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Henneman R, Schats W, Karakullukcu MB, van den Brekel MW, Smeele LE, Lohuis PF, van der Hage JA, Al-Mamgani A, Balm AJ. Surgical site complications of post-chemoradiotherapy neck dissection: Urgent need for standard registration. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 47:764-771. [PMID: 33268211 DOI: 10.1016/j.ejso.2020.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/05/2020] [Accepted: 10/10/2020] [Indexed: 11/30/2022]
Abstract
Nowadays, a substantial number of head and neck cancer patients are treated by organ-preserving chemoradiation (CRT), with a possible increased risk of complications after planned or salvage neck dissections. We try to determine the risk pattern of surgical site complications (SSC) post-CRT.
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Affiliation(s)
- Roel Henneman
- Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands.
| | - Winnie Schats
- Scientific Information Service, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - M Baris Karakullukcu
- Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Michiel Wm van den Brekel
- Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Amsterdam, the Netherlands; Institute of Phonetic Sciences-Amsterdam Center of Language and Communication, University of Amsterdam, the Netherlands
| | - Ludwig E Smeele
- Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Peter Fjm Lohuis
- Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Jos A van der Hage
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Abrahim Al-Mamgani
- Department of Radiation Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Alfons Jm Balm
- Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Amsterdam, the Netherlands
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Chung SR, Choi YJ, Suh CH, Lee JH, Baek JH. Diffusion-weighted Magnetic Resonance Imaging for Predicting Response to Chemoradiation Therapy for Head and Neck Squamous Cell Carcinoma: A Systematic Review. Korean J Radiol 2020; 20:649-661. [PMID: 30887747 PMCID: PMC6424826 DOI: 10.3348/kjr.2018.0446] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 11/11/2018] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To systematically review the evaluation of the diagnostic accuracy of pre-treatment apparent diffusion coefficient (ADC) and change in ADC during the intra- or post-treatment period, for the prediction of locoregional failure in patients with head and neck squamous cell carcinoma (HNSCC). MATERIALS AND METHODS Ovid-MEDLINE and Embase databases were searched up to September 8, 2018, for studies on the use of diffusion-weighted magnetic resonance imaging for the prediction of locoregional treatment response in patients with HNSCC treated with chemoradiation or radiation therapy. Risk of bias was assessed by using the Quality Assessment Tool for Diagnostic Accuracy Studies-2. RESULTS Twelve studies were included in the systematic review, and diagnostic accuracy assessment was performed using seven studies. High pre-treatment ADC showed inconsistent results with the tendency for locoregional failure, whereas all studies evaluating changes in ADC showed consistent results of a lower rise in ADC in patients with locoregional failure compared to those with locoregional control. The sensitivities and specificities of pre-treatment ADC and change in ADC for predicting locoregional failure were relatively high (range: 50-100% and 79-96%, 75-100% and 69-95%, respectively). Meta-analytic pooling was not performed due to the apparent heterogeneity in these values. CONCLUSION High pre-treatment ADC and low rise in early intra-treatment or post-treatment ADC with chemoradiation, could be indicators of locoregional failure in patients with HNSCC. However, as the studies are few, heterogeneous, and at high risk for bias, the sensitivity and specificity of these parameters for predicting the treatment response are yet to be determined.
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Affiliation(s)
- Sae Rom Chung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Young Jun Choi
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Chong Hyun Suh
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.,Department of Radiology, Namwon Medical Center, Namwon, Korea
| | - Jeong Hyun Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jung Hwan Baek
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Busoni M, Deganello A, Gallo O. Pharyngocutaneous fistula following total laryngectomy: analysis of risk factors, prognosis and treatment modalities. ACTA OTORHINOLARYNGOLOGICA ITALICA 2017; 35:400-5. [PMID: 26900245 PMCID: PMC4755046 DOI: 10.14639/0392-100x-626] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The aim of this study was to establish the incidence, risk factors, and the management of pharyngocutaneous fistula (PCF) after primary and salvage total laryngectomy. A retrospective, match-paired analysis of 86 patients who developed fistula after total laryngectomy was carried out and compared with a control group of 86 patients without fistula, randomly selected from a pool of 352 total laryngectomies, performed between January 1999 to October 2014. The overall incidence of PCF in the series was 24.4%; we recorded rates of 19.0%, 28.6% and 30.3% following primary total laryngectomy (PTL), salvage laryngectomy post-radiotherapy (RT-STL) and salvage laryngectomy postchemoradiotherapy (CRT-STL), respectively. Multivariate analysis revealed that the relative risk of fistula was respectively 2.47, 3.09 and 7.69 for hypoalbuminaemia ≤3.5 g/dL, RT-STL and CRT-STL. An early onset of PCF within 10 postoperative days was recorded in case of salvage total laryngectomy. The management of PCF significantly differed between PTL, RT-STL and CTRT-STL, with exclusive conservative treatment for PTL (93.55%), while in the CRT-STL group surgical closure with regional flaps (58.82%) prevailed. Conservative management, adjuvant hyperbaric oxygen therapy and surgical closure were equally distributed in the RT-STL group. Thorough knowledge of patient-related risk factors and its prognostic value, allows the surgeon to better evaluate preventive strategies with the aim of minimising fistula formation, hospitalisation times and related costs.
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Affiliation(s)
- M Busoni
- First Clinic of Otolaryngology Head-Neck Surgery, Department of Surgery and Translational Medicine, University of Florence, AOU-Careggi, Florence, Italy
| | - A Deganello
- First Clinic of Otolaryngology Head-Neck Surgery, Department of Surgery and Translational Medicine, University of Florence, AOU-Careggi, Florence, Italy
| | - O Gallo
- First Clinic of Otolaryngology Head-Neck Surgery, Department of Surgery and Translational Medicine, University of Florence, AOU-Careggi, Florence, Italy
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p16 status and interval neck dissection findings after a ‘clinically complete response’ to chemoradiotherapy in oropharyngeal squamous cell carcinoma. The Journal of Laryngology & Otology 2015; 129:801-6. [DOI: 10.1017/s0022215115001139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectives:To evaluate the histopathological findings from post-treatment neck dissection of p16 positive and negative oropharyngeal carcinoma cases, after completion of chemoradiotherapy, and to question the role of neck dissection after a ‘clinically complete response’ to chemoradiotherapy.Methods:Data were collected retrospectively from a cohort of patients treated with curative intent using chemoradiotherapy and post-treatment neck dissection. Primary tumours underwent p16 immunohistochemistry. Neck dissection specimens were examined for viable cancer cells.Results:A total of 76 cases were assessed. Viable cancer cells were detected from neck dissection in 29 per cent of p16 negative cases. Locoregional recurrence occurred in 12.9 per cent of p16 negative cases. The association between p16 positivity in the primary tumour and histopathologically negative neck dissection was significant (p < 0.05).Conclusion:p16 status appeared to be an independent marker of disease control for the cohort in this study. The data raise questions about the role of post-treatment neck dissection in p16 positive cases with a ‘clinically complete response’ to chemoradiotherapy.
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Süslü N, Senirli RT, Günaydın RÖ, Özer S, Karakaya J, Hoşal AŞ. Pharyngocutaneous fistula after salvage laryngectomy. Acta Otolaryngol 2015; 135:615-21. [PMID: 25762119 DOI: 10.3109/00016489.2015.1009639] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSION Preoperative chemoradiotherapy (CRT) was associated with a significantly higher rate of pharyngocutaneous fistula (PCF). OBJECTIVE PCF is the most frequent complication following total laryngectomy. Although organ-preserving radiotherapy (RT) or CRT offer good locoregional control, many patients still require salvage laryngectomy. The aim of this study was to evaluate the factors that predispose patients to PCF, with a focus on preoperative RT, induction chemotherapy (ICT), and CRT. METHODS This was a retrospective case series; 151 patients who underwent TL were reviewed. Preoperative RT, ICT, CRT, and some surgical parameters were analyzed as potential risk factors. RESULTS The overall PCF rate was 13%. CRT was the only preoperative treatment that had a significant effect on PCF (35.3%, p = 0.004, odds ratio (OR) = 10.75). Surgery extended to the pharynx (p = 0.005, OR = 8.34) and vacuum drain duration (p = 0.012, OR = 5.16) were observed to be associated with PCF.
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Affiliation(s)
- Nilda Süslü
- Department of Otorhinolaryngology-Head and Neck Surgery
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Schouten CS, de Graaf P, Alberts FM, Hoekstra OS, Comans EFI, Bloemena E, Witte BI, Sanchez E, Leemans CR, Castelijns JA, de Bree R. Response evaluation after chemoradiotherapy for advanced nodal disease in head and neck cancer using diffusion-weighted MRI and 18F-FDG-PET-CT. Oral Oncol 2015; 51:541-7. [PMID: 25725587 DOI: 10.1016/j.oraloncology.2015.01.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 01/25/2015] [Accepted: 01/28/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Evaluation of accuracy and interobserver variation of diffusion-weighted magnetic resonance imaging (DW-MRI) and 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDGPET-CT) to detect residual lymph node metastases after chemoradiotherapy (CRT) in advanced staged head and neck squamous cell carcinoma (HNSCC). MATERIALS AND METHODS Retrospectively, routinely performed DW-MRI (n=73) and 18F-FDG-PET-CT (n=58) 3months after CRT in HNSCC-patients with advanced nodal disease (N2-N3) were assessed by two radiologists and two nuclear medicine physicians (individually and in consensus). Imaging was scored dichotomously and on a five-point Likert scale. We also explored different scenarios for the potential added value of DW-MRI to PET-CT using the consensus Likert scale. Histopathology and a follow-up of 9months after CRT served as reference standard. RESULTS Five patients (7%) had residual regional disease. DW-MRI showed a sensitivity of 60% and a specificity of 93%, vs. 100% and 84% for PET-CT, respectively. DW-MRI and PET-CT observers had 'moderate' and 'substantial' interobserver agreement (κ=0.58 and κ=0.64, respectively) with the dichotomous system. The combination of PET-CT and DW-MRI showed a sensitivity of 100% and a specificity of 95%. CONCLUSION The high sensitivity of PET-CT authorizes a neck dissection in all patients with a positive test result and the high specificity of DW-MRI justifies avoidance of invasive neck dissections if the test is negative. Interobserver agreement varied as a function of test positivity criteria. Adding DW-MRI to PET-CT seemed to increase the specificity of PET-CT alone, thereby ensuring that less patients are exposed to unnecessary neck dissections.
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Affiliation(s)
- Charlotte S Schouten
- Department of Otolaryngology-Head and Neck Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Pim de Graaf
- Department of Radiology and Nuclear Medicine, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Femke M Alberts
- Department of Otolaryngology-Head and Neck Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Otto S Hoekstra
- Department of Radiology and Nuclear Medicine, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Emile F I Comans
- Department of Radiology and Nuclear Medicine, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - E Bloemena
- Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Center/Academic Center for Dentistry (ACTA), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; Department of Pathology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Birgit I Witte
- Department of Epidemiology and Biostatistics, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - E Sanchez
- Department of Radiology and Nuclear Medicine, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - C René Leemans
- Department of Otolaryngology-Head and Neck Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Jonas A Castelijns
- Department of Radiology and Nuclear Medicine, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Remco de Bree
- Department of Otolaryngology-Head and Neck Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; Department of Head and Neck Surgery, UMC Utrecht Cancer Center, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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Schouten CS, de Bree R, van der Putten L, Noij DP, Hoekstra OS, Comans EFI, Witte BI, Doornaert PA, Leemans CR, Castelijns JA. Diffusion-weighted EPI- and HASTE-MRI and 18F-FDG-PET-CT early during chemoradiotherapy in advanced head and neck cancer. Quant Imaging Med Surg 2014; 4:239-50. [PMID: 25202659 DOI: 10.3978/j.issn.2223-4292.2014.07.15] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 07/25/2014] [Indexed: 01/10/2023]
Abstract
MAIN PROBLEM Diffusion-weighted MRI (DW-MRI) has potential to predict chemoradiotherapy (CRT) response in head and neck squamous cell carcinoma (HNSCC) and is generally performed using echo-planar imaging (EPI). However, EPI-DWI is susceptible to geometric distortions. Half-fourier acquisition single-shot turbo spin-echo (HASTE)-DWI may be an alternative. This prospective pilot study evaluates the potential predictive value of EPI- and HASTE-DWI and 18F-fluorodeoxyglucose PET-CT (18F-FDG-PET-CT) early during CRT for locoregional outcome in HNSCC. METHODS Eight patients with advanced HNSCC (7 primary tumors and 25 nodal metastases) scheduled for CRT, underwent DW-MRI (using both EPI- and HASTE-DWI) and 18F-FDG-PET(-CT) pretreatment, early during treatment and three months after treatment. Median follow-up time was 38 months. RESULTS No local recurrences were detected during follow-up. Median Apparent Diffusion Coefficient (ADC)EPI-values in primary tumors increased from 77×10(-5) mm(2)/s pretreatment, to 113×10(-5) mm(2)/s during treatment (P=0.02), whereas ADCHASTE did not increase (74 and 74 mm(2)/s, respectively). Two regional recurrences were diagnosed. During treatment, ADCEPI tended to be higher for patients with regional control [(117.3±12.1)×10(-5) mm(2)/s] than for patients with a recurrence [(98.0±4.2)×10(-5) mm(2)/s]. This difference was not seen with ADCHASTE. No correlations between ΔADCEPI and ΔSUV (Standardized Uptake Value) were found in the primary tumor or nodal metastases. CONCLUSIONS HASTE-DWI seems to be inadequate in early CRT response prediction, compared to EPI-DWI which has potential to predict locoregional outcome. EPI-DWI and 18F-FDG-PET-CT potentially provide independent information in the early response to treatment, since no correlations were found between ΔADCEPI and ΔSUV.
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Affiliation(s)
- Charlotte S Schouten
- 1 Department of Otolaryngology-Head and Neck Surgery, 2 Department of Radiology and Nuclear Medicine, 3 Department of Epidemiology and Biostatistics, 4 Department of Radiation Oncology, VU University Medical Center, Amsterdam, the Netherlands
| | - Remco de Bree
- 1 Department of Otolaryngology-Head and Neck Surgery, 2 Department of Radiology and Nuclear Medicine, 3 Department of Epidemiology and Biostatistics, 4 Department of Radiation Oncology, VU University Medical Center, Amsterdam, the Netherlands
| | - Lisa van der Putten
- 1 Department of Otolaryngology-Head and Neck Surgery, 2 Department of Radiology and Nuclear Medicine, 3 Department of Epidemiology and Biostatistics, 4 Department of Radiation Oncology, VU University Medical Center, Amsterdam, the Netherlands
| | - Daniel P Noij
- 1 Department of Otolaryngology-Head and Neck Surgery, 2 Department of Radiology and Nuclear Medicine, 3 Department of Epidemiology and Biostatistics, 4 Department of Radiation Oncology, VU University Medical Center, Amsterdam, the Netherlands
| | - Otto S Hoekstra
- 1 Department of Otolaryngology-Head and Neck Surgery, 2 Department of Radiology and Nuclear Medicine, 3 Department of Epidemiology and Biostatistics, 4 Department of Radiation Oncology, VU University Medical Center, Amsterdam, the Netherlands
| | - Emile F I Comans
- 1 Department of Otolaryngology-Head and Neck Surgery, 2 Department of Radiology and Nuclear Medicine, 3 Department of Epidemiology and Biostatistics, 4 Department of Radiation Oncology, VU University Medical Center, Amsterdam, the Netherlands
| | - Birgit I Witte
- 1 Department of Otolaryngology-Head and Neck Surgery, 2 Department of Radiology and Nuclear Medicine, 3 Department of Epidemiology and Biostatistics, 4 Department of Radiation Oncology, VU University Medical Center, Amsterdam, the Netherlands
| | - Patricia A Doornaert
- 1 Department of Otolaryngology-Head and Neck Surgery, 2 Department of Radiology and Nuclear Medicine, 3 Department of Epidemiology and Biostatistics, 4 Department of Radiation Oncology, VU University Medical Center, Amsterdam, the Netherlands
| | - C René Leemans
- 1 Department of Otolaryngology-Head and Neck Surgery, 2 Department of Radiology and Nuclear Medicine, 3 Department of Epidemiology and Biostatistics, 4 Department of Radiation Oncology, VU University Medical Center, Amsterdam, the Netherlands
| | - Jonas A Castelijns
- 1 Department of Otolaryngology-Head and Neck Surgery, 2 Department of Radiology and Nuclear Medicine, 3 Department of Epidemiology and Biostatistics, 4 Department of Radiation Oncology, VU University Medical Center, Amsterdam, the Netherlands
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Cohen SM, Rockefeller N, Mukerji R, Durham D, Forrest ML, Cai S, Cohen MS, Shnayder Y. Efficacy and toxicity of peritumoral delivery of nanoconjugated cisplatin in an in vivo murine model of head and neck squamous cell carcinoma. JAMA Otolaryngol Head Neck Surg 2013; 139:382-7. [PMID: 23599074 DOI: 10.1001/jamaoto.2013.214] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Treatment of locally advanced head and neck squamous cell carcinoma (HNSCC) uses a multidisciplinary approach often limited by the toxicity and drug resistance of platinum agents. OBJECTIVES To test whether a nanocarrier-conjugated cisplatin boosting locoregional drug delivery improves tumor efficacy while decreasing systemic toxicity over systemic cisplatin in a murine model of locally advanced HNSCC. DESIGN A randomized, controlled, in vivo study compared standard cisplatin with nanocarrier (hyaluronan [HA])-conjugated cisplatin (HA-cisplatin) each at 50% of the maximum tolerated doses in a murine model of locally advanced HNSCC (10 mice/arm, each injected with 1 × 106 MDA-1986 HNSCC cells, with phosphate-buffered saline and HA-only control arms). Mice were treated for 3 weeks and observed for 3 additional weeks. SETTING Academic medical center. PARTICIPANTS Forty female Nu/Nu mice. Randomization and treatment arms were initiated once tumor volumes reached 30 mm3. INTERVENTION Injection with MDA-1986 HNSCC cells followed by 3 weeks of treatment with cisplatin, HA-cisplatin, phosphate-buffered saline, or HA only. MAIN OUTCOMES AND MEASURES Animal weights and tumor volumes were measured 3 times each week (modified RECIST [Response Evaluation Criteria in Solid Tumors]). At necropsy, animal kidneys were examined for nephrotoxic effects and cochleae were examined for ototoxic effects. RESULTS The mice treated with HA-cisplatin showed superior tumor efficacy (1 with complete clinical response, 3 with partial response, 1 with stable disease, and 5 with progressive disease) compared with standard cisplatin (no animals with complete clinical response, 1 with partial response, 1 with stable disease, and 8 with progressive disease), which was statistically significant (P = .003). All control animals developed progressive disease. Weight loss and body score were surrogate measures of treatment toxicity. The HA-cisplatin group had the least weight loss (mean [SD], 10.8% [4.7%]) compared with the cisplatin group (13.6% [5.6%]; P = .25). Body score dropped to 2 or less in all cisplatin-treated mice but not in any HA-cisplatin-treated mice, which also lacked any histologic signs of nephrotoxic or ototoxic effects. CONCLUSIONS AND RELEVANCE Nanoconjugated HA-cisplatin significantly improves tumor efficacy with lower toxicity compared with standard cisplatin in locally advanced HNSCC in vivo, justifying additional translational studies.
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Affiliation(s)
- Stephanie M Cohen
- Departments of Surgery, The University ofKansas Medical Center, KansasCity, KS, USA
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Planned neck dissection following radiation treatment for head and neck malignancy. Int J Otolaryngol 2012; 2012:954203. [PMID: 23049562 PMCID: PMC3462392 DOI: 10.1155/2012/954203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 08/22/2012] [Accepted: 08/22/2012] [Indexed: 12/05/2022] Open
Abstract
Introduction. Optimal therapy for patients with metastatic neck disease remains controversial. Neck dissection following radiotherapy has traditionally been used to improve locoregional control. Methods. A retrospective review of 28 patients with node-positive head and neck malignancy treated with planned neck dissection following radiotherapy between January 2002 and December 2005 was performed to assess treatment outcomes. Results. Median interval to neck dissection was 9.6 weeks with a median number of 21 + 9 lymph nodes per specimen. Ten of 31 (32%) neck dissection specimens demonstrated evidence of residual carcinoma. Overall survival at two years was 85%; five-year overall survival was 65%. Concurrent chemotherapy did not impact the presence of residual neck disease. Conclusion. Based on the frequency of residual malignancy in the neck of patients treated with primary radiotherapy, a planned, postradiotherapy neck dissection should be strongly advocated for all patients with advanced-stage neck disease.
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The contribution of neck dissection for residual neck disease after chemoradiotherapy in advanced oropharyngeal and hypopharyngeal squamous cell carcinoma patients. Int J Clin Oncol 2012; 18:578-84. [PMID: 22588781 DOI: 10.1007/s10147-012-0419-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 04/19/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Planned neck dissection after chemoradiotherapy (CRT) has remained controversial in advanced oro- and hypopharyngeal squamous cell carcinoma (OHSCC) patients. We evaluated the survival contribution of neck dissection (ND) in OHSCC patients with residual nodal disease following CRT. METHODS We retrospectively evaluated 84 OHSCC patients with N2-3 disease treated at Aichi Cancer Center Hospital between 1995 and 2006. ND after CRT was performed for residual neck disease in 36 patients, but not in 48 patients to achieve a complete response. These two groups were analyzed in terms of both overall survival (OS) and regional control (RC), and surgical complications were evaluated. RESULTS The 5-year OS was 76.7 % [95 % confidence interval (CI) 58.8-87.6] for the ND group and 73.9 % (58.6-84.3) for the non-ND group (P = 0.883). The 5-year RC was 91.6 % (76.1-97.2) for the ND group and 81.1 % (65.4-90.2) for the non-ND group (P = 0.252). Stratified by primary tumor site, the 5-year RC was 96.3 % (76.5-99.5) for the ND group, and 78.6 % (58.0-89.9) for the non-ND group (P = 0.072) in oropharyngeal squamous cell carcinoma patients, and 77.8 % (36.5-93.9) for the ND group and 85.9 % (54.0-96.3) for the non-ND group (P = 0.541) in hypopharyngeal squamous cell carcinoma patients. In addition, the complications after ND were tolerable. CONCLUSIONS We demonstrated that ND was feasible, safe, and correlated with clinical outcomes in OHSCC patients with residual nodal disease after CRT.
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Thariat J, Hamoir M, Garrel R, Cosmidis A, Dassonville O, Janot, Righini CA, Vedrine PO, Prades JM, Lacau-Saint-Guily J, Jegoux F, Malard O, De Mones E, Benlyazid A, Bensadoun RJ, Baujat B, Merol JC, Ferron C, Scavennec C, Salvan D, Mallet Y, Moriniere S, Vergez S, Choussy O, Dollivet G, Guevara N, Ceruse P, De Raucourt D, Lallemant B, Lawson G, Lindas P, Poupart M, Duflo S, Dufour X. Management of the Neck in the Setting of Definitive Chemoradiation: Is There a Consensus? A GETTEC Study. Ann Surg Oncol 2012; 19:2311-9. [DOI: 10.1245/s10434-012-2275-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Indexed: 11/18/2022]
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Thariat J, Ang KK, Allen PK, Ahamad A, Williams MD, Myers JN, El-Naggar AK, Ginsberg LE, Rosenthal DI, Glisson BS, Morrison WH, Weber RS, Garden AS. Prediction of neck dissection requirement after definitive radiotherapy for head-and-neck squamous cell carcinoma. Int J Radiat Oncol Biol Phys 2012; 82:e367-74. [PMID: 22284033 PMCID: PMC4124997 DOI: 10.1016/j.ijrobp.2011.03.062] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 03/17/2011] [Accepted: 03/23/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND This analysis was undertaken to assess the need for planned neck dissection in patients with a complete response (CR) of involved nodes after irradiation and to determine the benefit of a neck dissection in those with less than CR by tumor site. METHODS Our cohort included 880 patients with T1-4, N1-3M0 squamous cell carcinoma of the oropharynx, larynx, or hypopharynx who received treatment between 1994 and 2004. Survival curves were calculated by the Kaplan-Meier Method, comparisons of rates with the log-rank test and prognostic factors by Cox's proportional hazard model. RESULTS Nodal CR occurred in 377 (43%) patients, of whom 365 patients did not undergo nodal dissection. The 5-year actuarial regional control rate of patients with CR was 92%. Two hundred sixty-eight of the remaining patients (53%) underwent neck dissections. The 5-year actuarial regional control rate for patients without a CR was 84%. Those who had a neck dissection fared better with 5-year actuarial regional control rates of 90% and 76% for those operated and those not operated (p < 0.001). Variables associated with poorer regional control rates included higher T and N stage, non-oropharynx cancers, non-CR, both clinical and pathological. CONCLUSIONS With 92% 5-year neck control rate without neck dissection after CR, there is little justification for systematic neck dissection. The addition of a neck dissection resulted in higher neck control after partial response though patients with viable tumor on pathology specimens had poorer outcomes. The identification of that subgroup that benefits from additional treatment remains a challenge.
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Affiliation(s)
- Juliette Thariat
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030, Texas
- Department of Radiation Oncology/IBDC CNRS UMR 6543. Cancer Center Antoine-Lacassagne. University Nice Sophia-Antipolis. 33 Av. Valombrose. 06189 - NICE Cedex 2 (FRANCE)
| | - K. Kian Ang
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030, Texas
| | - Pamela K. Allen
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030, Texas
| | - Anesa Ahamad
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030, Texas
- The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Michelle D. Williams
- Department of Pathology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030, Texas
| | - Jeffrey N. Myers
- Department of Head and Neck Surgery, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030, Texas
- Department of Cancer Biology, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030, Texas
| | - Adel K. El-Naggar
- Department of Pathology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030, Texas
| | - Lawrence E. Ginsberg
- Department of Diagnostic Radiology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030, Texas
| | - David I. Rosenthal
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030, Texas
| | - Bonnie S. Glisson
- Department of Thoracic/Head and Neck Medicine, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030, Texas
| | - William H. Morrison
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030, Texas
| | - Randal S. Weber
- Department of Pathology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030, Texas
| | - Adam S. Garden
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030, Texas
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Wensing B, Deserno W, de Bondt R, Marres H, Merkx M, Barentsz J, van den Hoogen F. Diagnostic value of magnetic resonance lymphography in preoperative staging of clinically negative necks in squamous cell carcinoma of the oral cavity: A pilot study. Oral Oncol 2011; 47:1079-84. [DOI: 10.1016/j.oraloncology.2011.07.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 07/12/2011] [Accepted: 07/20/2011] [Indexed: 11/17/2022]
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van der Putten L, de Bree R, Kuik D, Rietveld D, Buter J, Eerenstein S, Leemans C. Salvage laryngectomy: Oncological and functional outcome. Oral Oncol 2011; 47:296-301. [DOI: 10.1016/j.oraloncology.2011.02.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 01/28/2011] [Accepted: 02/01/2011] [Indexed: 11/28/2022]
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Outcome with neck dissection after chemoradiation for N3 head-and-neck squamous cell carcinoma. Int J Radiat Oncol Biol Phys 2009; 77:414-20. [PMID: 19775825 DOI: 10.1016/j.ijrobp.2009.05.034] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Revised: 04/24/2009] [Accepted: 05/08/2009] [Indexed: 11/23/2022]
Abstract
PURPOSE To evaluate the role of neck dissection (ND) after chemoradiation therapy (CRT) for head and neck squamous cell carcinoma (HNSCC) with N3 disease. METHODS AND MATERIALS From March 1998 to September 2006, 70 patients with HNSCC and N3 neck disease were treated with concomitant CRT as primary therapy. Response to treatment was assessed using clinical examination and computed tomography 6 to 8 weeks posttreatment. Neck dissection was not routinely performed and considered for those with less than complete response. Of the patients, 26 (37.1%) achieved clinical complete response (cCR) after CRT. A total of 31 (44.3%) underwent ND after partial response (cPR-ND). Thirteen patients (29.5%) did not achieve cCR and did not undergo ND for the following reasons: incomplete response/progression at primary site, refusal/contraindication to surgery, metastatic progression, or death. These patients were excluded from the analysis. Outcomes were computed using Kaplan-Meier curves and were compared with log rank tests. RESULTS Comparing the cCR and cPR-ND groups at 2 years, the disease-free survival was respectively 62.7% and 84.9% (p = 0.048); overall survival was 63.0% and 79.4% (p = 0.26), regional relapse-free survival was 87.8% and 96.0% (p = 0.21); and distant disease-free survival was 67.1% and 92.6% (p = 0.059). In the cPR-ND group, 71.0% had no pathologic evidence of disease (PPV of 29.0%). CONCLUSIONS Patients with N3 disease achieving regional cPR and primary cCR who underwent ND seemed to have better outcomes than patients achieving global cCR without ND. Clinical assessment with computed tomography is not adequate for evaluating response to treatment. Because of the inherent limitations of our study, further confirmatory studies are warranted.
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Cannady SB, Lee WT, Scharpf J, Lorenz RR, Wood BG, Strome M, Lavertu P, Esclamado RM, Saxton JP, Adelstein DJ. Extent of neck dissection required after concurrent chemoradiation for stage IV head and neck squamous cell carcinoma. Head Neck 2009; 32:348-56. [PMID: 19672875 DOI: 10.1002/hed.21189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The management of initially bulky nodal disease after primary nonsurgical treatment for stage IV head and neck squamous cell carcinoma (HNSCC) continues to be a subject of debate. METHODS A retrospective chart review of neck management in patients after chemoradiation was performed. RESULTS Of the initially positive necks analyzed, 210/329 (65%) had a complete clinical response to treatment and 161 necks underwent neck surgery. Patients were pathologically positive 13.8% and 39.6% of the time after clinical complete or partial response, respectively. Regional recurrence was more frequent in necks with partial clinical (p = .04) or pathologic responses (p < .01) and with primary site recurrences (p < .01). CONCLUSIONS It is still safest at our institution to perform selective neck dissection on patients with > or = N2 neck disease when initially observed to prevent unsalvageable regional recurrence until more accurate interval assessment tools are confirmed.
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Affiliation(s)
- Steven B Cannady
- Department of Otolaryngology, Oregon Health Sciences University, Portland, Oregon, USA.
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de Bondt BJ, Stokroos R, Casselman JW, van Engelshoven JMA, Beets-Tan RGH, Kessels FGH. Clinical impact of short tau inversion recovery MRI on staging and management in patients with cervical lymph node metastases of head and neck squamous cell carcinomas. Head Neck 2009; 31:928-37. [DOI: 10.1002/hed.21060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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de Bondt RBJ, Nelemans PJ, Bakers F, Casselman JW, Peutz-Kootstra C, Kremer B, Hofman PAM, Beets-Tan RGH. Morphological MRI criteria improve the detection of lymph node metastases in head and neck squamous cell carcinoma: multivariate logistic regression analysis of MRI features of cervical lymph nodes. Eur Radiol 2008; 19:626-33. [PMID: 18839178 PMCID: PMC2816250 DOI: 10.1007/s00330-008-1187-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Revised: 08/08/2008] [Accepted: 08/16/2008] [Indexed: 11/28/2022]
Abstract
The aim was to evaluate whether morphological criteria in addition to the size criterion results in better diagnostic performance of MRI for the detection of cervical lymph node metastases in patients with head and neck squamous cell carcinoma (HNSCC). Two radiologists evaluated 44 consecutive patients in which lymph node characteristics were assessed with histopathological correlation as gold standard. Assessed criteria were the short axial diameter and morphological criteria such as border irregularity and homogeneity of signal intensity on T2-weighted and contrast-enhanced T1-weighted images. Multivariate logistic regression analysis was performed: diagnostic odds ratios (DOR) with 95% confidence intervals (95% CI) and areas under the curve (AUCs) of receiver-operating characteristic (ROC) curves were determined. Border irregularity and heterogeneity of signal intensity on T2-weighted images showed significantly increased DORs. AUCs increased from 0.67 (95% CI: 0.61–0.73) using size only to 0.81 (95% CI: 0.75–0.87) using all four criteria for observer 1 and from 0.68 (95% CI: 0.62–0.74) to 0.96 (95% CI: 0.94–0.98) for observer 2 (p < 0.001). This study demonstrated that the morphological criteria border irregularity and heterogeneity of signal intensity on T2-weighted images in addition to size significantly improved the detection of cervical lymph nodes metastases.
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Affiliation(s)
- R B J de Bondt
- Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands.
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Nikolarakos D, Bell RB. Management of the Node-Positive Neck in Oral Cancer. Oral Maxillofac Surg Clin North Am 2008; 20:499-511. [DOI: 10.1016/j.coms.2008.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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21
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Fung K, Teknos TN, Vandenberg CD, Lyden TH, Bradford CR, Hogikyan ND, Kim J, Prince MEP, Wolf GT, Chepeha DB. Prevention of wound complications following salvage laryngectomy using free vascularized tissue. Head Neck 2007; 29:425-30. [PMID: 17274047 DOI: 10.1002/hed.20492] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Total laryngectomy following radiation therapy or concurrent chemoradiation therapy is associated with unacceptably high complication rates because of wound healing difficulties. With an ever increasing reliance on organ preservation protocols as primary treatment for advanced laryngeal cancer, the surgeon must develop techniques to minimize postoperative complications in salvage laryngectomy surgery. We have developed an approach using free tissue transfer in an effort to improve tissue vascularity, reinforce the pharyngeal suture line, and minimize complications in this difficult patient population. The purpose of this study was to outline our technique and determine the effectiveness of this new approach. METHODS We conducted a retrospective review of a prospective cohort and compared it with a historical group (surgical patients of Radiation Therapy Oncology Group (RTOG)-91-11 trial). Eligibility criteria for this study included patients undergoing salvage total laryngectomy following failed attempts at organ preservation with either high-dose radiotherapy or concurrent chemo/radiation therapy regimen. Patients were excluded if the surgical defect required a skin paddle for pharyngeal closure. The prospective cohort consisted of 14 consecutive patients (10 males, 4 females; mean age, 58 years) who underwent free tissue reinforcement of the pharyngeal suture line following total laryngectomy. The historical comparison group consisted of 27 patients in the concomitant chemoradiotherapy arm of the RTOG-91-11 trial who met the same eligibility criteria (26 males, 1 female; mean age, 57 years) but did not undergo free tissue transfer or other form of suture line reinforcement. Minimum follow-up in both groups was 12 months. RESULTS The overall pharyngocutaneous fistula rate was similar between groups-4/14 (29%) in the flap group, compared with 8/27 (30%) in the RTOG-91-11 group. There were no major wound complications in the flap group, compared with 4 (4/27, 14.8%) in the RTOG-91-11 group. There were no major fistulas in the flap group, compared with 3/27 (11.1%) in the RTOG-91-11 group. The rate of pharyngeal stricture requiring dilation was 6/14 (42%) in the flap group, compared with 7/27 (25.9%) in the RTOG-91-11 group. In our patients, the rate of tracheoesophageal speech was 14/14 (100%), and complete oral intake was achieved in 13/14 (93%) patients. Voice-Related Quality of Life Measure (V-RQOL) and Performance Status Scale for Head and Neck Cancer Patients (PSS-HN) scores suggest that speech and swallowing functions are reasonable following free flap reinforcement. CONCLUSIONS Free vascularized tissue reinforcement of primary pharyngeal closure in salvage laryngectomy following failed organ preservation is effective in preventing major wound complications but did not reduce the overall fistula rate. Fistulas that developed following this technique were relatively small, did not result in exposed major vessels, and were effectively treated with outpatient wound care rather than readmission to the hospital or return to operating room. Speech and swallowing results following this technique were comparable to those following total laryngectomy alone.
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Affiliation(s)
- Kevin Fung
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI, USA
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Dequanter D, Lothaire P, Awada A, Lalami Y, Hien Nguyen T, Lemort M, Vandevelde L, Andry G. Does clinical and radiological response predict complete tumor control in N2-N3 squamous cell head and neck cancer after non-operative management of the neck? Acta Otolaryngol 2006; 126:1225-8. [PMID: 17050318 DOI: 10.1080/00016480600818088] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
CONCLUSION A complete clinical and radiological response observed following chemotherapy and radiotherapy is not predictive of the absence of residual disease. Moreover, salvage neck surgery does not always seem to be an effective strategy. Consequently, early neck dissection should be advised for patients with complete clinical and radiological response (CCRR) after chemoradiotherapy for tumors with N2-N3 disease. BACKGROUND We retrospectively reviewed the outcome of 28 patients with N2-N3 disease treated initially with chemotherapy and radiotherapy. PATIENTS AND METHODS A neck dissection was performed for all patients with residual disease in the neck. RESULTS A CCRR in the neck was achieved in 25 of 28 patients. The remaining three patients with residual neck mass underwent a salvage neck dissection: the pathological examination confirmed the persistence of tumoral disease. No regional failure was observed in these three patients. In 25 patients considered to have CCRR in the neck, 5 patients (20%) developed regional recurrence. Successful salvage approach was not possible for any of these patients.
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Affiliation(s)
- Didier Dequanter
- Department of Surgery, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles, Brussels, Belgium.
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Forest VI, Nguyen-Tan PF, Tabet JC, Olivier MJ, Larochelle D, Fortin B, Gélinas M, Soulières D, Charpentier D, Guertin L. Role of neck dissection following concurrent chemoradiation for advanced head and neck carcinoma. Head Neck 2006; 28:1099-105. [PMID: 16933313 DOI: 10.1002/hed.20479] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Our primary objective was to determine the role of neck dissection following concomitant chemoradiation (CRT) for advanced stage III-IV head and neck squamous cell carcinoma (HNSCC). METHODS One hundred eighty-four patients with HNSCC treated with CRT were included. One hundred twenty-three patients reached a regional complete response (CR) after CRT and no neck dissection was performed. Forty-five patients among the 58 who reached a regional partial response (PR) underwent a neck dissection. RESULTS Overall, regional CR rate after CRT was 68%. Patients who reached a regional CR (no neck dissection) had an overall neck recurrence rate of 5%. Patients with regional PR who underwent a neck dissection had a 7% neck recurrence rate. CONCLUSIONS Patients with regional CR not followed by a neck dissection have a low rate of neck recurrence. Systematic neck dissection is not mandatory for patients with nodes less than 6 cm reaching a regional CR. For patients with nodes larger than 6 cm, no firm recommendation can be given because of the small number of patients in this series. If the regional response is incomplete, cervical dissection is warranted.
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Affiliation(s)
- Véronique-Isabelle Forest
- Department of Otolaryngology-Head and Neck Surgery, Centre Hospitalier Universitaire de l'Université de Montréal, Pavillon B-Hôpital Notre-Dame, 1560, Sherbrooke East, Montreal, PQ, Canada H2L 4M1
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Yom SS, Machtay M, Biel MA, Sinard RJ, El-Naggar AK, Weber RS, Rosenthal DI. Survival Impact of Planned Restaging and Early Surgical Salvage Following Definitive Chemoradiation for Locally Advanced Squamous Cell Carcinomas of the Oropharynx and Hypopharynx. Am J Clin Oncol 2005; 28:385-92. [PMID: 16062081 DOI: 10.1097/01.coc.0000162422.92095.9e] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Patients who have received definitive radiation therapy (RT) for a nonlaryngeal T3/4 head and neck squamous cell carcinoma have a limited opportunity for post-RT surgical salvage. The authors reviewed the practice of planned post-RT restaging to determine its impact on the success of early surgical salvage. METHODS A retrospective review was performed for patients with resectable T3/4 cancers of the oropharynx and hypopharynx treated with RT +/- chemotherapy who underwent planned restaging clinically, radiographically (CT or MRI), and by direct laryngoscopy with biopsy at 4 to 8 weeks post-RT. Chemotherapy was given as induction, concurrently, or both. Neck dissection was performed at time of restaging in patients with primary tumor control and initial N2/N3 neck disease or persistent lymphadenopathy. RESULTS A total of 54 patients had a median follow-up of 34.7 months (range, 7.6-97.8 months). Forty-two patients (78.8%) achieved a complete response (CR) at the primary site immediately after RT. Six developed late local failure at 9 to 61 months, of whom 2 were successfully salvaged. The ultimate 2-year local control among patients with initial CR was 94.8%. The 2-year organ preservation, disease-free survival, and overall survival (OS) rates were was 92.5%, 87%, and 90%, respectively. Twelve patients did not achieve initial CR. Two patients with bulky stage IV disease had unresectable cancers. Ten underwent immediate surgical salvage and 7 achieved local control (1 of whom developed distant metastases) whereas 3 had continued local failure. For patients without initial CR, the 2-year ultimate local control rate was 46.7% and OS was 46.8%. For all patients, overall 2-year local control, organ preservation, and OS rates were 85.6%, 75.6%, and 81.8% respectively. The rate of local failure-free organ preservation was 71.5%. CONCLUSION For patients with T3/4 resectable nonlaryngeal head and neck cancers, planned clinical, radiographic, and pathologic restaging at 1 to 2 months after definitive RT provides the opportunity for early surgical salvage in those who fail at the primary site. This practice produces improved overall local control and survival rates compared with the literature reports for delayed attempted salvage with timing based on the findings of routine postradiation clinical surveillance. Future efforts may focus on the improved selection of patients who would be most likely to require early surgical intervention.
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Affiliation(s)
- Sue S Yom
- Department of Radiation Oncology, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Temam S, Pape E, Janot F, Wibault P, Julieron M, Lusinchi A, Mamelle G, Marandas P, Luboinski B, Bourhis J. Salvage surgery after failure of very accelerated radiotherapy in advanced head-and-neck squamous cell carcinoma. Int J Radiat Oncol Biol Phys 2005; 62:1078-83. [PMID: 15990011 DOI: 10.1016/j.ijrobp.2004.12.062] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2004] [Revised: 12/14/2004] [Accepted: 12/16/2004] [Indexed: 11/16/2022]
Abstract
PURPOSE To assess the efficacy and toxicity of salvage surgery for local or cervical nodal recurrence after accelerated radiotherapy for locally advanced head-and-neck squamous cell carcinoma (HNSCC). METHODS AND MATERIALS We reviewed the medical records of the 136 patients with HNSCC who had been treated in three consecutive clinical trials at the Institut Gustave-Roussy using a very accelerated radiotherapy regimen (62 to 64 Gy with 2 daily fractions of 1.8 to 2 Gy over 3.5 weeks). Sixty-nine patients of the 136 initial patients (51%) had local or neck lymph nodes relapse, or both. RESULTS Sixteen of these 69 patients (23%) had undergone salvage surgery for recurrence locally (n = 8) or in the cervical nodes (n = 8). All 16 had initially been diagnosed with locally advanced oropharyngeal carcinoma (T4, 11 patients; T3, 5 patients), and 13 had initially had cervical node involvement. After salvage surgery, 6 patients had had a local recurrence; 7, cervical node recurrence; and 3, distant metastasis. Thus, salvage surgery had been successful only in 3 patients. The 3- and 5-year overall actuarial survival rates were 20% and 11%, respectively. Eight patients had major postoperative wound complications, including carotid rupture in three cases. CONCLUSION Salvage surgery for relapse after very accelerated radiotherapy for advanced HNSCC is infrequently feasible and is of limited survival benefit. It should be used only in carefully selected cases.
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Affiliation(s)
- Stephane Temam
- Department of Otorhinolaryngology-Head and Neck Surgery, Institut Gustave-Roussy, 39 rue Camille Desmoulins, 94805 Villejuif, France
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D'cruz AK, Pantvaidya GH, Agarwal JP, Chaukar DA, Pathak KA, Deshpande MS, Pai PS, Chaturvedi P, Dinshaw KA. Split therapy: Planned neck dissection followed by definitive radiotherapy for a T1, T2 pharyngolaryngeal primary cancer with operable N2, N3 nodal metastases—A prospective study. J Surg Oncol 2005; 93:56-61. [PMID: 16353188 DOI: 10.1002/jso.20399] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The management of patients with a small pharyngolaryngeal cancer (T1 and T2) with large nodal metastases is a subject of debate. We present data on the feasibility and outcome of treating these patients with surgery for the nodal metastases followed by definitive radiotherapy. METHODS Prospective study of 59 patients of small pharyngolaryngeal primary squamous carcinomas with operable (N2/N3) nodal metastasis treated with neck dissection followed by radiotherapy. RESULTS Complete nodal clearance was achieved in 54 (90%). The mean nodal size was 4 cm and extranodal extension was seen in 88% of patients in the study group. There were no significant postoperative complications. Median interval between surgery and radiotherapy was 23 days. Forty-nine patients (83%) started their RT within 6 weeks of surgery. With a median follow-up of 25 months, the disease free and overall survival was 54% and 60% (5 years). CONCLUSION The management of patients with a radiocurable pharyngolaryngeal primary with large nodes by this approach is a feasible option with adequate control and survival.
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Affiliation(s)
- A K D'cruz
- Department of Head and Neck Surgery, Tata Memorial Hospital, Mumbai, India.
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McHam SA, Adelstein DJ, Rybicki LA, Lavertu P, Esclamado RM, Wood BG, Strome M, Carroll MA. Who merits a neck dissection after definitive chemoradiotherapy for N2-N3 squamous cell head and neck cancer? Head Neck 2003; 25:791-8. [PMID: 12966502 DOI: 10.1002/hed.10293] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The role of neck dissection (ND) after definitive chemoradiotherapy for squamous cell head and neck cancer is incompletely defined. We retrospectively reviewed 109 patients with N2-N3 disease treated with chemoradiotherapy to identify predictors of a clinical complete response in the neck (CCR-neck), pathologic complete response after ND (PCR-neck), and regional failure. METHOD All patients were given 4-day continuous infusions of 5-fluorouracil (1000 mg/m2/d) and cisplatin (20 mg/m2/d) during the first and fourth weeks of either once daily (n = 68) or twice daily (n = 41) radiation therapy. ND was considered for all patients after completion of chemoradiotherapy and was performed in 32 of the 65 patients achieving a CCR-neck after chemoradiotherapy and in all 44 patients with residual clinical evidence of neck disease. CCR-neck, PCR-neck, and regional failure were then correlated with potential predictors, including T, N, largest lymph node size (<3 cm, > or =3 cm), primary tumor site, and radiation fractionation schedule. RESULTS Achievement of a CCR-neck was predicted by N, N2 vs N3 (53 of 80 vs 12 of 29, p =.019) and by largest lymph node size, <3 cm vs > or =3 cm (19 of 25 vs 46 of 84, p =.06). Achievement of a PCR-neck could not be predicted by any clinical parameter. Regional failure occurred both in patients undergoing ND and those not dissected (5 of 76 vs 4 of 33, p =.33) and proved more likely only in the ND patients with residual positive pathology compared with those achieving a PCR-neck (5 of 25 vs 0 of 51, p <.001). Primary site was not a useful predictor of CCR-neck, PCR-neck, or regional failure. Most importantly, CCR-neck (vs <CCR-neck) did not predict either a PCR-neck (24 of 32 vs 27 of 44, p =.21) or regional failure (5 of 65 vs 4 of 44, p =.80). CONCLUSIONS After chemoradiotherapy, clinical parameters do not identify those patients with residual neck node disease or those at risk for regional failure, suggesting that ND be considered for all N2-N3 patients.
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Affiliation(s)
- Scott A McHam
- Department of Hematology and Medical Oncology, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk R 35, Cleveland, Ohio 44195, USA
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Grabenbauer GG, Rödel C, Ernst-Stecken A, Brunner T, Hornung J, Kittel K, Steinhart H, Iro H, Sauer R, Schultze-Mosgau S. Neck dissection following radiochemotherapy of advanced head and neck cancer--for selected cases only? Radiother Oncol 2003; 66:57-63. [PMID: 12559521 DOI: 10.1016/s0167-8140(02)00193-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To address the value of neck dissection (ND) in patients with advanced head and neck cancer following primary radiochemotherapy and to specifically analyse its impact on locoregional tumour control, survival and toxicity. PATIENTS AND METHODS Between 1987 and 1997 (9,335), a total of 142 patients (pts) were treated by primary radiochemotherapy (RCT) according to prospective protocols. There were 64 pts with involvement of the hypopharynx, 57 pts with oropharyngeal and 21 with oral cavity carcinoma. UICC (1997) stages included: 16 pts in stage III, 113 pts in stage IV A, 13 pts in stage IV B. All pts received platin-based RCT up to a median total dose of 70 Gy (range, 60-72 Gy). Six weeks after RCT, pts with complete response of the primary tumour (N=97) were offered a uni- or bilateral ND depending on the initially diagnosed nodal disease as part of a strict institutional policy. Fifty-six pts consented to ND and 41 refused. These two groups were analysed in terms of characteristics, local and regional tumour control, survival and long-term side effects. Median follow-up was 37 months (range, 22-124 months). RESULTS Among the 56 pts receiving ND, a total of 13 (23%) was found to have residual tumour in the neck specimen. The rates of positive histology according to clinical N category after RCT were: yN0 (2/22[9%]), yN1 (2/10[20%]), yN2a-b (2/10[20%), yN2c-3 (7/14[54%]). Five-year overall survival and disease-specific survival rates for pts with ND were 44 and 55%, for pts without ND 42 and 47%, respectively (P=0.9). No difference was seen for long-term local and regional control between the two patient groups. Comparing the group of patients with and without ND, a trend towards higher subjective morbidity of grade 3 and 4 (LENT-SOMA), i.e. pain recording (24% vs. 17%), dysphagia (48% vs. 35%) and hoarseness (20% vs. 9%) was evident in patients with ND. CONCLUSION No clear evidence for routine clinical use of ND after RCT in advanced head and neck tumours can be derived from these data. ND may be contemplated in selected cases with multiple residual nodes only.
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Affiliation(s)
- Gerhard G Grabenbauer
- Department of Radiation Therapy, University Hospitals of Erlangen, Universitätsstrasse 27, 91054 Erlangen, Germany
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Wolf GT. Options for Preserving the Larynx in Patients with Advanced Laryngeal and Hypopharyngeal Cancer. EAR, NOSE & THROAT JOURNAL 2001. [DOI: 10.1177/014556130108001217] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The introduction of newer surgical and combined-modality approaches to organ preservation in patients with advanced laryngeal or hypopharyngeal cancer is the most exciting clinical frontier in head and neck cancer-treatment today. The use of these techniques at other sites, the exploration of improved methods for patient selection and tumor assessment, and the development of newer combination regimens will need to be rigorously studied in future clinical trials. In all these efforts, the major focus must remain on improving survival. This article reviews the latest developments in organ-preservation strategies and techniques for patients with advanced laryngeal or hypopharyngeal cancer.
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Affiliation(s)
- Gregory T. Wolf
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor
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Teknos TN, Myers LL, Bradford CR, Chepeha DB. Free tissue reconstruction of the hypopharynx after organ preservation therapy: analysis of wound complications. Laryngoscope 2001; 111:1192-6. [PMID: 11568540 DOI: 10.1097/00005537-200107000-00011] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Previous series have demonstrated a 77% rate of major wound complications in salvage surgery of the larynx following organ preservation protocols. The purpose of this study is to determine the incidence of wound complications in these patients when microvascular free tissue transfers are used for reconstruction of the hypopharynx. DESIGN Retrospective case series. SETTING Academic tertiary care center. PATIENTS AND METHOD We reviewed the medical records of 42 patients with stage III and IV laryngeal squamous cell carcinoma treated with an organ-sparing protocol consisting of induction chemotherapy followed by definitive radiation therapy. Ten of these patients who required surgical salvage were reconstructed using radial forearm free tissue or lateral arm transfer and constitute the study group. MAIN OUTCOME MEASURES Wound complications. RESULTS Wound complications occurred in 2 patients (20%) undergoing free flap reconstruction of the hypopharynx after organ preservation protocols, which was significantly lower (P =.003) than previous reports using other forms of closure and/or reconstruction. One patient in this study group had a small pharyngocutaneous fistula that resolved with conservative therapy after 1 week. The other patient had a larger pharyngocutaneous fistula that resolved over 3 weeks. The mean interval from completion of the chemoradiation regimen to surgery was 21.3 months (range, 2-60 mo). The average free tissue flap size was 94.3 cm(2) (range, 45-165 cm(2)). Average harvest and ischemia times were 59 minutes (range, 41-87 min) and 187.7 minutes (range, 120-240 min), respectively. All flaps survived, and one patient had a minor donor site wound dehiscence. The average hospital stay was 7.8 days. There were no mortalities in this series. CONCLUSIONS Our results suggest that free tissue transfer reconstruction of the hypopharynx is the preferred method of reconstruction following combined chemotherapy and radiation therapy protocols. Surgical complications are significantly reduced and hospital stays are minimized.
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Affiliation(s)
- T N Teknos
- Department of Otolaryngology-Head and Neck Surgery, Division of Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan 48109-0312, USA.
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Gokhale AS, Lavertu P. Surgical salvage after chemoradiation of head and neck cancer: complications and outcomes. Curr Oncol Rep 2001; 3:72-6. [PMID: 11123873 DOI: 10.1007/s11912-001-0046-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The treatment of advanced squamous cell carcinoma involves a multidisciplinary approach among various physicians and ancillary personnel. The role of the head and neck surgeon continues to change, as concurrent chemotherapy and radiotherapy protocols have evolved in the initial management of this challenging patient population. More and more, the surgeon is called upon to operate on those patients with persistent or recurrent disease despite initial treatment with chemotherapy and radiotherapy. The purpose of this article is to analyze complications and outcomes of surgery in patients who have already received radiotherapy and chemotherapy.
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Affiliation(s)
- A S Gokhale
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals of Cleveland, Cleveland, OH 44106-5045, USA.
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Affiliation(s)
- Y P Talmi
- Department of Otolaryngology-Head and Neck Surgery, Chaim Sheba Medical Center, Tel Hashomer, Israel.
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Dagum P, Pinto HA, Newman JP, Higgins JP, Terris DJ, Goffinet DR, Fee WE. Management of the clinically positive neck in organ preservation for advanced head and neck cancer. Am J Surg 1998; 176:448-52. [PMID: 9874431 DOI: 10.1016/s0002-9610(98)00240-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND To investigate clinicopathologic predictive criteria for the optimal management of neck metastases in patients with advanced head and neck cancers treated with combined chemoradiotherapy. METHODS Prospective study, 48 patients. Mean length follow-up, 23 months. RESULTS Neck stage predicted neck response to chemoradiotherapy; N3 necks showed more partial responses (P = 0.04), and N1 necks showed more complete responses (P = 0.12). Primary tumor site strongly predicted the pathologic response found on neck dissection in patients with a clinical partial response (cPR) following chemoradiotherapy. There was no difference in survival between patients with a clinical complete response (cCR) after chemoradiotherapy, and patients with a pathologic complete response (pCR) after neck dissection (P = 0.20); however, when grouped together, these patients survived longer than did patients with a pPR at neck dissection (P = 0.06). CONCLUSIONS Clinical response to induction chemotherapy is a poor predictor of ultimate neck control. Induction chemotherapy followed by chemoradiotherapy, and planned neck dissection for patients with persistent cervical lymphadenopathy, provides good regional control.
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Affiliation(s)
- P Dagum
- Division of Otolaryngology/Head and Neck Surgery, Stanford University School of Medicine, California 94305-5407, USA
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Weisman RA, Robbins KT. Management of the neck in patients with head and neck cancer treated by concurrent chemotherapy and radiation. Otolaryngol Clin North Am 1998; 31:773-84. [PMID: 9735106 DOI: 10.1016/s0030-6665(05)70086-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The current high level of interest in organ preservation strategies for patients with advanced squamous cell carcinoma of the head and neck undoubtedly will result in increasing numbers of patients managed initially with chemotherapy and radiation, either sequentially or concurrently. In some protocols, surgery, and neck dissection in particular, will either be mandatory or offered based on the degree of response to treatment and initial stage of neck disease. Head and neck oncologic surgeons need to be involved and at the forefront of such trials, to allow meaningful data regarding pathologic response to treatment to be obtained, as well as to define the role of surgery in such patients. Although present data is limited, it would appear that in patients achieving a complete response to chemoradiation, the role of neck dissection may be more limited than in the past, even for patients with N2 to N3 neck disease at presentation. Surgical complications may be increased in this heavily treated patient population, and subsequent surgery should be designed to minimize the risk of wound complications, especially if performed before the patient has made a full recovery from the metabolic and immunologic derangements associated with chemoradiation. Head and neck surgeons need to play an active role in the design and conduct of chemoradiation trials so that these and other relevant questions will be answered by the data generated.
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Affiliation(s)
- R A Weisman
- Division of Otolaryngology, University of California Medical Center at San Diego, 92103-8891, USA
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