Postoperative radiotherapy improves survival in squamous cell carcinoma of the hypopharynx

Extranodal Extension in Bilateral Cervical Metastases: A predictor of Undesirable Survival Outcomes despite Aggressive Salvage Treatment in Oral Cancer Patients

Objectives: Despite the inclusion of extranodal extension (ENE) in the recent staging system, the presence of ENE alone is not sufficient to depict all clinical situations, as ENE is frequently found in multiple nodes. Thus, the purpose of this study was to evaluate the surgery-based treatment outcomes and clinicopathological features of oral cavity squamous cell carcinoma (OCSCC) patients with ENE found in bilateral multiple cervical metastases.

Materials and methods: A retrospective single-institutional study of OCSCC patients with bilateral ENE nodes was performed from January 2011 to December 2018. OCSCC patients of different admission statuses (with primary lesions (PL), recurrent lesions (RL) and isolated neck metastases (INM)) were included for subgroup comparisons. All patients received surgical treatment with/without adjuvant therapies and had complete follow-up data. Disease-free survival (DFS) was regarded as the main outcome. Time-to-relapse data were also collected for comparison.

Results: A total of 128 patients were included, of whom 97 (75.8%) were male. The mean follow-up period reached 15 months. Among the patients, 85 (66.4%) were treated for PLs, followed by 26 (20.3%) treated for RLs after failed prior therapy and 17 (13.3%) treated for INMs (concurrent or sequential). The DFS rate was merely 35.2%. Treatment-related factors such as surgical margin (p=0.003), postoperative adjuvant therapy (p=0.014) and perioperative complications (p=0.036) were significantly associated with patient outcomes. In addition, oral lesion-related variables such as oral subsites (p=0.037), T classification (p=0.026) and skull base involvement (p=0.040) were indicators of a worse prognosis. For bilateral ENE features, ENE subclassification (p=0.036), maximum size of ENE nodes (p=0.039) and arterial nodal encasement (p=0.025) tended to predict the surgery-based treatment outcomes of these patients.

Conclusions: Bilateral cervical metastases with ENE features, though uncommon, are a serious regional burden, and these patients have lower-than-expected treatment outcomes, especially those with RLs or INMs. A fairly large number of OCSCC patients with advanced oral lesions gain little benefit from intensified salvage surgical treatment. Such treatment should instead be offered to select patients with smaller bilateral ENE nodes (<3 cm) and those with lower ENE subclassifications and no arterial nodal encasement.

Use of Supraclavicular Flap by End to Side Technique in Pharyngeal SCC: A Case Report and Review of Literature

Objectives

In recent years, conservation laryngeal surgeries, including partial pharyngectomy, have been introduced as an alternative procedure for selected cases of hypopharyngeal squamous cell carcinoma (HSCC). Reconstruction of these defects presents a considerable challenge for the surgeon after partial pharyngectomy due to its circumferential nature. In this case report, we represent the innovative "End to side" technique to reconstruct hypopharyngeal defect using the rolled supraclavicular flap after laryngeal-preserving partial pharyngectomy.

Methods and Results

A 70-year-old female presented with a history of progressive dysphagia and odynophagia. The evaluations revealed a T3N0M0 SCC of pyriform sinus. The mass was successfully resected through partial pharyngectomy, and the hypopharyngeal defect reconstruction was achieved using the rolled supraclavicular flap via the "End to side" technique. The patient was discharged after decannulation on day 10. The 3-week barium swallow was performed with no evidence of anastomotic leakage, and the oral feeding was started after NG tube removal. At week 5, complete movement of the true vocal cord on the one side and good phonation and deglutition was observed. There was no evidence of recurrence after 1 year.

Conclusions

Laryngeal-preserving partial pharyngectomy and hypopharyngeal reconstruction with the rolled supraclavicular flap via the "End to side" technique could lead to good oncological and functional outcomes in selected cases of pyriform sinus.

Diagnostic performance of dynamic volume perfusion CT for differentiation of head and neck cancer from healthy tissue and post-therapeutic changes

BACKGROUND

Post-therapeutic tissue is bradytrophic and thus has low perfusion values in PCT. In contrast, malignant tissue is expected to show higher perfusion values as cancer growth partially depends on angiogenesis.

OBJECTIVES

This prospective study investigates perfusion computed tomography (PCT) for the post-therapeutic detection of cancer in the head and neck region.

METHODS

85 patients underwent PCT for 1) initial work-up of head and neck cancer (HNC; n=22) or 2) for follow-up (n=63). Regions of interest (ROIs) were placed in confirmed tumour, a corresponding location of benign tissue, and reference tissue. Perfusion was calculated using a single input maximum slope algorithm. Statistical analysis was performed with the Mann-Whitney U-test.

RESULTS

PCT allowed significant differentiation of malignant tissue from post-therapeutic tissue after treatment for HNC (p=0.018). Significance was even greater after normalization of perfusion values (p=0.007). PCT allowed highly significant differentiation of HNC from reference tissue (p<0.001).

CONCLUSIONS

PCT provides significantly distinct perfusion values for malignant and benign as well as post-therapeutically altered tissue in the head and neck area, thus allowing differentiation of cancer from healthy tissue. Our results show that PCT in conjunction with a standard algorithm is a potentially powerful HNC diagnostic tool.

The Efficacy of Low Postoperative Radiation Dose in Patients with Advanced Hypopharyngeal Cancer without High-Risk Factors

Objective

To evaluate the feasibility and efficacy of low postoperative radiotherapy (PORT) dose in patients with advanced hypopharyngeal squamous cell carcinoma (HPSCC) and identify prognostic factors in this group.

Patients and Methods

Between January 2013 and September 2015, 110 consecutive patients with HPSCC with no high-risk factors were treated postoperatively to 50 Gy (n=89), 56 Gy (n=12), and 60 Gy (n=9) in 2 Gy/fraction. Overall survival (OS), 3-year progression-free survival (PFS), 3-year loco-regional recurrence-free survival (LRFS), and treatment-related toxicities were analyzed.

Results

Median follow-up time was 40 months (range=6–75 months). The 3-year local-regional control (LRC) and 3-year neck control rate were 86.3% and 91.8%, respectively. The 3-year OS, PFS, and LRFS were 69.9%, 65.5%, and 80.5%, respectively. In a univariate analysis, T stage showed a significant correlation with improved OS, PFS, and LRFS (P=0.008, P=0.039, P=0.034). On multivariate analysis, T stage showed a significant correlation with improved OS and PFS. N stage showed a significant correlation with improved PFS. However, interval surgery-radiotherapy, reconstructive methods, and RT dose cannot serve as a significant prognostic factor for survival outcome.

Conclusion

This study suggests that treating no high-risk factors for locally advanced HPSCC with a dose of 50 Gy to the whole operative bed and elective lymph node levels cannot compromise disease control and survival.

Association of Survival With Shorter Time to Radiation Therapy After Surgery for US Patients With Head and Neck Cancer

Importance

Shortening the time from surgery to the start of radiation (TS-RT) is a consideration for physicians and patients. Although the National Comprehensive Cancer Network recommends radiation to start within 6 weeks, a survival benefit with this metric remains controversial.

Objective

To determine the association of delayed TS-RT with overall survival (OS) using a large cancer registry.

Design, Setting, and Participants

In this observational cohort study, 25 216 patients with nonmetastatic stages III to IV head and neck cancer were identified from the National Cancer Database (NCDB).

Exposures

Patients received definitive surgery followed by adjuvant radiation therapy, with an interval duration defined as TS-RT.

Main Outcomes and Measures

Overall survival as a function of TS-RT and the effect of clinicopathologic risk factors and accelerated fractionation.

Results

We identified 25 216 patients with nonmetastatic squamous cell carcinoma of the head and neck. There were 18 968 (75%) men and 6248 (25%) women and the mean (SD) age of the cohort was 59 (10.9) years. Of the 25 216 patients, 9765 (39%) had a 42-days or less TS-RT and 4735 (19%) had a 43- to 49-day TS-RT. Median OS was 10.5 years (95% CI, 10.0-11.1 years) for patients with a 42-days or less TS-RT, 8.2 years (95% CI, 7.4-8.6 years; absolute difference, -2.4 years, 95% CI, -1.5 to -3.2 years) for patients with a 43- to 49-day TS-RT, and 6.5 years (95% CI, 6.1-6.8 years; absolute difference, -4.1 years, 95% CI, -3.4 to -4.7 years) for those with a 50-days or more TS-RT. Multivariable analysis found that compared with a 42-days or less TS-RT, there was not a significant increase in mortality with a 43- to 49-day TS-RT (HR, 0.98; 95% CI, 0.93-1.04), although there was for a TS-RT of 50 days or more (HR, 1.07; 95% CI, 1.02-1.12). A significant interaction was identified between TS-RT and disease site. Subgroup effect modeling found that a delayed TS-RT of 7 days resulted in significantly worse OS for patients with tonsil tumors (HR, 1.22; 95% CI, 1.05-1.43) though not other tumor subtypes. Accelerated fractionation of 5.2 fractions or more per week was associated with improved survival (HR, 0.93; 95% CI, 0.87-0.99) compared with standard fractionation.

Conclusions and Relevance

Delayed TS-RT of 50 days or more was associated with worse overall survival. The multidisciplinary care team should focus on shortening TS-RT to improve survival. Unavoidable delays may be an indication for accelerated fractionation or other dose intensification strategies.

Comparative efficacy of six therapies for Hypopharyngeal and laryngeal neoplasms: a network meta-analysis

Background

Hypopharyngeal and laryngeal neoplasms are both fatal and hard to catch in early stages. Yet which treatment is the most efficacious one still remain unanswered. This network meta-analysis (NMA) was conducted to investigate effectiveness of six therapies being utilized in clinical practice nowadays.

Methods

PubMed and Embase were retrieved to synthesize data. Direct and indirect evidence was combined to compare efficacy of treatments. A relative ranking of the six regimens was calculated by the surface under the curve ranking area (SUCRA).

Results

A total of 28 trials with 9109 patients were included in our NMA. Five endpoints investigated included 3/5-year overall survival (3/5-OS), 3/5-year disease free survival (3/5-DFS) and 5-year overall survival rate (5-OSR). In terms of all efficacy outcomes, radiotherapy combined with surgery (RT + S) proved to be better than other therapies while radiotherapy (RT) alone also performed well. Induction chemoradiotherapy (ICRT) was the best regarding 3-DFS (SUCRA = 0.846) while current chemoradiotherapy (CCRT) ranked first in 5-DFS (SUCRA = 0.933) according to SUCRA results. No significant differences were demonstrated in 5-DFS and 5-OSR as shown in the results of NMA.

Conclusions

RT combined with surgery turned out to be optimal therapy of all the outcomes while the efficacy of RT was relatively poorer in the treatment of patients with larynx stage III-IV and hypopharynx stage II-IV. Also, the good performance of CCRT and ICRT in terms of DFS made them as secondary recommended therapies. There is no significant difference between surgery and transoral laser microsurgery (TLM) alone.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5412-z) contains supplementary material, which is available to authorized users.

Management of advanced hypopharyngeal carcinoma: systematic review of survival following surgical and non-surgical treatments

BACKGROUND

Advanced hypopharyngeal carcinoma has a dismal prognosis. The optimal treatment for these patients remains under debate. This systematic review aimed to compare survival following surgical and non-surgical treatments.

METHODS

A systematic review was conducted of randomised studies, with a descriptive analysis of retrospective observational studies.

RESULTS

Two randomised trials and 11 observational studies were included in the review. A meta-analysis of randomised trials reported a hazard ratio of 0.89 for overall survival in favour of surgical treatment (p = 0.44). Neither treatment was favoured in terms of overall survival. Observational studies did not report a survival advantage with either treatment. The five-year larynx preservation rates for non-surgically treated patients were between 38 and 58 percent.

CONCLUSION

Chemoradiotherapy offers similar survivorship compared to surgery in advanced disease, while also making larynx preservation feasible. It can be used as a treatment in all patients as an alternative to surgery.

Prognostic significance of surgical extranodal extension in head and neck squamous cell carcinoma patients

Background

Lymph node metastasis with extranodal extension represents one of the most important adverse prognostic factors for survival in patients with head and neck squamous cell carcinoma. We propose that extranodal extension occurs to differing extents. The aim of this study was to determine the prognostic significance of extranodal extension in patients with head and neck squamous cell carcinoma.

Methods

Two hundred and ninety-eight patients with head and neck squamous cell carcinoma who underwent surgical resection and neck dissection were included. Cervical lymph nodes were classified into four categories: (i) pathological N negative, (ii) extranodal extension negative, (iii) non-surgical extranodal extension and (iv) surgical extranodal extension.

Results

Lymph node metastases were detected in 67.1% of laryngeal/hypopharyngeal cancer patients and 52.7% of oral cancer patients. The 3-year disease-specific survival rates for patients in the pathological N negative, extranodal extension negative, non-surgical extranodal extension and surgical extranodal extension groups were 90.9%, 79.6%, 63.8% and 48.3%, respectively. In laryngeal/hypopharyngeal cancer patients, surgical extranodal extension was associated with a significantly poorer disease-specific survival than a pathological N negative, extranodal extension negative or non-surgical extranodal extension status. In oral cancer patients, no significant differences were observed between the non-surgical and surgical extranodal extension groups. However, non-surgical extranodal extension was associated with a poorer disease-specific survival than a pathological N negative or extranodal extension negative status.

Conclusions

Surgical extranodal extension was a poor prognostic factor in patients with head and neck squamous cell carcinoma. The prognostic significance of surgical extranodal extension differed between laryngeal/hypopharyngeal and oral cancer patients. The clinical significance of surgical extranodal extension was much greater for patients with laryngeal/hypopharyngeal cancer than oral cancer.

Improved overall survival and mortality in head and neck cancer with adjuvant concurrent chemoradiotherapy in national databases

BACKGROUND

Many studies have demonstrated the advantage of postoperative concurrent chemoradiotherapy (CRT) over radiotherapy (RT) alone in locoregional control, but few have examined overall survival with respect to national databases.

METHODS

The literature was searched for eligible randomized controlled trials. The Surveillance, Epidemiology, and End Results (SEER) Database and National Cancer Data Base (NCDB) were searched for 5-year overall survival data.

RESULTS

Twenty-eight studies were examined and demonstrated 44% greater locoregional control (relative risk [RR] = 0.56; 95% confidence interval [CI] = 0.46-0.68) and 12% overall survival benefit (RR = 0.88; 95% CI = 0.81-0.98) with postoperative adjuvant CRT compared to adjuvant RT. Overall SEER survival was 45.0% in 1973, rising to 53.2% in 2005. The NCDB documents a similar increase in overall survival from 45.5% in 1994 to 53.4% in 2005.

CONCLUSION

The literature shows mortality benefit of adjuvant CRT in patients with advanced head and neck cancer, reflected in SEER and NCDB.

Clinical outcome and patterns of recurrence of head and neck squamous cell carcinoma with a limited field of postoperative radiotherapy

BACKGROUND

Postoperative radiotherapy is the standard treatment for head and neck squamous cell carcinoma having high-risk features in surgical specimens. However, its severe toxicity can be a significant problem. This study was undertaken to evaluate the efficacy of our limited-field postoperative radiotherapy with the aim of reducing morbidity by minimizing the radiation field.

METHODS

Between 2000 and 2009, 154 patients with head and neck squamous cell carcinoma received limited-field postoperative radiotherapy. The reason for postoperative radiotherapy was close/positive margins in 33 patients and extracapsular extension in 91. The median radiation dose was 50 Gy (30-66.4). The radiation field covered the tumor bed without lymph node regions for close/positive margins and only involved sites of the neck region were irradiated for multiple nodes or extracapsular extension.

RESULTS

With a median follow-up of 43 months for surviving patients, the 3-year overall survival and progression-free survival rates were 53.7 and 42.1%, respectively. The 3-year rates of progression-free survival of the group having major risks (i.e. close/positive margins and/or extracapsular extension) and the group with other risks were 34.7 and 62.8%, respectively (P < 0.01). Thirty-one local recurrences (20%), of which 22 were located out-of-field, and 44 regional recurrences (29%), of which 16 were located out-of-field, developed. Late toxicity of grade 3 or greater developed in only six patients (3.8%).

CONCLUSIONS

Although the toxicities associated with limited-field postoperative radiotherapy could be kept to lower levels, the locoregional control rate did not seem to be sufficient. We should arrange the radiation field depending on risk factors.

Treatment results and prognostic factors of patients undergoing postoperative radiotherapy for laryngeal squamous cell carcinoma

Postoperative radiotherapy (PRT) is widely advocated for patients with squamous cell carcinomas of the head and neck that are considered to be at high risk of recurrence after surgical resection. The aims of this study were to evaluate the treatment outcomes of PRT for patients with laryngeal carcinoma and to identify the value of several prognostic factors. We reviewed the records of 256 patients treated for laryngeal squamous cell carcinoma between January 1993 and December 2005. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Log-rank test was employed to identify significant prognostic factors for DFS and OS. The Cox proportional hazards model was applied to identify covariates significantly associated with the aforementioned endpoints. Our results showed the 3-, 5-, and 10-year DFS for all patients were 69.9%, 59.5%, and 34.9%, respectively. The 3-, 5-, and 10-year OS rates were 80.8%, 68.6%, and 38.8%, respectively. Significant prognostic factors for both DFS and OS on univariate analysis were grade, primary site, T stage, N stage, overall stage, lymph node metastasis, overall treatment times of radiation, the interval between surgery and radiotherapy, and radiotherapy equipment. Favorable prognostic factors for both DFS and OS on multivariate analysis were lower overall stage, no cervical lymph node metastasis, and using 60Co as radiotherapy equipment. In conclusion, our data suggest that lower overall stage, no cervical lymph node metastasis, and using 60Co as radiotherapy equipment are favorable prognostic factors for DFS and OS and that reducing the overall treatment times of radiation to 6 weeks or less and the interval between surgery and radiotherapy to less than 3 weeks are simple measures to remarkably improve treatment outcome.

Traditional transcutaneous approaches in head and neck surgery

The treatment of laryngeal and hypopharyngeal malignancies remains a challenging task for the head and neck surgeon as the chosen treatment modality often has to bridge the gap between oncologically sound radicality and preservation of function. Due to the increase in transoral laser surgery in early tumor stages and chemoradiation in advanced stages, the usage of traditional transcutaneous approaches has decreased over the recent past. In addition, the need for a function-sparing surgical approach as well as highest possible quality of life has become evident. In view of these facts, rationale and importance of traditional transcutaneous approaches to the treatment of laryngeal and hypopharyngeal malignancies are discussed in a contemporary background. The transcutaneous open partial laryngectomies remain a valuable tool in the surgeon's armamentarium for the treatment of early and advanced laryngeal carcinomas, especially in cases of impossible laryngeal overview using the rigid laryngoscope. Open partial laryngetomies offer superior overview and oncologic safety at the anterior commissure, especially in recurrencies. In select advanced cases and salvage settings, the supracricoid laryngectomy offers a valuable tool for function-preserving but oncologically safe surgical therapy at the cost of high postoperative morbidity and a very demanding rehabilitation of swallowing.In hypopharyngeal malignancies, the increasing use of transoral laser surgery has led to a decline in transcutaneous resections via partial pharyngectomy with partial laryngectomy in early tumor stages. In advanced stages of tumors of the piriform sinus and the postcricoid area with involvement of the larynx, total laryngectomy with partial pharyngectomy is an oncologically safe approach. The radical surgical approach using circumferent laryngopharyngectomy with/without esophagectomy is indicated in salvage cases with advanced recurrences or as a primary surgical approach in patients where chemoradiation does not offer sufficient oncologic control or preservation of function. In cases with impending reconstruction, fasciocutaneous free flaps (anterolateral thigh flap, radial forearm flap) seem to offer superior results to enteric flaps in cases where the cervical esophagus is not involved leading to better voice rehabilitation with fewer complications and postoperative morbidity. In salvage situations, the Gastroomental Free Flap has proven to be a valuable tool.In conclusion, the choice of a surgical treatment modality is influenced by the patient's anatomy, tumor size and location as well as the surgeon's personal expertise.

Postoperative therapy in head and neck cancer: state of the art, risk subset, prognosis and unsolved questions

Head and neck cancer may be easily controlled at early stages, but resectable locally advanced disease often relapses at T and N sites. Therefore, adequate adjuvant treatment is of crucial importance for improving local control and/or survival. Unfortunately, little data are available on the adjuvant setting. Adjuvant radiotherapy is regarded as a standard approach for patients with locally advanced radically resected head and neck cancer, while postoperative chemotherapy alone cannot be considered outside of clinical trials. However, chemoradiotherapy is widely considered superior to radiotherapy in patients at a high risk of relapse and may be considered the standard treatment in this population. In this respect, in the last few decades, there has been a growing interest due to the emerging data on both tumor biology and clinical trials. Several pathological and molecular factors, affecting behavior and head and neck cancer prognosis, could allow for a better selection of postoperative treatment. More recently, new prognostic and predictive factors were identified, including biomolecular aspects, human papillomavirus infection and lifestyle. The integration of these new factors deserves dedicated clinical studies, but the available knowledge already allows some deductive hypotheses. We performed a review of the literature to analyze the role of therapy in the postoperative setting and to discuss both the possibility of a different approach to each class of risk and the unsolved question for which randomized trials are warranted.

Larynx-Preserving Partial Pharyngectomy via Lateral Pharyngotomy for the Treatment of Small (T(1~2)) Hypopharyngeal Squamous Cell Carcinoma

Objectives

To evaluate the oncologic and functional results of larynx-preserving partial pharyngectomy (LPP) via lateral pharyngotomy approach as a primary treatment for small (T1 or T2) hypopharyngeal squamous cell carcinoma (HPSCC).

Methods

We performed a retrospective review of 23 patients who underwent LPP through lateral pharyngotomy approach for small HPSCC at the our department between January 1991 and June 2007. Fourteen (61%) patients had adjuvant postoperative radiotherapy.

Results

The 2-years and 5-years disease specific survival rate was 77% and 61%, respectively. Nine patients (39%) had tumor recurrence. The most common pattern of recurrence was isolated distant failure (n=4, 44%) followed by local (n=2, 22%) and loco-regional (n=3, 34%) recurrence. The ultimate cure rate of the primary tumor was 87% (20 of 23). Twenty-two of the 23 patients (95%) could be decannulated, tolerate an oral diet, and had acceptable postoperative phonatory function.

Conclusion

LPP via lateral pharyngotomy approach appears to be a feasible procedure for selected small HPSCC patients in terms of both oncologic and functional outcomes.

Current trends in initial management of hypopharyngeal cancer: the declining use of open surgery

Squamous cell carcinoma of the hypopharynx represents a distinct clinical entity. Most patients present with significant comorbidities and advanced-stage disease. The overall survival is relatively poor because of high rates of regional and distant metastasis at presentation or early in the course of the disease. A multidisciplinary approach is crucial in the overall management of these patients to achieve the best results and maintain or improve functional results. Traditionally, operable hypopharyngeal cancer has been treated by total (occasionally partial) laryngectomy and partial or circumferential pharyngectomy, followed by reconstruction and postoperative radiotherapy in most cases. Efforts to preserve speech and swallowing function in the surgical treatment of hypopharyngeal (and laryngeal) cancer have resulted in a declining use of total laryngopharyngectomy and improved reconstructive efforts, including microvascular free tissue transfer. There are many surgical, as well as nonsurgical, options available for organ and function preservation, which report equally effective tumor control and survival. The selection of appropriate treatment is of crucial importance in the achievement of optimal results for these patients. In this article, several aspects of surgical and nonsurgical approaches in the treatment of hypopharyngeal cancer are discussed. Future studies must be carefully designed within clearly defined populations and use uniform terminology and standardized functional assessment and declare appropriate patient or disease endpoints. These studies should focus on improvement of results, without increasing patient morbidity. In this respect, technical improvements in radiotherapy such as intensity-modulated radiotherapy, advances in supportive care, and incorporation of newer systemic agents such as targeted therapy, are relevant developments.

Postoperative strategies after primary surgery for squamous cell carcinoma of the head and neck

This review discusses the role of adjuvant treatment after curative surgery for patients with head and neck squamous cell carcinoma (HNSCC). In general, patients with unfavourable prognostic factors have a high-risk of loco-regional recurrence and subsequent worse survival after surgery alone and are therefore considered proper candidates for adjuvant treatment by either postoperative radiotherapy alone or postoperative chemoradiation. Selection of the most optimal adjuvant treatment strategy should be based on the most important prognostic factors. In this review, the different treatment strategies will be discussed in general. More specifically, we will discuss the role of the interval between surgery and radiotherapy, the overall treatment time of radiation, the selection of target volumes for radiation and the value of adding concomitant chemotherapy to postoperative radiation.

Postoperative Radiotherapy in Head and Neck Cancer

Though early stage head and neck cancers can be cured either by surgery or radiation, patients with locally advanced disease continues to pose a therapeutic challenge. Locoregional failure is the major cause of death in head and neck cancers. As the outcome of locally advanced head and neck cancer is less than promising, a combined modality approach is generally undertaken in this group of patients. The combination of surgery, radiation and more recently, chemotherapy and targeted therapy can improve outcomes in locally advanced head and neck cancer patients. This overview discusses the rationale and role of postoperative radiotherapy (PORT) in advanced head and neck cancers, the radiotherapy technique in brief and methods of enhancing the efficacy of postoperative RT by altering the fractionation schedules and adding chemotherapy and targeted therapy.

Treatment results and prognostic factors in locally advanced hypopharyngeal cancer

CONCLUSIONS

We suggest that concurrent chemoradiation (CCRT) is an effective definitive treatment for patients with advanced hypopharyngeal carcinoma who are unfit for or refuse surgery. A high dose of radiation (> 70 Gy) should be given to achieve acceptable local control rates and survival.

OBJECTIVES

The purpose of this retrospective study was to compare the treatment results of locally advanced hypopharyngeal carcinoma with two different protocols.

PATIENTS AND METHODS

From December 1995 to December 2004, 74 patients with locally advanced hypopharyngeal cancer were treated with CCRT or surgery plus postoperative radiotherapy (SRT). Their treatment results were reviewed by retrospective analysis. The study points included outcome, toxicity, and prognostic factors.

RESULTS

There was no significant difference in T and N status between the two treatment groups, nor were there significant differences in overall or disease-free survival or the incidence of distant metastasis (p >0.05). In the CCRT group and SRT group, the estimated 3-year overall survival was 39% and 44%, respectively. The SRT group had better local control than the CCRT group (p <0.05). Relatively, 27% patients retained their larynx function for more than 2 years in the CCRT group. Radiation doses >70 Gy yielded significantly better survival and local control than doses <70 Gy (p <0.05).

A clinical study of post-cricoid carcinoma

CONCLUSION

The local control rate following surgery was very high in patients with post-cricoid carcinoma; however, many of the patients undergoing surgery later developed distant metastasis. Therefore, establishment of chemotherapeutic regimens for preventing distant metastasis is desirable.

OBJECTIVES

To define the clinical course of the cancer, the problems that might be associated with its treatment, and the future course of treatment of this cancer at our hospital.

PATIENTS AND METHODS

This study included 21 patients with post-cricoid carcinoma who had undergone primary treatment at our hospital between 1989 and 2004. The present study was designed to retrospectively investigate the therapeutic outcome of post-cricoid carcinoma at our hospital.

RESULTS

The 5-year cause-specific survival rate was 52%. All the patients who eventually died did so within 3 years of the treatment. Seven patients had distant metastases, representing a higher frequency as compared with that of patients with recurrence of the primary focus and cervical lymph node metastasis. All of these patients who had been treated by surgery died of the cancer.

Two-field versus three-field irradiation technique in the postoperative treatment of head-and-neck cancer

PURPOSE

We have increasingly used a two-field noncoplanar "caudal tilt" technique (CTT) for irradiating postlaryngectomy and pharyngectomy patients to avoid matchline problems that can be encountered with the classic three-field head-and-neck radiation technique (3FT). This report compares the clinical outcomes of patients treated with postoperative radiation (PORT) using either 3FT or CTT.

METHODS AND MATERIALS

We conducted a retrospective review of the medical records of all patients with laryngeal or hypopharyngeal cancers consecutively treated with PORT between 1997 and 2002. Three-dimensional dosimetric planning was carried out for all patients.

RESULTS

Of 91 patients, 39 were treated with 3FT and 52 with CTT. The median follow-up was 34 months. Estimated rates of 2-year locoregional control, disease-free survival, and overall survival for patients treated with 3FT and CTT were, respectively, 92% and 85% (p=0.241), 62% and 55% (p=0.497), and 77% and 72% (p=0.616). There were no significant differences in the incidence of acute or late side effects in the two groups.

CONCLUSIONS

"Caudal tilt" technique is often used as an alternative to 3FT for postoperative radiotherapy in cases of greater medical and technical complexity. Despite its use in more challenging cases, CTT provides similar long-term clinical outcomes compared with standard 3FT, when computerized three-dimensional dosimetry is used to assure adequate dosimetry throughout the treated volume.

Radical Radiotherapy in Head and Neck Squamous Cell Carcinoma: An Analysis of Prognostic and Therapeutic Factors

AIMS

Head and neck squamous cell carcinoma (HNSCC) continues to be a leading cancer in developing countries. Definitive radiation therapy either primary or as postoperative adjuvant is offered to most patients. We aimed to identify prognostic and therapeutic factors that affect locoregional control and survival in patients undergoing radical radiotherapy for head and neck squamous cell cancers.

MATERIALS AND METHODS

A retrospective analysis of 568 previously untreated patients with squamous head and neck cancers, who received radical radiotherapy between 1990 and 1996, using local control, locoregional control and disease-free survival (DFS) as outcome measures.

RESULTS

With a median follow-up of 18 months for living patients, the 5-year local control, locoregional control and DFS for all 568 patients were 53%, 45% and 41%, respectively, for all stages combined. The 5-year local control, locoregional control and DFS as per the American Joint Committee on Cancer stage grouping were 78%, 70% and 70%; 64%, 59% and 57%; 51%, 42% and 37%; and 40%, 27% and 22% from stages I to IV, respectively, with highly significant P values. Patients receiving higher doses (> or = 66 Gy) had a significantly better outcome compared with lower doses. The 5-year local control (59% vs 48%, P = 0.0015), locoregional control (47% vs 41%; P = 0.0043) and DFS (44% vs 37%; P = 0.0099) were significantly better in patients receiving > or = 66 Gy. Site of primary also affected outcome significantly, with oral cavity lesions faring badly.

CONCLUSION

Tumour stage remains the most important factor affecting outcome in radical radiotherapy of HNSCC. A definite dose-response relationship exists with higher total doses, leading to better local control, locoregional control and DFS in all stages. Site of primary affects outcome too, with laryngeal primaries doing well and oral cavity cancers faring the worst.

Head and neck squamous cell carcinoma: the role of post-operative adjuvant radiotherapy

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) is one of the leading cancers in India. Since a large majority present in loco-regionally advanced stages, surgery followed by adjuvant post-operative radiotherapy (PORT) has been the mainstay of treatment for resectable HNSCC.

AIM

To identify clinico-pathologic factors that could have an impact on outcome in HNSCC in the postoperative setting.

MATERIALS AND METHODS

A retrospective review of 348 previously untreated patients with HNSCC who received PORT following curative surgery. The outcome measures were local control, loco-regional control, and disease free survival (DFS).

RESULTS

With a median follow-up of 36 months (range: 2-127 months) for surviving patients, the 5-year local control, loco-regional control, and DFS was 79%, 63%, and 56%, respectively for all patients. On univariate analysis, site of primary was an independent prognostic factor for all the outcome measures (P = 0.005, 0.02, and 0.04, respectively) with oral cavity lesions faring the worst. Peri-nodal extension (PNE) affected loco-regional control (P = 0.002) and DFS (P = 0.0005), but was not predictive for local control (P = 0.9852). Cut margin positivity predicted for inferior local control alone (P = 0.03), the significance of which was lost on multivariate analysis. Cox regression analysis however confirmed the significance of primary site and PNE as independent prognostic factors.

CONCLUSION

Primary site and PNE are independent factors predicting outcome in the postoperative radiotherapeutic management of HNSCC.

Management of the patients with hypopharyngeal cancer: eight-year experience of Miyagi Cancer Center in Japan

The aim of this study is to evaluate the results of treatment for hypopharyngeal cancer and indicate the future prospect of the treatment. Seventy-four patients with squamous cell carcinoma of the hypopharynx admitted to Miyagi Cancer Center from 1993 through 2000 are reviewed. Sixty-four patients received radical treatment, and 10 patients received palliative treatment or no treatment. The cancer was advanced (stages III and IV) in 82% of all the patients. The overall 5-year survival rate of all the patients was 38%. The overall 5-year survival rate of 64 patients received radical treatment was 43%. The ten patients who received palliative treatment or no treatment died of cancer within 16 months. Fifty-two out of the 74 patients underwent neck dissection for the neck lymph node involvement; forty of the 52 patients underwent ipsilateral neck dissection and 12 underwent bilateral neck dissection. Four out of the 40 patients, who underwent ipsilateral neck dissection alone, developed late contralateral regional recurrence but were successfully treated by contralateral neck dissection at the time of recurrence. Twenty-three out of 74 patients had multiple primary cancers synchronously or metachronously (31%). Cause of the death of six patients out of 74 patients was confirmed to be primary cancers other than hypopharyngeal cancer, as judged by physicians in other department or other hospitals. Most of the patients died due to distant metastasis from hypopharyngeal cancer or other primary cancers. We therefore conclude that contralateral elective neck dissection which is frequently chosen for the treatment of hypopharyngeal cancer surgery is unnecessary. Even if locoregional control is accomplished, distant metastasis or multiple primary cancers emerge and make prognosis poor. To improve the prognosis, we should develop some strategy against hypopharyngeal cancer for each patient. New strategies including chemoprevention and surgery against distant metasistasis are necessary.

Carcinoma of the hypopharynx

Despite advances in surgical and nonsurgical treatment, overall survival rates for patients who have hypopharyngeal carcinoma have not improved,and this disease still has a poor prognosis. The best results are obtained with multimodality therapy. but at best, two thirds of patients are palliated rather than cured of disease. Radical surgery with postoperative radiation therapy remains the standard of care. Organ preservation strategies have not been as successful in hypopharyngeal cancer as for cancers of other head and neck sites. Chemoradiation is an effective alternative method of aggressive treatment but may be associated with significant dysfunction of the end organ when preservation is possible. Because of poor long-term survival rates, local control remains the most important factor in planning treatment, to provide meaningful palliation and best possible quality of life.

Long-term survival of patients with stage IV hypopharyngeal cancer: impact of fundus rotation gastroplasty

Stage IV circular hypopharyngeal cancer is a disease with poor long-term survival, and the only means of cure-surgery-is associated with high morbidity. All patients admitted with circular hypopharyngeal cancer and extension to the esophagus were enrolled in a multidisciplinary treatment protocol, including circular laryngopharyngoesophagectomy with tracheostomy, neck dissection, and pull-up of a fundus rotation gastric tube that was anastomosed to the oropharynx. Five weeks postoperatively high-dose radiotherapy (60 Gy) was given to the cervical region. Altogether, 18 qualifying patients were explored cervically, were found to have resectable lesions (i.e., without carotid artery infiltration), and were included in the protocol. After laryngopharyngoesophagectomy, an elongated gastric tube was pulled up to the oropharynx. The average distance bridged with the tube was 32 +/- 4 cm. No anastomotic leaks were found on postoperative Gastrografin swallow, and oral feeding was started between days 5 and 8. Patients were discharged with normal oral feeding on day 21 (+/- 17 days). Diarrhea, postprandial fullness, and reflux resolved within 6 months postoperatively. Five patients died during the follow-up period of 42 months (range 3-63 months): three due to cardiac events 18 and 38 months postoperatively and two within 12 months with residual disease and tumor recurrence, respectively. The estimated 5-year survival was 60%. We concluded that an aggressive multidisciplinary approach including circular laryngopharyngoesophagectomy, neck dissection, and high-dose radiotherapy ascertains good long-term survival and good functional results in patients with advanced hypopharyngeal cancer when the intestinal continuity is reconstructed with a fundus rotation gastroplasty.

Influence of the delay of adjuvant postoperative radiation therapy on relapse and survival in oropharyngeal and hypopharyngeal cancers

PURPOSE

To determine whether the delay between surgery and the beginning of radiation therapy influences survival or the risk of local-regional relapse in oropharyngeal or hypopharyngeal squamous cell carcinomas.

METHODS AND MATERIALS

From 2052 patients referred to the Henri Becquerel Center for the radiation therapy of an oropharyngeal or hypopharyngeal cancer between January 1, 1981 and December 31, 1992, 420 were included in a retrospective study. Exclusion criteria were another cancer, metastasis, incomplete resection, lack of homolateral lymph node resection, or previous chemotherapy. Radiation therapy delivered 45 to 75 Gy on initial location and lymph node. Follow-up was performed until December 31, 1997. A Cox proportional hazard regression analysis was used to evaluate the prognostic factors.

RESULTS

The delay between surgery and radiation therapy was not found to be a significant prognostic factor for survival or risk of local-regional relapse. The only parameters found to influence local-regional and survival control were margins' pathologic state (respectively p < 0.0001 and p = 0.015) and T (p < 0.0001) and N (respectively p < 0.0001 and p = 0.0004) stages. In terms of local-regional relapse only, age was a prognostic factor (p = 0.048), and a trend was noted for tumor emboli in vessels or nerves (p = 0.061).

CONCLUSION

In patients with oropharyngeal or hypopharyngeal squamous cell carcinoma, the delay between surgical procedure and radiation therapy does not influence survival or risk of local-regional relapse. Radiation therapy might be subjected to complete healing in these patients.

Surgical management of head and neck cancer

Head and neck cancer surgery continues to evolve through the years and undergo improvement and refinement. In this article, the current state of head and neck cancer surgery is summarized in a site-by-site basis. The most important developments include organ-sparing surgery and microvascular free-tissue transfer for reconstruction.

Post-operative radiotherapy in carcinoma of buccal mucosa, a prospective randomized trial

Squamous cell carcinoma of the buccal mucosa is a common cancer in India. We are referred a large number of locally advanced lesions where curative surgery is still possible. The objective of this study is to determine the role of post-operative radiotherapy in enhancing disease-free survival. Patients with stages III and IV cancer of the buccal mucosa potentially curable by surgery were randomized to surgery only or post-operative radiotherapy. Patients were followed up for 3 years. The clinico-pathological features in both arms were comparable. Disease-free survival at the end of the study was found to be 38% and 68% (P<0.005) respectively. Post-operative radiotherapy was thus seen to improve disease-free survival in squamous cell carcinoma of the buccal mucosa.

Study of tumour ploidy in early stages of buccal mucosa cancer

The purpose of this study was to determine whether a tumour's DNA content is a prognostic factor in screening out the biologically aggressive varieties of early buccal mucosa cancer. Seventy-eight cases of early squamous cell carcinoma of the buccal mucosa were studied, including 73 with aneuploid and diploid tumours. T1 and T2 tumours, pathological differentiation, vascular and perineural invasion, and the recurrence and disease-free survival rate in relation to aneuploid and diploid content were ascertained. The recurrence rate in aneuploid tumours is 72%, whereas in diploid tumours it is 6% (P<0.001). A Cox regression analysis demonstrated that tumour ploidy was a prognostic factor in disease-free survival, independent of other clinico-pathological characteristics examined. Aneuploidy is the most accurate predictor of biological aggressiveness of cancer of the buccal mucose. Aneuploid early buccal mucosa cancers should be treated by multimodal therapy to achieve a cure.