Disease-specific survival and locoregional control in tonsillar carcinoma

Biochemical analysis of saliva in head and neck cancer patients receiving definitive chemoradiotherapy

BACKGROUND

Radiation therapy leads to salivary gland damage that causes xerostomia, the standard radiation-induced complication during radiotherapy that affects the quality of life in head and neck cancer patients. This study was conducted at a tertiary cancer institute in Punjab state to analyze the influence of radiation therapy on various parameters and substances of saliva.

MATERIALS AND METHODS

Sixty head and neck cancer patients who underwent conventional radiotherapy on a Cobalt machine were included. Saliva was collected in both stimulated and unstimulated states. Stimulated whole saliva was collected by applying two to three drops of citric acid solution (2%) over the dorsum of the tongue bilaterally at 30-s intervals for 2 min. Biochemical changes in the whole saliva were evaluated by biochemical methods at baseline, completion of therapy, and 3 and 6 months post-radiotherapy completion.

RESULTS

The lowest concentration of proteins was seen after the therapy in unstimulated and stimulated saliva. Salivary protein levels showed a rising trend toward baseline in 3- and 6-month posttherapy samples. The peak value (0.4 mg/dl) was reached in the stimulated saliva after therapy. Salivary amylase did not show a consistent concentration graph. The salivary concentrations of sodium, potassium, and chloride showed peak values after radiotherapy. The lowest salivary pH was obtained at completion of therapy, both in unstimulated and stimulated saliva. After 3 months of chemoradiotherapy, the saliva reached a pH value of 8.3, whereas 6-month posttherapy sample showed a pH value of 8.4 in both unstimulated and stimulated saliva.

CONCLUSIONS

At the completion of chemoradiotherapy, the total salivary protein, albumin, and inorganic components (calcium, magnesium, phosphorus) showed a downward trend from the baseline values due to the damage caused to the acinar part of the salivary gland by radiotherapy. The rise in salivary electrolytes' concentrations is attributed to the fact that even though there is loss of absorptive property of the tubular portion of the salivary gland, it retains its secretory property. Saliva becomes thick, scarce, tenacious, and acidic during the period of chemoradiotherapy.

Long-term survival and swallowing outcomes in advanced stage oropharyngeal squamous cell carcinomas

BACKGROUND

There is a paucity of studies reporting long-term survival outcomes for HPV/p16 positive oropharyngeal squamous cell carcinoma (OPSCC). This study aims to compare long-term outcomes of advanced stage p16 positive and negative OPSCCs, treated by surgical and non-surgical modalities.

METHODS

OPSCC patients from 1998 to 2012 were identified through a prospectively collected cancer registry. P16 immunohistochemistry was used as a surrogate marker for HPV-OPSCC. Overall survival (OS) and aspiration free survival (AFS) comparisons were made between patients treated with chemoradiation (CRT) versus primary surgery and radiation/chemoradiation (S+RT/CRT) at 5, 10 and 15 years post-treatment.

RESULTS

A total of 319 patients were included. P16 positive patients and non-smokers had significantly higher long-term (5, 10 and 15-year) OS. Smokers and p16 negative patients treated with S+RT/CRT had improved long-term OS compared to patients who received CRT. Smokers and p16 negative patients had lower long-term AFS. Multivariate analysis showed improved OS was associated with p16 positivity (HR 0.42, 0.28-0.61) and surgery (HR 0.47, 0.32-0.69), whereas lower OS was associated with ECOG ≥ 2 (HR 2.46, 1.61-3.77), smoking (HR 2.37, 1.41-3.99) and higher stage (HR 1.68, 1.05-2.68).

CONCLUSIONS

In smokers and p16-negative OPSCC patients, primary surgery may be associated with improved long-term survival and dysphagia-related outcomes.

Long-term results of surgical treatment for advanced oropharyngeal squamous cell carcinoma

BACKGROUND

The purpose of this study was to review the oncologic and functional outcomes of patients with clinical stage III or IV squamous cell carcinoma (SCC) of the oropharynx submitted to tumor resection and neck dissection with or without postoperative radiotherapy (PORT).

METHODS

We conducted a retrospective review of medical charts of 256 consecutive patients.

RESULTS

Fatal postoperative complications were registered in 5 patients (1.9%). During follow-up, there were 74 local recurrences (29%), 27 neck recurrences (10.5%), and 19 distant metastases (7.4%). The 5-year overall survival (OS) was 43.0%. The Cox multivariate model identified pT3 and pT4, pN2 and pN3, and an intense lymphocytic infiltrate as independent prognostic markers for OS. The 5-year disease-free survival (DFS) rate was 54.5%.

CONCLUSION

Surgical treatment for oropharyngeal carcinoma can be performed with a low-risk of postoperative mortality but with a risk of long-term use of tracheostomy and feeding tubes.

Surgery and postoperative radiotherapy a valid treatment for advanced oropharyngeal carcinoma

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

The treatment of squamous cell carcinoma of the tonsil with neck node metastases

BACKGROUND

Patients with tonsillar carcinoma and neck nodes seen at the clinic are not an uncommon occurrence in head and neck practice. Over the years, treatment has ranged from radical jaw neck dissection to radical neck dissection for the nodes and primary radiotherapy to the primary site. Much controversy exists as to which treatment modality yields the best survival. Certainly, surgery to the oropharynx leads to gross morbidity, with problems of swallowing, speech, and cosmesis, although it has been claimed that radiotherapy with neck dissection yields a lower cure rate.

METHODS

We investigated a retrospective series of 96 patients all of whom had squamous cell carcinoma of the tonsil and associated lymph node metastases. Of these, 44 primary tumors were treated with surgery and 52 with irradiation. All 44 patients in the surgery group had a radical neck dissection, as did all but 12 in the radiotherapy group.

RESULTS

Of the tabulations, patients in good general condition were more likely to receive primary surgery. Overall cause-specific survival for all patients was 69%. Multiple logistic regression revealed no associations; thus, the radiotherapy and surgery groups were well matched. Five-year actuarial survival for those having irradiation was 74%. The five-year survival for the group receiving surgery was 63% (p =.4372). This lack of difference between survival for surgery and radiotherapy was confirmed using Cox's proportional hazards model.

CONCLUSION

We conclude that tonsillar carcinoma with lymph nodes can be safely treated by applying appropriate radiotherapy to the tonsillar region and treating the neck with radical surgery, if the disease is more than N1.

Conservation surgery in the management of T1 and T2 oropharyngeal squamous cell carcinoma: the Birmingham UK experience

The aim of this paper was to evaluate our experience using conservation surgery in the management of T1 and T2 oropharyngeal squamous cell carcinoma. Eighteen patients underwent conservation surgery between 1993 and 2000 and were analysed retrospectively. The mean age was 54 years and the male to female ratio was 8:1. There were 14 tonsil and 4 tongue base tumours and 83% of cases presented with neck nodes, thereby classifying them as having advanced disease (stages 2-4). All patients received postoperative radiotherapy. All patients were followed up to December 2001. The median follow-up time was 3.8 years (minimum was 1.5 years). The 2-year and 5-year survival rates were 100% and 92% respectively. Approximately 66% of patients returned the EORTC and GHQ/12 quality-of-life questionnaires. Of these, seventy-five percent had a high healthy level of general functioning in accordance with the EORTC general health section. These results show that conservation surgery techniques are effective in the treatment of T1 and T2 oropharyngeal squamous carcinoma associated with significant metastatic neck disease. The techniques are well tolerated, produce minimal functional deficit and do not have a negative impact on the patients quality of life in either the immediate postoperative period or up to 4 years post-treatment.

A comparison of published head and neck stage groupings in laryngeal cancer using data from two countries

The combination of T, N, and M classifications into stage groupings is meant to facilitate a number of activities including: the estimation of prognosis and the comparison of therapeutic interventions among similar groups of cases. We tested the UICC/AJCC fifth edition stage grouping and six other TNM-based groupings proposed for head and neck cancer for their ability to meet these expectations in laryngeal cancer using data from Ontario, Canada, and the area of Southern Norway surrounding Oslo. We defined four criteria to assess each grouping scheme: (1) the subgroups defined by T, N, and M comprising a given group within a grouping scheme have similar survival rates (hazard consistency); (2) the survival rates differ among the groups (hazard discrimination); (3) the prediction of cure is high (outcome prediction); and (4) the distribution of patients among the groups is balanced. We previously identified or derived a measure for each criterion, and the findings were summarized using a scoring system. The range of scores was from 0 (best) to 7 (worst). The data sets were population-based, with 861 cases from Ontario and 642 cases from Southern Norway. Clinical stage assignment was used and the outcome of interest was cause-specific survival. Summary scores across the seven schemes had similar ranges: 0.9 to 5.1 in Ontario and 1.8 to 5.7 in Southern Norway, but the ranking varied. Summing the scores across the two datasets, the TANIS-7 scheme (Head & Neck 1993;15:497-503) ranked first, and was ranked high in both datasets (first and second, respectively). The UICC/AJCC scheme ranked sixth out of seven schemes, and its ranking was fifth and seventh, respectively. UICC/AJCC stage groupings were defined without empirical investigation. When tested, this scheme did not perform best. Our results suggest that the usefulness of the TNM system could be enhanced by optimizing the design of stage groupings through empirical investigation.

A comparison of published head and neck stage groupings in carcinomas of the tonsillar region

BACKGROUND

The combination of T, N, and M classifications into stage groupings was designed to facilitate a number of activities including: the estimation of prognosis and the comparison of therapeutic interventions among similar groups of cases. The authors tested the UICC/AJCC 5th edition stage grouping and seven other TNM-based groupings proposed for head and neck cancer to determine their ability to meet these expectations in a specific site: carcinoma of the tonsillar region.

METHODS

The authors defined four criteria to assess each stage grouping scheme: 1) The subgroups defined by T and N comprising a given group within a grouping scheme have similar survival rates (hazard consistency); 2) The survival rates differ across the groups (hazard discrimination); 3) The prediction of cure is high (outcome prediction); and 4) The distribution of patients among the groups is balanced. The authors identified or derived a measure for each criterion and the findings were summarized using a scoring system. The range of scores was from 0 (best) to 7 (worst). Data were from a retrospective chart review on 642 cases of carcinoma of the tonsillar region treated with radiotherapy for cure at the Princess Margaret Hospital from 1970-1991. None of the patients had distant metastases.

RESULTS

The scheme proposed by Synderman and Wagner, which was published in Otolaryngology Head and Neck Surgery in 1995 (vol.112, pages 691-4), scored best at 1.2. The UICC/AJCC scheme scored worst at 6.1. The hazard consistency ranged from a 3.1% average survival difference to 6.7% across the 8 schemes. The hazard discrimination measure varied by 28% from the best to worst scheme. Prediction varied by up to almost twofold across the schemes assessed. The distribution of patients varied from expected by between 0.13% and 0.57%.

CONCLUSION

UICC/AJCC stage groupings were defined without empirical investigation. When tested, this scheme did not perform as well as any of seven empirically-derived schemes the authors evaluated. The results of the current study suggest that the usefulness of the TNM system can be enhanced by optimizing the design of stage groupings through empirical investigation.

A comparison of published head and neck stage groupings in carcinomas of the oral cavity

BACKGROUND

The combination of T, N, and M classifications into stage groupings is meant to facilitate a number of activities, including the estimation of prognosis and the comparison of therapeutic interventions among similar groups of cases. We tested the UICC/AJCC 5th edition stage grouping and seven other TNM-based groupings proposed for head and neck cancer for their ability to meet these expectations in a specific site: carcinomas of the oral cavity.

METHODS

We defined four criteria to assess each grouping scheme: (1) the subgroups defined by T, N, and M that make up a given group within a grouping scheme have similar survival rates (hazard consistency); (2) the survival rates differ among the groups (hazard discrimination); (3) the prediction of cure is high (outcome prediction); and (4) the distribution of patients among the groups is balanced. We identified or derived a measure for each criterion, and the findings were summarized by use of a scoring system. The range of scores was from 0 (best) to 7 (worst). The data are population based from a prospectively gathered series in Southern Norway, with 556 patients diagnosed from 1983 through 1995. Clinical stage assignment was used, and the outcome of interest was cause-specific survival.

RESULTS

Summary scores across the eight schemes ranged from 1.66 for TANIS-3 to 6.50 for UICC/AJCC-5. The TANIS-7 staging scheme performed best on the hazard consistency criterion. The Kiricuta scheme performed best on the hazard discrimination criterion. Synderman predicted outcome best overall and Berg produced the most balanced distribution of cases among its groups.

CONCLUSIONS

UICC/AJCC stage groupings were defined without empirical investigation. When tested, this scheme did not perform as well as any of seven empirically derived schemes we evaluated. Our results suggest that the usefulness of the TNM system could be enhanced by optimizing the design of stage groupings through empirical investigation.

[Cancer of the tonsillar region. Retrospective study and review of the literature]

It has been carried out a retrospective analysis of 34 patients suffering from carcinoma epidermoid of the tonsillar fossa being treated with two different therapies from 1989 to 1996. Twenty three of them were treated with surgery (transoral resection or bloc radical tonsillectomy with myocutaneous flap reconstruction and ipsilateral lymph node dissection). Eleven of them were treated with chemotherapy and radiotherapy. The rate of overall survival at 5 years were 41.2%. Actuarial survival rates were (71.4%) in stages I-II and 33.3% in stages III-IV (p = 0.08). On multivariate analysis, age (p = 0.28) and modality of treatment (p = 0.80) were not significant effect on survival. Advanced stages (III-IV) showed 3.4 times much more risk of death than early stages (I-II) (p = 0.11).