Definitive radiotherapy for tonsillar squamous cell carcinoma

Structured Literature Review to Identify Human Papillomavirus's Natural History Parameters for Dynamic Population Models of Vaccine Impacts

Human papillomavirus (HPV) is a common sexually transmitted virus that can cause cervical cancer and other diseases. Dynamic transmission models (DTMs) have been developed to evaluate the health and economic impacts of HPV vaccination. These models typically include many parameters, such as natural history of the disease, transmission, demographic, behavioral, and screening. To ensure the accuracy of DTM projections, it is important to parameterize them with the best available evidence. This study aimed to identify and synthesize data needed to parametrize DTMs on the natural history of HPV infection and related diseases. Parameters describing data of interest were grouped by their anatomical location (genital warts, recurrent respiratory papillomatosis, and cervical, anal, vaginal, vulvar, head and neck, and penile cancers), and natural history (progression, regression, death, cure, recurrence, detection), and were identified through a systematic literature review (SLR) and complementary targeted literature reviews (TLRs). The extracted data were then synthesized by pooling parameter values across publications, and summarized using the range of values across studies reporting each parameter and the median value from the most relevant study. Data were extracted and synthesized from 223 studies identified in the SLR and TLRs. Parameters frequently reported pertained to cervical cancer outcomes, while data for other anatomical locations were less available. The synthesis of the data provides a large volume of parameter values to inform HPV DTMs, such as annual progression rates from cervical intraepithelial neoplasia (CIN) 1 to CIN 2+ (median of highest quality estimate 0.0836), CIN 2 to CIN 3+ (0.0418), carcinoma in situ (CIS) 2 to local cancer+ (0.0396), and regional to distant cancer (0.0474). Our findings suggest that while there is a large body of evidence on cervical cancer, parameter values featured substantial heterogeneity across studies, and further studies are needed to better parametrize the non-cervical components of HPV DTMs.

Lymph node metastasis regulation by peritumoral tonsillar tissue mitochondria-related pathway activation in oropharyngeal cancer

Immune-related gene expression profiles of peritumoral tonsillar tissues are modified by oropharyngeal cancer (OPC) nodal status. This study explored immunometabolism and immune cell count alterations in peritumoral tonsillar tissue according to OPC nodal status. Microarray data analysis of 27 peritumoral tonsillar tissue samples, using a newly generated mitochondrial metabolism-related gene set comprised of 948 genes, detected 228 differentially expressed genes (DEGs) (206 up- and 22 downregulated) in metastasis-negative cases compared to metastasis-positive ones. REACTOME pathway analysis of the 206 upregulated genes revealed the Toll-like receptor 4 cascade were most enriched. Immune cell proportion analysis using the CIBERSORTx algorithm revealed a significantly higher rate of naïve B cells, but lower rates of regulatory T cells and resting natural killer cells in metastasis-negative cases. Digital spatial profiling of the 6 OPC tissues detected 9 DEGs in the lymphoid regions, in contrast, no DEGs were identified in tumor regions according to nodal status. Cancer cell nests and pair matched normal epithelia mitochondrial DNA (mtDNA) from 5 OPC tissues were analyzed by next generation sequencing for variant detection. However, no significant mtDNA variation was found. This study identified mitochondria-related immune cell transcriptional programs and immune cell profiles associated with OPC lymphatic spread in peritumoral tonsil tissue, further evaluation of which will elucidate targetable immune mechanisms associated with OPC lymphatic dissemination.

Immune-related gene expression profile at peri-tumoral tonsillar tissue is modified by oropharyngeal cancer nodal status

Secondary lymphoid organs (SLOs), such as lymph nodes and tonsils, serve as an interface between the immune system and tumor cells as an initial antigen presentation site, critical in anti-tumor immune response and disease progression. For oropharyngeal cancers (OPCs) originating from palatine tonsils, we hypothesized that characterizing the immunological process occurring at the peri-tumoral tonsillar tissue will elucidate immune mechanisms for the lymphatic spread of the disease. A total of 33 patients were enrolled and subdivided into two cohorts. For cohort 1 (6 cases), gene expression profiles at the peri-tumoral lymphoid regions and tumor regions were analyzed using the GeoMx whole transcriptome atlas. In the peri-tumoral lymphoid regions, 237 genes were upregulated in metastasis-negative cases compared with metastasis-positive ones, but only one gene in tumor regions. For cohort 2 (27 cases), microarray analysis of peri-tumoral tonsillar tissues revealed 192 upregulated genes. Gene Ontology (GO) analyses revealed the significantly enriched GO terms associated with T cell activation and detected 10 hub genes according to the degree rank (PTPRC, TLR4, CD80, CD40, STAT3, CD28, CD40LG, CD44, CCR7, and IL7R). Gene set enrichment analysis combined with principal component analysis effectively sorted patients with or without lymph node metastases. These findings suggest peri-tumoral tonsils as a potential target to investigate the immune mechanisms associated with the lymphatic spread of the disease in OPCs.

Association of Unilateral Radiotherapy With Contralateral Lymph Node Failure Among Patients With Squamous Cell Carcinoma of the Tonsil: A Systematic Review and Meta-analysis

Importance

Ipsilateral neck radiotherapy (RT) is controversial in some patients with tonsil cancer due to concern for nodal failure within the contralateral nonirradiated neck (hereinafter referred to as contralateral neck failure [CNF]).

Objective

To determine the rate of CNF following ipsilateral neck RT in patients with tonsil cancer.

Data Sources

Databases including PubMed, Embase, Web of Science, and Cochrane Library were queried for peer-reviewed, English language articles published between January 1, 1980, and December 31, 2021.

Study Selection

Studies reporting rates of CNF from at least 20 patients treated with ipsilateral neck RT. Studies were excluded if they lacked full text, reported results from databases or systematic reviews, or did not provide RT details.

Data Extraction and Synthesis

Data were extracted following the PRISMA reporting guideline. Study quality was assessed using criteria from a methodological index for nonrandomized studies. Pooled outcomes were estimated using random-effects models.

Main Outcomes and Measures

Primary outcome was the pooled rate of CNF following ipsilateral neck RT. Secondary outcomes were the pooled rates of CNF by tumor and nodal staging categories from the 7th edition of the AJCC Cancer Staging Manual and rates of toxic effects.

Results

A total of 17 studies (16 retrospective and 1 prospective) including 1487 unique patients were identified. The pooled risk of CNF was 1.9% (95% CI, 1.2%-2.6%). The rate of CNF by tumor (T) category was as follows: 1.3% (95% CI, 0.3%-2.3%) for T1; 3.0% (95% CI, 1.6%-4.4%) for T2; 11.3% (95% CI, 3.3%-19.2%) for T3; and 16.0% (95% CI, -7.8% to 39.8%) for T4. Patients with T3 to T4 tumors had a significantly higher rate of CNF than those with T1 to T2 tumors (11.5% [95% CI, 3.9%-19.1%] vs 1.8% [95% CI, 1.0%-2.6%]; P < .001). The rate of CNF by nodal (N) category was 1.2% (95% CI, 0.1%-2.2%) for N0; 4.8% (95% CI, 2.4%-7.2%) for N1; 3.1% (95% CI, 0.4%-5.8%) for N2a; 3.1% (95% CI, 1.2%-4.9%) for N2b; and 0 (95% CI, not applicable) for N3. Rates of CNF were similar for patients with N2b to N3 and N0 to N2a disease (3.0% [95% CI, 1.2%-4.7%] vs 1.7% [95% CI, 0.6%-2.8%], respectively; P = .07). Compared with bilateral RT, ipsilateral RT was associated with increased risk of CNF (log odds ratio, 1.29 [95% CI, 0.09-2.48]; P = .04). The crude rates of xerostomia of grade 3 or greater and feeding tube use were 0.9% (95% CI, -0.2% to 1.9%) and 13.3% (95% CI, 8.3%-18.3%), respectively.

Conclusions and Relevance

In this systematic review and meta-analysis, ipsilateral neck RT was associated with a low rate of CNF in patients with small, lateralized tonsil cancers. Bilateral neck RT was associated with lower risk of CNF compared with ipsilateral neck RT. Patients with tumors of a higher T category were at increased risk for CNF following ipsilateral neck RT, and advanced nodal stage was not associated with CNF. Rates of toxic effects appeared favorable in patients treated with ipsilateral neck RT.

Analysis of Outcomes following TORS in a Mixed Cohort of Recurrent and New T1-T2 Oropharyngeal Cancer- A Single Institution Study

Purpose

. The transoral robotic surgery is a newer modality being used in surgical treatment of early oropharyngeal cancer. The aim of this study is to assess the outcome of these cases in terms of two year disease free survival and overall survival.

Methods

Between July 2016 and September 2018, 58 patients suffering from early oropharyngeal cancer underwent transoral robotic surgery with neck dissection at a tertiary referral centre. 43 of them have completed two years follow up and were analyzed for disease free survival and overall survival. 41 patients had HPV analysis done .

Results

The surgical margins were positive in 9/43 patients ( 6 in upfront surgery and 3 in the salvage cohort). Adjuvant therapy was administered to 16/34 patients on account of either positive margins or multiple nodal metastasis. 88% patients were found to be HPV negative. The two year disease free survival for the upfront cohort was 88.2% and salvage cohort was 55.5%. The overall survival was 86.05%.

Conclusions

The study highlights good locoregional control and two year disease free survival in HPV negative oropharyngeal cancer undergoing robotic surgery. Additionally, a positive surgical margin and recurrence were the statistically significant variables influencing 2 year disease free survival. Trans oral robotic surgery is an excellent tool for early tumors of the oropharynx. The presence of a positive surgical margin is a grim sign for survival and has a significant impact on positive outcome.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03139-5.

Prognostic factors in oropharyngeal squamous cell carcinoma in the state of São Paulo, Brazil: 10-year follow-up

OBJECTIVE

To descriptively analyze the epidemiological data, clinical stage, and outcomes of oropharyngeal squamous cell carcinoma in the state of São Paulo, Brazil, and to estimate the influence of clinical stage and treatment type on overall and disease-free survival.

METHODS

We retrospectively analyzed epidemiological data from the São Paulo Cancer Center Foundation database relative to patients with oropharyngeal squamous cell carcinoma diagnosed between 2004 and 2014 in the state of São Paulo. Univariate and multivariate Cox regression analyses were performed to assess factors associated with the outcomes. A forward stepwise selection procedure was used. Survival curves were estimated by the Kaplan-Meier method and compared by the Gehan-Breslow-Wilcoxon test.

RESULTS

A total of 8075 individuals with oropharyngeal squamous cell carcinoma were identified. Of these, 86.3% were diagnosed at an advanced stage and 13.7% at an early stage. Only 27.2% of patients were treated surgically, whereas 57.5% were treated medically. Patients undergoing surgery had longer overall survival than those receiving medical treatment in both early- and advanced-stage oropharyngeal squamous cell carcinoma. However, there was no significant difference in disease-free survival between surgical and medical treatment.

CONCLUSION

No significant difference in disease-free survival between medical and surgical treatment suggests similar complete remission rates with both approaches. Patients receiving medical treatment had shorter overall survival, which may be due to complications from chemotherapy and radiotherapy. However, we cannot confirm this relationship based on the data provided by the São Paulo Cancer Center Foundation. Prospective studies are warranted to assess whether the lower overall survival rate in patients receiving medical treatment is secondary to complications from chemotherapy and radiotherapy.

LEVEL OF EVIDENCE

2C.

Current Evidence of a Deintensification Strategy for Patients with HPV-Related Oropharyngeal Cancer

Simple Summary

Human papillomavirus (HPV)-related oropharyngeal cancer represents a distinct disease entity, showing favorable treatment responses and survival outcomes. While the deintensification of treatment for HPV-related oropharyngeal cancer is widely considered necessary, details concerning patient selection and optimal strategies are undetermined. The heterogeneity of study populations and interventions in trials complicate the ability of physicians to apply the results in daily practice. The evolving landscape also requires physicians to consistently update the results of these trials. This article reviews the most recent evidence on the deintensification of HPV-related oropharyngeal cancer. We aim to provide physicians with some guidance regarding management options and assist researchers in appropriately designing trials in the future.

Abstract

Human papillomavirus (HPV)-related oropharyngeal cancer differs from HPV-negative oropharyngeal cancer in terms of etiology, epidemiology, and prognosis. Younger and lower comorbidity patient demographics and favorable prognosis allow HPV-related oropharyngeal cancer patients to anticipate longer life expectancy. Reducing long-term toxicities has become an increasingly important issue. Treatment deintensification to reduce toxicities has been investigated in terms of many aspects, and the reduction of radiotherapy (RT) dose in definitive treatment, replacement of platinum-based chemotherapy with cetuximab, response-tailored dose prescription after induction chemotherapy, and reduction of adjuvant RT dose after transoral surgery have been evaluated. We performed a literature review of prospective trials of deintensification for HPV-related oropharyngeal cancer. In phase II trials, reduction of RT dose in definitive treatment showed comparable survival outcomes to historical results. Two phase III randomized trials reported inferior survival outcomes for cetuximab-based chemoradiation compared with cisplatin-based chemoradiation. In a randomized phase III trial investigating adjuvant RT, deintensified RT showed noninferior survival outcomes in patients without extranodal extension but worse survival in patients with extranodal extension. Optimal RT dosage and patient selection require confirmation in future studies. Although many phase II trials have reported promising outcomes, the results of phase III trials are needed to change the standard treatment. Since high-level evidence has not been established, current deintensification should only be performed as part of a clinical study with caution. Implementation in clinical practice should not be undertaken until evidence from phase III randomized trials is available.

Cyberknife Radiosurgery for the Treatment of Head and Neck Cancer: A Systematic Review

Cyberknife radiosurgery is a frameless stereotactic robotic radiosurgery which has shown to deliver better treatment outcomes in the treatment of advanced head and neck (H&N) carcinomas, especially in previously irradiated and recurrent cases. The aim of the study was to perform a systematic review of the available data on the outcomes of Cyberknife radiosurgery for treatment of head and neck cancer and to evaluate its collective outcomes. This systematic review was registered with the university with the registration no. FRP/2019/63 and was approved by the Institutional Review Board (RC/IRB/2019/132). Literature search was performed in the following: PubMed, Science direct, SciELO, MyScienceWork, Microsoft Academ EMBASE, Directory of Open Access Journals, and Cochrane databases with the keywords “Cyberknife,” “oral cancer,” “oropharyngeal cancer,” and “head and neck cancer” and data was extracted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The records identified were 147 manuscripts. Excluded articles included 5 duplicate articles, 33 abstracts, 101 full text articles due to being off-topic, case reports, review, non-English, 1 survey, and 2 other articles containing data extracted from a main study which was already included. A total of 5 articles were evaluated for qualitative synthesis. The mean dose of Cyberknife radiosurgery delivered for previously irradiated recurrent H&N carcinoma patients was 34.57 Gy, with a mean sample size of 5 studied during the period of 2000 to 2016. The available evidence from the systematic review indicates that Cyberknife can be an efficacious treatment option for recurrent previously irradiated H&N carcinoma, especially for nonresectable tumors. There is paucity of homogenous data and studies in this arena; hence, meta-analysis could not be performed. Further standardized studies are essential, especially where the treatment of H&N carcinoma is considered.

Upfront Surgery vs. Primary Chemoradiation in an Unselected, Bicentric Patient Cohort with Oropharyngeal Squamous Cell Carcinoma-A Matched-Pair Analysis

Simple Summary

Oropharyngeal squamous cell carcinoma (OPSCC) is a common malignancy of the upper aerodigestive tract with rising incidence. While surgical and non-surgical approaches are applied in curative treatment, none of these has proven superior to date. In this study, we investigated overall survival in an unselected, bicentric cohort of patients with OPSCC and compared upfront surgery vs. primary chemoradiation treatments. A matched-pair analysis was performed to exclude confounding factors and reduce bias. Our results suggest that regardless of the treatment modality chosen, overall survival rates are comparable in both cohorts. As a consequence, future studies on functional outcome of patients with OPSCC are mandatory to identify the treatment modality most likely resulting in improved quality of life in patients with OPSCC.

Abstract

The two pillars of therapy for oropharyngeal squamous cell carcinoma (OPSCC) are upfront surgery and primary chemoradiotherapy. Substantial regional preferences exist with regard to the selection of treatment. Despite new therapeutic approaches, patient survival remains poor, with an approximate overall survival (OS) rate of 50% at five years. This study was conducted to investigate a potential survival benefit depending on the treatment modality in OPSCC patients. We retrospectively collected data of 853 patients with histologically confirmed OPSCC from the Giessen and Maastricht cancer databases. To identify risk factors affecting survival, a Cox-proportional hazard model was applied to 442 patients with complete data sets. Based on this cohort a matched-pair analysis with 158 patients was performed to compare OS rates of patients treated either with upfront surgery or primary chemoradiation. For the collective cohort, patients treated with upfront surgery had significantly improved OS rates compared to patients treated with primary chemoradiation. In the matched-pair analysis adjusted for patients’ T-, N- and HPV-status as well as risk profile, we observed that both treatment approaches offered equivalent OS rates. Our study emphasizes that treatment recommendations should be made whenever possible on the basis of side-effect profiles caused by the therapeutic approach used. To draw further conclusions, results of the ongoing “best of” (NCT2984410) study are eagerly awaited, investigating the functional outcome after treatment of OPSCC patients.

Radiation Oncology Applications in Plastic and Reconstructive Surgery: A Nonsystematic Review of Concepts and Principles

SUMMARY

Careful consideration of radiotherapy can determine the success of reconstructive therapy. There is a broad spectrum of radiotherapy modalities, both benign and malignant. Delivery mechanisms differ in the physical design, setup, radiation source, administrable dosage, and mode of delivery. This range of options allows radiation oncologists to tailor individualized treatment; however, radiotherapy concepts can be challenging for nonspecialists. The purpose of this article is to review general radiation oncology concepts, including essential equipment and radiobiology, and provide plastic surgeons with a basic conceptual understanding to facilitate effective multidisciplinary collaboration with radiation oncologists.

Evolving multidisciplinary treatment of squamous cell carcinoma of the head and neck in India✰

In this article, we highlight the evolution of a multimodal approach in the overall management of squamous cell carcinoma of the head and neck (SCCHN) in India; present advances in technology (newer surgical techniques), novel medical and radiotherapy (RT) approaches; review their roles for an integrated approach for treating SCCHN and discuss the current role of immunotherapy in SCCHN. For locally advanced (LA) SCCHN, the multidisciplinary approach includes surgery followed by RT, with or without chemotherapy (CT) or concurrent chemoradiotherapy. Improved surgical techniques of reconstruction and voice-preservation are being implemented. Advanced forms of high-precision conformal techniques like intensity-modulated radiotherapy are used to deliver highly conformal doses to tumors, sparing the surrounding normal tissue. Compared with RT alone, novel CT regimens and targeted therapeutic agents have the potential to improve locoregional control and survival and reduce treatment-induced toxicities. Several clinical trials have demonstrated efficacy, safety, and quality of life benefits of adding cetuximab to RT regimens in LASCCHN. Studies have also suggested a cetuximab-related laryngeal preservation benefit. At progression, platinum-based CT combined with cetuximab (a monoclonal anti-epidermal growth factor receptor antibody) is the only validated option available as the first-line therapy. Thus, an integrated multidisciplinary approach plays a key role in maximizing patient outcomes, reduction in treatment related morbidities that consequently impact quality of life of survivors.

Evaluation of robotic surgery for transoral resection of T1-2 squamous cell carcinoma of the tonsillar fossa

GOAL

To evaluate transoral robotic surgery (TORS) for isolated previously untreated squamous cell carcinoma (SCC) of the tonsillar fossa classified as T1-2.

METHOD

Retrospective analysis of two cohorts of isolated untreated T1-2 tonsillar fossa SCC consecutively operated on by a transoral approach, with (R=21) and without (NR=24) robotic assistance, in the period 2006-2014. Three main (survival, local control, and operative morbidity) and three secondary (pathologic data, incidence and duration of tracheotomy and nasogastric intubation, and hospital stay) endpoints were compared between groups. The significance threshold was set at P< .005.

RESULTS

Three- and five-year actuarial survival estimates were 80.2% and 74.5% respectively in group R, and 91.5% and 82.5% respectively in group NR (NS: P=.34). Three- and five-year actuarial local control estimates were 90% and 90% respectively in group R, and 95.8% and 91% respectively in group NR (NS: P=.81). There were no significant differences in morbidity, tracheotomy/nasogastric intubation time, or hospital stay. Positive resection margins (R1) were noted in 38.1% and 16.7% in groups R and NR, respectively (NS: P=.05) without significant impact on 5-year actuarial local control (P=0.78).

CONCLUSION

Robotic assistance in transoral lateral oropharyngectomy for T1-2 tonsillar fossa SCC did not significantly impact oncologic or functional outcome.

Transoral laser microsurgery for treatment of oropharyngeal cancer in 368 patients

BACKGROUND

Oncological and functional outcome of transoral laser microsurgery (TLM) for primary treatment of oropharyngeal cancer was examined using a multimodal treatment concept.

METHODS

A total of 368 patients with oropharyngeal squamous cell carcinoma (pT1-4, pN0-2, M0) underwent TLM +/- neck dissection (85%), +/- (chemo)radiotherapy (57%). The majority of patients had advanced stage III and IVa disease (79%).

RESULTS

Five-year Kaplan-Meier estimates for local control were 83.5% for pT1, 74.1% for pT2, 77.3% for pT3, and 76.0% for pT4a tumors. Five-year estimates of overall, disease-specific, and recurrence-free survival for stage I were 76.0%, 92.8%, and 69.1%; for stage II 71.1%, 85.7%, and 49.6%; for stage III 61.7%, 72.5%, and 58.8%; and for stage IVa 57.3%, 73.7%, and 63.9%, respectively. Postoperative (chemo)radiotherapy improved the outcome for advanced disease. p16-positive tumors had superior survival estimates. Overall, 93.5% maintained regular oral nutrition without feeding tube dependency.

CONCLUSION

Primary TLM in multimodal concepts of treatment offers good oncologic outcome even for advanced-stage oropharyngeal cancer.

Radiation-induced sensitivity of tissue-resident mesenchymal stem cells in the head and neck region

BACKGROUND

Tissue-resident mesenchymal stem cells (MSCs) possess the ability to migrate to areas of inflammation and promote the regeneration of damaged tissue. However, it remains unclear how radiation influences this capacity of MSC in the head and neck region.

METHODS

Two types of MSCs of the head and neck region (mucosa [mMSC] and parotid gland [pMSC]) were isolated, cultured and exposed to single radiation dosages of 2 Gy/day up to 10 days. Effects on morphology, colony forming ability, apoptosis, chemokine receptor expression, cytokine secretion, and cell migration were analyzed.

RESULTS

Although MSC preserved MSC-specific regenerative abilities and immunomodulatory properties following irradiation in our in vitro model, we found a deleterious impact on colony forming ability, especially in pMSC.

CONCLUSIONS

MSC exhibited robustness and activation upon radiation for the support of tissue regeneration, but lost their potential to replicate, thus possibly leading to depletion of the local MSC-pool after irradiation.

Chemoradiotherapy versus surgery followed by postoperative radiotherapy in tonsil cancer: Korean Radiation Oncology Group (KROG) study

Background

Treatment of tonsil cancer, a subset of oropahryngeal cancer, varies between surgery and radiotherapy. Well-designed studies in tonsil cancer have been rare and it is still controversial which treatment is optimal. This study aimed to assess the outcome and failure patterns in tonsil cancer patients treated with either approaches.

Methods

We retrospectively reviewed medical records of 586 patients with tonsil cancer, treated between 1998 and 2010 at 16 hospitals in Korea. Two hundred and one patients received radiotherapy and chemotherapy (CRT), while 385 patients received surgery followed by radiotherapy and/or chemotherapy (SRT). Compared with the SRT group, patients receiving CRT were older, with more advanced T stage and received higher radiotherapy dose given by intensity modulation techniques. Overall survival (OS), disease-free survival (DFS), locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMFS), and clinicopathologic factors were analyzed.

Results

At follow-up, the 5-year OS, DFS, LRRFS and DMFS rates in the CRT group were 82, 78, 89, and 94%, respectively, and in the SRT group were 81, 73, 87, and 89%, respectively. Old age, current smoking, poor performance status, advanced T stage, nodal involvement, and induction chemotherapy were associated with poor OS. Induction chemotherapy had a negative prognostic impact on OS in both treatment groups (p = 0.001 and p = 0.033 in the CRT and SRT groups, respectively).

Conclusions

In our multicenter, retrospective study of tonsil cancer patients, the combined use of radiotherapy and chemotherapy resulted in comparable oncologic outcome to surgery followed by postoperative radiotherapy, despite higher-risk patients having been treated with the definitive radiotherapy. Induction chemotherapy approaches combined with either surgery or definitive radiotherapy were associated with unfavorable outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3571-3) contains supplementary material, which is available to authorized users.

Squamous cell carcinoma of the retromolar trigone: Treatment outcomes

OBJECTIVE

Squamous cell carcinoma (SCC) of the retromolar trigone is uncommon, accounting for 1.4% of all oral cancer cases in Japan. Few studies have examined the optimal treatment for this cancer. The aim of this study was to evaluate the outcome of treatment for primary SCC of the retromolar area.

METHODS

We retrospectively analyzed the outcome and prognosis of 45 patients (38 men, 7 women) with SCC of the retromolar trigone who underwent treatment in our department between July 1992 and March 2011.

RESULTS

Mean age was 62.4 years. Clinical stages were: stage I (n=4, 8.9%); stage II (n=10, 22.2%); stage III (n=5, 11.1%); and stage IVa (n=26, 57.8%). Surgical resection was performed in all patients and 6 patients also received postoperative radiotherapy. Reconstructive surgery using free flaps was performed in 38 patients; postoperative complications occurred in 5 of these patients. The 3-year local control rate was 80%, and the 3-year over all survival rates for stage I, II, III, and IV disease were 100%, 80%, 40%, and 49.2%, respectively. Cause of death was the original disease in 23 cases and other diseases in 2 cases. The most common cause of death from the original disease was cervical lymph node metastasis.

CONCLUSION

The presence of cervical lymph node metastasis was a negative prognostic factor. Marginal mandibulectomy may be selected for patients without distinct bone-marrow infiltration.

Comparative Evaluation of Three Palliative Radiotherapy Schedules in Locally Advanced Head and Neck Cancer

Background

The aim of the study was to evaluate and compare the efficacy, tolerability and toxicity of three palliative radiotherapy (RT) schedules in locally advanced head and neck carcinoma (LAHNC), i.e. Quad Shot schedule, Christie schedule and conventional palliative schedule.

Methods

The patients were randomly divided into three groups of 30 each. Group I patients were planned for 14.8 Gy in 4 fractions over 2 days, repeated three weekly for two more cycles. Group II patients were planned for 50 Gy in 16 fractions over 3.1 weeks. Group III patients were planned for 20 Gy in 5 fractions over 5 days, repeated after an interval of 3 weeks. The quality of life was assessed before and after RT using University of Washington Quality of Life questionnaire version 4.

Results

Local control rates were 84%, 76%, and 76% for groups I, II and III, respectively. Disease status at 6-month follow-up was no evidence of disease (20%, 28%, and 16%), residual disease (72%, 48%, and 76%), and recurrent disease (8%, 24%, and 8%) in groups I, II and III, respectively. Grade III acute skin reactions were 28%, 44%, and 16% in groups I, II and III, respectively. Grade III acute mucosal reactions were 36%, 56%, and 24% in group I, II and III, respectively. Quality of life improved in all groups after RT.

Conclusion

Quad Shot schedule may be used in LAHNC with better local control and acceptable toxicity as compared to conventional palliative RT schedule in Indian setting.

Oropharyngeal cancer: United Kingdom National Multidisciplinary Guidelines

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. There has been significant debate in the management of oropharyngeal cancer in the last decade, especially in light of the increased incidence, clarity on the role of the human papilloma virus in this disease and the treatment responsiveness of the human papilloma virus positive cancers. This paper discusses the evidence base pertaining to the management of oropharyngeal cancer and provides recommendations on management for this group of patients receiving cancer care. Recommendations • Cross-sectional imaging is required in all cases to complete assessment and staging. (R) • Magnetic resonance imaging is recommended for primary site and computed tomography scan for neck and chest. (R) • Positron emission tomography combined with computed tomography scanning is recommended for the assessment of response after chemoradiotherapy, and has a role in assessing recurrence. (R) • Examination under anaesthetic is strongly recommended, but not mandatory. (R) • Histological diagnosis is mandatory in most cases, especially for patients receiving treatment with curative intent. (R) • Oropharyngeal carcinoma histopathology reports should be prepared according to The Royal College of Pathologists Guidelines. (G) • Human papilloma virus (HPV) testing should be carried out for all oropharyngeal squamous cell carcinomas as recommended in The Royal College of Pathologists Guidelines. (R) • Human papilloma virus testing for oropharyngeal cancer should be performed within a diagnostic service where the laboratory procedures and reporting standards are quality assured. (G) • Treatment options for T1-T2 N0 oropharyngeal squamous cell carcinoma include radical radiotherapy or transoral surgery and neck dissection (with post-operative (chemo)radiotherapy if there are adverse pathological features on histological examination). (R) • Transoral surgery is preferable to open techniques and is associated with good functional outcomes in retrospective series. (R) • If treated surgically, neck dissection should include levels II-IV and possibly level I. Level IIb can be omitted if there is no disease in level IIa. (R) • If treated with radiotherapy, levels II-IV should be included, and possibly level Ib in selected cases. (R) • Altering the modalities of treatment according to HPV status is currently controversial and should be undertaken only in clinical trials. (R) • Where possible, patients should be offered the opportunity to enrol in clinical trials in the field. (G).

Radiotherapy alone or combined with chemotherapy as definitive treatment for squamous cell carcinoma of the tonsil

This study is aimed at updating our institution's experience with definitive radiotherapy (RT) for squamous cell carcinoma of the tonsil. We reviewed 531 patients treated between 1983 and 2012 with definitive RT for squamous cell carcinoma of the tonsil. Of these, 179 patients were treated with either induction (n = 19) or concomitant (n = 160) chemotherapy. Planned neck dissection was performed on 217 patients: unilaterally in 199 and bilaterally in 18 patients. Median follow-up was 5.2 years for all patients (range 0.1-31.6 years) and 8.2 years for living patients (range 1.9-31.6 years). The 5-year local control rates by T stage were as follows: T1, 94 %; T2, 87 %; T3 79 %; T4, 70 %; and overall, 83 %. Multivariate analysis revealed that local control was significantly influenced by T stage and neck dissection. The 5-year cause-specific survival rates by overall stage were as follows: I, 94 %; II, 88 %; III, 87 %; IVA, 75 %; IVB, 52 %; and overall, 78 %. Multivariate analysis revealed that cause-specific survival was significantly influenced by T stage, N stage, overall stage, fractionation, neck dissection, sex, and ethnicity. Of 77 patients treated with ipsilateral fields only, contralateral neck failure occurred in 1 %. The rate of severe complications was 12 %. Definitive RT for patients with tonsillar squamous cell carcinoma provides control rates equivalent to other modalities with a comparatively low incidence of late complications. Patients with anterior tonsillar pillar or tonsillar fossa primaries that are well lateralized with no base of tongue or soft palate extension may be treated with ipsilateral fields.

RETRACTED: Laryngeal Function After Radiation Therapy

Laryngeal function after oncologic treatment is a key aspect and focus of interest in the contemporary management of head and neck cancers. Although historically the treatment of most locally advanced laryngeal cancers has been total laryngectomy, recent innovations in radiation therapy and combined chemotherapy and radiation therapy have shown that organ and function preservation can be achieved with good oncologic outcomes. Technical improvements, along with better understanding of tumor biology and dose tolerance of critical organs involved in speech and swallowing function, have paved the way for better outcomes. This article reviews in comprehensive detail the recent data of laryngeal function after radiotherapy.

Retromolar trigone squamous cell carcinoma treated with radiotherapy alone or combined with surgery: a 10-year update

PURPOSE/OBJECTIVES

Treatment outcomes were analyzed for patients who received radiotherapy for squamous cell carcinoma of the retromolar trigone at a single institution.

MATERIALS/METHODS

We reviewed the medical records of 110 patients treated with radiotherapy alone (n=36) or radiotherapy combined with surgical resection of the primary tumor (n=74) between June 1966 and October 2013. The median follow-up was 4.5years for all patients and 11.8years for living patients (range, 1.3-23.5years).

RESULTS

The 5-year local-regional control rates after definitive radiotherapy versus surgery and radiotherapy for stages I-III were 52% and 89% and for stage IV they were 46% and 58%, respectively. The 5-year cause-specific survival rates after definitive radiotherapy compared with surgery and radiotherapy for stages I-III were 57% and 82% and for stage IV they were 45% and 43%, respectively. Multivariate analyses revealed that the likelihood of cure was better with surgery and radiotherapy compared with radiotherapy alone (p=0.041).

CONCLUSION

Patients treated with surgery and radiotherapy had a better chance of cure than those treated with radiotherapy alone. Complications of treatment were common in both groups but more common in patients who underwent surgery.

Postoperative Hemorrhage After Transoral Oropharyngectomy for Cancer of the Lateral Oropharynx

Objective:

Assessment of incidence, risk factors, management, and outcome of postoperative hemorrhage after transoral oropharyngectomy for cancer of the lateral oropharynx.

Methods:

Retrospective review of a cohort of 514 cancers of the lateral oropharynx consecutively resected.

Results:

Incidence of postoperative hemorrhage was 3.6%. In 31.5% of cases, onset was after hospital discharge. No hemorrhages occurred after the end of the fourth postoperative week. Variables associated with increased risk of hemorrhage were advanced age ( P = .004), antithrombotic treatment ( P = .012), and robotic assistance ( P = .009). When the source of hemorrhage could be identified, hemostasis, performed transorally in most cases, was highly effective; no patients in this subgroup showed recurrence. In spontaneously resolved hemorrhage under observation or when no active site of bleeding was found on exploration under general anesthesia, the recurrence rate was 18.1%. Overall, hemorrhage resulted in death in 2 patients.

Conclusion:

Exploration under general anesthesia in case of active bleeding and observation with discussion of arterial exploration of the ipsilateral external carotid system in patients in whom no source of bleeding can be identified are the keys to successful management of this potentially lethal complication.

Transoral robotic surgery for oropharyngeal cancer: long-term quality of life and functional outcomes

IMPORTANCE

Because treatment for oropharyngeal squamous cell carcinoma (OPSCC), especially in patients of older age, is associated with decreased patient quality of life (QOL) after surgery, demonstration of a less QOL-impairing treatment technique would improve patient satisfaction substantially.

OBJECTIVE

To determine swallowing, speech, and QOL outcomes following transoral robotic surgery (TORS) for OPSCC.

DESIGN, PARTICIPANTS, AND SETTING

This prospective cohort study of 81 patients with previously untreated OPSCC was conducted at a tertiary care academic comprehensive cancer center.

INTERVENTIONS

Primary surgical resection via TORS and neck dissection as indicated.

MAIN OUTCOMES AND MEASURES

Patients were asked to complete the Head and Neck Cancer Inventory (HNCI) preoperatively and at 3 weeks as well as 3, 6, and 12 months postoperatively. Swallowing ability was assessed by independence from a gastrostomy tube (G-tube). Clinicopathologic and follow-up data were also collected.

RESULTS

Mean follow-up time was 22.7 months. The HNCI response rates at 3 weeks and 3, 6, and 12 months were 79%, 60%, 63%, and 67% respectively. There were overall declines in speech, eating, aesthetic, social, and overall QOL domains in the early postoperative periods. However, at 1 year post TORS, scores for aesthetic, social, and overall QOL remained high. Radiation therapy was negatively correlated with multiple QOL domains (P < .05 for all comparisons), while age older than 55 years correlated with lower speech and aesthetic scores (P < .05 for both). Human papillomavirus status did not correlate with any QOL domain. G-tube rates at 6 and 12 months were 24% and 9%, respectively. Greater extent of TORS (>1 oropharyngeal site resected) and age older than 55 years predicted the need for a G-tube at any point after TORS (P < .05 for both).

CONCLUSIONS AND RELEVANCE

Patients with OPSCC treated with TORS maintain a high QOL at 1 year after surgery. Adjuvant treatment and older age tend to decrease QOL. Patients meeting these criteria should be counseled appropriately.

Impact of primary tumor volume on local control after definitive radiotherapy for head and neck cancer

BACKGROUND

The impact of primary tumor volume (pTV) on local control after definitive radiotherapy (RT) for head and neck squamous cell carcinoma (HNSCC) is unclear.

METHODS

Pertinent literature was reviewed to address the impact of pTV on local control after definitive RT for HNSCC.

RESULTS

Reproducibility of pTV calculations is probably influenced by interobserver variability and may be reduced by relying on experienced observers. The impact of pTV on local control after definitive RT is probably influenced by primary site. A relatively limited impact of pTV on local control after RT for oropharyngeal squamous cell carcinomas (SCCs) might be attributable to human papillomavirus (HPV) positivity.

CONCLUSION

pTV may be a useful parameter to select patients for treatment with definitive RT, particularly for those with laryngeal SCCs. Patients with high-volume primary cancers, in which the probability of local control with a functional larynx is low, are likely better treated with surgery.

Improving imaging diagnosis of persistent nodal metastases after definitive therapy for oropharyngeal carcinoma: specific signs for CT and best performance of combined criteria

BACKGROUND AND PURPOSE

Criteria for detection of persistent nodal metastases in treated oropharyngeal tumors are sensitive but nonspecific, leading to unnecessary nodal dissections. Developing specific imaging criteria for persistent nodal metastases could improve diagnosis while decreasing patient morbidity.

MATERIALS AND METHODS

Patients with oropharyngeal squamous cell carcinoma with nodal metastases treated by definitive radiation therapy and subsequent nodal dissection were retrospectively evaluated. One hundred thirty-eight patients had pre- and posttherapy contrast-enhanced CTs evaluated by radiologists blinded to the status of pathologically proved hemineck persistent nodal metastases. Composite scoring criteria for CT, combined from individual parameters, were compared with radiologists' opinions, previous multiparameter criteria, and outcome data.

RESULTS

New low-attenuation areas and a lack of size change (<20% cross sectional area) were both highly specific for persistent nodal metastases (99%; P = .0004). Extranodal disease on pretherapy imaging was moderately specific (86%; P = .001). The CSC correctly placed 29 patients in a low-risk category compared with 14 by previously reported criteria and radiologist reports. With good second-rater reliability, the CSC cutoff values stratified patients at highest risk of persistent nodal metastases, thereby improving specificity while maintaining sensitivity.

CONCLUSIONS

Comparing pre- and posttherapy examinations improves specificity by discriminating focal findings and size change compared with a single time point. The CSC can categorize the risk of persistent nodal metastases more accurately than previous CT methods. This finding has the potential to improve resource use and reduce surgical morbidity.

Intensity-modulated radiation therapy as primary treatment for oropharyngeal squamous cell carcinoma

BACKGROUND

Over the past decade, intensity-modulated radiation therapy (IMRT) has gained widespread use in the treatment of head and neck cancer.

METHODS

All patients with squamous cell carcinoma of the oropharynx treated with primary IMRT with or without chemotherapy over a 5-year period were reviewed. Outcomes and morbidity were analyzed and compared with previously published data.

RESULTS

In all, 170 patients were included in the analysis. The 3-year local control, locoregional control, disease-free survival, and overall survival rates were 92%, 91%, 80%, and 87%, respectively. Feeding tubes were present in 55% of patients during treatment, but remained in only 1% 2 years following treatment.

CONCLUSIONS

This study confirms that IMRT yields excellent treatment outcomes for oropharyngeal carcinoma. Although acute toxicity remains a problem, late toxicity rates are low and long-term feeding tube dependence is rare compared with conventional radiation therapy.

Multidisciplinary care of the patient with head and neck cancer

Head and neck cancer is a heterogeneous group of cancers, which require a multidisciplinary approach to achieve excellent treatment results. This article focuses on current treatment guidelines and controversies in the management of head and neck cancer. It also provides insight into future directions and newest advances in the treatment of head and neck cancer.

Role of surgery in the management of head and neck cancer: a contemporary view of the data in the era of organ preservation

OBJECTIVE

Review of the literature on the role of surgery in the management of head and neck cancer in the era of organ preservation.

METHOD

Literature search based on the essential practice guidelines set out by the US National Comprehensive Cancer Network.

RESULTS

Despite the increasing popularity of non-surgical treatment options, the surgeon remains a key figure in the multidisciplinary head and neck cancer team, along with the radiation oncologist, the medical oncologist and the speech and swallowing therapist. Even when organ preservation is successful, early and late toxicity may cause serious complications, including laryngeal dysfunction with a 'frozen larynx'. When organ preservation fails, salvage surgery is often associated with increased complications and reduced survival.

CONCLUSION

There is a definite need to apply more rigorous standards to the use of organ preservation strategies, and to re-evaluate the role of surgery in head and neck cancer treatment.

Definitive Radiotherapy versus Postoperative Radiotherapy for Tonsil Cancer

Purpose

The purpose of this study is to analyze treatment outcome of radiotherapy (RT) in patients with stage III-IV tonsil cancer managed by surgery followed by postoperative RT (SRT) and definitive chemoradiotherapy (CRT), and to thereby evaluate the most feasible treatment modality.

Materials and Methods

Of 124 patients, 67 underwent CRT, and 57 underwent SRT. We compared survival and complication rates in both groups.

Results

The median follow-up time was 57 months (range, 19 to 255 months) for surviving patients. At five years, locoregional progression-free survival (LRPFS) and overall survival (OS) were 88% and 80%, respectively. No significant difference in LRPFS (p=0.491) and OS (p=0.177) was observed between CRT and SRT. In multivariate analysis, old age and higher T stage showed a significant association with poor LRPFS, PFS, and OS; higher N stage showed an association with poor PFS and a trend of poor LRPFS, while no association with OS was observed; treatment modality (CRT and SRT) showed no association with LRFPS, PFS, and OS. Grade 3 or higher mucositis was observed in 12 patients (21%) in the SRT group, and 25 patients (37%) in the CRT group.

Conclusion

Definitive CRT and SRT have similar treatment outcomes for patients with stage III-IV tonsil cancer. Although acute complication rate appears to be higher in the CRT group, it should be noted that not all data on complications were included in this retrospective study. To determine the most feasible treatment modality, not only mucositis and xerostomia, but also emotional aspect and quality of life, should 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.

Definitive radiation therapy for squamous cell carcinoma of the pharyngeal wall

PURPOSE

To analyze the results of definitive radiation therapy (RT) for squamous cell carcinoma of the pharyngeal wall.

METHODS AND MATERIALS

Between 1964 and 2009, 170 patients were treated with definitive RT; all living patients had a 1.7-year minimum follow-up.

RESULTS

The 5-year rates of local control and ultimate local control were the following: T1, 93% and 93%; T2, 84% and 91%; T3, 60% and 62%; and T4, 44% and 44%. Multivariate analysis revealed stage I-II tumors, female gender, and altered fractionation were associated with improved local-regional control. The 5-year cause-specific and overall survival rates were the following: I, 88% and 50%; II, 89% and 57%; III, 49% and 31%; IV, 35% and 21%; and overall, 50% and 31%, respectively. Fatal complications occurred in 9 patients (5%).

CONCLUSIONS

Local-regional control and survival are related to extent of disease and treatment technique. Although outcomes have improved in recent years, the morbidity of treatment is significant and a substantial proportion of patients die due to cancer.

Intended single-modality management of T1 and T2 tonsillar carcinomas: retrospective comparison of radical tonsillectomy vs radiation from a single institution

BACKGROUND

T1 and T2 tonsillar squamous cell cancer with limited neck disease can be managed with single-modality radiation or surgery. Over 11 years, 17 patients underwent radical tonsillectomies; and 33 patients underwent radiation-based treatments for T1 and T2 and N0 to N2a tonsil cancer. Patients were intended to receive single-modality treatment based on presentation; however, some ultimately received adjuvant treatments.

METHODS

A retrospective chart review to compare overall survival (OS), disease-specific survival (DSS), and locoregional control (LRC) between the groups was used.

RESULTS

In surgical group, of 17 patients, 11 underwent surgery alone, 3 underwent surgery and radiation, and 3 underwent surgery with concurrent chemoradiation. Five-year OS for the surgical and radiation groups was 93% and 72%, respectively (no significance achieved). Five-year DSS rates (93% and 80%) and LRC (69% and 89%) similarly did not yield any significant difference.

CONCLUSION

Surgery remains a viable option in the management of T1 and T2 tonsillar cancers with comparable LRC, OS, and DSS.

T but not N stage predicts survival for patients with tonsillar carcinoma treated with external radiotherapy and brachytherapy

BACKGROUND

Our aim was to determine the efficacy of a therapeutic schedule including external radiation and brachytherapy in a consecutive and retrospective series of tonsillar carcinoma patients.

PATIENTS AND METHODS

Ninety-six patients with tonsillar carcinoma were treated between 1988 and 2000 and were followed up for at least for three years. All patients were treated with accelerated hyperfractionated external radiotherapy, 68 patients had additional brachytherapy and 69 patients with advanced stages also received chemotherapy. There was no planned surgery even though 73% had N+ disease. Eleven patients with persistent neck nodes underwent ultimate salvage surgery.

RESULTS

The overall three-year survival (OS) was 70%. OS for the T stage was T1 90%, T2 89%, T3 54% and T4 60%. The corresponding numbers for the N stage were N0 61.5%, N1 73%, N2 78% and N3 66%. Accordingly OS was influenced by the T stage (p>0.001) rather than by N stage. Only four patients with salvage surgery had viable tumour cells in the specimen, their survival was not inferior.

DISCUSSION

The primary tumour stage is an essential determinant for survival in patients with irradiated tonsillar carcinoma. Neck dissection should be confined only as a salvage procedure.