Radical combined treatment of locally extensive head and neck cancer in the elderly

Management of head and neck cancer in older patients

OBJECTIVE

A progressive increase in the number of older patients with head and neck cancer has been observed in the last few years. The aim of this study was to assess our experience in the management of older patients with head and neck cancer (HNC) in comparison with younger patients.

STUDY DESIGN

A retrospective review was conducted for all patients admitted and treated for newly diagnosed HNC between January 2008 and December 2012. The clinical characteristics, management approaches, and outcome data were recorded.

RESULTS

In total, 316 patients with HNC (232 males, 84 females) were enrolled: 203 (64%) were in the young group, whereas 113 patients (36%) were in the older group. Comorbidities (P < .000005) and stage IV tumors (P < .0005) were more frequently observed in the older group. Treatment options were uniformly distributed within the 2 groups; only radiotherapy alone was more frequently administered in older patients (P < .0005).

CONCLUSIONS

Chronologic age should not be a reason to deny appropriate treatments that could prevent death in older patients. A careful pretreatment assessment should always be performed.

Management of head and neck cancer in elderly patients

Head and neck cancer (HNC) represents a heterogeneous group of tumours requiring multimodality approaches. It is debatable whether HNC treatment in geriatric patients should be different to that delivered for younger patients. Furthermore, the risk of death seems to be higher in HNC patients with higher co-morbidity status. Despite the fact that there is no significant difference in outcome in younger versus older patients, older HNC patients are more likely to receive nonstandard, less aggressive therapies than younger patients. Age alone should not be the basis for selecting treatment options in older HNC patients. A thorough pretreatment evaluation of co-morbidities should always be performed, and radical surgical options should not be excluded in older HNC patients treated with curative intent, as postoperative complications occur no more frequently in older patients than in younger patients. Locoregional control and disease-free survival in older patients treated with radiation therapy (either with curative intent or in the palliative setting) are comparable to the results seen in younger HNC patients, with the same acute toxicity profile. In patients receiving systemic therapies, special attention must be given to modification of chemotherapy dosages according to renal and hepatic function. Molecular-targeted therapies appear to be very useful in such patients because of their favourable tolerability. In conclusion, once all physiological and biological risk factors have been addressed, a large proportion of geriatric patients can and should be offered the same HNC treatment as is offered to younger patients.

Combined treatment of advanced stages of recurrent skin cancer of the head

Object. The authors investigated whether skull base resection and primary free-flap reconstruction in a single-stage surgery is oncologically effective for treating advanced stages of recurrent skin cancer (RSC) of the head.

Methods. Eighteen consecutive patients were surgically treated. Twelve of them underwent an anterolateral skull base resection, which was performed using a pterional craniotomy combined with an orbitozygomatic osteotomy. Six patients underwent a posterolateral skull base resection, which was performed using an asterional craniotomy combined with a retrolabyrinthine petrosectomy. The wide postoperative defects were covered with muscular or myocutaneous free flaps.

The main factor influencing survival was the extent of the resection: patients with no or minimal residual disease showed a statistically significant longer survival time than those with consistent residual disease. Basal cell carcinoma had a better prognosis than squamous cell carcinoma. A trend toward improved survival was observed in patients classified as T4M0 with negative lymph nodes (N0), but this trend was not statistically significant. Adjuvant radiotherapy significantly influenced both survival time and the rate of local recurrence. The surgical morbidity rate was 27.8%; there were two transient cerebrospinal fluid leaks and three seventh cranial nerve injuries. Late complications included radionecrosis in one patient and skin erosion requiring a second surgery in another patient. No deaths occurred during a 30-day postoperative period.

Conclusions. Advances in skull base surgery and free-flap reconstruction allowed the authors to treat patients with advanced-stage RSC of the head in a rather satisfactory manner. Only when it is impossible to achieve no or minimal residual disease should aggressive treatment be considered.

Reasons for non-standard treatment in elderly patients with advanced head and neck cancer

Elderly patients with head and neck cancer are less likely to receive standard treatment. This study assessed the influence that age, tumour characteristics, comorbidity, social support, depressive symptoms and quality of life have on treatment choice. One hundred and five patients between 45 and 60 years of age and 78 patients of > or =70 years of age with carcinoma of the oral cavity (stage > or =II), oro- and hypopharynx (stage > or =II) or larynx (stage > or =III) completed a questionnaire on quality of life (EORTC QLQ-C30 and H&N35), depressive symptoms (CES-D) and social support (RSS12-I). In the 45-60 age group, 89% received standard treatment, compared with 62% of the > or =70 age group. A multivariate logistic regression analysis showed that the following factors predicted non-standard treatment: marital status (widowed), advanced tumour stage, comorbidity, less pain, considering the length of life less important than its quality and old age. This study showed that age itself independently influences treatment choice. However, it should be emphasised that the choice of a treatment should be based on a medical assessment and the patient's preferences, not on chronological age.

Elderly patients with head and neck cancer: short-term effects of surgical treatment on quality of life

Elderly patients with head and neck cancer are less likely to be treated surgically. However, little is known about surgical outcome and quality of life (QOL) in elderly patients after a major surgery. This prospective study compared the QOL and the surgical outcome of 54 elderly (> or =70 years) and 75 younger patients (45-60 years) with carcinoma of the oral cavity (stage > or = II), pharynx (stage > or = II) or larynx (stage > or = III). Before and 3 months after surgery, the patients completed questionnaires about QOL (EORTC QLQ-C30 and QLQ-H&N35) and depression (CES-D). Before treatment, elderly and younger patients did not differ in QOL. Three months after the treatment, both groups scored worse on most QOL aspects, but there were no significant differences between the elderly and the younger patients. Surgical and systemic complication rates were similar for both the groups. In conclusion, we found no significant differences in the complication rate and QOL aspects between surgically treated elderly and younger patients.

Induction chemotherapy followed by concomitant chemoradiation-induced regression of advanced cervical lymphadenopathy in head and neck cancer as a predictor of outcome

OBJECTIVE

We sought to determine whether induction chemotherapy followed by concomitant chemoradiation (ICCR)-induced advanced neck disease regression could predict outcome, especially the need for complete neck dissection in patients with N2-3 stage IV head and neck cancer (HNC).

METHODS

A retrospective study of 339 patients evaluated for treatment of stage IV HNC during the years 1988 to 1997 revealed 36 individuals with N2-3 cervical lymphadenopathy who were treated with ICCR. Responses to treatment, patterns of failure, and survival rates were analyzed.

RESULTS

Primary and regional tumor regressions were complete in 21 patients (58%), partial in 9 (25%), and absent in 6 (17%); the corresponding local failure rates were 5%, 44%, and 33% (P < 0.02). The regional failure rates were 24%, 89%, and 83%, respectively (P < 0.001); distant failure rates were 10%, 0%, and 0% (P > 0.99). The estimated 2-year survival rates for complete and partial/nonresponders were 57% and 20%, respectively (P < 0.02).

CONCLUSION

Patients with advanced regional metastases of HNC who respond completely to ICCR have an excellent chance for survival. However, such ICCR-induced complete regression of regional tumor cannot reliably predict ultimate neck disease control.