Long-term regional control after radiation therapy and neck dissection for base of tongue carcinoma

Treatment of Cancer of the Base of the Tongue and Glosso-Epiglottic Region: A Multicenter Italian Survey

BACKGROUND

The current treatment options for cancer of the base of the tongue and glosso-epiglottic region are surgery, radiotherapy, or a combination of both modalities. Comparisons between different modalities are not common in the literature, and a real standard of treatment has not yet been established. The purpose of our study was to evaluate the results of treatment in a large series of patients from 18 Italian institutions in relation to the main treatment adopted.

METHODS

The present study is a retrospective survey. The series was divided into a combined surgery group and a radiotherapy group. The Kaplan-Meier method and the log-rank test were used for survival calculations and comparisons.

RESULTS

Eight hundred patients were registered (25.7% stage III and 62% stage IV), 336 in the surgery and 372 in the radiotherapy group. Conventional fractionation was adopted in almost all cases. The five-year overall and disease free survival of the whole series was 32% and 38%, respectively. Survival was slightly better for patients with tumors of the glosso-epiglottic region than for those with a tumor of the base of the tongue. Five-year disease-free survival was 55% for patients treated with surgery +/- radiochemotherapy and 26% for those submitted to radiotherapy alone or in combination with chemotherapy. As far as the total dose and the treatment duration were concerned, only 26% of the patients of the radiotherapy group met the established criteria of adequacy, but in patients with adequate radiation the control rate was better only for small tumors (T1-T2).

CONCLUSIONS

The results in patients treated with surgery +/- postoperative radiotherapy were similar to or better than those reported in the best series in the literature. By contrast, the survival rate of irradiated patients was lower than those reported by other centers.

Modern head and neck brachytherapy: from radium towards intensity modulated interventional brachytherapy

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.

Rare treatment of radiation induced carotid pseudoaneurysm and ensuing carotid blowout syndrome with placement of multiple contiguous endovascular stents: a case report

Cervical radiotherapy for treatment of head and neck cancer can result in the delayed carotid vasculopathy. Surgical management for an ensuing hemorrhage is challenging due to the associated high mortality and morbidity. We present a case of a relative rapid formation of common carotid pseudoaneurysm formation with subsequent carotid blowout syndrome in previously irradiated neck. Successful treatment in our patient is highlighted by the fact that multiple, contiguous endovascular stents were placed emergently to obtain control of pseudoaneurysm rupture.

Pulsed dose rate brachytherapy as the boost in combination with external beam irradiation in base of tongue cancer. Long-term results from a uniform clinical series

PURPOSE

To evaluate long time outcome with regard to local tumour control, side effects and quality of life of combined pulsed dose rate (PDR) boost and hyperfractionated accelerated external beam radiotherapy (EBRT) for primary base of tongue (BOT) cancers.

MATERIAL AND METHODS

Between 1994 and 2007, the number of 83 patients were treated with primary T1-T4 BOT cancers. Seven patients (8%) were T1-2N0 (AJCC stage I-II) and 76 (92%) patients were T1-2N+ or T3-4N0-2 (AJCC stage III-IV). The mean estimated primary tumour volume was 15.4 (1-75) cm3. EBRT was given with 1.7 Gy bid to 40.8 Gy to primary tumour and bilateral neck lymph nodes in 2.5 weeks. PDR boost of 35 Gy and a neck dissection in clinical node positive case was performed 2-3 weeks later. The patients were followed for a median of 54 (2-168) months.

RESULTS

The 2-, 5- and 10-years rates of actuarial local control were 91%, 89% and 85%, overall survival 85%, 65% and 44%, disease free survival 86%, 80% and 76%, respectively. The regional control rate was 95%. Six patients (7%) developed distant metastases. A dosimetric analysis showed a mean of 100% isodose volume of 58.2 (16.7-134) cm3. In a review of late complications 11 cases of minor (13%) and 5 of major soft tissue necroses (6%), as well as 6 cases of osteoradionecroses (7%) were found. The patients median subjective SOMA/LENT scoring at last follow up was as follow: grade 0 for pain and trismus, grade 1 for dysphagia and taste alteration, and grade 2 for xerostomia. Global visual-analogue-scale (VAS) scoring of quality of life was 8.

CONCLUSION

Local and regional tumour control rate was excellent in this treatment protocol. The data shows the PDR boost as at least as effective as published continuous low dose rate (CLDR) results.

Radiotherapy-induced common carotid pseudoaneurysm presenting with initially occult upper airway hemorrhage and successfully treated by endovascular stent graft

Radiation induced carotid vasculopathy may present as steno-occlusive disease or less commonly as a pseudoaneurysm. The latter most often presents with a pulsatile mass but is a potential cause of life threatening hemorrhage. We present a case of a small common carotid artery (CCA) pseudoaneurysm that was initially dismissed as the cause of the patients presenting epistaxis given its small size and location. After standard bilateral internal maxillary artery embolizations failed to prevent significant subsequent pharyngeal and tracheal blood loss and serial imaging demonstrated a progressive enlargement of the pseudoaneurysm, a stent graft was successfully placed across the lesion. At five months post stenting, follow-up imaging of the neck showed a stable obliteration of the pseudoaneurysm, good arterial patency, and the patient remained free of recurrent hemorrhage. This case demonstrates that even a small carotid pseudoaneurysm, can present with pharyngeal hemorrhage and should be treated aggressively--with endovascular stent grafting being a preferred treatment modality for arterial lesions in the irradiated neck.

Planned neck dissection for patients with complete response to chemoradiotherapy: a concept approaching obsolescence

The question of efficacy of "planned" neck dissection following complete response to chemoradiation of head and neck cancer is discussed. There is general agreement that preemptive neck dissection in patients who present initially with low volume (N1) neck disease is not necessary. However, routine performance of planned neck dissection for patients who present initially with high volume (> or =N2) disease remains controversial. The authors reviewed a large number of studies reported in the recent literature and discuss how they affect this debate.Twenty-four of the reviewed studies indicate a benefit in regional control obtained by "planned" neck dissection among patients who had bulky neck disease pretreatment. All these studies are retrospective, they do not assess treatment response prior to surgery, although they do show very good regional control rates. Twenty-six studies demonstrate no benefit from "planned" neck dissection after complete clinical response. The reasons for these different conclusions include the development of more effective chemoradiation regimens which have improved the initial locoregional control rates of patients undergoing primary chemoradiation treatment, and improvements in diagnostic technology which have increased ability to detect low volume persistent tumor in the post treatment period. When neck dissection is necessary for persistent or recurrent disease, recent studies have shown that selective or superselective neck dissection may produce results therapeutically equivalent to those obtained with more extensive procedures, with less morbidity.There is now a large body of evidence, based on long-term clinical outcomes, that patients who have achieved a complete clinical (including radiologic) response to chemoradiation have a low rate of isolated neck failure, and the continued use of planned neck dissection for these patients cannot be justified.

[Neck dissection following chemoradiation for node positive head and neck carcinomas]

The optimal timing and extent of neck dissection in the context of chemoradiation for head and neck cancer remains controversial. For some institutions, it is uncertain whether neck dissection should still be performed upfront especially for cystic nodes. For others, neck dissection can be performed after chemoradiation and can be omitted for N1 disease as long as a complete response to chemoradiation is obtained. The question is debated for N2 and N3 disease even after a complete response as the correlation between radiological and clinical assessment and pathology may not be reliable. Response rates are greater than or equal to 60% and isolated neck failures are less than or equal to 10% with current chemoradiation protocols. Some therefore consider that systematic upfront or planned neck dissection would lead to greater than or equal to 50% unnecessary neck dissections for N2-N3 disease. Positron-emission tomography (PET) scanning to assess treatment response and have shown a very high negative predictive value of greater than or equal to 95% when using a standard uptake value of 3 for patients with a negative PET at four months after the completion of therapy. These data may support the practice of observing PET-negative necks. More evidence-based data are awaited to assess the need for neck dissection on PET. Selective neck dissection based on radiological assessment and peroperative findings and not exclusively on initial nodal stage may help to limit morbidity and to improve the quality of life without increasing the risk of neck failure. Adjuvant regional radiation boosts might be discussed on an individual basis for aggressive residual nodal disease with extracapsular spread and uncertain margins but evidence is missing. Medical treatments aiming at reducing the metastatic risk especially for N3 disease are to be evaluated.

Clinical outcome following radiotherapy and planned neck dissection in N+ head and neck cancer patients

CONCLUSIONS

This study confirms earlier findings that patients with viable tumour cells in the neck after external beam radiotherapy (EBRT) have a poor prognosis. The study also indicates that neck dissection (ND) does not change the prognosis for patients with a complete clinical response in the neck. At the moment our guidelines concerning this matter are being reviewed.

OBJECTIVES

The protocol at our institution stipulates a planned ND in patients with metastasis in the neck after EBRT regardless of the response in the neck. As the necessity for a planned ND has not been clarified we wanted to evaluate our results.

PATIENTS AND METHODS

Patients diagnosed from 1998 to 2002 with metastasis in the neck who received EBRT were evaluated for histopathological findings and clinical outcome.

RESULTS

A total of 156 patients were included. Overall survival was 62% and disease-specific survival was 76%. There was a complete response (CR) in the neck in 63 patients (40%); among these 15 had viable tumour cells in the neck. In patients not achieving CR, 40% (37/93) had viable tumour cells left in the neck. Patients with viable tumour cells in the neck after EBRT had disease-specific survival of 48% compared with 90% among patients without viable tumour cells.

PET monitoring of therapy response in head and neck squamous cell carcinoma

In the Western world, more than 90% of head and neck cancers are head and neck squamous cell carcinomas (HNSCCs). The most appropriate treatment approach for HNSCC varies with the disease stage and disease site in the head and neck. Concurrent chemoradiotherapy has become a widely used means for the definitive treatment of locoregionally advanced HNSCC. Although this multimodality treatment provides higher response rates than radiotherapy alone, the detection of residual viable tumor after the end of therapy remains an important issue and is one of the major applications of (18)F-FDG PET. Studies have shown that negative (18)F-FDG PET or PET/CT results after concurrent chemoradiotherapy have a high negative predictive value (>95%), whereas the positive predictive value is only about 50%. However, when applied properly, FDG PET/CT can exclude residual disease in most patients, particularly patients with residual enlarged lymph nodes who would otherwise undergo neck dissection. In contrast to other malignancies, data are limited on the utility of (18)F-FDG PET for monitoring the response to induction chemotherapy in HNSCC or for assessing treatment response early during the course of definitive chemoradiotherapy. The proliferation marker (18)F-3'-deoxy-3'fluorothymidine is currently under study for this purpose. Beyond standard chemotherapy, newer treatment regimens in HNSCC take advantage of our improved understanding of tumor biology. Two molecules important in the progression of HNSCC are the epidermal growth factor receptor and the vascular endothelial growth factor (VEGF) and its receptor VEGF-R. Drugs attacking these molecules are now under study for HNSCC. PET probes have been developed for imaging the presence of these molecules in HNSCC and their inhibition by specific drug interaction; the relevance of these probes for response assessment in HNSCC will be discussed. Hypoxia is a common phenomenon in HNSCC and renders cancers resistant to chemo- and radiotherapy. Imaging and quantification of hypoxia with PET probes is under study and may become a prerequisite for overcoming chemo- and radioresistance using radiosensitizing drugs or hypoxia-directed irradiation techniques and for monitoring the response to these techniques in selected groups of patients. Although (18)F-FDG PET/CT will remain the major clinical tool for monitoring treatment in HNSCC, other PET probes may have a role in identifying patients who are likely to benefit from treatment strategies that include biologic agents such as epidermal growth factor receptor inhibitors or VEGF inhibitors.

Usefulness of fluorine-18 fluorodeoxyglucose positron emission tomography in patients with a residual structural abnormality after definitive treatment for squamous cell carcinoma of the head and neck

BACKGROUND

Residual structural abnormalities after definitive treatment of head and neck squamous cell carcinoma (HNSCC) are common and pose difficult management problems. The usefulness of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG PET) to supplement conventional evaluation with clinical and standard radiologic examination (CE) in such patients was assessed.

METHODS

Fifty-three eligible patients were identified with residual structural abnormalities on CE. True disease extent could be validated in 46 patients. Patients had a median potential follow-up of 55 months (range, 41-75 months) from the date of PET scan to the analysis closeout date.

RESULTS

PET had better diagnostic accuracy than CE (p = .0002) and induced management change in 21 patients (40%; 95% confidence interval [CI], 26%-54%), including avoidance of unnecessary planned surgery in 14 patients with negative PET. Appropriate management change was confirmed in 19 (95%) of 20 evaluable cases. Disease presence and extent assessment by PET were significant predictors of survival (p < .0001), whereas the extent of disease determined by CE was not.

CONCLUSION

PET added significantly to the value of CE in restaging disease in patients with structural abnormalities after definitive treatment of HNSCC. Management decisions based on PET were appropriate in most patients.

[Surgical treatment options in oropharyngeal cancer]

Therapy of oropharyngeal squamous cell cancer traditionally has been radiation-based, with surgery mainly in reserve. With increasing depth of local infiltration and volume of regional metastases the role of surgery in safeguarding curative chances increases. However, after failed chemoradiation of oropharynx cancer, few patients are cured by salvage surgery. Thus, primary surgery with postoperative radiotherapy may be contemplated if circumtances are favorable. The oropharynx can be approached by transoral, transmandibular or transcervical routes. Primary surgery is increasingly valuable when resultant morbidity is decreased as in the case of more elaborated transoral approaches. Classical approaches also have improved with increasing use of midline mandibulotomy, marginal mandibulectomy, reconstructive surgery, selective neck dissection (ND), and rehabilitation. Elective ND is restricted to levels I or II to III or IV, therapeutic ND is comprehensive (classic or modified radical depending on capsular integrity), and salvage ND is individualized. Surgery, most often followed by radiotherapy, in selected cases of oropharynx cancer is an interesting alternative to chemoradiation, and in advanced disease a facultative but essential part of multimodal therapy.

Clinical utility of 18F-FDG PET/CT in assessing the neck after concurrent chemoradiotherapy for Locoregional advanced head and neck cancer

For patients with locoregional advanced head and neck squamous cell carcinoma (HNSCC), concurrent chemoradiotherapy is a widely accepted treatment, but the need for subsequent neck dissection remains controversial. We investigated the clinical utility of 18F-FDG PET/CT in this setting.

METHODS

In this Institutional Review Board (IRB)-approved and Health Insurance Portability and Accountability Act (HIPPA)-compliant retrospective study, we reviewed the records of patients with HNSCC who were treated by concurrent chemoradiation therapy between March 2002 and December 2004. Patients with lymph node metastases who underwent 18F-FDG PET/CT > or = 8 wk after the end of therapy were included. 18F-FDG PET/CT findings were validated by biopsy, histopathology of neck dissection specimens (n = 18), or clinical and imaging follow-up (median, 37 mo).

RESULTS

Sixty-five patients with a total of 84 heminecks could be evaluated. 18F-FDG PET/CT (visual analysis) detected residual nodal disease with a sensitivity of 71%, a specificity of 89%, a positive predictive value (PPV) of 38%, a negative predictive value (NPV) of 97%, and an accuracy of 88%. Twenty-nine heminecks contained residual enlarged lymph nodes (diameter, > or =1.0 cm), but viable tumor was found in only 5 of them. 18F-FDG PET/CT was true-positive in 4 and false-positive in 6 heminecks, but the NPV was high at 94%. Fifty-five heminecks contained no residual enlarged nodes, and PET/CT was true-negative in 50 of these, yielding a specificity of 96% and an NPV of 98%. Lack of residual lymphadenopathy on CT had an NPV of 96%. Finally, normal 18F-FDG PET/CT excluded residual disease at the primary site with a specificity of 95%, an NPV of 97%, and an accuracy of 92%.

CONCLUSION

In patients with HNSCC, normal 18F-FDG PET/CT after chemoradiotherapy has a high NPV and specificity for excluding residual locoregional disease. In patients without residual lymphadenopathy, neck dissection may be withheld safely. In patients with residual lymphadenopathy, a lack of abnormal 18F-FDG uptake in these nodes also excludes viable tumor with high certainty, but confirmation of these data in a prospective study may be necessary before negative 18F-FDG PET/CT may become the only, or at least most-decisive, criterion in the management of the neck after chemoradiotherapy.

Planned Postradiotherapy Neck Dissection: Rationale and Clinical Outcomes

OBJECTIVES

In this study, we examine pathology results and clinical outcome for patients with locoregionally advanced squamous cell carcinoma of the head and neck (SCCHN) who present with advanced neck disease and undergo planned postradiotherapy neck dissection.

STUDY DESIGN

Review of all patients with SCCHN treated with primary radiation (or chemoradiation) and postradiotherapy neck dissection at the University of Wisconsin between 1992 to 2005 was performed. One hundred seven neck dissections were identified in 93 patients, 79 unilateral and 14 bilateral. All major treatment and outcome parameters were examined with particular emphasis on the postradiotherapy neck dissection.

RESULTS

Thirty of 107 neck dissection specimens (28%) showed evidence of residual carcinoma on pathologic review. The mean number of lymph nodes identified at neck dissection for the entire cohort was 21 per specimen (range, 1-60) with 1.3 nodes per positive neck dissection demonstrating residual carcinoma. No correlation was found between the type of neck dissection performed and the presence of residual nodal disease. Eighty-two evaluated patients (93%) remain free of regional disease recurrence, whereas six patients have subsequently manifested neck recurrence. Four of the six patients who developed regional recurrence showed residual carcinoma in their neck dissection specimen. Five of these patients underwent comprehensive neck dissection (levels I-V); one underwent selective neck dissection (<levels I-V).

CONCLUSION

Approximately one-fourth of the patients in this series showed pathologic evidence of residual carcinoma in the neck at the time of postradiotherapy neck dissection. The majority of these cases showed microscopic residual carcinoma in a single lymph node. Although in the early postradiotherapy setting, we cannot accurately predict the viability and growth potential of microscopic residual carcinoma in lymph nodes, these findings, combined with the modest overall morbidity of selective neck dissection, suggest that planned postradiotherapy neck dissection should be strongly considered for patients presenting with advanced neck disease. This remains a prevailing clinical practice at our institution.

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.

Control of nodal metastases in squamous cell head and neck cancer treated by radiation therapy or chemoradiation

BACKGROUND AND PURPOSE

In the present study, prognostic values of several CT-based pre-treatment nodal and treatment-related characteristics were evaluated among patients with squamous cell head and neck cancer treated with non-surgical modalities.

PATIENTS AND METHODS

Included were 79 patients with 210 pathological nodes, who underwent primary irradiation or chemoradiation. Several nodal characteristics were assessed on the planning CT scan. In addition, the 3D-dose distribution in the nodes was calculated by the planning system to allow for evaluation of underdosage in the pathological nodes and to correlate these results with control in the neck. Analysis was done on patient level (regional control) and node level (nodal control).

RESULTS

For regional control, total nodal volume and the use of chemotherapy in addition to radiation were significant prognostic factors. For nodal control, also the presence of central necrosis and radiological extranodal spread were of importance. In case of radiotherapy alone, a minimal dose <95% of the prescribed dose was associated with worse control. In case of combined modality treatment, the minimal radiation dose was of less importance.

CONCLUSIONS

Nodal volume and chemotherapy are the most important prognostic factors to control pathological nodes in the neck. Radiological central necrosis and extranodal growth, nodal volume and chemotherapy were significant prognostic factors for nodal control. Additionally, it appears that regional control in patients treated with primary radiation alone or with chemoradiation in case of a total nodal volume of more than 3.0 cm(3) results in an unacceptable high risk on regional recurrence.

Planned Neck Dissection after Concomitant Radiochemotherapy for Advanced Head and Neck Cancer

OBJECTIVES/HYPOTHESIS

Since 1998, at our academic, multidisciplinary head and neck cancer treatment center, it has been our policy to treat appropriate patients with locoregionally advanced squamous cell carcinoma of the head and neck (SCCHN) with concomitant radiochemotherapy followed within 6 weeks by planned neck dissection(s). Our objective was to investigate the oncologic efficacy of planned neck dissection, to date, in this patient population with a focus on outcomes in the neck.

STUDY DESIGN

Retrospective analysis of a cumulative patient database.

METHODS

The medical records of all patients who underwent planned neck dissection(s) after concomitant radiochemotherapy for locoregionally advanced SCCHN at Beth Israel Medical Center and The Institute for Head and Neck Cancer in New York City were reviewed. For each patient, preradiochemotherapy primary and neck stage, postradiochemotherapy/preneck dissection clinical and radiographic neck status, type of neck dissection(s) performed, pathologic status of the neck dissection specimen(s), length of follow-up (after planned neck dissection), disease status at last follow-up, and site(s) of recurrence were recorded. Local, regional, and distant disease control rates were calculated by the Kaplan-Meier method.

RESULTS

Fifty-one planned neck dissections were performed on 39 radiochemotherapy patients (12 patients had bilateral operations) between early 1998 and October, 2003. Thirty-two (82%) patients had N2 or greater neck disease, with 29 (74%) having T3/T4 disease at various upper aerodigestive tract primary sites. Patients received an average of 6,700 cGy and 6,000 cGy external beam radiation therapy to primary disease sites and involved cervical lymphatics respectively, concomitant with one of three platinum-based chemotherapy schedules. At a mean follow-up time of 24 (range 8-57) months for the entire study population, there has been only one neck recurrence (N2A neck). No patient with N2B (n = 11), N2C (n = 13, with majority of heminecks staged N2B), or N3 (n = 5) disease has recurred in the neck. No recurrences have occurred in the 41 heminecks (in 33 patients) where modified neck dissection (including 24 selective procedures) was performed despite the presence of residual carcinoma in 13 (32%) of these heminecks on pathologic review. Among all heminecks with residual carcinoma present (n = 18) in the neck dissection specimen, there has been only one neck recurrence. There have been no recurrences in the 26 heminecks (in 19 patients) with incomplete clinical response after radiochemotherapy despite the presence of residual carcinoma in 14 (54%) of these necks on pathologic review. The clinical and radiographic absence of residual disease after radiochemotherapy did not always predict a complete pathologic response. Surgical complications have been limited (1 chyle leak, 1 wound breakdown).

CONCLUSIONS

The integration of planned neck dissection into the multidisciplinary management of patients with locoregionally advanced SCCHN is highly effective in controlling cervical metastatic disease. Modified and selective neck dissection procedures can be performed in the majority of patients, regardless of the response in the neck subsequent to concomitant radiochemotherapy. We recommend a planned neck dissection(s) in all patients staged (pretreatment) with N2 or greater neck disease and in select N1 cases.

Management of cervical metastasis

Cervical metastasis from head and neck cancer is a common occurrence. Despite improvements in diagnostic modalities and treatment options, survival in this group of patients has not changed appreciably over the past few decades. Cervical metastasis portends a poor prognosis and also presents a diagnostic and treatment dilemma for the head and neck oncologist. This article reviews the current state of the art in the diagnosis and treatment of this difficult group of patients and the literature on the topic.

Disease control, survival, and functional outcome after multimodal treatment for advanced-stage tongue base cancer

BACKGROUND

Surgical resection and postoperative radiation for advanced-stage malignancies of the oral cavity, oropharynx, and hypopharynx result in a dismal overall survival of 38%. Patients with carcinoma of the tongue base frequently have advanced disease at the time of presentation, and combined-modality therapy is usually required to achieve cure. Because of the poor survival rates with advanced malignancies with standard therapy, new and innovative approaches continue to be developed in an attempt to have a greater impact on disease control, patient survival, and functional outcome after therapy. This study examines functional outcome, survival, and disease control in patients receiving an intensified treatment regimen with concomitant chemoradiotherapy, surgery, and intraoperative radiotherapy for previously untreated, resectable, stage III and IV squamous cell carcinoma (SCC) of the tongue base.

METHODS

Forty patients with previously untreated, resectable, stage III and IV squamous cell carcinoma of the tongue base were treated in one of three sequential phase II intensification regimens (IRs). Treatment consisted of perioperative, hyperfractionated radiotherapy (9.1 Gy) with concurrent cisplatin followed by surgical resection with intraoperative radiotherapy boost (7.5 Gy). Postoperative treatment involved concurrent chemoradiotherapy (40 Gy to the primary site and upper neck and 45 Gy to the supraclavicular areas) with cisplatin with or without paclitaxel. Locoregional and distant disease control, 2-year overall, and disease-specific survival rates were calculated. The Performance Status Scale (PSS) for Head and Neck Cancer Patients was administered to 25 of the surviving patients. The effects of the method of surgical reconstruction, surgery involving the mandible and/or larynx, and early versus advanced T stage on PSS score were evaluated with the Wilcoxon rank-sum test.

RESULTS

Median follow-up in months for IR1, IR2, and IR3 were 83.6, 75.2, and 26.8. The locoregional control rate was 100%, and the rate of distant metastases was 7.5% for all patients. Two-year overall and disease-specific survival rates for the entire study population were 74.7% and 93.6%, respectively. Mean PSS scores by subscales Eating in Public, Understandability of Speech, and Normalcy of Diet were 55 (range, 0-100), 73 (range, 25-100), and 49 (range, 0-100), respectively. PSS scores were significantly higher in patients with primary closure of the surgical defect, no mandibular surgery, and early T-stage lesions.

CONCLUSIONS

Although functional outcome may be decreased by certain surgical interventions and advanced T stage, the high rate of locoregional and distant disease control and excellent 2-year disease-specific survival supports an aggressive treatment regimen for advanced tongue base cancer.

Brachytherapy in the treatment of Stage IV carcinoma of the base of tongue

PURPOSE

Survival in patients with Stage IV carcinoma of the base of tongue (BOT) treated by surgery and radiotherapy remains poor. External beam radiotherapy (EBRT) and brachytherapy (BT) have been used as an alternative treatment.

METHODS AND MATERIALS

Eighteen patients with Stage IV carcinoma of the BOT were treated by EBRT and BT.

RESULTS

Local control is 89%. The 5-year overall (OS) and disease specific survival (DSS) rates are 52% and 67%. No neck node positive patient implanted in the neck developed cervical metastases. Two patients (11%) developed complications.

CONCLUSIONS

Local regional control, survival, and complications in patients with Stage IV carcinoma of the BOT treated by EBRT and BT have been satisfactory. The use of brachytherapy for nodal metastases has eliminated the need for neck dissection. We recommend this approach in the treatment of Stage IV carcinoma of the BOT.

Long-term outcomes after external beam irradiation and brachytherapy boost for base-of-tongue cancers

PURPOSE

To assess long-term efficacy and toxicity associated with external beam irradiation (EBRT) and interstitial (192)Ir implantation for the treatment of squamous carcinoma of the base of tongue.

METHODS AND MATERIALS

Between April 1975 and December 1993, 41 patients with base-of-tongue carcinomas were treated with (192)Ir interstitial implants after EBRT at Stanford University. One patient had Stage I, 6 had Stage II, 7 had Stage III, and 27 had Stage IV tumors. Twenty-eight patients had cervical lymph node involvement at diagnosis. All received EBRT to a median dose of 50 Gy (range 48.9-68 Gy) to the primary tumor and regional lymph nodes before brachytherapy. Interstitial implant was performed 2-4 weeks after EBRT. Intraoperatively, nylon catheters were placed via steel trocars into the base of tongue, glossotonsillar groove, and pharyngo-epiglottic fold using a catheter looping technique. Twenty-three of 28 node-positive patients also underwent simultaneous neck dissections. Postoperatively, the (192)Ir seeds were inserted and allowed to remain in place for approximately 35 h to achieve a median tumor dose of 26 Gy (range 20-34 Gy) to a median volume of 73 cc. Survival, local control, and complications were assessed.

RESULTS

With a median follow-up of 62 months (range 9-215) for all patients and 90 months for alive patients, the 5-year Kaplan-Meier survival estimate was 66%. The 5-year local control rate was 82%, with 7 patients recurring locally, 2 of whom were salvaged with surgery. Nodal control was achieved in 93% of patients with either EBRT alone or in combination with neck dissection. The 5-year freedom from distant metastasis rate was 83%. Acute complications included transient bleeding (5%) and infection (8%). Late complication included soft-tissue necrosis/ulceration (7%), osteoradionecrosis (5%), and xerostomia.

CONCLUSION

Base-of-tongue carcinoma can be effectively treated with EBRT and (192)Ir implant boost. Local control is excellent and complication rates are acceptable.

Neck dissection following radiochemotherapy of advanced head and neck cancer--for selected cases only?

PURPOSE

To address the value of neck dissection (ND) in patients with advanced head and neck cancer following primary radiochemotherapy and to specifically analyse its impact on locoregional tumour control, survival and toxicity.

PATIENTS AND METHODS

Between 1987 and 1997 (9,335), a total of 142 patients (pts) were treated by primary radiochemotherapy (RCT) according to prospective protocols. There were 64 pts with involvement of the hypopharynx, 57 pts with oropharyngeal and 21 with oral cavity carcinoma. UICC (1997) stages included: 16 pts in stage III, 113 pts in stage IV A, 13 pts in stage IV B. All pts received platin-based RCT up to a median total dose of 70 Gy (range, 60-72 Gy). Six weeks after RCT, pts with complete response of the primary tumour (N=97) were offered a uni- or bilateral ND depending on the initially diagnosed nodal disease as part of a strict institutional policy. Fifty-six pts consented to ND and 41 refused. These two groups were analysed in terms of characteristics, local and regional tumour control, survival and long-term side effects. Median follow-up was 37 months (range, 22-124 months).

RESULTS

Among the 56 pts receiving ND, a total of 13 (23%) was found to have residual tumour in the neck specimen. The rates of positive histology according to clinical N category after RCT were: yN0 (2/22[9%]), yN1 (2/10[20%]), yN2a-b (2/10[20%), yN2c-3 (7/14[54%]). Five-year overall survival and disease-specific survival rates for pts with ND were 44 and 55%, for pts without ND 42 and 47%, respectively (P=0.9). No difference was seen for long-term local and regional control between the two patient groups. Comparing the group of patients with and without ND, a trend towards higher subjective morbidity of grade 3 and 4 (LENT-SOMA), i.e. pain recording (24% vs. 17%), dysphagia (48% vs. 35%) and hoarseness (20% vs. 9%) was evident in patients with ND.

CONCLUSION

No clear evidence for routine clinical use of ND after RCT in advanced head and neck tumours can be derived from these data. ND may be contemplated in selected cases with multiple residual nodes only.

Impact of genomic instability in risk assessment and chemoprevention of oral premalignancies

Head-and-neck cancer is a disfiguring disease with increasing incidence rates even in young people, whose exposure to known risk factors is limited. This emphasizes the importance of early identification, on an individual basis, of precursor lesions that will develop into carcinomas. The clinical value of identifying individuals at high risk of oral cancer is emphasized by the fact that these patients are likely to benefit from available chemopreventive measures, largely without adverse effects.

Role of neck surgery in conjunction with radiation in regional control of node-positive cancer of the oropharynx

For patients with clinically node-positive oropharynx cancer treated with radiotherapy, planned neck dissection is controversial. We investigated whether neck surgery after radiation reduces nodal recurrence. Between 1970 and 1995, 263 patients at Massachusetts General Hospital received radiotherapy for clinically node-positive base of tongue or tonsil carcinomas. Patients received three different types of treatment: neck surgery followed by radiation (SR)-50 patients; radiation alone (RT)-160 patients; and radiation followed by surgery (RS)-53 patients. Median patient follow-up was 28 months. SR patients have an 84% complete response (CR) rate, RT patients 76%, and RS patients 13%. In multivariate analysis, among patients with a CR, the three treatment groups have the same regional control rates. Among patients with an incomplete response, the RS treatment group is 67% (p < 0.01) and 86% (p < 0.01) less likely to have recurrence than the RT and SR groups, respectively. Neck dissection after radiation therapy improves regional control for patients without a complete clinical response to radiation therapy but not for those with a CR. Despite higher CR rates, neck dissection before radiation confers no regional control benefit. We therefore recommend that primary radiotherapy with neck dissection be reserved for those without a complete clinical response.

Surgical treatment of squamous cell carcinoma of the base of tongue

INTRODUCTION

Squamous cell carcinoma (SSC) of the tongue base has historically been shown to be associated with a poor prognosis. We reviewed our experience with primary surgery followed by postoperative radiation therapy (XRT) to determine the impact of our treatment protocols on outcome.

METHODS

We retrospectively reviewed the records of all patients presenting to the University of Pittsburgh with previously untreated SSC of the tongue base between 1980-1997. Patients who were treated nonoperatively were excluded from analysis. Surgical excision of the primary was performed with ipsilateral neck dissection. The contralateral neck was dissected when the primary lesion was located in the midline or for clinically positive contralateral neck nodes. Postoperatively, most patients (93%) received XRT to the primary site and neck. Adjuvant chemotherapy was offered if histologic signs of aggressive behavior were identified (multiple nodes or extracapsular spread).

RESULTS

Of 87 patients identified, 39 (45%) were initially seen with T1 or T2 tumors. Seventy-nine patients (91%) were initially seen with stage III or IV disease. Contralateral neck dissection was performed in 36 patients (41%). Metastatic disease was demonstrated in 84% of ipsilateral neck nodes and in 47% of contralateral neck nodes. Occult metastases were found in 61% of clinically N0 necks. Local recurrence occurred in 5 patients, regional recurrence occurred in 12 patients, and distant metastases developed in 22 patients. Overall and disease-specific survival rates at 5 years for all patients were 49% and 56%, respectively. The 5 year disease-specific survival rates for stage I, stage II, stage III, and stage IV disease were 100%, 86%, 62%, and 48%. The 5-year disease-specific survival rate was 88% for T1 lesions, 64% for T2 lesions, 58% for T3 lesions, and 30% for T4 lesions (p <.05, log-rank test).

CONCLUSIONS

Surgical treatment of SCC of the tongue base is highly effective in achieving local disease control and disease-free survival for early lesions. Because both functional outcome and survival are poor after surgical treatment of advanced lesions, we now offer brachytherapy with XRT or participation in a combined chemoradiation protocol rather than primary surgical therapy to patients with advanced disease. Prospective studies are needed to compare the effect of these organ-preserving therapies with traditional combined surgery and XRT to determine the effect on functional outcome and quality of life.

The role of postradiotherapy neck dissection in supraglottic carcinoma

PURPOSE

To evaluate our policy of performing neck dissection based on regional response after definitive radiotherapy in patients with supraglottic carcinoma and to identify the prognostic factors in this group of patients.

METHODS AND MATERIALS

Between 1970 and 1995, 121 patients with node-positive squamous cell carcinoma of the supraglottic larynx were treated with definitive radiotherapy. Sixty-nine percent of patients presented with 1997 AJCC Stage IV disease. The N-stage distribution was N1, 49; N2, 62; and N3, 10. The median size of the lymph nodes was 3 cm (range, 0.5-8 cm). Forty-five patients received once-a-day treatment with a median total dose of 65 Gy (range, 58.0-70.8 Gy) in 1.8-2.0 Gy per fraction over 48 days, and 76 patients received split-course accelerated hyperfractionation with a median total dose of 67.2 Gy (range, 63.2-73.6 Gy) in 1.6 Gy twice a day over 43 days. Patients whose lymph nodes were not clinically detectable at 4-6 weeks after the completion of radiotherapy (complete response) were followed without any neck dissection. Patients with persistent neck adenopathy (partial response) underwent neck dissection whenever possible. Mean follow-up of the living patients was 6.5 years.

RESULTS

Regional response was related to the size of lymph nodes at presentation. Eighty-seven percent of patients with nodal size of 3 cm or less had a complete response, whereas 43% of patients with nodal size greater than 3 cm had a partial response. The rate of regional control at 3 years for all patients in the study was 66%. The 3-year ultimate regional control rate after salvage neck dissection was 75%. A relapse in both the primary and regional sites was the most common pattern of relapse, accounting for 39% of all the failures. Local failure was associated with subsequent regional relapse with a relative risk of 4.3. For patients with complete response in whom postradiotherapy neck dissection was withheld, the regional control rates were 75% and 86% for N1 and N2, respectively. The rate of isolated regional relapse in this group of patients was 7.5%. In multivariate analysis, significant favorable factors predictive for regional control were female gender, accelerated hyperfractionation, and complete response; whereas factors predictive for overall survival were Karnofsky Performance Scale score and regional response. The rate of Radiation Therapy Oncology Group (RTOG) Grade 2 or 3 neck fibrosis was 17% and 23% for patients with and without postradiotherapy neck dissection, respectively.

CONCLUSION

Isolated regional relapse is not common in patients with supraglottic carcinoma when a complete response is achieved at 4-6 weeks after definitive radiotherapy and postradiotherapy neck dissection is not performed. Female gender, accelerated hyperfractionation, and complete response are favorable predictors of regional control.

Planned neck dissection for advanced primary head and neck malignancy treated with organ preservation therapy: disease control and survival outcomes

BACKGROUND

The role of planned neck dissection after organ preservation therapy with radiotherapy or chemotherapy/radiotherapy for advanced head and neck cancers presenting with clinically positive neck disease is still being elucidated. The aim of this study is to review the outcomes of such patients treated by organ preservation therapy at our institution.

METHODS

A retrospective chart review of 33 patients who underwent planned neck dissections after organ preservation therapy for advanced primary head and neck malignancy. Endpoints measured were disease-free survival and local, regional, and distant control.

SETTING

Tertiary metropolitan medical center.

RESULTS

Two-year actuarial disease-free survival was 61%, and neck control was 92%, with only two failures in the neck. The use of neoadjuvant chemotherapy and total dose of radiotherapy did not correlate with neck control or disease-free survival. The presence of pathologically positive nodal disease at the time of neck dissection did not correlate with recurrent neck disease, but was a predictor of local recurrence (p = .0086).

CONCLUSIONS

Our data suggest that for patients undergoing planned neck dissection after organ preservation therapy, neck control is obtained in almost all cases. The presence of pathologically positive nodal disease at the time of surgery may have implications for the incidence of local recurrence.

Markers of neck failure in oral cavity and oropharyngeal carcinomas treated with radiotherapy

BACKGROUND

Neck management after radiotherapy remains controversial. It is not clear which patients may benefit from postradiotherapy neck dissection. Biologic markers may be useful in this setting.

METHOD

This study includes 81 patients with oral cavity and oropharyngeal carcinomas. The primary tumor had been treated with radical radiotherapy. Immunohistochemical staining to p53, ki-67, NEU, HSP-27, and GST has been performed.

RESULTS

There were 50 T1-2 and 31 T3-4 patients, as well as 36 NO and 45 N1-3. A total of 25 nodal failures was observed. With expressed HSP2, 23% of patients had neck failure compared with 51% when HSP-27 was absent (p = .02). With NEU overexpression, nodal control decreased from 72% to 34% (p = .008). In a Cox model, NEU (p = .01) and HSP-27 (p = .05) were associated with neck failure.

CONCLUSIONS

HSP-27 and NEU expression may play a role in predicting nodal failure. This should be confirmed in a larger, prospective study.

External beam radiation followed by planned neck dissection and brachytherapy for base of tongue squamous cell carcinoma

BACKGROUND

Surgical resection of tongue base cancer can leave the patient with significant functional deficits. Other therapies, such as external beam radiation followed by neck dissection and radiation implants, have shown equal tumor control with good functional outcome.

METHODS

Between March 1991 and July 1999, 12 patients at Oregon Health Sciences University, the Portland Veterans Administration Medical Center and West Virginia University School of Medicine Hospital were treated with external beam radiation followed by neck dissection and Ir192 implants. Two patients had T1 disease, two had T2, five patients had T3 tumors, and three had T4 tumors. Six had N2a necks, three had N2b necks, and three had N2c. Follow-up ranged from 13 months to 8 years.

RESULTS

After external beam radiation, five patients had complete response and seven had partial response in the neck without complications. One patient underwent a unilateral radical neck dissection, eight had unilateral selective neck dissections involving levels I to IV, and three had dissections involving levels I to III. One of the five patients who had a complete clinical response in the neck had pathologically positive nodes. One patient had a pulmonary embolus that was treated and had no permanent sequelae. There were three complications from brachytherapy. Two patients had soft tissue necrosis at the primary site and one patient had radionecrosis of the mandible. All healed without further therapy. One patient had persistent disease and underwent a partial glossectomy but died of local disease. Distant metastasis developed in two patients. All others show no evidence of disease and are able to eat a normal diet by mouth.

CONCLUSION

This combination of therapies should be considered when treating tongue base cancer.

How to optimize therapeutic ratio in brachytherapy of head and neck squamous cell carcinoma?

Considerable experience has been accumulated with low dose rate (LDR) brachytherapy in the treatment of squamous cell carcinoma of the oral cavity and oropharynx, 4 cm or less in diameter. Recent analysis of large clinical series provided data indicating that modalities of LDR brachytherapy should be optimized in treating these tumours for increasing therapeutic ratio. LDR brachytherapy is now challenged by high dose rate (HDR) brachytherapy and pulsed dose rate (PDR) brachytherapy. Preliminary results obtained with the last two modalities are discussed in comparison with those achieved with LDR brachytherapy.