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De Felice F, Lei M, Oakley R, Lyons A, Fry A, Jeannon JP, Simo R, Guerrero Urbano T. Risk stratified follow up for head and neck cancer patients - An evidence based proposal. Oral Oncol 2021; 119:105365. [PMID: 34058702 DOI: 10.1016/j.oraloncology.2021.105365] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/11/2021] [Accepted: 05/23/2021] [Indexed: 11/29/2022]
Abstract
Head and neck squamous cell carcinoma (HNSCC) has a significant impact on patients' quality of life and treatment can be associated with severe morbidity. Following completion of treatment, patients are followed up in order to detect potentially salvageable recurrences and to manage long-term toxicities. In recent years, a growing interest has been given to risk stratified follow-up interventions to prevent and detect recurrences and manage treatment toxicities in other tumour sites as well as to transfer some of that care to community services. We review the literature for HNSCC and propose a risk stratified follow up protocol to address these issues and assist clinicians in decision making. A shift in patterns of care is suggested in order to provide a basis to improve care for HNSCC patients after complete response to primary treatment.
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Affiliation(s)
- Francesca De Felice
- Department of Clinical Oncology, Guy's and St Thomas' NHS Trust, London, UK; Department of Radiotherapy, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Mary Lei
- Department of Clinical Oncology, Guy's and St Thomas' NHS Trust, London, UK
| | - Richard Oakley
- Department of Head and Neck Surgery Guys and St Thomas' NHS Trust, London, UK
| | - Andrew Lyons
- Department of Head and Neck Surgery Guys and St Thomas' NHS Trust, London, UK
| | - Alastair Fry
- Department of Head and Neck Surgery Guys and St Thomas' NHS Trust, London, UK
| | - Jean-Pierre Jeannon
- Department of Head and Neck Surgery Guys and St Thomas' NHS Trust, London, UK; King's College London, UK
| | - Ricard Simo
- Department of Head and Neck Surgery Guys and St Thomas' NHS Trust, London, UK
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Sanabria A, Kowalski LP, Nixon IJ, Simo R. Microscopic positive surgical margins in thyroid carcinoma: a proposal for thyroid oncology teams. Langenbecks Arch Surg 2021; 406:563-569. [PMID: 33555410 DOI: 10.1007/s00423-021-02095-y] [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: 01/11/2021] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE In the case of well-differentiated thyroid cancer, the importance of microscopic margin status remains controversial. We discuss the relevance of the effect of microscopic positive surgical margins in the early stages of differentiated thyroid cancer. METHODS A comprehensive literature search and review of available evidence in English literature was undertaken. RESULTS A previous meta-analysis did not find an association between microscopic positive surgical margins and local recurrence. Heterogeneity of definitions and differences between microscopic surgical margins and extrathyroid extension are discussed. Impact on clinical decision-making is explored. CONCLUSION The finding of microscopic positive surgical margins in a patient with a thyroid tumor without intraoperative evidence of macroscopic invasion to adjacent structures, with complete resection made by the surgeon and without pathological report of extrathyroid extension, does not have a worse prognostic effect. We present a classification of surgical margins that may help thyroid oncology teams to tailor further management in patients with thyroid cancer.
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Affiliation(s)
- Alvaro Sanabria
- Department of Surgery, School of Medicine, Universidad de Antioquia, CEXCA. Centro de Excelencia en Enfermedades de Cabeza y Cuello, Cra. 51d #62-29, Medellín, Colombia.
| | - Luiz P Kowalski
- Head and Neck Surgery Department, University of Sao Paulo Medical School and Head and Neck Surgery and Otorhinolaryngology Department, A.C. Camargo Cancer Center, Sao Paulo, Brazil
| | - Iain J Nixon
- Department of Otolaryngology Head and Neck Surgery, NHS Lothian, University of Edinburgh, Edinburgh, UK
| | - Ricard Simo
- Department of Otorhinolaryngology, Head and Neck Surgery, Thyroid Oncology Unit Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
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Singh A, Mair M, Singhvi H, Ramalingam N, Bal M, Lamba K, Nair D, Nair S, Chaturvedi P. Incidence and impact of dysplasia at final resection margins in cancers of the oral cavity. Acta Otolaryngol 2020; 140:963-969. [PMID: 32662707 DOI: 10.1080/00016489.2020.1785642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The literature often cites margin status as being free, close or involved by tumor but there is very sparse evidence of the relevance of dysplasia at resection margin. Aims/Objectives: To compare the impact of dysplasia at final resection margin (D-FRM) and other margin statuses on overall survival (OS) and disease free survival (DFS). METHODS This is a retrospective review of 1700 treatment naïve oral squamous carcinoma patients who underwent surgery between January 2012 and December 2015. The study arm consisted of patients with dysplasia at final resection margin (D-FRM). Each of these patients were double propensity matched to obtain positive (P-FRM), close (C-FRM) and free final resection margins (F-FRM). RESULTS There was no hazard discrimination in survival among the D-FRM and C-FRM (vs F-FRM; p-0.597, HR-1.207 (0.621-2.346) and p-0.075, HR-1.594 (0.947-2.684), respectively). A decreasing survival trend was observed as the grade and number of D-FRM margins increased. Although not significant, the addition of adjuvant therapy for D-FRM showed a trend towards improved survival outcomes compared to C-FRM, especially with chemotherapy. Conclusion and relevance: The presence of D-FRM, irrespective of grade, had a similar impact on survival as C-FRM and underscores the possible need for treatment intensification.
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Affiliation(s)
- Arjun Singh
- Head and Neck Oncology Department, Tata Memorial Hospital, Mumbai, India
| | - Manish Mair
- Head and Neck Oncology Department, Tata Memorial Hospital, Mumbai, India
| | - Hitesh Singhvi
- Head and Neck Oncology Department, Tata Memorial Hospital, Mumbai, India
| | | | - Munita Bal
- Head and Neck Oncology Department, Tata Memorial Hospital, Mumbai, India
| | - Komal Lamba
- Head and Neck Oncology Department, Tata Memorial Hospital, Mumbai, India
| | - Deepa Nair
- Head and Neck Oncology Department, Tata Memorial Hospital, Mumbai, India
| | - Sudhir Nair
- Head and Neck Oncology Department, Tata Memorial Hospital, Mumbai, India
| | - Pankaj Chaturvedi
- Head and Neck Oncology Department, Tata Memorial Hospital, Mumbai, India
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Franco R, de Matos LL, Kulcsar MAV, de Castro-Júnior G, Marta GN. Influence of time between surgery and postoperative radiation therapy and total treatment time in locoregional control of patients with head and neck cancer: a single center experience. Clinics (Sao Paulo) 2020; 75:e1615. [PMID: 32725072 PMCID: PMC7362720 DOI: 10.6061/clinics/2020/e1615] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/08/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the effect of the delay to initiate postoperative radiation therapy (RT) on locoregional control to head and neck squamous cell carcinoma patients. METHODS Retrospective cohort study that included patients submitted to surgery followed by adjuvant RT (with/without chemotherapy). The time interval between surgery and RT was dichotomized by the receiver operating characteristics curve method at 92 days. Other possible sources of heterogeneity with potential impact on locoregional control were explored by regressive analysis. RESULTS A total of 168 patients were evaluated. The median time for locoregional recurrence (LRR) was 29.7 months. The relapse-free survival rates were 66.4% and 75.4% for patients who initiated RT more than and within 92 postoperative days (p=0.377), respectively. Doses lower than 60Gy were associated with worse rates of locoregional control (HR=6.523; 95%CI:2.266-18.777, p=0.001). Patients whose total treatment time (TTT) was longer than 150 days had LRR rate of 41.8%; no patient with TTT inferior to 150 days had relapses (p=0.001). CONCLUSIONS The interval between surgery and RT did not show influence on locoregional control rates. However, doses <60Gy and the total treatment time >150 days were associated with lower locoregional control rates.
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Affiliation(s)
- Rejane Franco
- Programa de Pos-Graduacao, Departamento de Radiologia e Oncologia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Hospital de Clinicas, Universidade Federal do Parana, Curitiba, PR, BR
| | - Leandro Luongo de Matos
- Departamento de Cirurgia de Cabeca e Pescoco, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Marco Aurélio Vamondes Kulcsar
- Departamento de Cirurgia de Cabeca e Pescoco, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Gilberto de Castro-Júnior
- Unidade Clinica de Oncologia, Departamento de Radiologia e Oncologia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Departamento de Oncologia Clinica, Hospital Sirio-Libanes, Sao Paulo, SP, BR
| | - Gustavo Nader Marta
- Departamento de Radiologia e Oncologia, Servico de Radioterapia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Departamento de Radioterapia, Hospital Sirio-Libanes, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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Tel A, Bagatto D, Tuniz F, Sembronio S, Costa F, D'Agostini S, Robiony M. The evolution of craniofacial resection: A new workflow for virtual planning in complex craniofacial procedures. J Craniomaxillofac Surg 2019; 47:1475-1483. [DOI: 10.1016/j.jcms.2019.06.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 06/18/2019] [Accepted: 06/27/2019] [Indexed: 02/03/2023] Open
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Sanabria A, Rojas A, Arevalo J, Kowalski LP, Nixon I. Microscopically positive surgical margins and local recurrence in thyroid cancer. A meta-analysis. Eur J Surg Oncol 2019; 45:1310-1316. [PMID: 30795955 DOI: 10.1016/j.ejso.2019.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 01/06/2019] [Accepted: 02/05/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Microscopically positive surgical margins are a prognostic factor of recurrence in advanced thyroid carcinoma. However, information on early and completely resected thyroid tumors is scarce. Some studies do not identify any association between positive margin and local recurrence. The objective of this study was to perform a meta-analysis to measure the association of microscopically positive surgical margins and local recurrence in patients who underwent total thyroidectomy. METHODS Clinical trials assessing the association between microscopically positive surgical margin and local recurrence in patients with early-stage, well-differentiated thyroid carcinoma who underwent total thyroidectomy were evaluated. The outcome measured was local recurrence in the thyroid bed. A systematic review and meta-analysis was done using a random-effects model. RESULTS Six studies with 7696 patients were identified. Methodological quality was good, and we did not identify statistical heterogeneity or publication bias. The risk difference for microscopically positive surgical margin and local recurrence was 0% (95% CI 0 to 1). CONCLUSION Meta-analysis did not find a statistically significant association between microscopically positive surgical margin and local recurrence in this population. A finding of microscopically positive surgical margin in the absence of other adverse factors is not an indication for adjuvant treatment.
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Affiliation(s)
- Alvaro Sanabria
- Department of Surgery, School of Medicine, Universidad de Antioquia, Cra. 51d #62-29, Medellín, Antioquia, Colombia; Head and Neck Service, Clínica Vida, Carrera 50 A # 64 - 42, Medellin, Colombia.
| | - Andres Rojas
- Head and Neck Service, Clínica Vida, Carrera 50 A # 64 - 42, Medellin, Colombia.
| | - Joel Arevalo
- Head and Neck Service, Clínica Vida, Carrera 50 A # 64 - 42, Medellin, Colombia.
| | - Luiz P Kowalski
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, R. Professor Antônio Prudente, 211, Liberdade, Sao Paulo, SP, Brazil.
| | - Iain Nixon
- ENT Department, NHS Lothian, Waverley Gate 2-4 Waterloo Place, Edinburgh, UK.
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Nishio N, Fujii M, Hayashi Y, Hiramatsu M, Maruo T, Iwami K, Kamei Y, Yagi S, Takanari K, Fujimoto Y. Preoperative surgical simulation and validation of the line of resection in anterolateral craniofacial resection of advanced sinonasal sinus carcinoma. Head Neck 2016; 39:512-519. [PMID: 27905167 DOI: 10.1002/hed.24653] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 06/15/2016] [Accepted: 10/21/2016] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The purpose of this study was to assess the usefulness and accuracy of preoperative 3D virtual simulation of anterolateral craniofacial resection in cases of advanced sinonasal sinus carcinoma. METHODS Seven patients with advanced (T4 classification) sinonasal sinus carcinoma who underwent anterolateral craniofacial resection in our hospital between 2011 and 2013 were included in this study. Postsimulation CT images were fused with postoperative CT images and differences between the planned and actual osteotomy were measured in 3 regions of the skull base. RESULTS The differences ranged from 0 mm to 5.8 mm (average, 3.1 mm) at the inferior wall of the cavernous sinus, from 0.8 mm to 8.3 mm (average, 3.5 mm) at the inferior wall of the sphenoid sinus, and from 0 mm to 13.6 mm (average, 2.3 mm) in the palatine bone. CONCLUSION Preoperative 3D virtual surgical simulation and postoperative feedback can contribute to training for surgeons. © 2016 Wiley Periodicals, Inc. Head Neck 39: 512-519, 2017.
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Affiliation(s)
- Naoki Nishio
- Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masazumi Fujii
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Yuichiro Hayashi
- Information and Communications, Nagoya University, Nagoya, Japan
| | - Mariko Hiramatsu
- Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Maruo
- Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenichiro Iwami
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Yuzuru Kamei
- Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shunjiro Yagi
- Department of Plastic and Reconstructive Surgery, Tottori University Faculty of Medicine, Tottori, Japan
| | - Keisuke Takanari
- Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasushi Fujimoto
- Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Intensity modulated radiation therapy (IMRT) for sinonasal tumors: a single center long-term clinical analysis. Radiat Oncol 2016; 11:17. [PMID: 26847089 PMCID: PMC4743109 DOI: 10.1186/s13014-016-0595-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 01/29/2016] [Indexed: 01/25/2023] Open
Abstract
Background Radiotherapy has a central role in the treatment of sinonasal malignancies, either as postoperative or as primary therapy. To study the efficacy and safety of intensity modulated radiotherapy (IMRT) for sinonasal tumors a single center retrospective evaluation focusing on survival and therapy related toxicity was performed. Methods One hundred twenty two patients with primary (n = 82) or recurrent (n = 40) malignant sinonasal tumors were treated with intensity modulated radiotherapy between 1999 and 2009 at the University Clinic of Heidelberg and the German Cancer Research Center and retrospectively analyzed. Most patients had adenoid cystic carcinomas (n = 47) or squamous cell carcinoma (n = 26). 99 patients received postoperative radiotherapy. The median total dose was 64 Gy in conventional fractionation (1.8–2 Gy). Overall survival (OS), progression free survival (PFS) and local recurrence free survival (LRFS) rates were calculated using the Kaplan-Meier method. The log-rank test and Fishers Exact test were applied for univariate analysis, Cox-regression was used for multivariate analysis. Results Median follow up was 36 months. 1-, 3- and 5-year estimated overall survival rates were 90, 70 and 54 % respectively. Median progression free survival and local recurrence free survival was 45 and 63 months respectively. Progression free survival and local recurrence free survival at 1, 3 and 5 years were 76, 57 and 47, and 79, 60 and 51 % respectively. 19 patients (15.5 %) were diagnosed with distant metastases. Univariate analysis revealed significantly improved OS and LRFS for treatment of tumors after primary diagnosis, first series of irradiation and radiation dose ≥60 Gy. Multivariate analysis revealed only treatment in primary situation as an independent prognostic factor for OS and LRFS. Acute CTC grade III mucositis was seen in 5 patients (4.1 %) and CTC grade II dysgeusia in 19 patients (15.6 %). Dysgeusia, dysosmia and ocular toxicity were the most common late adverse events. Conclusions Our data support the results of previous studies and indicate that intensity modulated radiation therapy (IMRT) represents an effective and safe treatment approach for patients with sinonasal carcinomas.
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Kovács G. Modern head and neck brachytherapy: from radium towards intensity modulated interventional brachytherapy. J Contemp Brachytherapy 2015; 6:404-16. [PMID: 25834586 PMCID: PMC4300360 DOI: 10.5114/jcb.2014.47813] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 10/29/2014] [Accepted: 11/27/2014] [Indexed: 11/17/2022] Open
Abstract
Intensity modulated brachytherapy (IMBT) is a modern development of classical interventional radiation therapy (brachytherapy), which allows the application of a high radiation dose sparing severe adverse events, thereby further improving the treatment outcome. Classical indications in head and neck (H&N) cancers are the face, the oral cavity, the naso- and oropharynx, the paranasal sinuses including base of skull, incomplete resections on important structures, and palliation. The application type can be curative, adjuvant or perioperative, as a boost to external beam radiation as well as without external beam radiation and with palliative intention. Due to the frequently used perioperative application method (intraoperative implantation of inactive applicators and postoperative performance of radiation), close interdisciplinary cooperation between surgical specialists (ENT-, dento-maxillary-facial-, neuro- and orbital surgeons), as well interventional radiotherapy (brachytherapy) experts are obligatory. Published results encourage the integration of IMBT into H&N therapy, thereby improving the prognosis and quality of life of patients.
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Affiliation(s)
- György Kovács
- Interdisciplinary Brachytherapy Unit, University of Lübeck/University Hospital Schleswig-Holstein Campus Lübeck, Germany
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Boehm A, Lindner F, Wichmann G, Bauer U, Wittekind C, Knoedler M, Lordick F, Dietzsch S, Scholz M, Kortmann R, Dietz A. Impact of indication-shift of primary and adjuvant chemo radiation in advanced laryngeal and hypopharyngeal squamous cell carcinoma. Eur Arch Otorhinolaryngol 2014; 272:2017-25. [PMID: 24961436 DOI: 10.1007/s00405-014-3134-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 06/03/2014] [Indexed: 01/15/2023]
Abstract
Based on level I evidence, postoperative platinum-based radiochemotherapy (PORCT) is the recommended standard of care in defined risk situations after resection of squamous cell carcinomas of the larynx and hypopharynx (LHSCC). The value of the addition of chemotherapy to adjuvant radiation in intermediate and high risk situations other than extracapsular spread or R1-/R2 resection is still debated. From 1993 to 2009, 555 patients (median follow-up: 24.4 months) with advanced LHSCC (UICC stages III-IVB) were treated in a curative intent. Patient data were continuously documented in the county of Leipzig cancer registry and were retrospectively analyzed as mono institutional survey. PORCT was introduced into the standard procedures in 2004, but also applied before in selected cases. Based on this paradigm shift, the patient population was divided into two comparative groups treated before and after 2004. 361 patients were treated before 2004. 43.8 % received primary surgery (OP) + postoperative radiotherapy (PORT) and 20.2 % OP + PORCT. 194 patients were treated after 2004: 21.1 % received OP + PORT and 35.6 % OP + PORCT. Regarding the PORCT groups, 20.6 % received cisplatin plus 5FU before 2004 which shifted to 59.4 % after 2004. The 3-year tumor-specific-survival rate of the whole cohort was improved from 47 to 60 % (p = 0.006). The subgroup treated with OP + PORT or PORCT improved from 56.1 to 68.5 % (p = 0.028). Localization proved to be a significant and independent factor. Only patients with advanced laryngeal cancer had significant improved survival (p < 0.01), while the improvement for hypopharyngeal cancer patients was not significant (p < 0.2). After 2004, there was a slight increase (+10.2 %) of primary radiochemotherapy (pRCT) due to stronger selection if R0 > 5 mm-resectability is unlikely. Standardised use of PORCT and pRCT considering clear indications showed to be significantly involved in improved survival in advanced LHSCC.
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Affiliation(s)
- A Boehm
- Department of Otolaryngology, Head and Neck Surgery, University Hospital of Leipzig, Liebigstraße 10-14, 04103, Leipzig, Germany,
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Mannelli G, Meccariello G, Deganello A, Maio V, Massi D, Gallo O. Impact of low-thermal-injury devices on margin status in laryngeal cancer. An experimental ex vivo study. Oral Oncol 2013; 50:32-9. [PMID: 24269533 DOI: 10.1016/j.oraloncology.2013.10.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 09/27/2013] [Accepted: 10/03/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Status of margins significantly affects disease-free survival. This study examines in ex vivo model the effect of thermal-injury on margins status comparing traditional instrument with several low-thermal-injury devices. METHODS We conducted a prospective study on 10 excised larynges from patients affected by advanced laryngeal cancer, to assess the thermal-effect due to surgical incisions made at standard distance by using: scalpel, CO2 Laser, harmonic scalpel and electrocautery. Upon histopathological examination, thermal damage (Surgical Artifact, SA), tissue lost/retraction (Shrinkage, S), and tissue alterations were compared for each instrument. RESULTS Low-thermal-injury devices increased SA mean value from 800.7 to 11447.85 μm (72%), and S mean value from 2.226 to 2.910 mm (68.4%) (p<0.05). CONCLUSIONS The choice of surgical device could influence the histopathological margins status, consequently affecting post operative therapeutic strategies and risk of recurrence.
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Affiliation(s)
- Giuditta Mannelli
- First Clinic of Otolaryngology, Department of Surgery and Translational Medicine, University of Florence, Italy.
| | - Giuseppe Meccariello
- First Clinic of Otolaryngology, Department of Surgery and Translational Medicine, University of Florence, Italy
| | - Alberto Deganello
- First Clinic of Otolaryngology, Department of Surgery and Translational Medicine, University of Florence, Italy
| | - Vincenza Maio
- Division of Pathological Anatomy, Department of Surgery and Translational Medicine, University of Florence, Viale G.B. Morgagni, 85, 50134 Florence, Italy
| | - Daniela Massi
- Division of Pathological Anatomy, Department of Surgery and Translational Medicine, University of Florence, Viale G.B. Morgagni, 85, 50134 Florence, Italy
| | - Oreste Gallo
- First Clinic of Otolaryngology, Department of Surgery and Translational Medicine, University of Florence, Italy
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Sopka DM, Li T, Lango MN, Mehra R, Liu JCJ, Burtness B, Flieder DB, Ridge JA, Galloway TJ. Dysplasia at the margin? Investigating the case for subsequent therapy in 'low-risk' squamous cell carcinoma of the oral tongue. Oral Oncol 2013; 49:1083-7. [PMID: 24054332 DOI: 10.1016/j.oraloncology.2013.08.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 08/02/2013] [Accepted: 08/07/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE This is a retrospective analysis of the impact of moderate dysplasia at the resection margin for early stage cancer of the oral tongue. MATERIALS AND METHODS Patients with T1-2N0 oral tongue cancer treated with surgery alone at Fox Chase Cancer Center (FCCC) from 1990 to 2010 were reviewed. Tumor and margin characteristics were abstracted from the pathology report. Overall survival (OS), disease-free survival (DFS) and local control (LC) were calculated using the Kaplan Meier method. Predictors of LC, OS and DFS were analyzed. RESULTS 126 Patients met the inclusion criteria. Dysplasia was present at the final margin in 36% of the cases (severe: 9%, moderate: 15%, mild: 12%). Median follow-up was 52 months. 3 and 5-year actuarial LC for the entire cohort was 77% and 73%, respectively. Actuarial 5-year LC and DFS were significantly worse for patients with moderate or severe dysplasia at the margin vs. none or mild dysplasia at the margin (49% vs 82%, p=0.005 and 49% vs 80%, p=0.008, respectively); 3-year comparisons were not significant. When analyzed separately, the detrimental local effect of moderate dysplasia at the margin persisted (p=0.02) and the effect of severe dysplasia at the margin was approaching significance (p=0.1). Mild dysplasia at the margin did not significantly impair LC or DFS. Multivariate analysis demonstrated worse LC (HR: 2.99, p=0.006) and DFS (HR: 2.84, p=0.008) associated with severe or moderate dysplasia at the margin. CONCLUSIONS Both severe and moderate dysplasia at the margin appear to be correlated with inferior LC and DFS. Additional therapy may be justified, despite added morbidity.
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Affiliation(s)
- Dennis M Sopka
- Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, United States
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Quon H, O'Malley BW, Weinstein GS. Postoperative adjuvant therapy after transoral robotic resection for oropharyngeal carcinomas: rationale and current treatment approach. ORL J Otorhinolaryngol Relat Spec 2011; 73:121-30. [PMID: 21389744 DOI: 10.1159/000319890] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Accepted: 08/02/2010] [Indexed: 12/12/2022]
Abstract
The advancement of transoral surgical techniques for the management of oropharyngeal carcinomas has raised questions about how adjuvant therapy can best be integrated. Some of these questions have come from the application of established oncologic principles of adjuvant therapy, and some are unique to the evolving experience with transoral surgery and in particular with the recent advancement of robotic surgery. It is important for all members of the multidisciplinary treatment team to have a clear understanding of the foundation for adjuvant therapy and the issues unique to transoral robotic surgery to provide optimal patient care as this new treatment paradigm gains popularity for its safe application.
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Affiliation(s)
- Harry Quon
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA.
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Karatzanis AD, Waldfahrer F, Psychogios G, Hornung J, Zenk J, Velegrakis GA, Iro H. Effect of repeated laser microsurgical operations on laryngeal cancer prognosis. Head Neck 2010; 32:921-8. [PMID: 19924806 DOI: 10.1002/hed.21272] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate whether repeated sessions of transoral CO(2) laser microsurgery (TLM) aiming to achieve clear histologic margins carry a negative effect on the prognosis of laryngeal cancer. METHODS This was a retrospective evaluation of 763 cases that underwent primary TLM treatment for laryngeal cancer. Cases were compared for overall survival and local control rates with respect to status of surgical margins and number of procedures necessary to achieve these margins. RESULTS No significant differences were noted among cases with negative surgical margins regardless of the number of procedures necessary to achieve these margins. On the other hand, positive margins at the end of surgical treatment carried significant negative prognostic effect. CONCLUSION The prognostic effect of negative surgical margins in TLM for laryngeal cancer is significant regardless of the number of procedures required to obtain such margins.
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Affiliation(s)
- Alexander D Karatzanis
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Erlangen - Nuremberg Medical School, Erlangen, Germany
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Chimioradiothérapie postopératoire des cancers des voies aérodigestives : vers un nouveau standard ? Cancer Radiother 2010; 14:217-21. [DOI: 10.1016/j.canrad.2010.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Revised: 03/02/2010] [Accepted: 03/03/2010] [Indexed: 11/23/2022]
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16
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Langendijk JA, Ferlito A, Takes RP, Rodrigo JP, Suárez C, Strojan P, Haigentz M, Rinaldo A. Postoperative strategies after primary surgery for squamous cell carcinoma of the head and neck. Oral Oncol 2010; 46:577-85. [PMID: 20400361 DOI: 10.1016/j.oraloncology.2010.03.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Revised: 03/29/2010] [Accepted: 03/29/2010] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen/University of Groningen, Groningen, The Netherlands.
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17
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Karatzanis AD, Waldfahrer F, Psychogios G, Hornung J, Zenk J, Velegrakis GA, Iro H. Resection margins and other prognostic factors regarding surgically treated glottic carcinomas. J Surg Oncol 2010; 101:131-6. [PMID: 20035539 DOI: 10.1002/jso.21449] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES This study aims to assess the prognostic significance of free histopathologic margins in the surgical treatment of glottic cancer. Furthermore, it evaluates other prognostic factors regarding cases that receive surgical management for glottic lesions. METHODS A retrospective case-series study was conducted at an academic tertiary referral center. The files of 1,314 cases that underwent primary surgical treatment for glottic cancer were studied. Various prognostic factors, including age, surgical procedure, T classification, N classification, histological grade, and status of margins were assessed in univariate and multivariate analyses. All variables were investigated for their association with local and regional disease control as well as disease specific and overall survival. RESULTS Status of margins significantly affected disease specific survival and local control regardless of tumor stage in this series. All other variables assessed in the univariate analysis for their association with survival were also found to be significant. However, status of surgical margins and N classification were the only significant variables in multivariate analysis. CONCLUSION The prognostic value of negative surgical margins for the treatment of glottic cancer cannot be overestimated. Responsibility of the surgeon during primary surgical treatment of glottic carcinomas is emphasized.
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Affiliation(s)
- Alexander D Karatzanis
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Erlangen-Nuremberg Medical School, 91054 Erlangen, Germany
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Murthy V, Kundu S, Shahid T, Budrukkar A, Gupta T, Laskar SG, Agarwal J. Postoperative Radiotherapy in Head and Neck Cancer. ACTA ACUST UNITED AC 2010. [DOI: 10.5005/jp-journals-10003-1016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract
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.
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Pandey M, Rao L, Das S, Shukla M. Tumor stage and resection margins not the mandibular invasion determines the survival in patients with cancers of oro-mandibular region. Eur J Surg Oncol 2009; 35:1337-42. [DOI: 10.1016/j.ejso.2009.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Revised: 07/02/2009] [Accepted: 07/06/2009] [Indexed: 10/20/2022] Open
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20
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Voice and swallowing after laryngopharyngectomy and free ileocolic flap reconstruction for hypopharyngeal cancer. Ann Plast Surg 2009; 62:390-4. [PMID: 19325343 DOI: 10.1097/sap.0b013e31819031dc] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Sixteen patients with hypopharyngeal carcinoma who underwent laryngopharyngectomy had immediate reconstruction with a free ileocolic flap to restore voice and swallowing. All patients had satisfactory voice production and swallowing in the early postoperative stage. Maintaining adequate tension and decreasing redundancy of the transferred colon prevented food pooling and provided smooth, rapid swallowing. A wedge resection of the subserosa of the ileocecal valve to increase the intraluminal pressure helped prevent food reflux and provide good phonation. Although this modified technique yielded good initial results, both voice and swallowing deteriorated after concurrent chemoradiotherapy, possibly because of radiation injury to the transferred bowel.
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21
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Jäckel MC, Ambrosch P, Martin A, Steiner W. Impact of re-resection for inadequate margins on the prognosis of upper aerodigestive tract cancer treated by laser microsurgery. Laryngoscope 2007; 117:350-6. [PMID: 17204985 DOI: 10.1097/01.mlg.0000251165.48830.89] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Positive or uncertain surgical margins left untreated have a distinct prognostic relevance in squamous cell carcinoma of the upper aerodigestive tract. An advantage of transoral laser microsurgery is that it can be easily repeated if inadequate resection margins are found postoperatively. The present study investigates the impact of laser surgical reresection on the outcome of patients. STUDY DESIGN The authors conducted a retrospective unicenter study. METHODS A review of 1,467 patients with squamous cell carcinoma of the upper aerodigestive tract who were initially treated by transoral laser microsurgery with curative intent between August 1986 and December 2002 was conducted. Locoregional control as well as TNM adjusted and overall survival were analyzed using the Kaplan-Meier method. RESULTS Three hundred eighty-six patients have required reresection to obtain clear surgical margins, in 70 of whom residual carcinoma has been detected in revision specimens. Patients without need for revision and those in whom revision specimens were found tumor-free had an almost identical locoregional control (P = .4611). In patients with positive revision specimens, however, locoregional control was significantly worsened (P = .0058). Neither the need for reresection nor the detection of further tumor tissue in revision specimens affected TNM adjusted or overall survival. CONCLUSIONS Survival of patients was similar whether clear resection margins were reached within the first surgical step or with revision surgery. However, patients in whom reresection specimens contained residual carcinoma had an increased risk of locoregional failure and should undergo a further reresection or at least a very close follow up.
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Affiliation(s)
- Martin C Jäckel
- Department of Otorhinolaryngology, Hospital of Darmstadt, Darmstadt, Germany.
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22
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Hinerman RW, Morris CG, Amdur RJ, Lansford CD, Werning JW, Villaret DB, Mendenhall WM. Surgery and Postoperative Radiotherapy for Squamous Cell Carcinoma of the Larynx and Pharynx. Am J Clin Oncol 2006; 29:613-21. [PMID: 17149000 DOI: 10.1097/01.coc.0000242319.09994.78] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the rates of local-regional control, survival, and complications for patients treated with postoperative radiation for squamous carcinomas of the larynx, hypopharynx, and oropharynx. METHODS There were 295 patients with previously untreated squamous cell carcinomas of the larynx (n = 199), hypopharynx (n = 80), and oropharynx (n = 16) treated postoperatively with radiotherapy (RT). RESULTS Five-year local-regional control rates according to site and pathologic American Joint Committee on Cancer (AJCC) stage were: stage III larynx, 89% versus stage IVA larynx, 85% (P = 0.33); stage III oropharynx/hypopharynx, 76% versus stage IVA oropharynx/hypopharynx, 79% (P = 0.72). Local-regional control rates steadily declined as the number of indications for administering postoperative RT increased. Five-year absolute survival rates versus pathologic AJCC stage for the entire group were: stage III 59% and stage IVA 40% (P = 0.40). CONCLUSION Rates of local-regional control, survival, and complications support the use of postoperative radiation in selected patients. Tumor control and survival will hopefully improve further with the addition of chemotherapy to postoperative radiation.
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Affiliation(s)
- Russell W Hinerman
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL 32510-0385, USA.
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23
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Mendenhall WM, Hinerman RW, Amdur RJ, Malyapa RS, Lansford CD, Werning JW, Villaret DB. Postoperative radiotherapy for squamous cell carcinoma of the head and neck. Clin Med Res 2006; 4:200-8. [PMID: 16988100 PMCID: PMC1570489 DOI: 10.3121/cmr.4.3.200] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This review discusses the role of postoperative radiotherapy (RT) for patients with squamous cell carcinoma of the head and neck. Patients with unfavorable pathologic features have a high-risk of local-regional recurrence and a decreased likelihood of survival after surgery alone. Postoperative RT reduces the risk of local-regional failure and probably improves survival. Patients who are at high risk for recurrence may benefit from more aggressive altered fractionation schedules to decrease the overall time from surgery to the completion of RT. Adjuvant cisplatin-based chemotherapy also appears to improve the probability of cure in high-risk patients.
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Affiliation(s)
- William M Mendenhall
- Department of Radiation Oncology, University of Florida, College of Medicine, Gainesville, FL, USA.
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24
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Sanguineti G, Richetti A, Bignardi M, Corvo' R, Gabriele P, Sormani MP, Antognoni P. Accelerated versus conventional fractionated postoperative radiotherapy for advanced head and neck cancer: results of a multicenter Phase III study. Int J Radiat Oncol Biol Phys 2005; 61:762-71. [PMID: 15708255 DOI: 10.1016/j.ijrobp.2004.07.682] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2004] [Revised: 07/05/2004] [Accepted: 07/12/2004] [Indexed: 10/25/2022]
Abstract
PURPOSE To determine whether, in the postoperative setting, accelerated fractionation (AF) radiotherapy (RT) yields a superior locoregional control rate compared with conventional fractionation (CF) RT in locally advanced squamous cell carcinomas of the oral cavity, oropharynx, larynx, or hypopharynx. METHODS AND MATERIALS Patients from four institutions with one or more high-risk features (pT4, positive resection margins, pN >1, perineural/lymphovascular invasion, extracapsular extension, subglottic extension) after surgery were randomly assigned to either RT with one daily session of 2 Gy up to 60 Gy in 6 weeks or AF. Accelerated fractionation consisted of a "biphasic concomitant boost" schedule, with the boost delivered during the first and last weeks of treatment, to deliver 64 Gy in 5 weeks. Informed consent was obtained. The primary endpoint of the study was locoregional control. Analysis was on an intention-to-treat basis. RESULTS From March 1994 to August 2000, 226 patients were randomized. At a median follow-up of 30.6 months (range, 0-110 months), 2-year locoregional control estimates were 80% +/- 4% for CF and 78% +/- 5% for AF (p = 0.52), and 2-year overall survival estimates were 67% +/- 5% for CF and 64% +/- 5% for AF (p = 0.84). The lack of difference in outcome between the two treatment arms was confirmed by multivariate analysis. However, interaction analysis with median values as cut-offs showed a trend for improved locoregional control for those patients who had a delay in starting RT and who were treated with AF compared with those with a similar delay but who were treated with CF (hazard ratio = 0.5, 95% confidence interval 0.2-1.1). Fifty percent of patients treated with AF developed confluent mucositis, compared with only 27% of those treated with CF (p = 0.006). However, mucositis duration was not different between arms. Although preliminary, actuarial Grade 3+ late toxicity estimates at 2 years were 18% +/- 4% and 27% +/- 6% for CF and AF, respectively (p = 0.10). CONCLUSION Accelerated fractionation does not seem to be worthwhile for squamous cell carcinoma of the head and neck after resection; however, AF might be an option for patients who delay starting RT.
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Affiliation(s)
- Giuseppe Sanguineti
- Department of Radiation Oncology, Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy.
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Hinerman RW, Mendenhall WM, Morris CG, Amdur RJ, Werning JW, Villaret DB. Postoperative irradiation for squamous cell carcinoma of the oral cavity: 35-year experience. Head Neck 2004; 26:984-94. [PMID: 15459927 DOI: 10.1002/hed.20091] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The purpose of this study was to analyze factors influencing outcome in patients who received postoperative irradiation for advanced squamous cell carcinoma of the oral cavity. METHODS Between October 1964 and November 2000, 226 patients with 230 previously untreated primary invasive squamous cell carcinomas of the oral cavity were treated postoperatively with continuous-course external beam irradiation. All patients had a minimum follow-up of 2 years (analysis, November 2002). No patient was lost to follow-up. RESULTS The 5-year actuarial rates of locoregional control by pathologic American Joint Committee on Cancer stage were: stage I, 100%; stage II, 84%; stage III, 78%; and stage IV, 66%. Recurrence of cancer above the clavicles developed in 55 patients (24%). In multivariate analysis of locoregional control, positive margins, vascular invasion, perineural invasion, extracapsular extension, and T classification remained significant. CONCLUSIONS This article provides additional data defining relatively favorable and unfavorable groups of patients in the postoperative setting. Dose recommendations are re-examined and selectively increased for high-risk patients.
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Affiliation(s)
- Russell W Hinerman
- Department of Radiation Oncology, University of Florida Shands Cancer Center, PO Box 100385, Gainesville, FL 32610-0385, USA.
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26
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Lapeyre M, Bollet MA, Racadot S, Geoffrois L, Kaminsky MC, Hoffstetter S, Dolivet G, Toussaint B, Luporsi E, Peiffert D. Postoperative brachytherapy alone and combined postoperative radiotherapy and brachytherapy boost for squamous cell carcinoma of the oral cavity, with positive or close margins. Head Neck 2004; 26:216-23. [PMID: 14999796 DOI: 10.1002/hed.10377] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Postoperative radiotherapy is necessary for squamous cell carcinoma (SCC) of the oral cavity with positive or close margins. The aim of the study is to define the indications of postoperative brachytherapy (BRT). METHODS From 1979 to 1993, 82 patients with positive or close margins had postoperative BRT (58 T1-2, 24 T3-4, 45 mobile tongue, 37 floor of mouth). Forty-six patients had combined radiotherapy (RT) with a mean dose of 48 Gy, and BRT boost with a mean dose of 24 Gy. Thirty-six patients had BRT alone with a mean dose of 60 Gy. BRT was performed with interstitial low dose rate Iridium 192. RESULTS Overall survival (OS), cause-specific survival (CSS), and local control (LC) at 5 years were, respectively, for T1-2/N0N- with BRT, 75%, 85%, and 88%,and with RT-BRT 70%, 92%, and 92%; for T1-2/N+ with RT-BRT, 44%, 67%, and 78%; for T3-4/N- with RT-BRT, 42%, 90%, and 80%; and for T3-4/N+ with RT-BRT, 22%, 43%, and 57%. Prognostic factors for OS, CSS, and LC were N+ (p </=.009), extracapsular spread (ECS+;p </=.000001), and T stage for LC only (p =.02). Prognostic factors for complications were a high number of wires with a cutoff at five wires (p =.008), a high dose rate with a cutoff at 0.57 Gy/hr (p =.01), and a high total dose (BRT + RT) with a cutoff at 71 Gy (p =.07). CONCLUSIONS BRT alone for SCC T1-2/N0N- is better than RT-BRT because, with equivalent results, it avoids the adverse events of postoperative RT (xerostomia) and permits the treatment of a second head and neck primary in nonirradiated tissue. The results for the T3-4/N- are acceptable with this approach (ie, RT-BRT) but may be improved for N+.
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Affiliation(s)
- Michel Lapeyre
- Radiotherapy Department, Centre Alexis Vautrin, Radiotherapy Department, Avenue de Bourgogne, 54511 Vandoeuvre-les-Nancy, France.
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Takeshita K, Fujii K, Anzai K, Ozawa T. In vivo monitoring of hydroxyl radical generation caused by x-ray irradiation of rats using the spin trapping/EPR technique. Free Radic Biol Med 2004; 36:1134-43. [PMID: 15082067 DOI: 10.1016/j.freeradbiomed.2004.02.016] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2003] [Revised: 01/21/2004] [Accepted: 02/06/2004] [Indexed: 11/19/2022]
Abstract
Measurement of hydroxyl radical (*OH) in living animals irradiated with ionizing radiation should be required to clarify the mechanisms of radiation injury and the in vivo assessment of radiation protectors, because generation of *OH is believed to be one of the major triggers of radiation injury. In this study, *OH generation was monitored by spin trapping the secondary methyl radical formed by the reaction of *OH with dimethyl sulfoxide (DMSO). Rats were injected intraperitoneally with a DMSO solution of alpha-phenyl-N-tert-butylnitrone (PBN). X-irradiation of the rats remarkedly increased the six-line EPR signal in the bile. The strengthened signal was detectable above 40 Gy. Use of 13C-substituted DMSO revealed that the signal included the methyl radical adduct of PBN as a major component. The EPR signal of the PBN-methyl radical adduct was completely suppressed by preadministration of methyl gallate, a scavenger of *OH but not of methyl radical. Methyl gallate did not reduce the spin adducts to EPR-silent forms. These observations indicate that what we were measuring was *OH generated in vivo by x-irradiation. This is the first report of the in vivo monitoring of *OH generation at a radiation dose close to what people might receive in the case of radiological accident or radiation therapy.
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Affiliation(s)
- Keizo Takeshita
- Redox Regulation Research Group, National Institute of Radiological Sciences, Chiba 263-8555, Japan
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Shikama N, Sasaki S, Nishikawa A, Koiwai K, Yoshino F, Hirase Y, Kawakami R, Kadoya M, Oguchi M. Risk factors for local-regional recurrence following preoperative radiation therapy and surgery for head and neck cancer (stage II-IVB). Radiology 2003; 228:789-94. [PMID: 12954897 DOI: 10.1148/radiol.2283012044] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To discover possible risk factors for local-regional recurrence (LRR) following preoperative radiation therapy and curative surgery for head and neck squamous cell carcinoma (SCC) (stage II-IVB). MATERIALS AND METHODS Clinical records from 1987 to 1999 of 161 patients with head and neck SCC (oral cavity, 80 patients; larynx, 50; hypopharynx, 19; oropharynx, 12) who underwent preoperative radiation therapy and surgery were retrospectively reviewed. One hundred thirty-two (82%) of the patients had stage III or IV cancer. The median radiation dose was 38 Gy. RESULTS The 5-year overall survival rate and LRR rate were 58% and 35%, respectively. At multivariate analysis, oral cavity cancer (P =.020), clinical T stage (P =.016), clinical N stage (P =.017), and status of surgical margins (P =.008) emerged as variables that were significantly associated with LRR. The analysis of only those patients with lymph node involvement showed that oral cavity cancer (P =.008), advanced N-stage cancer (P =.045), and long interval between the start of preoperative radiation therapy and surgery (> or =7 weeks) (P =.019) emerged as variables that were significantly associated with LRR. CONCLUSION Oral cavity cancer, advanced T or N stage of disease, and unsatisfactory margins were risk factors for LRR. A long interval (> or =7 weeks) was a risk factor for LRR in patients with lymph node involvement.
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Affiliation(s)
- Naoto Shikama
- Department of Radiology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan.
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Pfreundner L, Hoppe F, Willner J, Preisler V, Bratengeier K, Hagen R, Helms J, Flentje M. Induction chemotherapy with paclitaxel and cisplatin and CT-based 3D radiotherapy in patients with advanced laryngeal and hypopharyngeal carcinomas--a possibility for organ preservation. Radiother Oncol 2003; 68:163-70. [PMID: 12972311 DOI: 10.1016/s0167-8140(03)00076-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND To evaluate the effect of paclitaxel/cisplatin induction chemotherapy (ICHT) and CT-based radiotherapy (RT) on larynx preservation, tumor control, and survival in patients with larynx/hypopharynx carcinoma eligible for total laryngectomy (TL) or TL plus partial pharyngectomy (TLPP). PATIENTS AND METHODS Fifty patients eligible for TL or TLPP were enrolled onto a prospective study and treated with ICHT (200 mg/m(2) paclitaxel, 100 mg/m(2) cisplatin; day 1, 22). In patients with complete or partial tumor response RT (69.9 Gy in 5.5 weeks at the gross tumor, 50.4 Gy in the lymphatic drainage; single dose: 1.8 Gy, concomitant boost: 1.5 Gy) was applied. Non-responders had TL/TLPP and RT with total doses adapted to the radicality of tumor resection (56-70 Gy). RESULTS The response rate to ICHT was 88% (10% complete, 78% partial response). At a median follow-up period of 25 months the larynx preservation rate was 84%. The 2-year local-regional control rate was 91% and the 2-year overall survival rate was 72.3%. The 3-year estimate to survive with functional larynx is 60%. CONCLUSION In a large portion of patients eligible for TL or TLPP the larynx was preserved by paclitaxel/cisplatin ICHT and 3D RT.
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Affiliation(s)
- Leo Pfreundner
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str.11, 97080 Wuerzburg, Germany.
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Mendenhall WM, Amdur RJ, Hinerman RW, Villaret DB, Siemann DW. Postoperative radiation therapy for squamous cell carcinoma of the head and neck. Am J Otolaryngol 2003; 24:41-50. [PMID: 12579482 DOI: 10.1053/ajot.2003.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To discuss the role of postoperative radiation therapy (RT) for patients with squamous cell carcinoma of the head and neck. RESULTS Patients with adverse pathologic features have a high likelihood of local-regional recurrence and a decreased probability of survival after surgery alone. Postoperative RT reduces the risk of local-regional failure and probably improves survival. Patients who are at high risk for recurrence after surgery benefit from more aggressive dose-fractionation schedules that may include altered fractionation to decrease the overall time from surgery to the completion of RT. Adjuvant chemotherapy also appears to improve the probability of cure in high risk patients. CONCLUSION Patients who have a high likelihood of local-regional recurrence after surgery have improved disease control and survival after postoperative RT.
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Affiliation(s)
- William M Mendenhall
- Departments of Radiation Oncology, University of Florida, College of Medicine, Gainesville, FL 32610-0385, USA
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Fortin A, Couture C, Doucet R, Albert M, Allard J, Tetu B. Does histologic grade have a role in the management of head and neck cancers? J Clin Oncol 2001; 19:4107-16. [PMID: 11689578 DOI: 10.1200/jco.2001.19.21.4107] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE High histologic grade is usually associated with a greater propensity to distant metastases (DM). Its role to predict DM in head and neck cancer is not yet defined. The aim of this study is to evaluate the role of histologic grade as an independent predictor of DM and to determine a subgroup of patients who may benefit from systemic chemotherapy. PATIENTS AND METHODS This is a retrospective study of 1,266 consecutive patients treated by definitive or postoperative radiotherapy between 1989 and 1997. All patients received at least 50 Gy. All stages and subsites of head/neck were included. DM rates were evaluated by the Kaplan-Meier method with a subsequent Cox analysis. RESULTS There is a strong correlation of grade with N stage (P <.000001). The metastases-free survival (MFS) was 98%, 90%, and 72% for grades 1, 2, and 3, respectively (P <.000001). In patients with N0 stage, MFS is always greater than 90%, whatever the grade. In the 222 N1 patients, MFS was more than 90% in grade 1 and 2 but dropped to 75% for grade 3 (P =.001). In patients with N2 and N3, MFS was 91%, 79%, and 59% for grades 1, 2, and 3, respectively (P =.008). The same conclusion is applicable when only patients with neck control are analyzed. In a Cox model, grade was an independent predictor of DM (P =.000001) as well as T stage (P =.003), N stage (P =.000001), and neck failure (P =.0003). Higher grade was also an independent predictor of survival (P =.02). CONCLUSION Patients with histologic grade 1 and grade 2 (except N3) are at low risk of DM. Patients with grade 2 and N3 or patients with grade 3 and N1 to N3 have a higher risk of distant metastases and should be considered for systemic treatment.
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Affiliation(s)
- A Fortin
- Department of Radiation Oncology and Department of Pathology, L'Hôtel-Dieu de Québec, Québec, Canada.
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Muriel VP, Tejada MR, de Dios Luna del Castillo J. Time-dose-response relationships in postoperatively irradiated patients with head and neck squamous cell carcinomas. Radiother Oncol 2001; 60:137-45. [PMID: 11439208 DOI: 10.1016/s0167-8140(01)00381-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE To define the influence of the dose and time on the response to treatment in postoperatively irradiated head and neck cancer patients and to establish a good prediction of failure. METHODS AND MATERIALS From January 1985 to December 1995, 214 patients with histologically proven head and neck squamous cell carcinomas were irradiated after radical surgery or single tumour resection according to surgical and histopathological findings. The total doses given ranged between 50 and 75 Gy to the primary bed tumour and between 42 and 56 Gy to the neck with fraction sizes of 1.7-2 Gy/day. The median length of the time interval between surgery and radiotherapy, time of irradiation and total treatment time were 81, 59 and 139 days, respectively. The end-point analyzed was the local-regional tumour control rate at the primary tumour bed and neck for 5 years from the beginning of radiotherapy. Univariate and multivariate analyses were used to determine predictors of failure from among the following studied variables: (i), clinical stage (T/N) of the patients; (ii), tumour grade; (iii), neck surgery; (iv), tumour margins; (v), histological tumour nodal extension; (vi), chemotherapy; (vii), normalized total dose; (viii), time interval between surgery and radiotherapy; (ix), time of irradiation; and (x), total treatment time. RESULTS The actuarial 5-year tumour control rate for the entire group was 72%, and 92% of the patients who achieved local control are currently alive without disease. Tumour control was inversely related to T stage (83% for T2 vs. 57% for T4) and the probability of local control within each stage was dependent on the N status (> or =71% for T3-T4/N0 vs. 31-44% for T3-T4/N1-N3). Histological N status and tumour margins, but not tumour grade, impacted significantly on tumour control. When local control was analyzed as a function of the dose to the primary, a non-significant negative dose-response relationship was found. The total treatment time was a significant prognostic factor, and the time interval between surgery and irradiation proved to be an independent predictor of failure. CONCLUSIONS Despite the absence of a statistically significant dose-response relationship, the present results suggest that postoperative irradiation treatment given to patients with head and neck squamous cell carcinomas should not be unduly prolonged, in order to minimize the amount of tumour cell proliferation. In these patients, nodal involvement, positive margins of the resected specimens and time interval between surgery and irradiation were the most important prognostic factors.
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Affiliation(s)
- V P Muriel
- Department of Radiation Oncology, University Hospital, Avda. Dr Oloriz s/n, 18012, Granada, Spain
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