Surgical management of head and neck cancer

The role of human papillomavirus on the prognosis and treatment of oropharyngeal carcinoma

Human papillomavirus positive oropharyngeal cancer (HPV-positive OPC) is a distinct subtype of head and neck carcinoma (HNC) distinguished from HPV-negative HNC by its risk factor profile, clinical behavior, and molecular biology. Compared to HPV-negative HNC, HPV-positive OPC exhibits significantly better prognosis and an enhanced response to treatment. Recognition of the survival benefit of HPV-positive tumors has led to therapeutic de-intensification strategies aiming to mitigate treatment-related toxicities while maintaining high response rates. In this review, we summarize key aspects of oral HPV infection and the molecular mechanisms of HPV-related carcinogenesis. We review the clinical and molecular characteristics of HPV-positive OPC that contribute to its improved prognosis compared to HPV-negative HNC. We also discuss current and emerging treatment strategies, emphasizing potential mechanisms of treatment sensitivity and the role of therapeutic de-intensification in HPV-positive OPC. Lastly, we examine literature on the management and prognosis of recurrent/metastatic HPV-positive OPC with a focus on the role of salvage surgery in its management.

[Primary tumors of the submandibular gland: report of 25 cases]

Les tumeurs des glandes salivaires sont rares, elles constituent 3% des tumeurs de la tête et du cou et 0,6% des tumeurs humaines. La pathologie tumorale de la glande sous-maxillaire est moins fréquente que celle de la parotide et pose autant de problèmes aussi bien diagnostiques que thérapeutiques, surtout l'opportunité de la radiothérapie post-opératoire et l'attitude vis-à-vis des récidives. L'objectif de notre étude est de discuter les problèmes diagnostiques, les résultats thérapeutiques et évolutifs que présentent ces tumeurs afin d'en dégager l'attitude thérapeutique la plus appropriée en se basant sur une étude rétrospectif incluant une série de 25 cas de tumeurs de la glande sous maxillaire colligées aux services d'orl et au service de radiothérapie du CHU MED VI de Marrakech sur une période allant de Janvier 2009 jusqu'au décembre 2014. L’étude a concerné 09 hommes et 18 femmes. La moyenne d’âge était de 48 ans (25 - 71 ans), La tuméfaction sous mandibulaire était le principal symptôme révélateur. Le caractère douloureux a été signalé par 09 patients. Une seule paralysie du rameau mentonnier du nerf facial a été objectivée au moment de l'examen chez un malade. Les adénopathies cervicales ont été retrouvées chez 09 patients. La localisation jugulo-carotidienne haute homolatérale est la plus fréquente. Sur le plan thérapeutique, une sous maxillectomie a été réalisée chez 24 malades dont 02 réopéré pour récidive d'un adénome pléomorphe et un patient pour un carcinome adénoïde kystique. 3 tumeurs malignes n'ont pu bénéficier d'aucun traitement chirurgical du fait du caractère explosif de la lésion Les résultats histopathologiques ont montré une répartition largement dominée par l'adénome pléomorphe pour les tumeurs bénignes (66,66% des tumeurs bénignes), et le carcinome adénoïde kystique pour les tumeurs malignes (37,5% des tumeurs malignes). Neuf malades de notre série ont été irradiés en post opératoire. Deux tumeurs bénignes ayant présenté une première récidive sont toutes des adénomes pléomorphes, 04 tumeurs malignes ont présenté une première récidive (03 carcinome adénoïde kystique, 01 carcinome epidermoide) et un carcinome adénoïde kystique a présenté une deuxième récidive après un complément radiothérapeutique. La pathologie tumorale de la glande sous-maxillaire est complexe, dominée par les tumeurs malignes, elle pose des problèmes diagnostiques et thérapeutiques; Son diagnostic est orienté par des arguments cliniques et radiologiques, repose sur l'analyse anatomopathologique de la pièce d'exérèse opératoire. Un retard diagnostic joint a un traitement initial inadéquat assombrit d'avantage son pronostic.

Primary surgery versus chemoradiotherapy for advanced oropharyngeal cancers: a longitudinal population study

Background

Treatment for advanced stage oropharyngeal squamous cell carcinoma (OPSCC) includes combined chemoradiation therapy or surgery followed by radiation therapy alone or in combination with chemotherapy. The goal of this study was to utilize available evidence to examine survival outcome differences in patients with advanced stage OPSCC treated with these different modalities.

Methods

Patients with advanced stage OPSCC were identified. Primary outcome measurements were disease specific and overall survival rates with differences examined via Kaplan-Meier and logistic regression analysis.

Results

344 patients were enrolled. 94 patients underwent triple modality therapy inclusive of surgery followed by adjuvant combined chemotherapy and radiation therapy (S-CRT). 131 had surgery and radiation therapy (S-RT), while 56 had chemoradiation (CRT) therapy as their primary treatment. A total of 63 patients had single modality radiation therapy and were excluded from analysis due to the large number of palliative patients.

Kaplan-Meier overall survival analysis showed that therapy with S-CRT had the highest disease specific survival at five years (71.1%). This is contrasted against S-RT and CRT, with five year survival rates at 53.9%, and 48.6%, respectively.

Cox regression showed that the comparison of S-CRT vs. S-RT, and CRT is associated with statistically significant increased hazard ratios of 1.974, and 2.785, indicating that both S-RT and CRT are associated with a reduced likelihood of survival at 5 years when compared to S-CRT.

Conclusions

In this population based cohort study S-CRT is associated with a 17–22% 5 year disease specific survival benefit compared to CRT or S-RT.

Radiation therapy for early-stage carcinoma of the oropharynx

PURPOSE

To evaluate the outcomes of radiation therapy treatment of patients with Stage I and II squamous cell carcinoma (SCC) of the oropharynx and discover adverse prognostic factors that may help select a subgroup of patients for a different management approach.

METHODS AND MATERIALS

A search of the database maintained by the Department of Radiation Oncology of The University of Texas M. D. Anderson Cancer Center for patients with Stage I or II SCC of the oropharynx was performed. This search identified 175 patients treated between 1970 and 1998 who met the inclusion criteria for this retrospective study. Distribution of primary sites was: tonsillar fossa/pillar, 60 patients; soft palate, 55 patients; base of tongue, 40 patients; and pharyngeal wall, 20 patients. Twenty-five patients were stage T1, 124 were T2, and 26 were Tx. All patients were treated with fractionated radiation to a median dose of 66 Gy. Eighty-five patients were treated with conventionally fractionated radiation, 73 were treated with the concomitant boost fractionation schedule, and the remaining 17 were treated with other altered fractionation schedules or with intraoral or interstitial boosts.

RESULTS

The median follow-up for all patients was 76 months (range, 2-302 months). The actuarial 5-year local control (LC), regional control, locoregional control (LRC), and disease-free survival (DFS) rates were 85%, 93%, 81%, and 77%, respectively. Only 7 patients (5%) with LC developed nodal metastases, and 10 patients (7%) with LRC developed distant metastases. Eleven patients (32%) with locoregional recurrence were rendered without evidence of disease after a surgical salvage procedure, resulting in a 5- year ultimate LRC rate of 87%. T-stage classification was statistically significant (p = 0.03) in univariate analysis for actuarial 5-year LRC, 88% for Stage I vs. 72% for Stage II. The 5- and 10-year disease-specific survival rates were 85% and 79%, respectively, while the actuarial 5- and 10-year overall survival rates were 70% and 43%, respectively. Fifty-one patients (29%) developed second primary tumors, 86% of which were cancers of the upper aerodigestive tract (UADT). Heavy alcohol consumption was associated with both an increased risk of disease recurrence and development of a second cancer of the UADT.

CONCLUSIONS

Patients with early-stage oropharynx cancer have high rates of disease control when treated with radiation. Lymphatic and hematogenous metastases are uncommon. Surgical salvage of disease recurrence is successful in approximately one-third of patients. As the majority of recurrences occur within the first 2 years from treatment, close observation during this time period is important. The development of second primary tumors of the UADT adversely impacts survival in these patients to as great a degree as the index cancer.

Carcinoma of the head and neck: a 5- to 20-year experience with preoperative chemotherapy, uncompromised surgery, and selective radiotherapy

BACKGROUND

A 5- to 20-year evaluation of preoperative chemotherapy uncompromised surgery and selective radiotherapy in stage III/IV head and neck squamous cell carcinoma.

METHODS

Eighty-two consecutive patients, single surgeon previously untreated, operable, and resectable for cure. Sites included the oral cavity, oropharynx, larynx, and hypopharynx. Two chemotherapeutic regimens were used: initial regimen (A), cisplatin/bleomycin (n = 45 patients); revised regimen (B), cisplatin/5-fluorouracil (n = 37 patients). The extent of surgery was carefully documented before chemotherapy-tattoo when feasible. This forms a strict guide for uncompromised surgery. Selective postoperative radiotherapy was based on specific criteria.

RESULTS

Minimum follow-up was 5 years. Absolute survival: total group, 60%; regimen A, 46%; and regimen B, 77% (P =.004). Relative survival (correcting for life table mortality): total group, 66%; regimen A, 50%; and regimen B, 83% (P =.003). Recurrences: primary site, n = 9 (regimen A, n = 7 [16%]; regimen B, n =2 [5%]) and neck, n = 6 (13%, all in regimen A). Distant metastasis occurred in 12 patients (10 [22%] in regimen A and 2 [5%] in regimen B).

CONCLUSIONS

This study suggests treatment of advanced head and neck squamous cell carcinoma (resectable for cure) with preoperative chemotherapy (regimen B); resection of original tumor volume, regardless of response to chemotherapy; and selective (rather than routine) postoperative radiotherapy results in improved survival. More controlled studies are recommended.

Changes in presentation and survival of head and neck carcinomas in Northeastern Italy, 1975-1998

BACKGROUND

During the last 20 years, survival rates of head and neck carcinoma patients in the United States and Europe have plateaued. To determine the factors that can reduce mortality rates, we examined changes in clinical presentation and survival rates across 24 years of treatment of head and neck carcinoma patients.

METHODS

A retrospective study of patients with head and neck carcinoma was conducted from January 1, 1975, to December 31, 1998. We identified 2143 eligible patients with squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, and larynx. Changes in gender, clinical stage, and therapy were evaluated separately for each site of cancer across five consecutive periods. Probability of dying and overall survival rates were estimated. Odds ratios (ORs) and hazard ratios were calculated.

RESULTS

An increase in T1 versus T2 or higher stage carcinoma was more probable for the oral cavity and larynx (OR = 4.1 and 3.0, respectively) in the last versus the earliest period. An increase in radical treatments was more probable for carcinomas of the oral cavity, oropharynx, hypopharynx, and larynx (10.2, 34.8, 12.5, and 2.1-fold, respectively) in the last versus the earliest period. A decreasing trend of probability of dying from the first head and neck carcinoma during the 1970s versus the 1990s was found. The overall survival rates at 5 years was 32% in 1975-1978 versus 51% in 1989-1993.

CONCLUSIONS

In contrast with survival rates in the United States and Europe, our findings show a significant increase in overall survival rates during the last 20 years. This increase is attributable to changes in diagnostic-therapeutic approaches and to early consultation with a physician for symptoms arising in the head and neck region.

Preoperative nutritional support at home in head and neck cancer patients: from nutritional benefits to the prevention of the alcohol withdrawal syndrome

PURPOSE OF REVIEW

Preoperative nutritional support in severely malnourished patients decreases complications after major surgery. This review summarizes previous studies on head and neck cancer patients undergoing surgery, and offers recommendations on preoperative nutritional support based on the literature and our experience.

RECENT FINDINGS

Head and neck cancer has a large impact on the patient's quality of life and a high mortality rate. Aggressive surgical resection followed by soft-tissue and osseous reconstruction is the gold standard of treatment. The incidence of postoperative complications is high at 20-50%. Malnutrition and alcohol withdrawal syndrome are often present, and are considered risk factors for developing wound infection after head and neck cancer surgery. Proactive intervention by preoperative nutritional support may correct nutrient deficiencies, minimize malnutrition-related morbidity and mortality, reduce the length and cost of hospitalization, and may prevent alcohol withdrawal syndrome. Nutritional support given preoperatively for 7-10 days decreases postoperative complications by approximately 10% in malnourished patients with weight loss of 10% or more. Oral liquid supplements and enteral nutrition are useful to support head and neck cancer patients preoperatively. Enteral nutrition is safer, more physiological, less expensive and practicable at home compared with parenteral nutrition, which is not usually indicated in these patients.

SUMMARY

Enteral nutrition is efficient in preoperative phase to prevent postoperative complications. However evidence is insufficient to conclude that preoperative immune-enhancing enteral feeding provides any supplementary benefit by comparison with a standard diet. Our experience with the preoperative approach in head and neck cancer patients is reported in this paper.

Squamous cell carcinoma of the oropharynx: surgery, radiation therapy, or both

BACKGROUND

The treatment of patients with squamous cell carcinoma (SCC) of the oropharynx remains controversial. No randomized trial has addressed adequately the question of whether surgery (S), radiation therapy (RT), or combined treatment is most effective.

METHODS

Treatment results from North American academic institutions that used S with or without adjuvant RT (S +/- RT) or used RT alone or followed by neck dissection (RT +/- ND) for patients with SCC of the tonsillar region or the base of tongue were compiled through a MEDLINE search (from 1970 to August, 2000) and from the references cited in each report. Studies were eligible for inclusion if they contained direct, actuarial (life-table), or Kaplan-Meier calculations for the following end points: local control, local-regional control, 5-year absolute survival, 5-year cause specific survival, or severe or fatal treatment complications. Weighted average results, which took into account series size, were calculated for each end point for the purposes of treatment comparison. Results and conclusions were based on data from 51 reported series, representing the treatment of approximately 6400 patients from the United States and Canada.

RESULTS

The results for patients with SCC of the base of tongue who underwent S +/- RT versus RT +/- ND, respectively, were as follows: local control, 79% versus 76% (P = 0.087); local-regional control, 60% versus 69% (P = 0.009); 5-year survival, 49% versus 52% (P = 0.2); 5-year cause specific survival, 62% versus 63% (P = 0.4); severe complications, 32% versus 3.8% (P < 0.001); and fatal complications, 3.5% versus 0.4% (P < 0.001). The results for patients with SCC in the tonsillar region who underwent S +/- RT versus RT +/- ND, respectively, were as follows: local control, 70% versus 68% (P = 0.2); local-regional control, 65% versus 69% (P = 0.1); 5-year survival, 47% versus 43% (P = 0.2); 5-year cause specific survival, 57% versus 59% (P = 0.3); severe complications, 23% versus 6% (P < 0.001); and fatal complications, 3.2% versus 0.8% (P < 0.001).

CONCLUSIONS

The information in this article provides a useful benchmark for evidence-based counseling of patients with SCC of the oropharynx. The rates of local control, local-regional control, 5-year survival, and 5-year cause specific survival were similar for patients who underwent S +/- RT or RT +/- ND, whereas the rates of severe or fatal complications were significantly greater for the S +/- RT group. Furthermore, available data on the functional consequences of treatment suggest the superiority of RT +/- ND. The authors conclude that RT +/- ND is preferable for the majority of patients with SCC of the oropharynx.