.91, p = 0.01), 0.44(95% CI 0.26-0.77, p = 0.004), and 0.81 (95% CI 0.64-1.03, p = 0.09), respectively. Irradiation of the neck plus potential primary tumor sites (PPTS) showed a benefit for 5-year DFS (RR 0.75, 95% CI 0.61-0.92, p = 0.005), NR (RR = 0.72, 95% CI 0.56-0.92, p = 0.009), and PTE (RR = 0.23, 95% CI 0.12-0.45, p < 0.0001) compared to neck-only irradiation. Adverse events occurred more frequently with bilateral neck plus PPTS irradiation. For NCUP, surgery plus RT of the bilateral neck and PPTS was associated with greater improvement of clinical outcomes.

Prognostic factors for head and neck cancer of unknown primary including the impact of human papilloma virus infection

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.

Management of lymph node metastases from an unknown primary site to the head and neck (Review)

Cancer of unknown primary site (CUP) is an intriguing clinical phenomenon found in ~3-9% of all head and neck cancers. It has not yet been determined whether CUP forms a distinct biological entity with specific genetic and phenotypic characteristics, or whether it is the clinical presentation of metastasis in patients with an undetected primary tumor and no visible clinical signs. The treatment of patients with cervical lymph node metastases from CUP remains controversial, due to the lack of randomized clinical trials comparing different treatment options. Consequently, treatment is currently based on non-randomized data and institutional policy. In the present review, the range and limitations of diagnostic procedures are summarized and an optimal diagnostic work-up is recommended. The initial preferred diagnostic procedures include fine-needle aspiration biopsy (FNAB) and imaging. Although neck dissection followed by postoperative radiotherapy is the the most generally accepted approach, other curative options may be used in certain patients, such as neck dissection alone, nodal excision followed by postoperative radiotherapy, or radiotherapy alone. There remains controversy regarding target radiation volumes, ranging from ipsilateral neck irradiation to prophylactic irradiation of all the potential mucosal sites and both sides of the neck. When no primary lesion is identified with imaging and endoscopy in patients without history of smoking and alcohol abuse, molecular profiling of an FNAB sample for human papillomavirus and/or Epstein-Barr virus is required.

[Target volumes in cervical lympadenopathies of unknown primary: toward a selective customized approach? On behalf of REFCOR]

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.

Head and neck cancer with lower neck nodal metastases: management of 23 cases and review of the literature

To investigate the patient outcomes associated with the applied modes of therapy in head and neck cancer with lower neck nodal metastases. The medical records of 23 consecutive individuals who were managed by intent to treat for head and neck cancer with metastatic disease in the lower neck nodes over a 19-year period were reviewed. The mean age was 53.5 years, and the larynx was the most frequently affected primary site (57%). Overall, locoregional tumor control was achieved in the majority (75%) of the cases and the 2-year survival rate was 48%. The 2-year survival rates of people managed by surgery and postoperative radiotherapy, chemoradiation or single modality therapy were 63%, 56% and 17%, respectively, (p=0.04). Aggressive therapy resulted in five (22%) long-term (>5 years) survivors. The combination of treatment modalities proved to be effective management for head and neck cancer with lower neck nodal metastases and should be further investigated in prospective trials.

Unknown primary cancer of the head and neck: a multidisciplinary approach

The management of patients with cervical lymph node metastases from an unknown primary cancer (CUP) remains a matter of controversy. Although new advanced diagnostic tools, such as positron emission tomography, have recently been introduced in oncology, the frequency of this tumour entity in clinical practice means it is still relevant. Recently introduced molecular profiling platforms may provide biological classification for the primary tissue of origin as well as insights into the pathophysiology of this clinical entity, including the characterisation of the Epstein-Barr virus and human papilloma virus genomas in the metastatic cervical nodes. Due to the lack of randomised trials, a standard therapy has not been identified yet. Although neck dissection followed by post-operative radiotherapy is the most generally accepted approach, there are other curative options that can be used in some patients: neck dissection alone, nodal excision followed by post-operative radiotherapy or radiotherapy alone. A major controversy remains in the target radiation volumes that range from ipsilateral neck irradiation to prophylactic irradiation of all potential mucosal sites and both sides of the neck. Finally, the administration of concurrent chemotherapy is currently being advised for patients with adverse prognostic factors.

Open cervical lymph node biopsy for head and neck cancers: any benefit?

Background

Most patients with head and neck cancers in our environment present late and usually first to the general surgeons whose practice is to subject these patients to open cervical lymph node biopsy without a prior examination under anesthesia and endoscopic biopsy from the primary tumor site in order to obtain a histological diagnosis.

This paper presents the influence of open cervical lymph node biopsy on the clinical outcome of patients with head and neck cancers in our environment.

Methods

This is a ten-year retrospective review of patients with head and neck cancers in the Jos University Teaching Hospital, Jos, Nigeria.

Results

Eighty nine patients aged between 23 and 78 years had head and neck cancers with 38/89 (42.7%) patients having cervical lymphadenopathy at presentation and these initially presented to the general surgeons. Twenty six (68.4%) patients had open cervical lymph node biopsy and 12/38 (31.6%) patients had FNAB. Eleven (28.9%) patients presented to the otolaryngology unit 6 months after they presented to the general surgeons and 27 (71.1%) patients beyond 6 months. Nine deaths were recorded. Ten patients were lost to follow-up.

Conclusion

All patients with head and neck lymphadenopathy who present to any physician for diagnostic examination should undergo formal ENT staging and FNAB to avoid the problems of tumor spread and the reduction in consequent prognosis.