Squamous cell carcinoma of the oropharynx--an analysis of treatment results in 289 consecutive patients

Distant metastases in squamous cell carcinoma of the pharynx and larynx: a population-based DAHANCA study

BACKGROUND

In head and neck cancer, distant metastases may be present at diagnosis (M1) or occur after treatment (DM). It is unknown whether M1 and DM follow the same clinical development and share prognosis, as population-based studies regarding outcomes are scarce. Therefore, we investigated the incidence, location of metastases and overall survival of patients with M1 and DM.

MATERIALS AND METHODS

Patients diagnosed with squamous cell carcinoma of the pharynx and larynx in Denmark 2008-2017 were identified in the Danish Head and Neck Cancer Group (DAHANCA) database. We identified 7300 patients, of whom 197 (3%) had M1 and 498 (8%) developed DM during follow-up.

RESULTS

The 5-year cumulative incidence of DM was 8%. 1- and 2-year overall survival for DM (27% and 13%) vs. M1 (28% and 9%) were equally poor. There was no significant difference in location of metastases for M1 and DM and the most frequently involved organs were lungs, bone, lymph nodes and liver, in descending order. In oropharyngeal squamous cell carcinomas, the location of metastases did not differ by p16-status. For p16-positive patients, 21% of DM occurred later than three years of follow-up compared to 7% of p16-negative patients.

CONCLUSION

Incidence, location of metastases and prognosis of primary metastatic (M1) or post-treatment metastatic (DM) disease in pharyngeal and laryngeal squamous cell carcinoma are similar in this register-based study.

Subsite variation in survival of oropharyngeal squamous cell carcinomas 2004 to 2011

OBJECTIVES/HYPOTHESIS

To evaluate subsite-specific differences in survival between squamous cell carcinomas of the base of tongue and tonsillar fossa in a modern cohort likely to have been treated with intensity-modulated radiation therapy, chemotherapy for stage III and IV, and have had a high incidence of human papillomavirus-associated tumors.

STUDY DESIGN

Retrospective cohort analysis utilizing data from the Surveillance, Epidemiology, and End Results program of patients with base of tongue and tonsillar fossa squamous cell carcinoma from 2004 to 2011.

METHODS

The cohort included 15,299 primary base of tongue and tonsillar fossa squamous cell carcinoma patients without distant metastases treated between 2004 and 2011. Subsite differences in overall survival and disease-specific survival were examined with Kaplan-Meier curves. Multivariate cox proportional hazard ratios were estimated for overall and disease-specific survival.

RESULTS

The cohort included 7,220 (47.2%) base of tongue and 8,079 (52.8%) tonsillar fossa squamous cell carcinoma patients. Overall survival with all stages combined favored tonsillar fossa (P < .001) and remained superior when stratified by stage. In multivariate analyses adjusted for age, gender, race, and treatment, the hazard ratio for overall survival was superior for tonsillar fossa tumors compared to base of tongue tumors for all stages (stage 1, P = .041; stage 2, P = .006; stages 3 and 4, P < .001). Disease-specific survival also favored improved outcomes for tonsillar fossa.

CONCLUSIONS

In this large modern cohort, overall and disease-specific survival favored outcomes in tonsillar fossa compared with base of tongue. Further study is required to evaluate factors that influence survival differences between tonsillar fossa and base of tongue despite modern therapy.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:1087-1092, 2017.

Response evaluation of the neck in oropharyngeal cancer: Value of magnetic resonance imaging and influence of p16 in selecting patients for post-radiotherapy neck dissection

BACKGROUND

Residual neck disease after radiotherapy in advanced oropharyngeal squamous cell carcinoma (OPSCC) is associated with increased mortality, and some patients may benefit from post-radiotherapy neck dissection (PRND). The aim of the present study was to assess the value of magnetic resonance imaging (MRI) and other clinical characteristics in selecting patients for PRND.

MATERIALS AND METHODS

Retrospective cohort study. Consecutive patients with N+ OPSCC were included. Medical records, pathology reports and imaging reports were reviewed. Pre- and post-therapeutic imaging was re-evaluated.

RESULTS

A total of 100 consecutive patients from a three-year period were included. Neck response was evaluated with MRI two months after treatment. Sixty patients were suspicious for residual neck disease, and were offered surgery; seven of these patients had histologic evidence of carcinoma. Cumulative neck failure after three years was 14% (8.4-24%), and did not differ significantly among patients with positive compared to negative MRI (radiologist's initial description; p = 0.47, log-rank test). Applying neck failure as gold standard, sensitivity and specificity of MRI was 69% and 41%, respectively; positive and negative predictive value was 15% and 90%. Patients with p16 + disease had significantly larger lymph nodes after treatment, and imaging based on lymph node size resulted in many false positives. Analysis of receiver operating characteristic curves in 191 individual lymph nodes showed that a short axis ≥ 10 mm should be classified as suspicious. Furthermore, T-stage and p16-status were associated with increased risk of neck recurrence. Salvage was successful in four patients with early detected nodal recurrence.

CONCLUSION

These results suggest that lymph node size, T-stage and p16 status could be used in selecting patients for PRND in OPSCC. Yet, early anatomical imaging may be inappropriate for evaluating neck response in patients with p16 + disease as enlarged lymph nodes often do not indicate residual neck disease.

Increasing incidence of base of tongue cancers from 2000 to 2010 due to HPV: the largest demographic study of 210 Danish patients

BACKGROUND

We assessed the development in the number of new base of tongue squamous-cell carcinoma (BSCC) cases per year in eastern Denmark from 2000 to 2010 and whether HPV may explain any observable increased incidence.

METHODS

We performed HPV DNA PCR and p16 immunohistochemistry analysis for all (n=210) BSCCs registered in the Danish Head and Neck Cancer Group (DAHANCA) and the Danish Pathology Data Bank, and genotyped all HPV-positive specimens with amplicon-based next-generation sequencing.

RESULTS

The overall crude incidence of BSCCs increased significantly (5.4% per year) during the study period. This was explained by a significant increase in the number of HPV-positive BSCCs (8.1% per year), whereas the number of HPV-negative BSCCs did not increase significantly. The overall HPV prevalence was 51%, with HPV16 as the predominant HPV type.

CONCLUSIONS

The increased number of HPV-positive BSCCs may explain the increasing incidence of BSCCs in eastern Denmark, 2000-2010.

Tumor volume reduction rate measured during adaptive definitive radiation therapy as a potential prognosticator of locoregional control in patients with oropharyngeal cancer

BACKGROUND

The purpose of this study was to evaluate the prognostic significance of the tumor volume reduction rate (TVRR) measured during adaptive definitive radiation therapy (RT) in patients with oropharyngeal cancer.

METHODS

We reviewed the RT records of 59 patients with oropharyngeal cancer who were treated with definitive RT with or without concurrent chemotherapy between January 2006 and October 2010. Adaptive replanning was performed in all patients during RT. The pre-RT and mid-RT gross tumor volumes (GTVs) of the primary and the metastatic lymph nodes were measured and analyzed for their possible impacts on locoregional control.

RESULTS

After the median follow-up period of 41.3 months (range, 9.3-73.5 months) for survivors, there were 10 treatment failures (8 locoregional recurrences and 2 distant metastases). The locoregional control rate at 3 years in all the patients was 84.1%. The mean pre-RT and mid-RT total GTVs were 27.5 cm(3) (±17.9 cm(3) ) and 16.9 cm(3) (±12.1 cm(3) ), and the mean GTV reduction rate was 37.9% (±22.6%), respectively. The patients who achieved locoregional control had a higher TVRR than those with locoregional failure (p = .010), and those with the TVRR >35% achieved significantly higher locoregional control at 3 years (94.4% vs 72.4%; p = .018). On multivariate analysis when adjusted with other clinical prognostic factors, the TVRR was found to be a significant factor affecting the locoregional control (hazard ratio = 0.136; 95% confidence interval = 0.022-0.852; p = .033).

CONCLUSION

The TVRR measured during adaptive RT proved a significant prognosticator on locoregional disease control in patients with oropharyngeal cancer, based on which a few therapeutic modifications may be considered.

Results of transoral laser microsurgery in 102 patients with squamous cell carcinoma of the tonsil

The objective of this study is to assess the feasibility of transoral laser microsurgery (TLM) in the treatment of squamous cell cancer of the tonsil and to report the oncological and functional outcomes, using retrospective chart review in the setting of single-institute, academic tertiary referral center. Between October 1987 and December 2006, 102 patients were eligible for this study, mostly suffering from advanced disease: 13% presented with stage I and II (UICC/AJCC 2002) tumors and 87% with stages III and IVa. The median follow-up was 63 months. All patients were treated by TLM with (or without) neck dissection (95%) and with (66%) postoperative radiotherapy. Overall survival, recurrence-free survival, disease-free survival, local control and loco-regional control were analyzed as end points. Rate of tracheotomies, postoperative complications and swallowing function were also analyzed. 5-year Kaplan-Meier local and loco-regional control was 78% for pT1 and pT2 and 75 % for pT3 and pT4a tumors. 5-year Kaplan-Meier disease-free survival, recurrence-free survival, and overall survival and was 74, 64 and 59% for stage I and II, 68, 60 and 56 % for stage III and IVa, respectively. Our data supports the conclusion, that TLM should be considered as a therapeutic option for the treatment of cancer of the tonsil. The oncological and functional results are comparable to any other treatment regimen, while the morbidity and complications tend to be lower.

Concurrent radiochemotherapy in locally-regionally advanced oropharyngeal squamous cell carcinoma: analysis of treatment results and prognostic factors

BACKGROUND

Concurrent radiochemotherapy is a recommended treatment option for patients with locally advanced squamous cell head and neck carcinomas with recent data showing the most significant absolute overall and event-free survival benefit achieved in patients with oropharyngeal tumours. The aim of this study was to analyse the results of three-dimensional conformal radiotherapy given with concomitant weekly cisplatin in patients with advanced oropharyngeal carcinoma and to identify prognostic factors influencing outcomes of this patients category.

METHODS

Sixty-five patients with stage III or IV squamous cell carcinoma of the oropharynx who underwent concurrent radiochemotherapy between January 2005 and December 2010 were retrospectively analyzed. All patients received radiotherapy to 70 Gy/35 fractions/2 Gy per fraction/5 fractions per week. Concurrent chemotherapy consisted of weekly cisplatin (30 mg/m(2)) started at the first day of radiotherapy.

RESULTS

Median age was 57 years (range, 36 to 69 years) and 59 (90.8%) patients were male. Complete composite response was achieved in 47 patients (72.3%). Local and/or regional recurrence was the most frequent treatment failure present in 19 out of 25 patients (76.0%). At a median follow-up of 14 months (range, 5 to 72 months), 2-year local relapse-free, regional relapse-free, locoregional relapse-free, disease-free, and overall survival rates were 48.8%, 57.8%, 41.7%, 33.2% and 49.7%, respectively.On multivariate analysis the only significant factor for inferior regional relapse-free survival was the advanced N stage (p = 0.048). Higher overall stage was independent prognostic factor for poorer local relapse-free survival, locoregional relapse-free survival and disease-free survival (p = 0.022, p = 0.003 and p = 0.003, respectively). Pre-treatment haemoglobin concentration was an independent prognostic factor for local relapse-free survival, regional relapse-free survival, locoregional relapse-free survival, disease-free survival, and overall survival (p = 0.002, p = 0.021, p = 0.001, p = 0.002 and p = 0.002, respectively).

CONCLUSIONS

Poor treatments results of this study suggested that introduction of intensity-modulated radiotherapy, use of induction chemotherapy followed by concurrent radiochemotherapy, accelerated radiotherapy regimens, and molecular targeted therapies could positively influence treatment outcomes. The incorporation of reversal of anaemia should be also expected to provide further improvement in locoregional control and survival in patients with advanced squamous cell carcinoma of the oropharynx.

Salvage treatment for recurrent oropharyngeal squamous cell carcinoma

BACKGROUND

This study evaluates the oncological outcome of patients with recurrent oropharyngeal squamous cell carcinoma (OPSCC) after primary radiation therapy +/- chemotherapy, primary surgical therapy, and surgical therapy followed by radiation therapy +/- chemotherapy.

METHODS

A total of 156 patients (36%) of a cohort of 427 treated for OPSCC between 1990 and 2006 developed recurrent disease. Fifty-one patients (12%) qualified for salvage treatment. Study endpoints were 5-year overall survival (OS) and disease-specific survival (DSS).

RESULTS

The 5-year OS and DSS rates after salvage treatment were 29% and 40%; after initial primary radiation therapy, 25% and 40%; after initial surgery followed by radiation therapy, 40% and 40%; and after initial surgery alone, 20% and 40%.

CONCLUSIONS

Patients with an advanced OPSCC have a considerable risk for recurrence. Despite poor ultimate outcome, salvage treatment should be attempted in patients with resectable disease, good performance status, and absence of distant metastases.

Surgery and postoperative radiotherapy a valid treatment for advanced oropharyngeal carcinoma

Since 1992 we have prospectively included all head and neck cancer patients in our health region in a departmental based register. Our hospital takes care of all head and neck cancer patients in our health region consisting of approximately 1 million people. In 1997, we evaluated the results of the treatment of oropharyngeal cancer in the 1992–1997 period. On the basis of this evaluation, we changed our treatment policy for tonsillar and base of tongue carcinoma. We first changed the treatment for the lesions with worst prognosis, i.e., those with T3–T4 carcinomas, from radiotherapy only, to radical surgery and postoperative radiotherapy. We have since that time increasingly also operated the smaller oropharyngeal carcinomas. The 2 years’ overall survival and disease-specific survival for all patients diagnosed in the 1992–1997 period was 56 and 63%, respectively. The results from a similar group of patients in the 6 years’ period from 2000 to 2005, after the change in treatment, have increased to 83 and 88%. When we looked at the subgroup of patients in the 2000–2005 period treated with surgery and postoperative radiotherapy, 45 out of 69 patients (65%) presenting with an oropharyngeal cancer were fit for operation. With radical surgery and postoperative radiation therapy, the 2 years overall survival is now 91%. The 2-year disease-specific survival is 96% and the locoregional control is 98%. This is a marked improvement as compared to radiotherapy alone and definitely competitive with modern radiochemotherapy.

The role of human papillomavirus in the increased incidence of base of tongue cancer

Numerous reports have shown that the incidence for oropharyngeal cancer is increasing and that human papillomavirus (HPV) is a risk factor. However, few studies have investigated the specific subsites of the oropharynx. Following our previous research on tonsillar cancer, we assessed the increase in the incidence of base of tongue cancer and the prevalence of HPV in this disease. Between 1998 and 2007, 109 patients were diagnosed for base of tongue cancer in Stockholm county. Ninety-five paraffin-embedded diagnostic tumor biopsies from patients were obtained and tested for HPV, both by general HPV PCR and HPV-16/HPV-33 type-specific PCR. Expression of HPV-16 RNA was analyzed to confirm E6 and/or E7 expression. Incidence data were obtained from the Swedish Cancer Registry. An overall increase in the incidence of base of tongue cancer from 0.15/100,000 person-years during 1970-1974 to 0.47/100,000 person-years during 2005-2007 was found in Sweden. The prevalence of HPV in base of tongue cancer in Stockholm county increased from 58% during 1998-2001 to 84% during 2004-2007 (p < 0.05). In the HPV-positive tumors, HPV-16 dominated (86%) but interestingly, HPV33 was detected in as many as 10%. E6 and/or E7 RNA were found in 85% of the samples tested. The incidence of base of tongue cancer, as well as the proportion of HPV-positive tumors, has increased in Sweden during the study period, suggesting that HPV may contribute to this increase.

Value of intraoperative ultrasonography in tonsil cancer

BACKGROUND

The exact assessment of a tonsil carcinoma's size is often difficult because of the tumour's submucosal extension and deep infiltration.

AIM

The aim of the study is to assess the usefulness of intraoperative ultrasonography in tonsil cancer.

MATERIAL

Twenty patients with carcinoma of the tonsil were included in the study (squamous cell carcinoma keratosis - 12, squamous cell carcinoma akeratosis - 6, diffuse large B cell lymphoma - 1, neoplasma malignum microcellulare - 1).

METHOD

Transcutaneous, endoscopic, and intraoperative ultrasonography were performed using a linear 7.5 MHz probe.

RESULTS

The difference in the results was statistically significant between palpation examination and intraoperative ultrasonographic examination, between transcutaneous ultrasonographic examination and intraoperative ultrasonographic examination, and between endoscopic ultrasonographic examination and intraoperative ultrasonographic examination in tonsil tumours. Generally, tumour size assessed by intraoperative ultrasonography was more advanced than those assessed by other methods.

CONCLUSIONS

Intraoperative ultrasonography is a safe, non-invasive method, which can be repeated at every stage of surgery. There were no contraindications or side effects. In all cases histological margins corresponded to sonographic margins. Intraoperative ultrasonography provides a quick and reliable orientation during resection of tonsil carcinoma.

Pretreatment prognostic factors of survival in patients with locally advanced nonmetastatic squamous cell carcinoma of the head and neck treated with radiation therapy with or without concurrent chemotherapy

BACKGROUND

Identification of pretreatment prognostic factors influencing overall survival (OS) in locally advanced squamous cell carcinoma of the head and neck is an important issue in head and neck oncology.

METHODS

A total of 289 patients were treated with standard fraction or hyperfractionated radiation therapy with or without concurrent low-dose daily chemotherapy.

RESULTS

Gender (P = 0.43) and age (P = 0.26) did not influence OS whereas Karnofsky Performance Status (KPS) (P < 0.0001), T stage (P < 0.0001), and N stage (P < 0.0001) did. Stage grouping was another factor that influenced OS (P < 0.001). Patients with larynx and nasopharynx fared better than those with other primaries (P = 0.0153). Finally, treatment significantly influenced OS. Multivariate analysis showed that KPS, T and N stage, and treatment were independent prognosticators of OS.

CONCLUSIONS

KPS, T and N stage, and treatment are independent prognosticators of OS in patients with locally advanced squamous cell carcinoma of the head and neck treated with radiation therapy with or without concurrent low-dose daily chemotherapy.

Long-term follow-up and a detailed prognostic analysis of patients with oropharyngeal cancer treated with radiotherapy

PURPOSE

To find a prognostic factor for patients with oropharyngeal cancer (OPC) who were followed for long term after definitive radiotherapy.

METHODS

OPC patients that had been treated with radiotherapy at our institution were reviewed. Sex, age, performance status (PS), subsite, disease stage, T-stage, N-stage, RT dose, concurrent chemotherapy, the duration of RT, hemoglobin concentration before any treatment, and a double cancer were assessed for their impact on overall survival (OS) and locoregional control (LRC).

RESULTS

Among a total of 141 patients enrolled into this retrospective study, the disease of most patients (81%) was stage III or IV. The median follow-up time of the surviving patients was 56 months (range 5-175 months). Radiotherapy was administered in conventional fractionation, and the median RT dose was 66 Gy. Most patients (90%) received systemic chemotherapy. The 5-year estimates of progression-free survival, LRC, and OS were 66.0, 72.7, and 65.1%, respectively. In the univariate analysis, LRC and OS in the lateral wall at the primary site, T-stage <or=3, and PS <or=1 groups were significantly superior to those in the other groups, and OS in age <or=60 or the hemoglobin level >13.0 g/dL groups were also significantly superior to those in the other groups. In the multivariate analysis, age and T-stage remained significant factors for OS.

CONCLUSIONS

Primary radiotherapy was recommended for OPC patients with the lateral wall at the primary site because of good LRC. The treatment method to the older population and T4 tumor is future tasks.

Metabolic tumor volume predicts for recurrence and death in head-and-neck cancer

PURPOSE

To evaluate the prognostic value of metabolic tumor volume measured on 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging and other clinical factors in patients treated for locally advanced head-and-neck cancer (HNC) at a single institution.

MATERIALS AND METHODS

Between March 2003 and August 2007, 85 patients received positron emission tomography (PET)/computed tomography-guided chemoradiotherapy for HNC. Metabolically active tumor regions were delineated on pretreatment PET scans semiautomatically using custom software. We evaluated the relationship of (18)F-fluorodeoxyglucose-PET maximum standardized uptake value (SUV) and total metabolic tumor volume (MTV) with disease-free survival (DFS) and overall survival (OS).

RESULTS

Mean follow-up for surviving patients was 20.4 months. The estimated 2-year locoregional control, DFS, and OS for the group were 88.0%, 69.5%, and 78.4%, respectively. The median time to first failure was 9.8 months among the 16 patients with relapse. An increase in MTV of 17.4 mL (difference between the 75th and 25th percentiles) was significantly associated with an increased hazard of first event (recurrence or death) (1.9-fold, p < 0.001), even after controlling for Karnofsky performance status (KPS) (1.8-fold, p = 0.001), and of death (2.1-fold, p < 0.001). We did not find a significant relationship of maximum SUV, stage, or other clinical factors with DFS or OS.

CONCLUSIONS

Metabolic tumor volume is an adverse prognostic factor for disease recurrence and death in HNC. MTV retained significance after controlling for KPS, the only other significant adverse prognostic factor found in this cohort. MTV is a direct measure of tumor burden and is a potentially valuable tool for risk stratification and guiding treatment in future studies.

Prognostic significance of tumor hypoxia inducible factor-1alpha expression for outcome after radiotherapy in oropharyngeal cancer

PURPOSE

Head-and-neck squamous cell carcinoma (HNSCC) represents a heterogeneous group of patients in terms of subsite, treatment, and biology. Currently most management decisions are based on clinical parameters with little appreciation of patient differences in underlying tumor biology. We investigated the prognostic significance of clinicopathologic features and tumor hypoxia-inducible factor-1alpha (HIF-1alpha) expression in a homogeneous series of patients who underwent radiotherapy.

METHODS AND MATERIALS

An audit identified 133 consecutive patients with histologically proven squamous cell carcinoma of the tonsil or tongue base. All patients received primary radiotherapy between 1996 and 2001. Tumor HIF-1alpha expression was examined in 79 patients.

RESULTS

Features associated with poor locoregional control were low Hb level (p = 0.05) and advancing T (p = 0.008), N (p = 0.03), and disease (p = 0.008) stage. HIF-1alpha expression was a more significant adverse prognostic factor in the tonsil (hazard ratio [HR], 23.1; 95% confidence interval [CI]. 3.04-176.7) than the tongue-base tumor (HR, 2.86; 95% CI, 1.14-7.19) group (p = 0.03, test for interaction). High tumor HIF-1alpha expression was associated with low blood Hb levels (p = 0.03). In a multivariate analysis HIF-1alpha expression retained prognostic significance for locoregional control (HR, 7.10; 95% CI, 3.07-16.43) and cancer-specific survival (HR, 9.19; 95% CI, 3.90-21.6).

CONCLUSIONS

There are significant differences in radiation therapy outcome within a homogeneous subsite of the oropharynx related to molecular marker expression. The work highlights the importance of studying homogeneous groups of patients in HNSCC, and the complex interrelationships between tumor biology and clinicopathologic factors. The establishment of tumor-type specific markers would represent a major advance in this area.

Definitive chemoirradiation for resectable head and neck cancer: treatment outcome and prognostic significance of MRI findings

The aim of this study was to evaluate the outcome and prognosticators for patients with resectable head and neck cancer (RHNC) undergoing definitive concurrent chemotherapy and radiotherapy (CCRT). In total, 110 RHNC patients receiving definitive CCRT to defer radical surgery were enrolled. Radiotherapy was given as either 2 Gy once daily with 70 Gy, or 1.2 Gy twice daily with 74.4 Gy. Chemotherapy involved the administration of 5-fluorouracil and cisplatin in two concomitant and two post-radiotherapy adjuvant cycles. 3 months after CCRT, MRI was performed to evaluate the response and determine further treatment plans. Survival outcome was calculated by the Kaplan-Meier method. Log-rank test and Cox regression analyses were used to estimate the significance of prognosticators. 4-year local-regional control, distant metastasis-free survival, disease-free survival and overall survival rates were 76.1%, 85.6%, 67.5% and 53.2%, respectively. Local recurrence (odds ratio = 4.09; p < 0.0001) and T3/T4 stage (odds ratio = 2.34; p = 0.01) were the independent factors associated with poor survival. T stage (odds ratio = 3.29; p = 0.03) and/or remission status on post-CCRT MRI (odds ratio = 7.22; p < 0.0001) were significantly associated with local control, distant metastasis-free survival and disease-free survival. 13 of 20 patients with imaging residuum had local recurrence, compared with 12 of 89 with complete remission (4-year local control rate of 27% vs 86%; p < 0.0001). Post-CCRT MRI may thus be used to predict the chance of a successful non-surgical approach.

Overall Survival of Oropharyngeal Cancer Patients Treated With Different Treatment Modalities

Therapeutic modalities of use in tumor therapy can be applied in various combinations to treat malignant lesions of the mesopharynx. A study was made of the overall survival of patients with mesopharyngeal carcinoma treated with different modalities in our institution in the period 1995-2000. In this retrospective study, a total of 66 patients were divided into 4 groups: Patients who took part in 1) intra-arterial chemotherapy and subsequent irradiation; 2) intra-arterial chemotherapy and surgical care; 3) only surgical care; or 4) only irradiation or palliative treatment. In each group, the five-year survival rate was examined, as a function of the age of the patient, the initial tumor size, the lymph node status and the clinical stage. The five-year overall survival rate in group 1 was 28.57%, in both group 2 and group 3 was 66.66%, and in group 4 was 20%. For all of the 66 patients, it was 43.93%. For groups 2 and 3, the Kendall rank correction test did not reveal a significant effect of the lymph node state or the clinical stage on the survival, whereas the effects of the age and the initial tumor size did prove to be significant. The Cox regression test showed the latter of these two effects to be the stronger. As 64 of the 66 patients examined were treated for tumors in clinical stages III or IV, the five-year survival rate of 43.93% may be said to be good. The comparison of groups 2 and 3 revealed that (in spite of the poorer initial prognosis in group 2) the survival rates were the same, i.e. the neoadjuvant intra-arterial chemotherapy improved the prognosis.

Prognostic influence of retropharyngeal lymph node metastasis in squamous cell carcinoma of the oropharynx

PURPOSE

To investigate the impact of involvement of retropharyngeal lymph nodes on the prognosis of squamous cell carcinoma of the oropharynx.

METHODS AND MATERIALS

The pretreatment computed tomographic scans of 208 patients with squamous cell carcinoma of the oropharynx were reviewed for the presence of metastatic retropharyngeal lymph nodes. All patients were treated at the Leuven department between 1984 and 2003: by radiotherapy alone in 84.1% of patients, by surgery with postoperative radiotherapy in 11.5%, and by concomitant chemoradiotherapy in 4.4%. Retropharyngeal node involvement was present in 34 (16%) patients. The influence on recurrence (local and regional), distant metastasis, and survival was retrospectively analyzed. Median follow-up was 47 months (3.9 years), and results were analyzed for 201 patients.

RESULTS

At 5 years, patients with retropharyngeal adenopathy had significantly more regional recurrences (45% vs. 10%, p = 0.004). Involvement of retropharyngeal lymph nodes significantly (relative risk 4.29 [95% confidence interval 3.33-5.25], p = 0.01) and independently predicted regional recurrence in multivariate analysis. Disease-specific survival was significantly lower in the retropharyngeal node positive group (38% vs. 58%, p = 0.03).

CONCLUSIONS

Retropharyngeal node involvement has a negative impact on the prognosis of squamous cell cancer of the oropharynx. Patients are particularly at risk for regional recurrence, resulting in worse disease-specific survival. Retropharyngeal node involvement should be taken into account in designing the treatment plan for these patients.

Paradigma da disseminação linfática no carcinoma espinocelular da base da língua

OBJETIVO: O carcinoma espinocelular CEC da base da língua tem um comportamento agressivo, disseminando-se precocemente para o pescoço uni ou bilateralmente. O objetivo deste trabalho é estabelecer critérios de tratamento eletivo ou terapêutico dos linfonodos cervicais metastáticos ou não para o CEC da base de língua. MÉTODO: Estudo retrospectivo de 290 pacientes com CEC de base de língua atendidos no Departamento de Cirurgia de Cabeça e Pescoço e Otorrinolaringologia do Hospital Heliópolis, Hosphel, São Paulo, de 1997 a 2000. Após análise loco-regional, foram classificados segundo os níveis I, II, III, IV e V do estadiamento TNM da UICC (1998). Os resultados foram analisados segundo o teste do Qui-quadrado para o estudo da associação de sítios, tamanho do tumor, presença de metástases e invasão da linha média. RESULTADOS: Houve um predomínio do sexo masculino em relação ao feminino (9:1), da 6ª década, dos fumantes e etilistas (83,8%). Quanto à disseminação linfonodal, diagnosticamos N0 (21,0%), N1 (13,4%), N2 (43,1%), N3 (22,5%) e níveis I(11,6%), II(69,0%), III (13,5%), IV (2,8%) e V (3,1%). Quanto à invasão da linha média, não houve relação significante com o nível comprometido. CONCLUSÃO: O tratamento do CEC da base da língua deve envolver o sítio primário e os níveis de disseminação linfonodal, uni e bilateral.

Salvage surgery after radical accelerated radiotherapy with concomitant boost technique for head and neck carcinomas

BACKGROUND

Definitive radiotherapy (RT) for head and neck cancer is increasingly used to preserve organ function, whereas surgery is reserved for treatment failure. However, data are sparse regarding the feasibility of salvage surgery, particularly for unselected patients after accelerated RT.

METHODS

From 1991 to 2001, 297 patients, most with stage III to IV cancer (Union Internationale Contre le Cancer) were treated with concomitant boost RT (median dose, 69.9 Gy in 41 fractions) with or without chemotherapy (in 33%, usually cisplatin with or without 5-fluorouracil). The 75 patients seen with local and/or regional failure were studied. We analyzed the factors influencing the decision to attempt surgical salvage, the oncologic outcome, and the associated complications.

RESULTS

Seventeen (23%) of the 75 patients had a salvage operation. This included all five patients with laryngeal cancers but only 16% to 20% of patients with tumors in other locations. Most patients could not be operated on because of disease extension (40%) and poor general condition/advanced age (30%). Patients with low initial primary T and N classification were more likely to undergo surgery (p = .002 and .014, respectively). Median post-recurrence survival was significantly better for patients who had salvage operations than for those without surgical salvage treatment (44 vs 11 months, p = .0001). Thirteen patients were initially seen with postoperative complications (mostly delayed wound healing and fistula formation).

CONCLUSIONS

After definitive accelerated RT with the concomitant boost technique, only a minority of patients with local or regional recurrence underwent salvage surgery. Disease stage, tumor location, and patient's general condition at the initial diagnosis seemed to be the main factors influencing the decision to attempt surgical salvage. For patients with initially resectable disease who undergo radical nonsurgical treatment, more effective follow-up is needed to favor early detection of treatment failure, which may lead to a timely and effective salvage surgery.

Intensity-modulated radiation therapy for oropharyngeal carcinoma: impact of tumor volume

PURPOSE

To assess the therapeutic outcomes in oropharyngeal cancer patients treated with intensity-modulated radiotherapy (IMRT) and analyze the impact of primary gross tumor volume (GTV) and nodal GTV (nGTV) on survival and locoregional control rates.

METHODS AND MATERIALS

Between February 1997 and September 2001, 74 patients with squamous cell carcinoma of the oropharynx were treated with IMRT. Thirty-one patients received definitive IMRT; 17 also received platinum-based chemotherapy. Forty-three patients received combined surgery and postoperative IMRT. The median follow-up for all patients was 33 months (range, 9-60 months). Fifty-two patients (70.3%) had Stage IV disease, 17 patients (23%) had Stage III, 3 patients (4.1%) had Stage II, and 2 patients (2.7%) had Stage I tumors. The mean prescription dose was 70 and 66 Gy, respectively, for the definitive and postoperative cohorts. The daily fraction dose was either 1.9 or 2 Gy, five times weekly. The GTV and/or nGTV were determined and derived using the Computational Environment for Radiotherapy Research, a free software package developed at Washington University. The mean GTV was 30.5 +/- 22.3 cm(3), and the mean nGTV was 23.2 +/- 20.6 cm(3).

RESULTS

Ten locoregional failures were observed. Six patients died of disease and three died of concurrent disease. Distant metastasis developed in 6 patients. The 4-year estimate of overall survival was 87%, and the 4-year estimate of disease-free survival was 81% (66% in the definitive vs. 92% in the postoperative RT group). The 4-year estimate of locoregional control was 87% (78% in the definitive vs. 95% in the postoperative RT group); the 4-year estimate of distant metastasis-free survival was 90% (84% in the definitive vs. 94% in the postoperative group). Multivariate analysis showed that GTV and nGTV were independent risk factors determining locoregional control and disease-free survival for definitive oropharyngeal IMRT patients. The worst late toxicities documented were as follows: 32 patients with Grade 1 and 9 with Grade 2 xerostomia; 2 with Grade 1 and 1 with Grade 2 skin toxicity; 3 with Grade 1 late mucositis; and 3 with Grade 1 trismus. Seventeen patients required gastrostomy tube placement.

CONCLUSION

IMRT is an effective treatment modality for locally advanced oropharyngeal carcinoma. The GTV and nGTV are the most important factors predictive of therapeutic outcome.

Supraglottic carcinoma: patterns of failure and salvage treatment after curatively intended radiotherapy in 410 consecutive patients

PURPOSE

In a series of consecutive patients with squamous cell carcinoma of the supraglottic larynx, in which almost all were treated by primary radiotherapy, the study describes the path from diagnosis to cure or death, and evaluates the patterns of failure and the treatment of recurrences.

METHODS AND MATERIALS

The analysis included 410 patients, 104 females and 306 males, treated between 1963 and 1991. Most patients were in Stage I (33%), and the remaining were in Stage II (18%), III (23%), and IV (26%). Primary intended curative treatment was delivered in 398 (radiotherapy, 394; surgery, 4) of 410 cases (98%).

RESULTS

Initial radical treatment resulted in 173 cured patients and 225 patients with a recurrence. Curatively intended salvage could be applied in 158 patients: surgery in 154 patients (74 cured) and radiotherapy in 4 (none cured). Overall, 247 patients (60%) obtained tumor control, 179 (44%) without a laryngectomy. Sixty-three patients had a total laryngectomy, and five had a partial laryngectomy. The 5-year locoregional tumor control, disease-specific survival, and overall survival rates were 43%, 61%, and 47%, respectively. With a follow-up of 20 years posttreatment, 91 new primary malignant tumors were detected.

CONCLUSIONS

Radiotherapy is effective in the treatment of supraglottic laryngeal carcinoma, and the patients have a relatively good prognosis. Many patients retained their larynx intact. Recurrence after primary radiotherapy can be treated by surgery, with a high success rate even in advanced stages. Development of second primary cancer is a growing problem.