Planned early neck dissection before radiation for persistent neck nodes after induction chemotherapy

The effect of treatment on survival in patients with advanced laryngeal carcinoma

OBJECTIVES/HYPOTHESIS

Over the last 2 decades, survival from laryngeal cancer has decreased. We sought to identify factors associated with decreased survival in laryngeal cancer.

METHODS

Patients diagnosed with laryngeal squamous cell carcinoma from 1985 to 2002 were retrospectively reviewed.

RESULTS

A total of 451 patients met study criteria. Five-year survival rates were 85% for stage I, 77% for stage II, 51% for stage III, and 35% for stage IV disease. Survival for patients with stage I-III disease was similar for patients treated operatively or nonoperatively (P = .4). However, patients with stage III disease treated nonoperatively had worse survival with radiation alone (XRT) compared to chemoradiation (CR) (P = .006). Patients with stage IV disease had significantly better survival with surgery (49%) than CR (21%) or XRT alone (14%) (P < .0001). Analysis by primary tumor stage demonstrated that survival for T1-T3 disease was independent of treatment modality (P = .2); however, for T4 patients, operative treatment was associated with significantly better survival (55%) than CR (25%) or XRT (0%) (P < .0001). Proportional hazards models confirmed significantly worse survival for stage IV, T4, N2 or N3 disease, and nonoperative treatment. For T4 disease, after controlling for nodal status, nonoperative treatment was the only significant predictor of worse survival.

CONCLUSIONS

Primary surgical treatment is associated with improved survival for patients with stage IV disease and specifically T4 primary tumors. These data suggest that the observed national decrease in survival from laryngeal cancer may be due to a shift toward nonoperative treatment in that subset of patients with advanced primary disease.

Integrating Surgery Into Treatment Paradigms for Organ Preservation: Tailoring Treatment to Biology Improves Outcomes

PURPOSE

Neoadjuvant chemotherapy was introduced into treatment paradigms for curable head and neck cancer in the early 1970s in an effort to reduce the magnitude of mutilating surgery and to provide a rationale for adjuvant systemic chemotherapy in patients who responded to initial chemotherapy. The large number of trials that followed failed to demonstrate improved survival when neoadjuvant chemotherapy was added to conventional surgery or radiation. Importantly, a consistent observation in these neoadjuvant trials was the significant association of clinical tumor response to neoadjuvant therapy and favorable prognosis.

RESULTS

The findings led to development of a new treatment paradigm that was based on the hypothesis that the biology of an individual cancer is more predictive of response to specific therapy and overall outcome than is anatomic tumor site or extent, and on the corollary that matching treatment modality to biology will improve overall survival rates.

CONCLUSIONS

This report identifies key findings that are important in the design and analysis of organ preservation trials and biologic markers predictive of response and outcomes. Ongoing studies incorporating biomarkers such as p53, Bcl-xL, HPV, EGFR, COX-2, and tumor promoter gene methylation are underway and will identify new targets for molecular manipulation, response monitoring, and tumor imaging that could allow real-time changes in how we integrate the various components of multi-modal therapy.

Cancer of the oropharynx

Oropharyngeal cancer is a rare tumour. Tobacco use and alcohol consumption are recognised as major risk factors. Several carcinogens, occupational exposures and vitamin deficiencies represent the most significant predisposing factors. A varying host susceptibility to carcinogens can be inferred. Carcinoma of the oropharynx has to be suspected whenever sore throat, odynophagia, and ear-ache are described by the patient. Biopsy is mandatory for the definitive diagnosis. TNM classification is crucial for treatment decision-making, while stage grouping is less important. Prognostic factors are treatment-related. Standard treatment of T1-T2 tumours is radiation therapy, for T3 and T4 tumour treatment options are controversial. More advanced tumours can be treated either with surgery followed by conventional radiotherapy or by combined chemo-radiation. Non-conventional fractionation radiotherapy in combination with chemotherapy may represent a third option. Acute toxicity needs to be managed promptly. Late sequelae are less known. Treatment of such tumours requires a multidisciplinary approach within experienced centres.

Options for Preserving the Larynx in Patients with Advanced Laryngeal and Hypopharyngeal Cancer

The introduction of newer surgical and combined-modality approaches to organ preservation in patients with advanced laryngeal or hypopharyngeal cancer is the most exciting clinical frontier in head and neck cancer-treatment today. The use of these techniques at other sites, the exploration of improved methods for patient selection and tumor assessment, and the development of newer combination regimens will need to be rigorously studied in future clinical trials. In all these efforts, the major focus must remain on improving survival. This article reviews the latest developments in organ-preservation strategies and techniques for patients with advanced laryngeal or hypopharyngeal cancer.

Unresectable primary tumor of head and neck: does neck dissection combined with chemoradiotherapy improve survival?

A study regarding patients with primary and previously untreated advanced histologically proven squamous cell carcinoma of the head and neck was performed to compare two treatment modalities: neck dissection followed by chemoradiotherapy (Group I) versus chemoradiotherapy alone (Group II). Fifty-four patients were randomly chosen to receive Group I or II treatment. Our results demonstrate that Group I treatment has a higher and statistically significant disease-specific survival rate. We suggest that an association of neck dissection plus chemoradiotherapy can be useful in the event of unresectable advanced carcinomas.

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.