Clinical nodal stage is an independently significant predictor of distant failure in patients with squamous cell carcinoma of the larynx

Metastasis to the gastrostomy site in a patient with pharynx cancer after percutaneous endoscopic gastrostomy: a case report

A stenosing tumour in the throat region is a common indication for percutaneous endoscopic gastrostomy (PEG), which may be used for enteral nutrition in palliative cases or placed prior to curative treatment (surgery, radiotherapy and/or chemotherapy) and removed when the patient has recovered and has a reliable and adequate oral intake. Major complications related to PEG are rare, but their treatment poses a challenge. We are presenting a case of the transmission of metastasis to the gastrostomy site in a patient with pharynx cancer after percutaneous endoscopic gastrostomy.

Occult Metastasis in Laryngeal Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

OBJECTIVE

The incidence of occult metastasis (OM) in laryngeal squamous cell carcinoma (SCC) is still widely debated. In this systematic review, we aim to determine the rate of OM in laryngeal SCC, its impact on recurrence, and the role of elective neck dissection (END) in the management of the clinically negative neck.

METHODS

A systematic review of the English-language literature in Web of Science, PubMed, MEDLINE, and Cochrane Library databases on occult metastasis in laryngeal SCC from 1977 to 2018 was conducted. Studies evaluating occult metastasis (OM) in patients with laryngeal SCC with clinically negative necks undergoing surgery were included. Studies evaluating other head and neck subsites, clinically node positive, and salvage patients were excluded.

RESULTS

Twenty-one articles with a total of 5630 patients were included. The overall rate of OM was 20.5% and was 23% and 12.2% in supraglottic and glottic tumors, respectively. The OM rate in T1-T2 tumors was 13% and 25% in T3-T4 tumors. T3-T4 tumors had significantly greater odds of developing OM compared to T1-T2 tumors (Odds Ratio [OR] = 2.61, 95% Confidence Interval [CI] = 1.92-3.55, P < .00001). Patients with OM were more likely to develop distant metastasis (OR = 5.65, 95% CI = 3.36-9.51, P < .00001).

CONCLUSIONS

Patients with advanced T-stage laryngeal SCC should undergo elective neck treatment. More aggressive treatment for patients with history of OM should be considered due to the risk of subsequent regional and distant metastasis.

LEVEL OF EVIDENCE

II.

Lymph node ratio as a prognostic marker in advanced laryngeal and hypopharyngeal carcinoma after primary total laryngopharyngectomy

BACKGROUND

We evaluated the prognostic value of lymph node ratio (LNR) in patients with advanced laryngeal and hypopharyngeal squamous cell carcinoma.

STUDY DESIGN

Retrospective chart review.

METHODS

Between 1994 and 2018, 79 patients underwent total laryngopharyngectomy and adjuvant therapy. LNR was determined and statistically compared to patients' overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), locoregional and distant failure.

RESULTS

The 5-year OS, DSS and DFS rates were 45.6%, 73.4% and 56.9%, respectively. 24.1% and 25.3% developed loco- regional failure or distant metastatic disease, respectively. Univariate analyses showed that high LNR (cut-off >0.07) was significantly associated with distant and locoregional failure. On multivariate analysis, LNR remained an independent predictor for OS (P = .004), DSS (P = .009) and DFS (P = .044).

CONCLUSION

Increased LNR in patients with advanced laryngeal or hypopharyngeal carcinoma is significantly linked to shortened OS, DSS, DFS and higher locoregional and distant metastatic disease.

Survival analysis of distant metastasis of laryngeal carcinoma: analysis based on SEER database

BACKGROUND

The purpose of this study was to investigate the prognostic factors and the value of surgical treatment of patients with newly diagnosed laryngeal cancer with distant metastasis (DM).

METHODS

The Surveillance, Epidemiology and End Result database (SEER) was used to analyze 446 patients with laryngeal cancer with DM at the time of initial diagnosis from 2010 to 2014.The survival prognosis of patients with DM was performed by using Kaplan-Meier and log-rank test. The prognostic factors and the effect of surgery were analyzed using the Cox regression analysis and R-language data package.

RESULTS

The incidence of DM was 3.21% (446/13865). Lung was the most common distant metastatic site of laryngeal cancer (62.6%), and brain metastases had the worst prognosis in patients at 2 months. T stage and brain metastasis were independent risk factors affecting the survival (P < 0.05). The hazard ratio (HR) of DM in T4 stage was nearly twice than that in T1 stage. Surgical treatment of primary and metastatic tumors can cause better survival for patients. Patients who didn't underwent primary tumor surgery were approximately twice as likely to die from cancer as those who did. The nomogram model was constructed to visually present the 1-, 2- and 3-year survival rates of patients.

CONCLUSIONS

T stage, brain metastasis and surgical treatment are prognostic factors of patients with M1 stage laryngeal cancer. Surgical treatment of primary tumors and metastases can lead to better survival for patients.

TRIAL REGISTRATION

Not applicable.

Matched-pair analysis of survival in the patients with T3 laryngeal squamous cell carcinoma treated with supracricoid partial laryngectomy or total laryngectomy

Background

The survival outcomes between supracricoid partial laryngectomy (SCPL) and total laryngectomy (TL) were compared in the groups of matched-pair patients with T3 laryngeal squamous cell carcinoma (LSCC).

Methods

Patients with T3 LSCC were matched based on prognostic factors. The Kaplan–Meier curve and the Cox proportional hazards model were used for analysis on survival.

Results

A total of 212 patients with T3 LSCC were included after matching (106 underwent SCPL and 106 underwent TL). Multivariable analysis showed no differences in overall survival (hazard risk [HR]=1.15; 95% CI: 0.79–1.67; P=0.47), disease-specific survival (HR=1.11; 95% CI: 0.69–1.80; P=0.66), and recurrence-free survival (HR=1.07; 95% CI: 0.68–1.68; P=0.77) between the SCPL group and TL group.

Conclusion

SCPL provides reliable therapeutic outcomes and can be used to avoid a TL surgery in some patients with advanced primary laryngeal cancer.

Total lesion glycolysis on FDG-PET/CT before salvage surgery predicts survival in laryngeal or pharyngeal cancer

We investigated whether 18F-fluorodeoxyglucose uptake parameters using positron emission tomography combined with computed tomography predicts several survival outcomes, including lung metastasis-free survival, in patients with laryngeal or pharyngeal cancer who underwent salvage surgery. The maximum standardized uptake value, metabolic tumor volume, and total lesion glycolysis were calculated as 18F-fluorodeoxyglucose uptake parameters in 51 patients with laryngeal or pharyngeal cancer before salvage surgery. In univariate analysis, the maximum standardized uptake value ≥ 22.8, metabolic tumor volume ≥ 2.4, and total lesion glycolysis ≥ 5.4 were significantly correlated with shorter overall survival. In multivariate analysis with adjustment for clinical stage, patients with total lesion glycolysis ≥ 5.4 exhibited significantly shorter overall survival. Furthermore, total lesion glycolysis ≥ 5.4 was significantly correlated with shorter disease-specific survival, distant metastasis-free survival, and lung metastasis-free survival in univariate analysis. In conclusion, total lesion glycolysis predicts the survival outcomes including lung metastasis in patients with laryngeal or pharyngeal cancer who underwent salvage surgery.

Sacrifice and extracranial reconstruction of the common or internal carotid artery in advanced head and neck carcinoma: Review and meta-analysis

BACKGROUND

Sacrifice and reconstruction of the carotid artery in cases of head and neck carcinoma with invasion of the common or internal carotid artery is debated.

METHODS

We conducted a systematic search of electronic databases and provide a review and meta-analysis.

RESULTS

Of the 72 articles identified, 24 met the inclusion criteria resulting in the inclusion of 357 patients. The overall perioperative 30-day mortality was 3.6% (13/357). Permanent cerebrovascular complications occurred in 3.6% (13/357). Carotid blowout episodes were encountered in 1.4% (5/357). The meta-regression analysis showed a significant difference in 1-year overall survival between reports published from 1981-1999 (37.0%) and 2001-2016 (65.4%; P = .02).

CONCLUSION

This review provides evidence that sacrifice with extracranial reconstruction of common or internal carotid artery in selected patients with head and neck carcinoma may improve survival with acceptable complication rates. However, all of the published literature is retrospective involving selected series and, therefore, precludes determining the absolute effectiveness of the surgery.

Comparison of the therapeutic effects of total laryngectomy and a larynx-preservation approach in patients with T4a laryngeal cancer and thyroid cartilage invasion: A multicenter retrospective review

BACKGROUND

In T4a laryngeal cancer with thyroid cartilage invasion, no optimal frontline treatment has yet been defined in controlled trials.

METHODS

We reviewed data from 89 patients with T4a laryngeal cancer featuring thyroid cartilage invasion who were treated initially with either total laryngectomy (n = 53) or a larynx-preservation strategy (n = 36).

RESULTS

The median progression-free survival (PFS) of the total laryngectomy group had not been attained at the time of analysis and was thus significantly longer than that of the larynx-preservation group (8.7 months). The median overall survival (OS) of patients who underwent total laryngectomy was 87.2 months, significantly longer than that of the larynx-preservation group (31.3 months). The survival benefit of primary surgery compared to a larynx-preservation strategy was more striking in patients of lower N classifications.

CONCLUSION

Total laryngectomy may be a better therapeutic option to treat T4a laryngeal cancer featuring thyroid cartilage invasion, especially in patients exhibiting limited nodal involvement (N0/N1). © 2016 Wiley Periodicals, Inc. Head Neck, 2016 © 2016 Wiley Periodicals, Inc. Head Neck 38:1271-1277, 2016.

The benefit of abdominal sonography and chest X-ray for staging oral squamous cell carcinomas in stages UICC I and II

PURPOSE

The purpose of this study was to evaluate how often distant metastases occur in localized oral squamous cell carcinomas (OSCC). The investigators hypothesize that abdominal sonography and chest X-ray may not be necessary for initial staging of early oral squamous cell carcinoma in UICC stage I/II.

MATERIAL AND METHODS

The investigators implemented a retrospective study. The study collective was composed of 124 patients with OSCC, who were treated in the department of oral and maxillofacial surgery during the years 2011-2015 at the University Medical Center Hamburg Eppendorf, Germany. We focused on age, gender, date of diagnosis, tumour stage (clinical and pathological), HPV status, occurrence of metastases, recurrences, date and frequency of staging and restaging (abdominal sonography, chest X-ray, CT Abdomen/Thorax, PET CT), follow up time and date of death. Descriptive and bivariate statistics were computed (chi-square test) and the P value was set at .05.

RESULTS

19 distant metastases were found in 13 out of 124 patients (10.48%). Of those 20 metastases 5 were found in the liver (26.32%), 11 in the lung (57.89%) and 4 in the bone (15.79%). Hepatic metastases co-occurred in every case with pulmonary metastases. In one case bone metastases occurred without the presence of pulmonary metastases. There was no significant correlation of metastasis rate to T stage. But distant metastases were solely found in node positive patients. This was significant for pulmonary metastases, not for liver metastases. Only one out of 11 pulmonary metastases was diagnosed by chest X-ray.

CONCLUSION

Abdominal sonography and chest X-ray can be omitted as a standard procedure in staging of localized node negative oral squamous cell carcinoma. A thoracic CT including the liver should be performed in patients with suspected lymph nodes metastases in the neck on CT. A skeletal scintigraphy or alternatively a PET/PET-CT should be added if there are signs and symptoms suspicious for bone metastases.

Survival of T4aN0 and T3N+ laryngeal cancer patients: a retrospective institutional study and systematic review

OBJECTIVE

We aim to assess the correlation of tumor and nodal staging to survival in pT3N+ and T4aN0 laryngeal cancer with subgroup analysis within stage IVa (pT4N0 and pT3N2).

STUDY DESIGN

Retrospective cohort study with systematic review of the literature.

SETTING

Hotel Dieu de France University Hospital (tertiary referral center).

SUBJECTS AND METHODS

Laryngeal cancer patients' registries were reviewed from 1998 to 2012 selecting pT3N+ and pT4aN0 patients treated by primary total layngectomy. Overall survivals were compared using Log rank and Kaplan-Meier analysis. A systematic review was performed by 2 reviewers including all the articles reporting the outcome of these categories of patients. Online databases, including PubMed and EMBASE, were used. Reference sections of identified studies were examined for additional articles.

RESULTS

Thirteen T3N+ patients and 19 T4aN0 patients treated by primary total laryngectomy were included. Five-year overall survival for T3N+, T3N2 and T4aN0 was respectively 33%, 32.1% and 73.7%. Due to the small sample, the difference was not significant. The systematic review revealed three articles reporting overall survival outcome for the T4N0 group and 6 articles for the T3N+. At 5years, the survival ranged from 62.5% to 73% in T4N0 and from 32.2% to 77% in T3N+.

CONCLUSION

In advanced stage laryngeal cancer, T4aN0 tends toward a better survival than T3N+ especially when compared to T3N2 although they are grouped in the same TNM stage IVa.

Efficacy and feasibility of docetaxel, cisplatin, and 5-fluorouracil induction chemotherapy for locally advanced head and neck squamous cell carcinoma classified as clinical nodal stage N2c, N3, or N2b with supraclavicular lymph node metastases

BACKGROUND

We evaluated the efficacy and feasibility of docetaxel, cisplatin, and 5-fluorouracil (TPF) induction chemotherapy followed by concurrent chemoradiotherapy (CRT) for locally advanced head and neck squamous cell carcinoma (HNSCC) with a high risk of distant metastases compared with CRT alone.

METHODS

We retrospectively analyzed 29 HNSCC patients with clinical nodal stage N2c, N3, or N2b disease and supraclavicular lymph node metastases receiving CRT alone (CRT group; n = 16) or TPF induction chemotherapy followed by CRT (TPF group; n = 13) between April 2008 and May 2012.

RESULTS

The median follow-up periods were 14.5 (range 5.0-65.0) and 25.0 (range 14.0-32.0) months for CRT and TPF groups, respectively. A greater proportion of patient characteristics in the CRT group had advanced T and N stages. The overall response rate to induction TPF was 50.0%; grade 3-4 toxicities included neutropenia, febrile neutropenia, anorexia, and hyponatremia. Complete response rates after CRT completion were 55.5% in the TPF and 42.9% in the CRT group; median overall survival was not reached in the TPF group and was 14.0 months in the CRT group (p = 0.037). Multivariate analysis revealed that induction TPF and T stage were independent prognostic factors [hazard ratio (HR) = 0.196; 95% confidence interval (CI) 0.043-0.898; p = 0.036, HR = 9.966; 95% CI 2.270-43.75; p = 0.002, respectively).

CONCLUSION

TPF followed by CRT is tolerated and may be an option for the treatment of locally advanced stage N2c, N3, or N2b HNSCC.

Should elective neck dissection be routinely performed in patients undergoing salvage total laryngectomy?

BACKGROUND

The prevalence of occult neck metastasis in patients undergoing salvage total laryngectomy remains unclear, and there is controversy regarding whether elective neck dissection should routinely be performed.

METHOD

A retrospective case note review of 32 consecutive patients undergoing salvage total laryngectomy in a tertiary centre was performed, in order to correlate pre-operative radiological staging with histopathological staging.

RESULTS

The median patient age was 61 years (range, 43-84 years). With regard to lymph node metastasis, 28 patients were pre-operatively clinically staged (following primary radiotherapy or chemoradiotherapy) as node-negative, 1 patient was staged as N1, two patients as N2c and one patient as N3. Fifty-two elective and seven therapeutic neck dissections were performed. Pathological analysis up-staged two patients from clinically node-negative (following primary radiotherapy or chemoradiotherapy) to pathologically node-positive (post-surgery). No clinically node-positive patients were down-staged. More than half of the patients suffered a post-operative fistula.

CONCLUSION

Pre-operative neck staging had a negative predictive value of 96 per cent. Given the increased complications associated with neck dissection in the salvage setting, consideration should be given to conservative management of the neck in clinically node-negative patients (staged following primary radiotherapy or chemoradiotherapy).

[Results of radical surgery in group of 355 patients with advanced laryngeal cancer]

INTRODUCTION

The aim of the study was to evaluate the results of radical surgery in group of 355 patients with advanced laryngeal cancer.

MATERIAL AND METHOD

The paper presents results of treatment in group of 355 patients with advanced laryngeal cancer treated in the ENT Clinical Department in Zabrze in the following years 1998-2007. The advancement stage was defined as III in 147 patients (42%), as IV in 208 patients (58%). Group of 250 patients (70%) underwent total laryngectomy and group of 105 patients (30%) underwent pharyngolaryngectomy. In the group of 327 patients (92%) operation was performed microscopically radically. 298 patients (84%) underwent postoperative radiotherapy. Median follow-up period was 5 years. Local recurrence, nodal recurrence and distant metastasis were rated as treatment failure. Treatment effectiveness was evaluated in relation to overall survival, disease-free survival, local control, locoregional control and observation free from metastases. All of these parameters were analyzed with the method of updated percentages.

RESULTS

During observation period 177 patients (50%) died. Local recurrence occurred in 47 patients (13%), nodal recurrence occurred in 19 patients (5%). Distant metastases occurred in 26 patients (7%). 5-year overall survival rate (OS) was 50%. 5-year disease-free survival rate (DFS) was 47%. 5-year local control rate (LC) was 81%. 5-year locoregional control rate (LRC) was 75%. The updated 5-year observation free from metastases rate (FFM) was 89% respectively.

CONCLUSION

Radical surgery is the chance of 5-year survival of 50% of patients with advanced cancer of the larynx and of 5-year locoregional control of 75% patients.

Reduced expression of TRF1 is associated with tumor progression and poor prognosis in oral squamous cell carcinoma

The functions of telomeric repeat-binding factor 1 (TRF1) and 2 (TRF2) in oral carcinogenesis are largely unexplored. This study examined the relationship between the expression of TRF1 and TRF2 and clinicopathological variables and survival in oral cavity squamous cell carcinoma (OCSCC). Western blotting and immunohistochemistry were used to evaluate the protein expression of TRF1 and TRF2 in paired OCSCC patient specimens. Expression of TRF1 and TRF2 was assessed by immunohistochemistry in 256 OCSCC patients who underwent tumor resection without previous radiotherapy. The results were analyzed using Fisher's exact test. Protein expression of TRF1 and TRF2 was significantly lower in the OCSCC than in the adjacent non-tumor tissue. Reduced TRF1 and TRF2 levels in 256 patients, as revealed by immunohistochemistry, were significantly associated with aggressive clinicopathological features, such as advanced tumor stage (p<0.001) and advanced tumor node metastasis stage (p<0.001). According to Kaplan-Meier analysis, reduced TRF1 expression was significantly correlated with an unfavorable cumulative 5-year overall survival rate (p<0.001). In conclusion, decreased expression of TRF1 was significantly associated with tumor progression and poor prognosis in OCSCC patients.

Ten years single institutional experience of treatment for advanced laryngeal cancer in Kyoto University

CONCLUSION

It is important to suppress lymph node recurrence and distant metastasis to achieve better survival of advanced laryngeal cancer, especially supraglottic cancer.

OBJECTIVE

The therapeutic outcomes of 33 cases with advanced laryngeal cancer treated at Kyoto University Hospital between 2000 and 2008 were reviewed.

METHODS

Thirty-one males and two females were involved. Their ages ranged from 49 to 81 years (average 65.6 years). All tumors were squamous cell carcinoma, arising at the glottis in 21 cases and the supraglottis in 12 cases. Most glottic cancers (90.5%) and supraglottic cancers (83.3%) were classified as T3 or T4. Total laryngectomy with neck dissection was performed in the treatment of T3 or T4 cases. Two cases of T2 cancers were treated by radiotherapy (66-72 Gy) with neck dissection, and one case of T2 cancer was treated by radiotherapy (66 Gy). Partial laryngectomy with neck dissection was performed in one T3 case.

RESULTS

Five-year overall survival rates for stage III of glottic cancer, stage IV of glottic cancer, stage III of supraglottic cancer, and stage IV of supraglottic cancer were 100%, 40.9%, 100%, and 24.2%, respectively. Five-year disease-specific survival rates for stage III of glottic cancer, stage IV of glottic cancer, stage III of supraglottic cancer, and stage IV of supraglottic cancer were 100%, 56.3%, 100%, and 28.1%, respectively. No local recurrence occurred. Regional lymph node recurrence occurred in two cases- one patient with glottic cancer and one with supraglottic cancer. Both of them died of disease despite undergoing chemotherapy. One case initially had lung metastasis, and post-treatment distant metastasis occurred in the lung in four cases, in the skin in one, and in multiple organs in one case.

Isolated skeletal muscle metastasis following successful treatment of laryngeal cancer: case report

Skeletal muscle metastases from tumors are a rare occurrence and can present difficult management decisions. We report here on a patient that had been previously treated for squamous cell laryngeal cancer with surgical resection and adjuvant systemic chemotherapy that presented with a metastasis to the rectus abdominis muscle without evidence of recurrent disease at the primary site. After a metastatic workup with PET/CT scan suggested this to be an isolated lesion, surgical excision with negative margins was performed based upon limited treatment options secondary to the location of the tumor and his favorable prognosis suggested by his pathological staging at the time of the initial resection. Here we discuss the incidence of distant metastases from laryngeal cancer and appropriate screening methods. Additionally, skeletal muscle metastases and treatment considerations are discussed.

Comprehensive review of small bowel metastasis from head and neck squamous cell carcinoma

Secondary tumours of small intestine account for 10% of all small bowel cancers. The most common sites of primary tumour metastasizing to small bowel are uterus, cervix, colon, lung, breast and melanoma. The majority of these metastatic tumours come from adenocarcinoma primaries; squamous cell carcinoma constitutes a very small proportion of all metastatic small intestinal lesions. Metastasis to small bowel by head and neck squamous cell carcinoma is extremely rare and carries an unfavourable prognosis. Owing to the limited number of published studies, its characteristic features, clinical presentation and outcomes are poorly described. This work aims at specifying these characteristics by reviewing, compiling, analysing and reporting all published cases in the published literature on small bowel metastasis secondary to head and neck squamous cell carcinoma. To the best of our knowledge, this is the first comprehensive review article on the small intestinal metastasis from head and neck squamous cell carcinoma.

Predictors of outcome for advanced-stage supraglottic laryngeal cancer

BACKGROUND

The objective of this study was to report our experience in the management of patients with advanced-stage supraglottic laryngeal carcinoma and to identify factors predictive of outcome.

METHODS

In total, 181 patients with advanced-stage supraglottic laryngeal carcinoma were treated at Memorial Sloan-Kettering Cancer Center between 1984 and 1998. Sixty-nine (38%) patients were treated by surgery +/- postoperative radiotherapy (SRT), 93 (52%) by chemoradiotherapy (CTRT), and 19 (10%) by radiotherapy alone (RT). Survival outcomes were calculated using the Kaplan-Meier method. Predictors of outcome were identified using multivariate analysis.

RESULTS

The-5 year overall survival (OS) and disease-specific survival (DSS) were 53% and 71%, respectively. Patients treated with SRT and CTRT had comparable outcomes. The main independent predictors of OS and DSS were age greater than 60 years and stage of the neck at presentation.

CONCLUSION

Regardless of index treatment, age over 60 years and clinical stage of the neck at presentation were the main independent predictors of OS and DSS.

Survival after laryngectomy: a review of 133 patients with laryngeal carcinoma

Survival trends in survival for laryngeal cancer in Europe are varied. Five-year survival varied around 60-64% but numbers below 50% have been commonly reported. The aim of this study was to assess the factors influencing survival in patients with laryngeal cancer in our region. A total of 128 male and 5 female patients with larynx cancer (91 glottic and 42 supraglottic) were treated at Patras University Hospital between March 1992 and August 2004. Except 3, all were smokers and 56 (41%) heavy alcohol users. Postsurgical staging showed that most had been classified at stages III (38%) and IV (49%). By histology, 31 tumors were classified as poorly differentiated, 78 as moderately differentiated and 23 as well differentiated. All patients underwent laryngectomy with extension of the procedure where appropriate. Also, a total of 45 patients received adjuvant therapy (either chemotherapy or radiotherapy). Farmers, construction workers, professional drivers and mechanics and coffee shop and bar employees account for more than 70% of patients. Results showed that 64 (48.1%) patients died during the follow-up, 58 (43.6%) of them died from cause related to their disease. With a median follow-up of 25 months, the 5-year disease-free survival (DFS) was 53% and the 5-year overall survival (OS) was 45%. Significant prognostic factors for OS included patient age, advanced staging, heavy alcohol use and poor tumor differentiation while for DFS affected mainly by poor tumor differentiation. We conclude that the disease stage at presentation, tumor grade and alcohol consumption prove to be important predictors for the OS as well as the DFS in our series.

Management of the N0 neck in moderately advanced squamous carcinoma of the larynx

OBJECTIVE

To assess the oncological efficacy of selective neck dissection (SND) in patients with T3-4 N0 laryngeal squamous carcinoma.

SUBJECTS AND METHODS

A total of 327 patients underwent 654 neck dissections; each side of the neck was individually evaluated.

RESULTS

Three percent of patients who had SND developed regional recurrence (RR) in comparison with 11.7 percent of patients who underwent modified radical neck dissection (MRND) (P=0.005). Only 3 (0.9%) patients developed RR outside the field of SND. The presence of extracapsular extension (P=0.002) in node-positive (pN+) group and of microvascular invasion (P=0.007), together with the type of neck dissection (ND) (P=0.0003) in node-negative (pN0) group had statistical impact on RR. The development of RR significantly affected disease-specific survival (P=0.0001). Equivalent rates of RR were found in pN+ (2.6%) or pN0 (3.2%) patients treated with SND (P=0.98) as well as in pN+ patients who underwent SND (2.6%) or MRND (4.7%) (P=0.85).

CONCLUSION

This study confirmed the adequacy of SND as a satisfactory staging and therapeutic procedure, and suggests its use in the treatment of limited node-positive (N+) neck.

Bilateral Neck Node Metastasis: A Predictor of Isolated Distant Metastasis in Patients With Oral and Oropharyngeal Squamous Cell Carcinoma After Primary Curative Surgery

OBJECTIVES/HYPOTHESIS

The presence of distant metastasis after the initial treatment of oral and oropharyngeal squamous cell carcinoma (OOSCC) is often associated with a poor prognosis. The purpose of our study was to evaluate the frequency of isolated distant metastasis (IDM) that occurred without any local or regional failure, and to identify its predictive factors in patients who were surgically treated.

STUDY DESIGN

Retrospective chart review.

METHODS

We performed a retrospective analysis of 230 OOSCC patients who underwent surgical treatment of the primary lesion along with a simultaneous neck dissection between May 1992 and August 2004. We evaluated the frequency of IDMs without local or regional recurrences and the influence of different variables in their appearance.

RESULTS

The frequency of IDMs was 6%. Patients with oropharyngeal carcinoma had higher isolated distant failure compared with patients with oral cavity carcinoma (P<.05). In univariate analysis, the following conditions were significant predictors of IDM in patients with OOSCC: advanced local stage; clinical or pathologic positive neck node; the presence of more than two pathologic neck nodes; more than two bilateral pathologic nodal metastases; use of adjuvant radiotherapy; and advanced American Joint Committee on Cancer (AJCC) stage. However, in multivariate analysis, only the presence of pathologic positive lymph node, especially bilateral neck metastases, was an independent risk factor for the appearance of IDMs.

CONCLUSIONS

The incidence of IDMs in patients with OOSCC is relatively low. These events were significantly associated with bilateral neck node metastases.

Oral cancer

Five percent of all tumors occur in the head and neck, and approximately half of those occur specifically in the oral cavity. Of the 615,000 new cases of head and neck [corrected] tumors reported worldwide in 2000, 300,000 were primary oral cavity squamous cell carcinomas. Recent data from the Surveillance, Epidemiology, and End Results Program suggest that 28,900 new cases of oral cancer will be identified and 7400 deaths attributed to oral cancer each year in the United States. The sixth leading cause of cancer-related mortality, oral cancer accounts for 1 death every hour in the United States. However, despite advances in screening tools, imaging technology, and access to primary care physicians, a considerable percentage of patients present with advanced-stage disease. Clinical signs and symptoms of head and neck tumors are often nonspecific and may be mistaken for other common ailments. Primary care physicians must be aware of the possibility of oral cancer, particularly the increasing incidence in young patients without traditional risk factors of alcohol and tobacco abuse. To improve survival, all patients should be routinely and vigilantly screened for oral mucosal lesions.

Therapeutic outcomes of laryngeal cancer at Kyoto University Hospital for 10 years

CONCLUSION

It is important to prevent regional lymph node recurrence and distant metastasis to achieve better survival of laryngeal cancer.

OBJECTIVE

Therapeutic outcomes of 130 cases with laryngeal cancer treated at Kyoto University Hospital between 1995 and 2004 were reviewed.

PATIENTS AND METHODS

In all, 121 males and 9 females were involved. Their ages ranged from 40 years to 92 years (average 66 years). All tumors were squamous cell carcinoma - arising at the glottis in 111 cases, the supraglottis in 18, and the subglottis in 1 case. Most glottic cancers (77.5%) were classified as stage I or II, while most supraglottic cancers (77.8%) were at stage III or IV. Stage I/II cancers were basically treated by conventional radiotherapy (60-66 Gy) and twice-daily hyperfractionated radiotherapy (70-74 Gy), respectively, attempting to preserve the larynx. Total laryngectomy with neck dissection was performed in the treatment of stage III/IV cases.

RESULTS

Five-year disease-specific survival rates were 100%, 96%, 100%, and 68% for stage I, II, III, and IV, respectively. Five-year laryngeal preservation rates were 98%, 100%, 86%, 0%, and 0% for T1a, T1b, T2, T3, and T4 of glottic cancer, respectively. Local recurrence occurred in five cases of stage I/II glottic cancer, which was successfully salvaged. Regional lymph node recurrence occurred in five cases including four patients with glottic cancer and one with supraglottic cancer. Two of them died of disease despite undergoing salvage therapy. Distant metastasis occurred in the lung in four cases including one glottic and three supraglottic cancer patients after initial treatment.

Predictive Value of Lymph Node Metastases and Extracapsular Extension for the Risk of Distant Metastases in Laryngeal Carcinoma

OBJECTIVE

The objective of this retrospective chart analysis was to determine the prognostic value of the lymph node status and extracapsular lymph node extension (ECE) of the neck for the development of distant metastases in squamous cell carcinoma of the larynx.

METHODS

One hundred sixty-five patients treated for laryngeal carcinoma with a neck dissection with histologic evaluation were included. Primary study end point was distant metastasis-free survival. Univariate analysis with the Kaplan-Meier method was used to calculate distant metastasis-free survival and overall survival for the whole group and for groups according to ECE/lymph node status. Patients were classified as 1) no metastatic lymph nodes, 2) metastatic lymph nodes without ECE, or 3) metastatic lymph nodes with ECE. Univariate Cox regression was performed with outcome distant metastasis-free survival.

RESULTS

The median overall survival for the whole group was 5.1 years and the 5-year survival rate was 51%. The median distant metastasis-free survival for the whole group could not be calculated and the 5-year metastasis-free survival rate was 78%. The hazard ratio was 3.4 (95% confidence interval [CI] = 1.0-12.1) for patients with positive nodes and without ECE and 10.5 (95% CI = 3.6-30.8) for the patients with metastatic nodes and with ECE compared with the patients without metastatic lymph nodes.

CONCLUSION

The presence of ECE in metastatic lymph nodes augments the risk of distant metastasis by nine times in laryngeal carcinoma. Metastatic lymph nodes without ECE show a risk three times greater.

Increased NBS1 expression is a marker of aggressive head and neck cancer and overexpression of NBS1 contributes to transformation

PURPOSE

Head and neck squamous cell carcinoma (HNSCC) represents the sixth most frequent type of cancer worldwide. However, the molecular genetic alterations underlying its malignant behavior and progression are little known. We showed previously that c-MYC directly activates the expression of the DNA double-strand break repair gene NBS1, and NBS1 overexpression contributes to transformation. Here, we investigate the role of NBS1 overexpression in HNSCC.

EXPERIMENTAL DESIGN

Immunohistochemistry analysis of NBS1 expression was done in 81 locally advanced HNSCC patients. Real-time PCR and Western blot analysis were used to confirm immunohistochemistry results. Human hypopharyngeal cancer cell lines (FADU) with overexpressing NBS1 (FADUNBS) or inducible short interference RNA to repress endogenous NBS1 (FADUNBSi) were generated by stable transfection. Soft agar clonogenicity assay was used to determine the transformation activity. Western blot analysis and phosphatidylinositol 3-kinase (PI3K) assay were done to evaluate the signaling pathways that were involved.

RESULTS

NBS1 overexpression was identified in 45% of advanced HNSCC patients. It was an independent marker of poor prognosis. NBS1 expression levels correlated with the transformation activity of FADU clones and also correlated with the phosphorylation levels of Akt and its downstream target mammalian target of rapamycin (mTOR). PI3K activity was increased in NBS1-overexpressing FADU clones. NBS1 overexpression also correlated with increased Akt phosphorylation levels in tumor samples.

CONCLUSIONS

Increased NBS1 expression is a significant prognostic marker of advanced HNSCC, and the underlying mechanism may involve the activation of the PI3K/Akt pathway.

Screening for distant metastases in patients with head and neck cancer: what is the current clinical practice?

OBJECTIVES

The detection of distant metastases during screening influences the choice of treatment in patients with head and neck squamous cell carcinoma (HNSCC). There is no consensus on the diagnostic technique that has to be used nor on the subgroup of HNSCC patients that may benefit from screening.

DESIGN

Questionnaire on current practice concerning the diagnostic work-up in HNSCC patients for screening for distant metastases.

PARTICIPANTS

Investigators in the 12 otolaryngology / head and neck and seven oromaxillofacial departments treating head and neck cancer in the Netherlands.

RESULTS

The response rate was 100%. Indications for screening were cervical lymph node metastases (63%), mutilating surgery (58%), locoregional recurrence (47%), advanced T-stage (32%), second primary tumour (21%). Diagnostic techniques routinely used for screening besides chest X-ray were chest CT (84%), liver ultrasound (53%), liver CT (16%) and bone scintigraphy (42%). Forty-two per cent of the clinicians were not satisfied with the current methods of screening.

CONCLUSION

This survey shows a substantial variation in indications and diagnostic techniques used for screening for distant metastases between the major institutions treating head and neck cancer in the Netherlands. There is a need for guidelines for screening for distant metastases in patients with head and neck cancer.

Distant muscular (gluteus maximus muscle) metastasis from laryngeal squamous cell carcinoma

Clinical evidence of non-lymphatic distant metastasis has been reported in approximately 10% of cases of head and neck squamous cell carcinoma (HNSCC). The lungs are the commonest site of distant metastasis of HNSCC, followed by the bones, liver and skin. A 65-year-old male underwent supraglottic laryngectomy and left modified neck dissection for a carcinoma of the laryngeal surface of the epiglottis extending to both false cords. Eight months later the patient underwent right radical modified neck dissection for hypodermal metastatic disease involving the underlying (sternocleidomastoid) muscle. Thirty-two months later, surgical excision of a lesion in the right gluteus maximus muscle was performed. Histological study diagnosed a muscular metastasis with the same morphological aspect as the laryngeal carcinoma. The patient showed no evidence of cervical or distant recurrence at follow-up after 13 months. Although skeletal muscles represent approximately 50% of total body mass and receive a large proportion of total cardiac output, haematogenous metastases to skeletal muscle are extremely uncommon. Most skeletal muscle metastases are of pulmonary origin. Distant skeletal muscle metastasis from HNSCC is an extremely rare occurrence. Treatment options, depending upon the clinical setting, include observation, radiotherapy, chemotherapy and excision; these approaches rarely alter the patient outcome. The prognosis associated with skeletal muscle metastasis is thought to be poor, consistent with the fact that it generally occurs as a feature of systemic spread.

Management of Stage IV Glottic Carcinoma: Therapeutic Outcomes

OBJECTIVES/HYPOTHESIS

The best therapeutic approach for the treatment of stage IV glottic carcinoma is controversial.

STUDY DESIGN

A retrospective study.

METHODS

A retrospective study of Tumor Research Project data was performed using patients with stage IV glottic squamous cell carcinoma treated with curative intent by five different treatment modalities from 1955 to 1998 at Washington University School of Medicine and Barnes-Jewish Hospital (St. Louis, MO).

RESULTS

Ninety-six patients with stage IV glottic carcinoma were treated by five modalities: total laryngectomy (TL) (n = 13), total laryngectomy with neck dissection (TL/ND) (n = 18), radiation therapy alone (RT) (n = 7) (median dose, 69.5 Gy), total laryngectomy combined with radiation therapy (TL/RT) (n = 10), and total laryngectomy and neck dissection combined with radiation therapy (TL/ND/RT) (n = 48). The overall 5-year observed survival (OS) rate was 39%, and the 5-year disease-specific survival (DSS) rate was 45%. The 5-year DSS rates for the individual treatment modalities included the following: TL, 58.3%; TL/ND, 42.9%; RT, 50.0%; TL/RT, 30.0%; and TL/ND/RT, 43.9%. There was no significant difference in DSS for any individual treatment modality (P =.759). The overall locoregional control rate was 69% (66 of 96). The overall recurrence rate was 39% with recurrence at the primary site and in the neck at 19% and 17%, respectively. Recurrence was not related to treatment modality. The 5-year DSS after treatment of locally recurrent cancer (salvage rate) was 30% (3 of 10) and for recurrent neck disease (28 of 67) was 42%. The incidence of delayed regional metastases was 28%; of distant metastasis, 12%; and of second primary cancers, 9%. There was no statistically significant difference in survival between node-negative (N0) necks initially treated (5-y DSS, 31%) versus N0 necks observed and later treated if necessary (5-y DSS, 44%) (P =.685).

CONCLUSION

The five treatment modalities had statistically similar survival, recurrence, and complication rates. The overall 5-year DSS for patients with stage IV glottic carcinoma was 45%, and the OS was 39%. The cumulative disease-specific survival (CDSS) was 0.4770 with a mean survival of 10.1 years and a median survival of 3.9 years. Patients younger than age 55 years had better survival (DSS) than patients 56 years of age or older (P =.0002). Patients with early T stage had better survival than patients with more advanced T stage (P =.04). Tumor recurrence at the primary site (P =.0001) and in the neck (P =.014) and distant metastasis (P =.0001) had a deleterious effect on survival. Tumor recurrence was not related to treatment modality. Patients with clear margins of resection had a statistically significant improved survival (DSS and CDSS) compared with patients with close or involved margins (P =.0001). Post-treatment quality of life was not significantly related to treatment modality. Patients whose N0 neck was treated with observation and appropriate treatment for subsequent neck disease had statistically similar survival compared with patients whose N0 neck was treated prophylactically at the time of treatment of the primary. A minimum of 7 years of follow-up is recommended for early identification of recurrent disease, second primary tumors, and distant metastasis. None of the standard treatment modalities currently employed has a statistical advantage regarding survival, recurrence, complications, or quality of life.