Risk factors for local-regional recurrence following preoperative radiation therapy and surgery for head and neck cancer (stage II-IVB)

Postoperative radiotherapy dose requirement in standard combined-modality practice for head and neck squamous cell carcinoma: Analysis of salient surgical and radiotherapy parameters in 2 cohorts

BACKGROUND

This study compared 2 sequential cohorts to identify the postoperative radiotherapy (PORT) dose requirement for head and neck squamous cell carcinoma (HNSCC).

METHODS

Two distinct PORT dose regimens were prescribed over 11 years; group 1 received 56 Gy or less, and group 2 received 60 Gy or more. The 2D and 3D techniques were used.

RESULTS

Two sequential cohorts consisted of 478 patients, with mean and median follow-up for group 1 and 2 as: 37.0 versus 28.5 months and 13.8 versus 13.1 months, respectively. Grades 3-4 mucosal toxicities (11.4% vs 28.3%), hospitalization (3.2% vs 17.4%), and nasogastric feeding (11.9% vs 29.7%) were higher in group 2. The 2-year disease-free survival (DFS) was higher with PORT >60 Gy for the following factors: age ≤ 50 years (P = .041); ≥ 4 positive nodes (P = .029); and overall treatment time (OTT) ≥ 100 days (P = .042).

CONCLUSION

Except for the benefit of doses >60 Gy for limited parameters, a lower PORT dose did not compromise the results and can potentially reduce the morbidities and healthcare costs.

Neoadjuvant treatment combined with planned surgery in laryngeal function preservation for locally advanced pyriform sinus carcinoma

OBJECTIVES

This study aimed to determine the efficacy and feasibility of preoperative radiotherapy with or without chemotherapy (XRT) followed by surgery of locally advanced pyriform sinus carcinoma.

MATERIALS AND METHODS

We performed a retrospective study of 482 patients with T3 and T4 pyriform sinus carcinoma treated with curative intent between 1979 and 2008. The patients were divided into 4 groups according to different treatment patterns.

RESULTS

The 5-year disease-special survival rate was 32%. Survival was best for the patients treated with surgery followed by XRT (41.1%) and with neoadjuvant XRT followed by surgery (39.4%), but it was worse with surgery only (27.1%) and XRT alone (23%). The disease-special survival was significantly different between the patients who accepted multidisciplinary therapy and those who accepted single therapy (P<0.001). The 5-year laryngeal function preservation survival rate of the patients with XRT followed by surgery was 13.6%, which was similar to those with XRT alone (16.2%), and superior to those who accepted surgery followed by XRT (3.8%) and surgery alone (0). Multivariate analysis results revealed that treatment pattern is an independent predictor of both overall and laryngeal function preservation survival rates (P < 0.001; hazard ratio, 0.56; 95% confidence interval, 0.44-0.71). Perioperative wound complications were not different among the patients in the 3 groups who accepted surgical treatment (P > 0.05).

CONCLUSIONS

The results suggested that neoadjuvant XRT followed by planned surgery was feasible with satisfactory oncological and functional outcomes.

Neoadjuvant chemoradiation and duration of chemotherapy before surgical resection for pancreatic cancer: does time interval between radiotherapy and surgery matter?

BACKGROUND

Neoadjuvant chemoradiation and chemotherapy provided for borderline or locally advanced, potentially resectable pancreatic adenocarcinoma improves resectability rates. Response to therapy is also an important prognostic factor. There are no data in the literature regarding optimal time interval or duration of chemotherapy after chemoradiation before surgery, and pathologic response rates. Using our database, we evaluated these relationships and the effect on overall and progression-free survival.

METHODS

We retrospectively analyzed the records of 83 patients who underwent neoadjuvant chemoradiation for locally advanced, potentially resectable, and borderline resectable pancreatic cancers before definitive resection. We divided patients into three groups according to time interval between completion of chemoradiation and resection: group A (0-10 weeks), group B (11-20 weeks), and group C (>20 weeks). After chemoradiation, patients underwent ongoing chemotherapy before resection. Pathologic response was defined as major (>95% fibrosis), partial (50-94% fibrosis), or minor (<50% fibrosis).

RESULTS

There were 56 patients in group A, 17 patients in group B, and 10 patients in group C. Patients in groups B and C were significantly more likely to experience a major response than group A (p < 0.013). Patients in group C had significantly increased median progression-free and overall survival (p < 0.05). Multivariable classification and regression tree analysis demonstrated pathologic response to be the only significant factor in overall survival.

CONCLUSIONS

Patients who underwent a prolonged time interval after neoadjuvant chemoradiation with ongoing chemotherapy were more likely to have an improved pathologic response at time of surgical resection, which was associated with improved median overall survival.

Lateral pharyngotomy extended by resection of the mandibular angle-an alternative approach to the surgical treatment of oropharyngeal (tonsillar) cancers

CONCLUSION

The authors found the procedure, when used with the proper indications, to be an uncomplicated and expeditious method that presents little risk to surrounding structures, has no residual cosmetic or functional consequences for the patient, presents a low risk of complications, and has a good oncological outcome. The main indications for this procedure are related to the extent of the tumour and the surgeon's experience with the method.

OBJECTIVES

This study assessed the radical extent of each surgery, which was determined histopathologically, local and general complications to determine the safety of the procedure, and oncological and post-operative efficacy.

METHOD

In the 1970s, Tichy described, in Czech literature, an approach to treating oropharyngeal tumours through a lateral pharyngotomy with the approach extended by resection of the mandibular angle. From 2000 to 2006 the authors use this method to treat 63 patients having oropharyngeal cancer in various stages (T1 19%, T2 46%, T3 14%, T4 21%).

RESULTS

Microscopically, the operation was non-radical in three cases (4.8%). Of the local complications encountered, pharyngocutaneous fistulas were the most frequent, three cases (4.8%), and postoperative bleeding was seen in two cases (3.2%). General complications were seen in four cases (6.4%).

Preoperative chemoradiotherapy in the management of oral cancer: a review

INTRODUCTION

Multi-modality treatment concepts involving preoperative radiotherapy (RT) or chemoradiotherapy (CRT) and subsequent radical resection are used much less frequently than postoperative treatment for oral and oropharyngeal squamous cell carcinomas. In some centres, however, the preoperative approach has been established for several years.

MATERIAL

The present review is a compilation of the existing evidence on this subject.

METHODS

In a literature-based meta-analysis, the survival data of 1927 patients from 32 eligible publications were analysed.

RESULTS

The calculated survival rates of documented patients show remarkably good results with preoperative CRT and radical surgery. However, the findings of this analysis are based on data with a large proportion of studies using consecutive patient series.

CONCLUSION

Hard evidence providing sufficient data from prospective randomised studies is as yet missing for preoperative CRT. Prospective randomised studies are mandatory in this area.

Salvage Reconstruction of Extensive Recurrent Oral Cancer Defects With the Pectoralis Major Myocutaneous Flap

PURPOSE

This study aimed to evaluate the usefulness of the pectoralis major myocutaneous flap for reconstruction of oral and facial defects after excision of recurrent oral cancer and the results of salvage surgery.

PATIENTS AND METHODS

Twenty-four patients with recurrent squamous cell carcinoma of the oral cavity underwent salvage surgical treatment. Pectoralis major flaps were used for reconstruction of the extensive defects caused by excision of the tumors. The complications of the flap and the prognosis of the patients were analyzed with a follow-up from 5 to 65 months (mean = 18.5 months).

RESULTS

Fourteen flaps were used for mucosal lining of the mouth, and 10 flaps were used for reconstruction of the cutaneous defects. The overall success rate of the flap was 70.8%. Flap-related complications developed in 13 patients (54.2%). Major complications occurred in 7 patients (29.2%), and minor complications occurred in 6 (25.0%). Three patients (12.5%) had complications unrelated to the flap. The reconstruction of the base of the tongue, the floor of the mouth, and the oropharynx emerged as a significant risk factor for flap necrosis on binary logistic regression analysis (P < .05). The overall 1-, 3-, and 5-year overall survival rate was 72.8%, 30.9%, and 20.6%, respectively.

CONCLUSION

The pectoralis major myocutaneous flap is a reliable choice for reconstruction of extensive soft tissue defects caused by excision of recurrent oral cancer. The major complications correlate with the site of reconstruction. Many patients benefit from salvage surgery, and some of them can survive 2 to 4 years postoperatively.

Screening for local and regional cancer recurrence in patients curatively treated for laryngeal cancer: definition of a high-risk group and estimation of the lead time

BACKGROUND

All patients treated for laryngeal cancer are offered the same follow-up schedule to detect asymptomatic locoregional recurrences. In this study, we evaluated the prognostic profile of patients for cancer recurrence and estimated the lead time.

METHODS

A cohort study was performed between 1990 and 1995. Cox proportional hazards model was used to analyze the prognostic factors. The effect of altering the follow-up for asymptomatic recurrence detection was determined after estimating the lead time.

RESULTS

The variables cT classification, smoking, and histologic grade proved to be prognostic factors. The risk of locoregional failure was 15% in the low-risk group versus 29% in the high-risk group. The estimated lead time was 2 to 4 weeks.

CONCLUSION

Risk profiles for locoregional relapse were defined. Intensifying the follow-up schedule is not advisable because the lead time is very short. An excessively high number of routine visits would have to be performed to increase the detection rate for asymptomatic recurrences.

Does Acid Suppressive Therapy Reduce the Risk of Laryngeal Cancer Recurrence?

OBJECTIVE/HYPOTHESIS

Gastroesophageal reflux disease (GERD) is implicated in laryngeal cancer pathogenesis and recurrence posttherapy. There are currently limited data on the effect of acid suppressive therapy in decreasing the recurrence of laryngeal cancer. Therefore, we conducted this study to identify potential effect of GERD and acid suppressive therapy on recurrences after larynx-preserving therapies.

STUDY DESIGN

Case control study.

METHODS

Cases and controls, derived from a single tertiary care center, were patients who had newly diagnosed localized laryngeal cancer (T3 or less and absence of nodes) and having undergone larynx-preserving surgery or radiotherapy/chemotherapy were followed between January 1, 2000 and December 31, 2003. Univariable associations were performed for demographics, smoking and alcohol patterns, stage of tumor, initial treatment, surgeon of record, presence of GERD, and the use of acid suppressive medications. Multivariable associations were performed for clinically significant variables.

RESULTS

Of 258 patients with laryngeal cancer, 61 satisfied the selection criteria. Twenty-two of 61 (36%) developed recurrence and constituted cases, whereas 39/61 (64%) did not have recurrence and constituted controls. On univariable analysis, significant factors for decreased recurrences were GERD, hazard ratio 0.24 (95% confidence interval [CI] 0.08-0.71), and acid suppressive therapy, hazards 0.22 (95% CI 0.07-0.66). On multivariable analysis, laryngeal cancer recurrence was significantly less in those on acid suppressive therapy, hazard 0.31 (95% CI 0.13-0.75).

CONCLUSIONS

Acid suppression postlaryngeal cancer therapies may have protective effect on laryngeal cancer recurrences. A prospective study is needed to better define this perceived beneficial effect.

The effect of pre-operative conventional and hyperfractionated radiotherapy schedules on wound healing and tensile strength in rats: an experimental study

We examined the effects of pre-operative conventional and hyperfractionated radiotherapy schedules on wound healing and tensile strength in 90 female Wistar rats weighing between 182 and 240 g. The animals were randomized into three groups (n = 30 each). Group I was sham-irradiated. Group II (conventional) received 20 daily fractions of 200 cGy, to a total dose of 4000 cGy. Group III (hyperfractionated) received 40 fractions of 120 cGy, twice daily, to a total dose of 4800 cGy. Four weeks after radiotherapy, incision and primary repair with simple suturing was performed on one side of the neck. Twenty-one days after wounding, all the rats were sacrificed. Non-parametric Kruskal-Wallis and Mann-Whitney U-tests were used for the statistical analysis of wound tensile strength. The chi-squared test was used for the statistical analysis of the histopathologic findings. The hyperfractionated group had a significantly lower tensile strength than that of the control group (P = 0.03, z = -2.18). According to the histopathologic findings, fibrosis was increased significantly in the hyperfractionated group as compared to the other groups (P = 0.038, chi2 = 6.52). Hyperfractionated radiotherapy significantly reduced the wound tensile strength in the early evaluation period as compared to the control group.