Organ preservation therapy using induction plus concurrent chemoradiation for advanced resectable oropharyngeal carcinoma: a University of Pennsylvania Phase II Trial

Oncological and functional outcomes of partial or total laryngopharyngectomy for hypopharyngeal cancer with thyroid or cricoid cartilage invasion

BACKGROUND

Patients with cartilage invasion in hypopharyngeal squamous cell carcinoma (HPSCC) would benefit from partial laryngopharyngectomy (PLP).

AIMS/OBJECTIVES

The purpose of this study was to examine the treatment outcomes of PLP for HPSCC with cartilage invasion, with a focus on the oncological safety and the function preservation.

MATERIALS AND METHODS

We performed a retrospective review of 28 patients with HPSCC with thyroid or cricoid cartilage invasion who had undergone upfront surgery and were followed for more than one year between 1993 and 2019.

RESULTS

Twelve patients treated with PLP (42.9%) and 16 patients treated with total laryngopharyngectomy (TLP) for cartilage invasion in HPSCC were identified. There was no significant difference in recurrence between the PLP group (7/12, 58.3%) and the TLP group (8/16, 50.0%) (p = .718). PLP was not associated with decreased five-year disease free survival (p = .662) or disease specific survival (p = .883) rates compared to TLP. Nine patients receiving PLP could be decannulated and retained intelligible speech (9/12, 75%). Gastrostomy tubes were placed in the PLP group (5/12, 42.9%) and TLP group (1/16, 6.2%) (p = .057).

CONCLUSIONS AND SIGNIFICANCE

PLP appears to be a feasible option for the treatment of thyroid or cricoid cartilage invasion in HPSCC.

Clinical Studies on Ultrafractionated Chemoradiation: A Systematic Review

Aim

The efficacy of low-dose fractionated radiotherapy (LDFRT) and chemotherapy (CHT) combination has large preclinical but little clinical evidence. Therefore, the aim of this review was to collect and analyze the clinical results of LDRT plus concurrent CHT in patients with advanced cancers.

Methods

A systematic literature search was conducted on PubMed using the PRISMA methodology. Only studies based on the combination of LDFRT (< 1 Gy/fraction) and CHT were included. Endpoints of the analysis were tumor response, toxicity, and overall survival, with particular focus on any differences between LDFRT-CHT and CHT alone.

Results

Twelve studies (307 patients) fulfilled the selection criteria and were included in this review. Two studies were retrospective, one was a prospective pilot trial, six were phase II studies, two were phase I trials, and one was a phase I/II open label study. No randomized controlled trials were found. Seven out of eight studies comparing clinical response showed higher rates after LDFRT-CHT compared to CHT alone. Three out of four studies comparing survival reported improved results after combined treatment. Three studies compared toxicity of CHT and LDFRT plus CHT, and all of them reported similar adverse events rates. In most cases, toxicity was manageable with only three likely LDFRT-unrelated fatal events (1%), all recorded in the same series on LDFRT plus temozolomide in glioblastoma multiforme patients.

Conclusion

None of the analyzed studies provided level I evidence on the clinical impact of LDFRT plus CHT. However, it should be noted that, apart from two small series of breast cancers, all studies reported improved therapeutic outcomes and similar tolerability compared to CHT alone.

Systematic Review Registration

www.crd.york.ac.uk/prospero/, identifier CRD42020206639.

Human papillomavirus oropharynx carcinoma: Aggressive de-escalation of adjuvant therapy

BACKGROUND

Aggressive dose de-escalated adjuvant radiation therapy (RT) in patients with human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV(+)OPSCC).

METHODS

Patients with HPV(+)OPSCC on a phase II clinical trial of primary surgery and neck dissection followed by dose de-escalated RT (N = 79) were compared with a cohort of patients who received standard adjuvant therapy (N = 115). Local recurrence-free, regional recurrence-free, distant metastases-free survival, and progression-free survival (PFS) were assessed.

RESULTS

Of 194 patients, 23 experienced progression at a median of 1.1 years following surgery (interquartile range [IQR] 0.7-2.0; range 0.3-5.4); 10 patients in the de-escalated cohort and 13 patients in the standard cohort. The 3-year PFS rate for the de-escalated cohort was 87%, and in the standard cohort was 90% (hazard ratio [HR] 1.18, 95% confidence interval (CI) [0.50-2.75]).

CONCLUSION

Patients with HPV(+)OPSCC who undergo surgical resection and neck dissection and meet criteria for adjuvant therapy can undergo aggressive dose de-escalation of RT without increasing risk of progression locally, regionally or at distant sites.

Low-dose fractionated radiation with induction docetaxel and cisplatin followed by concurrent cisplatin and radiation therapy in locally advanced nasopharyngeal cancer: A randomized phase II-III trial

OBJECTIVE/BACKGROUND

To evaluate the efficacy and outcome of adding low-dose fractionated radiotherapy (LDFRT) to induction chemotherapy plus concurrent chemoradiation in locally advanced nasopharyngeal carcinoma (LANPC).

METHODS

A single-institute, phase II-III, prospectively controlled randomized clinical trial was performed at King Faisal Specialist Hospital and Research Centre. Patients aged 18-70 years with WHO type II and III, stage III-IVB nasopharyngeal carcinoma, Eastern Cooperative Oncology Group performance score of 0-2, with adequate hematological, renal, and hepatic function were eligible. In total, 108 patients were enrolled in this trial. All patients received two cycles of induction docetaxel and cisplatin (75 mg/m² each) chemotherapy on Days 1 and 22, followed by concurrent chemoradiation therapy. Radiation therapy consisted of 70 Gy in 33 fractions, with concurrent cisplatin 25 mg/m² for 4 days on Days 43 and 64. Patients were randomly assigned to either adding LDFRT (0.5 Gy twice daily 6 hours apart for 2 days) to induction chemotherapy in the experimental arm (54 patients) or induction chemotherapy alone in the control arm (54 patients).

RESULTS

There was no significant difference in the post-induction response rates (RRs) or in toxicity between the two treatment arms. The 3-year overall survival (OS), locoregional control (LRC), and distant metastases-free survival (DMFS) rates for experimental arm and control arm were 94% versus 93% (p = .8), 84.8% versus 87.5% (p = .58), and 84.1% versus 91.6% (p = .25), respectively.

CONCLUSION

The results showed no benefit from adding LDFRT to induction chemotherapy in terms of RR, OS, LRC, and DMFS.

The GIRAFE phase II trial on MVCT-based "volumes of the day" and "dose of the day" addresses when and how to implement adaptive radiotherapy for locally advanced head and neck cancer

During exclusive curative radiotherapy for head and neck tumors, the patient's organs at risk (OAR) and target volumes frequently change size and shape, leading to a risk of higher toxicity and lower control than expected on planned dosimetry. Adaptive radiotherapy is often necessary but 1) tools are needed to define the optimal time for replanning, and 2) the subsequent workflow is time-consuming. We designed a prospective study to evaluate 1) the validity of automatically deformed contours on the daily MVCT, in order to safely use the "dose-of the day" tool to check daily if replanning is necessary; 2) the automatically deformed contours on the replanning CT and the time gained in the replanning workflow. Forty-eight patients with T3-T4 and/or involved node >2 cm head and neck squamous cell carcinomas, planned for curative radiotherapy without surgery, will be enrolled. They will undergo treatment with helical IMRT including daily repositioning MVCTs. The contours proposed will be compared weekly on intermediate planning CTs (iCTs) on weeks 3, 4, 5 and 6. On these iCTs both manual recontouring and automated deformable registration of the initial contours will be compared with the contours automatically defined on the MVCT. The primary objective is to evaluate the Dice similarity coefficient (DSC) of the volumes of each parotid gland. The secondary objectives will evaluate, for target volumes and all OARs: the DSC, the mean distance to agreement, and the average surface-to-surface distance. Time between the automatic and the manual recontouring workflows will be compared.

Treatment, survival, and costs of oropharyngeal cancer care in the elderly

OBJECTIVES/HYPOTHESIS

To examine associations between treatment, survival, and costs in elderly patients with oropharyngeal squamous cell cancer (OPSCC).

STUDY DESIGN

Retrospective cross-sectional analysis of Surveillance, Epidemiology, and End Results-Medicare data.

METHODS

We evaluated 666 patients diagnosed with OPSCC from 2004 to 2007 using cross-tabulations, multivariate logistic and generalized linear regression modeling, and survival analysis.

RESULTS

The majority of patients were nonsmokers (79%), had advanced-stage disease (59%), and received chemoradiation (38%) or radiation (28%). Surgery with postoperative radiation (hazard ratio [HR]: 0.33 [95% CI: 0.20-0.53]) and chemoradiation (HR: 0.45 [95% CI: 0.29-0.71]) were associated with improved survival, whereas stage IV disease was associated with poorer survival (HR: 1.95 [95% CI: 1.13-3.38]). Additional cancer-directed treatment after primary treatment was more likely following chemoradiation (odds ratio [OR]: 3.44 [95% CI: 1.78-6.63]). Salvage surgery was performed in 25% of patients undergoing subsequent additional cancer-directed treatment, and was associated with high-volume hospitals (OR: 2.81 [95% CI: 1.07-7.74]). Additional radiation (HR: 0.47 [95% CI: 0.31-0.72]) and salvage surgery (HR: 0.61 [95% CI: 0.38-0.99]) were associated with improved overall survival when performed >6 months following initial treatment, whereas salvage neck dissection alone was not significantly associated with survival after controlling for time to salvage (HR: 0.38 [95% CI: 0.05-2.78]). Treatment and 5-year overall costs were highest for chemoradiation, surgery with postoperative radiation, and additional cancer-directed treatment.

CONCLUSIONS

Multimodality treatment in elderly OPSCC patients was associated with improved survival and increased costs. Chemoradiation was associated with an increased likelihood of additional cancer-directed treatment. Salvage surgery was centralized at high-volume hospitals, and was associated with improved survival when performed >6 months after last initial treatment date, but was performed in <20% of patients undergoing additional treatment.

LEVEL OF EVIDENCE

2c. Laryngoscope, 128:1103-1112, 2018.

Association of Transoral Robotic Surgery With Short-term and Long-term Outcomes and Costs of Care in Oropharyngeal Cancer Surgery

Importance

The treatment of oropharyngeal cancer has undergone a paradigm shift in the past 2 decades, with an increase in the use of nonoperative treatment owing to poor functional outcomes associated with traditional surgical approaches. Transoral robotic surgery (TORS) allows surgical resection of oropharyngeal cancer (OPC) with less morbidity through a minimally invasive approach.

Objective

To investigate the relationship among TORS and short- and long-term outcomes and costs in surgically treated patients with OPC.

Design, Setting, and Participants

Retrospective cross-sectional analysis of 3573 patients who underwent an ablative procedure for OPC in 2010 to 2012 using the MarketScan Commercial Claim and Encounters database.

Main Outcomes and Measures

The association between TORS and short- and long-term outcomes, length of hospitalization, and treatment-related costs was analyzed using descriptive statistics and multivariate regression modeling.

Results

Transoral robotic surgery was performed in 304 surgical cases (8.5%); 94.7% of patients were 40 to 64 years old, and 70.7% were male. The use of TORS increased from 4.1% of surgical cases in 2010 to 13.2% of surgical cases in 2012. Patients who underwent TORS had a lower rate of tracheotomy during treatment (3.9% vs 11.4%), and posttreatment gastrostomy tube use (21.9% vs 34.2%), compared with patients undergoing non-TORS procedures. On multivariate analysis, TORS was not associated with significant differences in postoperative complications or length of hospitalization. There was no significant difference in the odds of receiving postoperative radiation therapy between patients who underwent TORS and those who did not; however, among patients receiving radiation therapy, chemoradiation was significantly less likely following TORS (odds ratio [OR], 0.52; 95% CI, 0.29-0.90). TORS was associated with significantly decreased odds of posttreatment gastrostomy (OR, 0.54; 95% CI. 0.30-0.95) and tracheostomy during treatment (OR, 0.17; 95% CI, 0.06-0.55) at 1 year, and was associated with significantly decreased overall treatment-related costs of care (mean incremental cost, -$22 724).

Conclusions and Relevance

The use of TORS for surgical resection of OPC is increasing in the United States and is associated with significantly lower use of adjuvant chemoradiation, late gastrostomy and tracheostomy dependence, and lower overall treatment-related costs of care. These data have implications for discussions of value in OPC care at a time of health care reform.

Extended Lateral Pharyngotomy for Selected Squamous Cell Carcinomas of the Lateral Tongue Base

Objectives

In a retrospective review of an inception cohort of 26 patients with an isolated, previously untreated, moderately to well-differentiated invasive squamous cell carcinoma of the lateral tongue base, consecutively managed with an extended lateral pharyngotomy approach at a single tertiary referral care center, the authors review the key surgical points, highlight the potential technical pitfalls, and document the complications and long-term functional and oncological outcomes in terms of survival and local control.

Methods

The adjunctive measures included induction chemotherapy, ipsilateral neck dissection, and postoperative radiotherapy, used in 96.1%, 96.1%, and 38.5% of patients, respectively. All patients but 2 were followed for at least 5 years or until death (maximum, 158 months).

Results

The significant postoperative complications included pharyngocutaneous fistula in 3 patients (11.5%) and hemorrhage requiring reoperation, partial flap necrosis, and pneumonia from aspiration in 1 patient (3.8%) each. In univariate analysis, no significant statistical relationship was noted between the significant postoperative complications noted and the variables under analysis. Overall, successful oral alimentation was achieved in 100% of patients by the first postoperative month without gastrostomy, tracheotomy, or completion total laryngectomy. There were no intraoperative or perioperative deaths. The main causes of death were metachronous second primary tumor, intercurrent disease, and distant metastasis, resulting in 84.6%, 64%, and 46.9% 1-, 3-, and 5-year Kaplan-Meier actuarial survival estimates, respectively. Two patients (7.6%) had local recurrence, resulting in 100%, 86.7%, and 86.7% 1-, 3-, and 5-year Kaplan-Meier actuarial local control estimates, respectively. As a function of T stage, the 3- and 5-year actuarial local control estimates were 100%, 87.5%, and 90.9% in patients with tumors classified as T1, T2, and T3–T4a, respectively.

Conclusions

Such results suggest that extended lateral pharyngotomy should be integrated among the various conservative treatment options available to patients with selected carcinomas of the lateral tongue base.

Dysphagia, Stricture, and Pneumonia in Head and Neck Cancer Patients: Does Treatment Modality Matter?

Objectives

Dysphagia-related sequelae are common after head and neck cancer treatment. Our aims were 1) to document overall and site-specific dysphagia, stricture, and pneumonia rates in a Medicare population, 2) to calculate treatment-specific rates and adjusted odds of developing these complications, and 3) to track changes in rates between 1992 and 1999.

Methods

Head and neck cancer patients between 1992 and 1999 were identified in combined Surveillance Epidemiology and End Results (SEER) registry and Medicare databases. Multivariate analyses determined odds of dysphagia, stricture, and pneumonia based on modality.

Results

Of 8,002 patients, 40% of experienced dysphagia, 7% stricture, and 10% pneumonia within 3 years of treatment. In adjusted analyses, patients treated with chemoradiation had more than 2.5-times-greater odds of dysphagia than did those treated with surgery alone. Combined therapy was associated with increased odds of stricture (p < 0.05). The odds of pneumonia were increased in patients treated with radiation with or without chemotherapy. Temporally, the dysphagia rates increased 10% during this period (p < 0.05).

Conclusions

Sequelae of head and neck cancer treatment are common and differ by treatment regimen. Those treated with chemoradiation had higher odds of experiencing dysphagia and pneumonia, whereas patients treated with any combined therapy more commonly experienced stricture. These sequelae represent major sources of morbidity and mortality in this population.

Long-Term Enteral Nutrition Facilitates Optimization of Body Weight

BACKGROUND

Optimization of body mass index (BMI) among cancer survivors is a priority. Long-term enteral nutrition is required by many head and neck cancer survivors and may be utilized to affect changes in BMI.

METHODS

We used a retrospective review of head and neck cancer survivors dependent on enteral nutrition. Patients were grouped according to their BMI at initiation of enteral feeding. Patients with normal, low, or elevated BMI were assigned a goal of weight maintenance, weight gain, or weight reduction, respectively. Changes in BMI over time were recorded.

RESULTS

We identified 39 head and neck cancer survivors requiring enteral nutrition. Median time on enteral nutrition was 32 +/- 39.6 months. At the initiation of enteral feeding, 51% of patients had a normal BMI and were assigned to the weight maintenance group, 84% successfully maintained a normal BMI (mean 22.4 +/- 1.7 kg/m(2)), and 18% had a low BMI and were assigned to the weight gain group. In all, 85% achieved or trended toward a normal BMI (from 16.5 +/- 1.9 to 19.2 +/- 1.6 kg/m(2); p = .02). When enteral feedings began, 31% of patients had an elevated BMI and were assigned a goal of weight reduction; all were able to reduce their BMI (from 30.2 +/- 5 to 27.3 +/- 6 kg/m(2); p < .001).

CONCLUSIONS

Long-term enteral feeding facilitates body weight optimization among ambulatory head and neck cancer survivors. These findings may potentially be generalized to all ambulatory patients who are dependent on enteral nutrition.

The Predictive Value of Early Assessment After 1 Cycle of Induction Chemotherapy with 18F-FDG PET/CT and Diffusion-Weighted MRI for Response to Radical Chemoradiotherapy in Head and Neck Squamous Cell Carcinoma

The objective of this study was to assess the predictive value of early assessment (after 1 cycle of induction chemotherapy [IC]) with 18F-FDG PET/CT and diffusion-weighted (DW) MRI for subsequent response to radical chemoradiotherapy in locally advanced head and neck squamous cell carcinoma (HNSCC).

METHODS

Twenty patients with stage III-IVa HNSCC prospectively underwent 18F-FDG PET/CT and DW MRI before and 2 wk after each cycle of IC (first cycle, IC1; second cycle, IC2). Response was assessed 3 mo after completion of chemoradiotherapy with clinical examination, MRI, and 18F-FDG PET/CT. Patients with persistent disease were classed as nonresponders. Changes in functional and molecular imaging parameters after IC1 were compared between responders and nonresponders with the Mann-Whitney U test. The significance threshold was set at a P value of less than 0.05.

RESULTS

Responders showed a significantly greater reduction in metabolic tumor volume (P = 0.03) and total lesion glycolysis (P = 0.04) after IC1 than nonresponders. Responders also showed a tendency toward a larger but statistically nonsignificant increase in apparent diffusion coefficient after IC1. There was no significant difference in the changes from baseline between the IC1 and IC2 for all functional and molecular imaging parameters, indicating that most biologic response to IC measured by 18F-FDG PET/CT and DW MRI was observed early after the first cycle of IC.

CONCLUSION

Our preliminary data indicate that the 18F-FDG PET/CT-derived metabolic tumor volume or total lesion glycolysis, acquired after IC1, are early predictive biomarkers for ultimate response to subsequent chemoradiotherapy. These early biomarkers enable identification of patients at risk of treatment failure at an early time point, permitting treatment individualization and consideration of alternative strategies such as radiotherapy dose escalation or surgery.

Quality of Life Outcomes in Laryngeal and Oropharyngeal Cancer Patients after Chemoradiation

OBJECTIVE: The purpose of this study was to compare quality of life issues in patients with advanced laryngeal versus oropharyngeal cancer after treatment with chemoradiation.

DESIGN: A cohort study of 31 patients with laryngeal or oropharyngeal squamous cell carcinoma treated with chemoradiation completed the University of Washington quality of life instrument version 4 (UW-QOL v4). Statistical analysis was performed with Wilcoxon rank sum and chi-square tests.

SETTING: Academic tertiary care center.

RESULTS: Both groups reported similar impairment in the domains of swallowing, chewing, and taste. Oropharyngeal cancer patients reported significantly worse quality of life in the domain of saliva ( P < 0.007).

CONCLUSION: Swallowing, chewing, and taste were adversely affected by chemoradiation for both groups. Oropharyngeal patients experienced significantly worse problems with saliva than laryngeal patients. These patients reported high levels of satisfaction with health-related quality of life issues.

SIGNIFICANCE: Specific head and neck subsites have different morbidities when treated with primary chemoradiation for advanced tumors.

Using low-dose radiation to potentiate the effect of induction chemotherapy in head and neck cancer: Results of a prospective phase 2 trial

Purpose

Low-dose fractionated radiation therapy (LDFRT) induces effective cell killing through hyperradiation sensitivity and potentiates effects of chemotherapy. We report our second investigation of LDFRT as a potentiator of the chemotherapeutic effect of induction carboplatin and paclitaxel in locally advanced squamous cell cancer of the head and neck (SCCHN).

Experimental design

Two cycles of induction therapy were given every 21 days: paclitaxel (75 mg/m²) on days 1, 8, and 15; carboplatin (area under the curve 6) day 1; and LDFRT 50 cGy fractions (2 each on days 1, 2, 8, and 15). Objectives included primary site complete response rate; secondary included overall survival, progression-free survival (PFS), disease-specific survival, and toxicity.

Results

A total of 24 evaluable patients were enrolled. Primary sites included oropharynx (62.5%), larynx (20.8%), oral cavity (8.3%), and hypopharynx (8.3%). Grade 3/4 toxicities included neutropenia (20%), leukopenia (32%), dehydration/hypotension (8%), anemia (4%), infection (4%), pulmonary/allergic rhinitis (4%), and diarrhea (4%). Primary site response rate was 23/24 (95.8%): 15/24 (62.5%) complete response, 8/24 (33.3%) partial response, and 1/24 (4.2%) stable disease. With median follow-up of 7.75 years, 9-year rates for overall survival were 49.4% (95% confidence interval [CI], 30.5-79.9), PFS was 72.2% (CI, 55.3-94.3), and disease-specific survival was 65.4% (44.3-96.4).

Conclusion

Chemopotentiating LDFRT combined with paclitaxel and carboplatin is effective in SCCHN and provided an excellent median overall survival of 107.2 months, with median PFS not yet reached in this locally advanced SCCHN cohort. This compares favorably to prior investigations and caused fewer grade 3 and 4 toxicities than more intensive, 3-drug induction regimens. This trial demonstrates the innovative use of LDFRT as a potentiator of chemotherapy.

Treatment of Squamous Cell Carcinoma of the Tongue Base: Irradiation, Surgery, or Palliation?

Objectives:

Squamous cell carcinoma of the tongue base has a poor prognosis, and treatment is accompanied by a number of major problems. In view of this, it is important to recognize which patients will benefit from treatment with curative intent and which treatment method to use.

Methods:

One hundred sixty-five patients with squamous cell carcinoma of the tongue base were identified on our database. Eighty-two patients were treated by radical irradiation, and 41 by surgery. A further 42 patients were considered unsuitable for curative treatment.

Results:

The 5-year cause-specific survival rate was 41% for those treated by irradiation, 58% for those treated by surgery, and 9% for untreated patients. There was no difference in the efficacy of treatment methods (p = .5362), but a highly significant difference was seen in survival rate between treated and untreated patients (p = .0028). The decision regarding administration of curative treatment was based on the extent of locoregional involvement at the primary site (p = .0139; odds ratio, 0.43) and in the neck (p = .0078; odds ratio, 0.23). No factors affected the decision to treat by irradiation or surgery. When the observed survival rate was calculated, there was no significant difference in 5-year survival rate between treated and untreated patients (p = .2762). Those with early (T1-2) disease at the primary site had an improved survival rate from 0.5 to 4 years compared with those who were untreated (T3-4; p = .0081; odds ratio, 2.2). In addition, those with early (T1-2) disease had a better survival rate than those with advanced cancers (p = .0139; odds ratio, 2.09). There was, however, no difference in survival rate at 5 years. Those with early disease compared with those with advanced disease were twice as likely to be alive at 2 years; however, all survival advantages had disappeared by 5 years.

Conclusions:

In terms of observed survival, treating tongue base squamous cell carcinoma that is locally advanced (T3-4) at presentation offers no survival advantage over palliation alone. Treating early disease (T1-2) doubles the survival rate for up to 4 years, but by 5 years this survival advantage is lost. The present study finds radiotherapy and surgery to be equivalent at controlling this disease.

Neck Dissection Followed by Chemoradiotherapy for Stage IV (N+) Oropharynx Cancer

PURPOSE: This study evaluated the strategy of performing neck dissection (ND) without primary tumor resection prior to definitive chemoradiotherapy (CRT) for N2+ oropharynx cancer.

METHODS: We analyzed records of 25 patients who underwent ND before concurrent CRT with weekly low-dose concurrent paclitaxel and a platinum compound. The extent of ND was highly customized (1 to 39 nodes) and median radiotherapy dose was 70 Gy.

RESULTS: Median follow-up was 36 months. Two-year and 3-year actuarial locoregional control rates were 95% and 88%. No patient had regional neck nodal failure. Two-year rate of freedom from distant metastases was 91%. The 2- and 3-year event-free survival rates were 88% and 75%. Fifteen percent had Grade 3+ late toxicity; none had permanent gastrostomy tube dependence.

CONCLUSIONS: Neck dissection without primary tumor resection before definitive chemoradiotherapy for oropharynx cancer is a safe and effective management program and warrants further exploration.

Induction docetaxel and S-1 followed by concomitant radiotherapy with low-dose daily cisplatin in locally advanced head and neck carcinoma

BACKGROUND

The purpose of this study was to assess the efficacy and safety of induction chemotherapy with docetaxel-S-1, and radiotherapy (RT) with concurrent daily cisplatin in locally advanced head and neck carcinoma.

METHOD

Fifty patients received 2 cycles of induction chemotherapy with induction chemotherapy with docetaxel and S-1, followed by 7 cycles of RT with concurrent daily cisplatin.

RESULTS

The most frequent grade 3 to 4 hematologic toxicity was neutropenia (14%). Forty of 50 patients who completed induction chemotherapy with docetaxel and S-1 subsequently started RT with concurrent daily cisplatin, all within 3 to 4 weeks after the start of the second cycle of induction chemotherapy with docetaxel and S-1. The best response to induction chemotherapy with docetaxel and S-1 and after completion of RT with concurrent daily cisplatin was partial response (PR) in 52.5% and complete response in 47.5%, respectively. With a median follow-up of 61 months, 5-year progression-free survival (PFS) and overall survival (OS) were 63.3% and 65.7%, respectively.

CONCLUSION

Administration of induction chemotherapy with docetaxel and S-1 before RT with concurrent daily cisplatin chemoradiotherapy (CRT) resulted in a high response rate with good tolerability, and did not compromise subsequent CRT. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1653-E1659, 2016.

Morbidity, mortality and cost from HPV-related oropharyngeal cancer: Impact of 2-, 4- and 9-valent vaccines

OBJECTIVE

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) related to human papillomavirus (HPV) is increasing at a dramatic rate, with men affected more commonly than women. Individuals who develop this disease suffer significant morbidity and potential mortality from their cancer and its associated treatment. We aim to evaluate the possible impact that the currently available HPV vaccines will have on this group of cancers.

DATA SOURCES

Available peer-reviewed literature, practice guidelines, and statistics published by the Center for Disease Control and Prevention.

REVIEW METHODS

Contemporary peer-reviewed medical literature was selected based on its scientific validity and relevance to the impact HPV vaccination may have on the morbidity, mortality and cost resulting from HPV-related OPSCC in the United States.

CONCLUSIONS

The incidence of HPV-related OPSCC is increasing at a near epidemic rate in the United States. The cost of treatment of HPV-related OPSCC is high, and the disease and its therapy result in significant morbidity and potential mortality to individuals. Using a cut-off of $50,000/Quality-Adjusted Life Year, expansion of current HPV vaccine indications to include prevention of OPSCC in both men and women should be recommended.

Management of locally advanced HPV-related oropharyngeal squamous cell carcinoma: where are we?

HPV-related (HPV+) oropharyngeal cancer (OPC) has a better prognosis compared to HPV unrelated (HPV-) OPC. This review summarizes and discusses several of the controversies regarding the management of HPV+ OPC, including the mechanism of its treatment sensitivity, modern surgical techniques, chemotherapy regimens, and treatment de-intensification protocols. We also discuss and reconsider potential adverse prognostic factors such as tumor EGFR expression, tumor hypoxia, and patient smoking history, as well as the significance of retropharyngeal adenopathy. Finally, we discuss elective nodal treatment of uninvolved lymph node stations. While this review does not exhaust all controversies related to the management of HPV+ OPC, it aims to highlight some of the most clinically relevant ones.

Organ sparing and clinical outcome with step-and-shoot IMRT for head and neck cancer: a mono-institutional experience

PURPOSE

Intensity-modulated radiotherapy has been suggested as the technique of choice for locally advanced head and neck cancer patients. In the last decade, most radiotherapy departments have focused their efforts in programs to implement this technique. We report our experience for parotid gland and constrictor muscle sparing with intensity-modulated radiotherapy in head and neck cancer using a step-and-shoot technique.

METHODS

Thirty-four consecutive patients with squamous cell carcinoma of the nasopharynx, oropharynx and larynx treated between June 2008 and June 2011 were retrospectively evaluated. A simultaneous integrated boost was adopted to treat different volumes in 30 fractions over 6 weeks. Priority as organs at risk was given to the parotid glands as well as the constrictor muscle of the pharynx in 53 % (n = 18). Dysphagia and xerostomia were evaluated according to RTOG/EORTC scale at 6, 12 and 24 months. Outcomes were analysed using Kaplan-Meier curves.

RESULTS

The median follow-up was 43 months. The 5-year overall survival was 70 %, and local control was 94 %. Grade 2 dysphagia and xerostomia at 6, 12 and 24 months were as follows: 26 % (n = 9), 23 % (n = 8), 23 % (n = 8) and 21 % (n = 7), 12 % (n = 4), 12 % (n = 4), respectively. No grade 3 or 4 toxicity was found. Ordinal logistic regression analysis demonstrated that hyposalivation was the main predictive factor for late dysphagia.

CONCLUSION

Excellent loco-regional results were achieved with acceptable acute and late toxicities. The low rate of late dysphagia was related to parotid gland sparing; we did not observe a correlation between late dysphagia and dose to pharyngeal constrictors.

Definitive intensity-modulated radiotherapy compared with definitive conventional radiotherapy in cervical oesophageal squamous cell carcinoma

PURPOSE

The authors compared definitive intensity-modulated radiotherapy (IMRT) with definitive conventional radiotherapy (2D-RT) in cervical oesophageal squamous cell carcinoma (CESCC).

MATERIALS AND METHODS

A total of 101 patients with CESCC treated with definitive radiotherapy from January 2001 to April 2012 were analysed. 37 patients were irradiated using 2D-RT, whereas 64 cases were treated using IMRT.

RESULTS

The median follow-up time was 15.5 months for all the patients. For all patients, the overall 2-year local failure-free survival (LFFS), regional failure-free survival (RFFS), and overall survival (OS) rate was 67.4, 85.2 and 46.2%, respectively. The 2-year LFFS rate and the 2-year RFFS rate in the IMRT group were higher than the 2D-RT group, although no statistically significant difference was observed in LFFS and RFFS. No statistically significant difference was observed in overall survival (OS) between the groups. Compared with 2D-RT, the rate of grade 3 dysphagia after radiotherapy was lower (6.3 vs. 8.1%) and none had hypothyroidism requiring lifelong thyroxine replacement in the IMRT group. Matched-cases analysis did not show a statistical difference in terms of LFFS, RFFS and OS between the groups.

CONCLUSIONS

Although no statistically significant difference was observed in OS, LFFS and RFFS between the IMRT group and the 2D-RT group, the incidence of late toxicity declined using IMRT, thereby resulting in an improved therapeutic ratio for patients with CESCC.

[18F]-FDG PET-CT prediction of response to induction chemotherapy in head and neck squamous cell carcinoma: preliminary findings

OBJECTIVES

The present study assessed the predictive value of [18F]-FDG PET-CT (positron emission tomography with 18-fluoro-eoxyglucose radiotracer, coupled to computerized tomography) for response to induction chemotherapy in head and neck squamous cell carcinoma (HNSCC).

MATERIAL AND METHODS

[18F]-FDG PET-CT was systematically performed before treatment initiation and after the first cycle of chemotherapy. Results were compared with those of endoscopy and pathologic analysis of biopsy and surgical specimens.

RESULTS

This preliminary study included 21 previously untreated HNSCC patients. A decrease of more than 30% in SUVmax (maximum standard uptake value) during induction was predictive of tumor response to chemotherapy (P=0.04). PET-CT measurement of hypermetabolic volume based on a predetermined SUV threshold (SUV=2.5), on the other hand, proved non-predictive.

CONCLUSION

These preliminary findings are promising. A larger sample, however, would be required in order to determine a more precise SUVmax reduction cut-off threshold during induction. Other methods for determining metabolic volume thresholds will be investigated. If functional imaging proves contributive, it could enable early screening of non-responders, avoiding unnecessary intoxication.

Swallowing function in patients with vertical hemipharyngolaryngectomy for hypopharyngeal squamous cell carcinoma

BACKGROUND

The purpose of this study was to evaluate the long-term swallowing function in patients with vertical hemipharyngolaryngectomy (VHPL) for hypopharyngeal cancer.

METHODS

A retrospective review of 30 patients followed for more than 2 years with VHPL between 1998 and 2011 was performed.

RESULTS

Five patients (16.7%) experienced gastrostomy tube placement, 4 patients (13%) had pharyngoesophageal stricture, and 13 patients (45%) had aspiration pneumonia. There was a significant difference in the fraction of gastrostomy tube placement among type II VHPL (35.7%), type I VHPL (0%), and type III VHPL (0%; p = .014). Gastrostomy tube dependence was significantly associated with flap size (larger than 70 cm(2) ; p = .043) and aspiration pneumonia (p = .009). A significant positive correlation was found between current smokers and aspiration pneumonia (p = .030).

CONCLUSION

Type II VHPL, large flap reconstruction, and aspiration pneumonia had predictable values for gastrostomy tube dependence. Smoking status correlated with aspiration pneumonia. Better counseling and vigilance concerning swallowing difficulties may be possible.

Analysis of the prognostic factors for distant metastasis after induction chemotherapy followed by concurrent chemoradiotherapy for head and neck cancer

Purpose

The aim of this study is to identify the prognostic factors of distant metastasis (DM) after induction chemotherapy (IC) followed by concurrent chemoradiotherapy (CRT) for locoregionally advanced head and neck cancer (HNC).

Materials and Methods

A total of 321 patients with HNC who underwent IC followed by CRT treated between January 2005 and December 2010 were analyzed retrospectively. IC consisted of three courses of docetaxel (70 mg/m²) and cisplatin (75 mg/m²) every three weeks, followed by radiotherapy of 66-70 Gy/2 Gy per fraction/5 fractions per week concurrent with weekly cisplatin (40 mg/m²). Tumor/nodal stage, primary site, tumor differentiation, lower neck node involvement (level IV, VB, and supraclavicular regions), number of concurrent chemotherapy cycles, overall duration of radiotherapy, and response to IC were assessed as potential prognostic factors influencing DM and survival outcome.

Results

The five-year loco-regional recurrence and DM rates were 23.6% and 18.2%. N stage, overall duration of radiotherapy, lower neck node involvement, and response to IC were significant factors for DM. With a median follow-up period of 52 months (range, 4 to 83 months), the 5-year progression-free, DM-free, and overall survival rates were 41.2%, 50.7%, and 55.1%, respectively. Lower neck node involvement (p=0.008) and poor response to IC (p < 0.001) showed an association with significantly inferior DM-free survival.

Conclusion

Even with the addition of IC, the DM rate and survival outcome were poor when metastatic lower neck lymph nodes were present or when patients failed to respond after receiving IC.

Current treatment of head and neck squamous cell cancer

Head and neck cancer is a heterogenous group of cancers involving the upper aerodigestive tract. In this review article, the most common sites will be discussed, including the oral cavity, oropharynx, hypopharynx, and larynx. Etiology and epidemiology will be discussed followed by staging, treatment, and survival.

Transoral robotic reconstructive surgery

Transoral robotic surgery (TORS) has emerged as a technique that allows head and neck surgeons to safely resect large and complex oropharyngeal tumors without dividing the mandible or performing a lip-split incision. These resections provide a reconstructive challenge because the cylinder of the oropharynx remains closed and both physical access and visualization of oropharyngeal anatomy is severely restricted. Transoral robotic reconstruction (TORRS) of such defects allows the reconstructive surgeon to inset free flaps or perform adjacent tissue transfer while seeing what the resecting surgeon sees. Early experience with this technique has proved feasible and effective. Robotic reconstruction has many distinct advantages over conventional surgery, and offers patients a less morbid surgical course. In this review, we discuss the clinical applicability of transoral robotic surgery in head and neck reconstruction, highlighting the benefits and limitations of such an approach, and outlining the guidelines for its utilization.

Transoral Robotic Surgery in the HPV Era

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) has markedly increased over the last three decades mostly due to human papillomavirus (HPV)-related infections. Cancers resulting from HPV infection bear a better prognosis than those that are smoking-related. Because HPV-positive patients are often younger, with lower rates of co-morbid illness and longer overall life expectancies, long-term sequelae of therapy have become an important issue. Treatment of oropharyngeal cancers has typically involved the use of radiation and chemotherapy to avoid the morbidity of open surgery which included mandibulotomy and composite resection. Transoral robotic surgery (TORS) is an emerging treatment option for this disease, avoiding the morbidity of open approaches while providing excellent oncologic and functional outcomes. With overall survival rate at 2 years exceeding 80%, and local failure rate of less than 3%, patients receiving TORS report relatively good health-related quality of life (QOL) scores. The aim of the current review is to provide a summary of the current literature with regard to the oncologic and functional outcomes following treatment of OPSCC with TORS.

Future chemotherapy and radiotherapy options in head and neck cancer

Chemoradiation is a standard approach to advanced unresectable head and neck cancer, although the optimum combination regimen remains controversial. However, in the past few years, chemoradiation has been successfully extended from the treatment of unresectable disease to the postsurgical therapy of high-risk patients and its value as an organ preservation procedure is under evaluation. More recently, molecular-targeted therapies have emerged, which interfere with mechanisms of chemo- and radioresistance, and preliminary data are promising. Their use in the combined treatment of head and neck cancer will hopefully further improve the value of chemoradiation in the clinical setting.

Head and neck squamous cell carcinoma: optimizing the therapeutic index

The four recent noteworthy strategies aimed at improving therapeutic outcomes for the curative treatment of head and neck squamous cancers include the development of altered fractionation regimens, integration of chemotherapy, incorporation of intensity-modulated radiation therapy and introduction of targeted biologic therapy. Clinical investigations during the last 30 years have demonstrated the benefits of biologically sound altered fractionation and concurrent chemoradiation regimens in improving locoregional control and overall survival. These results have contributed to redefining the standard of care, with the caveat that proper patient selection for those who will benefit from potentially toxic combined modality treatment regimens remains controversial. These benefits have come at the expense of increased acute toxicity (i.e., mucositis) and sometimes at the expense of late toxicity (i.e., fibrosis and dysphagia). There are two additional developments that may help to further widen the therapeutic ratio. Intensity-modulated radiation therapy allows for the delivery of a highly conformal 3D radiation dose distribution around intended targets, thereby limiting the volumes of mucosa receiving a high dose per fraction and high total doses. The technical basis for intensity-modulated radiation therapy delivery reopens many fractionation questions that are still being addressed and challenges us to determine which of these is optimal for use with intensity-modulated radiation therapy alone or in combination with concurrent sensitizers. Finally, combined radiation therapy and biologic therapies directed at targets expressed predominately or exclusively by tumor cells have the promise to help increase tumor cell kill, while at least not substantially increasing normal tissue toxicity. These strategies are reviewed in a clinical context.

Induction Chemotherapy to Weekly Paclitaxel Concurrent with Curative Radiotherapy in Stage IV (M0) Unresectable Head and Neck Squamous Cell Carcinoma: a Dose Escalation Study

The purpose was to determine the maximum tolerated dose (MTD) of weekly paclitaxel with concurrent, daily irradiation in patients with unresectable head and neck squamous cell carcinoma previously submitted to induction chemotherapy. Patients with stage IV, and unresectable tumor and/or node/s were enrolled. Nine male patients were submitted to a course of paclitaxel 175 mg/m2 day 1 and cisplatin 75 mg/m2 day 2 given every 3 weeks for three courses. Curative radiotherapy (RT) started 3 weeks after the last cycle of chemotherapy with the goal of delivering a total dose of 66-70 Gy. During RT weekly paclitaxel was administered for 6 courses if feasible; paclitaxel was given according to a dose escalation schema in cohorts of three patients. Dose level A, 30 mg/m2; dose level B, 40 mg/m2; dose level C, 50 mg/m2. During weekly paclitaxel the major toxicity was mucositis that required a treatment break in two of three patients in dose level C; mucositis grade 4 required interruption of paclitaxel administration in all these patients. RT can be given in a continuous fashion with weekly paclitaxel after induction chemotherapy. The MTD of weekly paclitaxel was 40 mg/m2.

Prevention and management of treatment-induced pharyngo-oesophageal stricture

Pharyngo-oesophageal stricture (PES) is a serious complication that occurs in up to a third of patients treated with external beam radiotherapy or combined chemoradiotherapy for head and neck cancer. This entity is under-reported and as a result, our understanding of the pathophysiology and prevention of this complication is restricted. This Review presents the knowledge so far on radiation-related and non-radiation-related risk factors for PES, including tumour stage and subsite, patient age, and comorbidities. The interventions to decrease this toxicity are discussed, including early detection of PES, initiation of an oral diet, and protection of swallowing structures from high-dose radiation. We discuss various treatment options, including swallowing exercises and manoeuvres, endoscopic dilatations, and for advanced cases, oesophageal reconstruction. Study of the subset of patients who develop this toxicity and early recognition and intervention of this pathological change in future trials will help to optimise treatment of these patients.

Comparison of carboplatin-paclitaxel to docetaxel-cisplatin-5-flurouracil induction chemotherapy followed by concurrent chemoradiation for locally advanced head and neck cancer

OBJECTIVES

In head and neck squamous cell carcinoma (HNSCC), docetaxel, cisplatin and 5-fluorouracil (TPF) has become an accepted induction chemotherapy regimen. However, carboplatin-paclitaxel (CT) regimens have shown comparable outcomes. Here, we compared the outcomes of patients treated with either TPF or CT as induction chemotherapy followed by definitive chemoradiation.

PATIENTS AND METHODS

We performed a single-institution retrospective analysis of patients with Stage III-IV HNSCC. From a database of 803 patients, we identified 143 patients treated with TPF or CT induction chemotherapy between 1999 and 2012.

RESULTS

53 patients and 90 patients received TPF or CT induction chemotherapy, respectively. The median follow-up was 18.9 months. The 1 year locoregional control was 80.5% for CT compared to 55.5% for TPF (HR 0.32, P=.0002). The 1 year progression free survival was 73.2% for CT compared to 60.7% for TPF (HR 0.57; P=.02). On multivariable analysis, CT remained significant for LRC (HR 0.28; P=0.04). TPF induction chemotherapy was associated with worse renal toxicity as measured by peak creatinine increases during induction chemotherapy (P=0.001). TPF was also associated with a trend toward more chemotherapy dose reductions or changes in systemic agents during concurrent chemoradiation (43.4% for TPF vs. 27.8% for CT; P=0.06).

CONCLUSIONS

Compared to TPF induction chemotherapy, CT induction chemotherapy had at least similar if not better LRC and PFS in patients while having less renal toxicity. Thus, CT induction chemotherapy may benefit patients with locally advanced HNSCC by facilitating adequate chemoradiation regimens that enhanced disease control.

Incidence of pneumonia and risk factors among patients with head and neck cancer undergoing radiotherapy

BACKGROUND

This study investigated the incidence and patient- and treatment-related risk factors related to pneumonia acquired during radiotherapy (PNRT) in head and neck cancer (HNC) patients.

METHODS

Using the universal insurance claims data, 15,894 total HNC patients between 1998 and 2007 were included in this analysis. PNRT was defined as the occurrence of pneumonia within 90 days of the commencement of radiotherapy. Information also included some demographic characteristics, treatment-related factors, and comorbidities. Appropriate statistical tests were performed to assess the difference between patients with and those without PNRT. A logistic regression was used to estimate the odds ratio (OR) of PNRT among the variables examined.

RESULTS

In total, 772 patients (4.86%) were identified with PNRT as the case group, whereas 15,122 subjects of the same cancer without PNRT formed the control group. Of patients with PNRT, 632 (81.9%) were hospitalized with a mean length of stay of 25.9 days. Results from the multiple logistic regression showed that an older age and certain comorbidities were associated with an increased risk of PNRT. Patients with cancer of the tongue, buccal mucosa, oropharynx, and hypopharynx/larynx were at particularly higher risk (OR = 1.28, 1.28, 1.67, and 1.74, respectively). Compared to radiotherapy alone, concurrent chemoradiotherapy had no effect on the PNRT. Patients in the PNRT group had higher overall medical costs and length of stay.

CONCLUSION

The incidence of PNRT in HNC patients receiving radiotherapy was approximately 5%. Notably, an older age, certain comorbidities, and certain specific tumor sites were associated with an increased risk.

Standardizing treatment: a crisis in cancer care

The Institute of Medicine has emphasized the roles of multidisciplinary treatment planning, evidence-based clinical practice guidelines, and regionalization of healthcare in optimizing the quality of cancer care. We discuss these critical elements as they pertain to head and neck cancer care.

Aspiration in head and neck cancer patients: a single centre experience of clinical profile, bacterial isolates and antibiotic sensitivity pattern

Most patients with head and neck cancer have dysphagia and are at increased risk of having aspiration and subsequent pneumonia. It can cause prolonged hospitalization, treatment delay and/or interruption and mortality in cancer patients. The treatment of these infections often relies on empirical antibiotics based on local microbiology and antibiotic sensitivity patterns. The aim of present study is to analyse respiratory tract pathogens isolated by sputum culture in head and neck cancer patients undergoing treatment at a tertiary cancer centre in South India who presented with features of aspiration. The study is carried out to establish empirical antibiotic policy for head and neck cancer patients who present with features of aspiration. This was a retrospective study. The study included sputum samples sent for culture and sensitivity from January 2011 to December 2012. Analysis of microbiologic species isolated in sputum specimen and the antibiotic sensitivity pattern of the bacterial isolates was performed. A detailed study of case files of all patients was done to find out which is the most common site prone for producing aspiration. There were 47 (31.54 %) gram positive isolates and 102 (68.45 %) gram negative isolates. The most common bacterial isolates were Klebsiella pneumoniae (25.50 %), Pseudomonas aeruginosa (16.77 %) and Haemophilus influenzae (15.43 %). Levofloxacin was the most effective antibiotic with excellent activity against both gram positive and gram negative isolates. Most patients with aspiration had laryngeal cancer (34.89 %). Aspiration pneumonia was present in 14 (9.39 %) patients. Gram negative bacteria are common etiologic agents in head and neck cancer patients presenting with features of aspiration. Levofloxacin should be started as empirical antibiotic in these patients while awaiting sputum culture sensitivity report. As aspiration in head and neck cancer is an underreported event such institutional antibiotic sensitivity studies should be encouraged for prompt initiation of antibiotic that is most likely to be effective against etiologic pathogens.

Low-dose fractionated radiation with induction chemotherapy for locally advanced head and neck cancer: 5 year results of a prospective phase II trial

OBJECTIVE

This study aims to report the long-term outcomes of a novel treatment approach utilizing induction low-dose fractionated radiation therapy (LDFRT) and chemotherapy for locally advanced squamous cell carcinoma of head and neck (SCCHN).

METHODS

We prospectively enrolled 40 patients with locally advanced SCCHN (77 % stage IV) on a phase II clinical trial and treated with induction paclitaxel (225 mg/m2), carboplatin (AUC 6), and LDFRT (80 cGy BID on days 1 and 2) every 21 days for two cycles.

RESULTS

Forty patients enrolled; 39 were evaluable. The acute toxicity and response data have been previously reported; overall response rate (RR) was 82 %. After induction, definitive therapy was concurrent chemoradiation (CRT) in 51 %, XRT alone in 39 %, surgery in 5 %, and surgery and XRT in 5 %. The long-term outcomes are now reported with a median follow-up of 83 months. Locoregional control (LRC) is 80 % and distant control (DC) is 77 %. Five-year overall survival (OS), disease-specific survival, and progression-free survival (PFS) are 62 %, 66 %, and 58 %, respectively.

CONCLUSION

Induction chemotherapy with LDFRT has a high initial RR, comparable toxicity to two-drug induction regimens, but adds a third novel and effective agent, LDFRT. Five-year follow-up shows favorable outcomes compared to historical controls and excellent compliance with definitive therapy. This novel treatment approach is now planned for phase 3 trial evaluation.

Clinical evaluation of intensity-modulated radiotherapy for head and neck cancers

Radiotherapy and surgery are the principal curative modalities in treatment of head and neck cancer. Conventional two-dimensional and three-dimensional conformal radiotherapy result in significant side effects and altered quality of life. Intensity-modulated radiotherapy (IMRT) can spare the normal tissues, while delivering a curative dose to the tumour-bearing tissues. This article reviews the current role of IMRT in head and neck cancer from the point of view of normal tissue sparing, and also reviews the current published literature by individual head and neck cancer subsites. In addition, we briefly discuss the role of image guidance in head and neck IMRT, and future directions in this area.

Concurrent radiochemotherapy in locally-regionally advanced oropharyngeal squamous cell carcinoma: analysis of treatment results and prognostic factors

BACKGROUND

Concurrent radiochemotherapy is a recommended treatment option for patients with locally advanced squamous cell head and neck carcinomas with recent data showing the most significant absolute overall and event-free survival benefit achieved in patients with oropharyngeal tumours. The aim of this study was to analyse the results of three-dimensional conformal radiotherapy given with concomitant weekly cisplatin in patients with advanced oropharyngeal carcinoma and to identify prognostic factors influencing outcomes of this patients category.

METHODS

Sixty-five patients with stage III or IV squamous cell carcinoma of the oropharynx who underwent concurrent radiochemotherapy between January 2005 and December 2010 were retrospectively analyzed. All patients received radiotherapy to 70 Gy/35 fractions/2 Gy per fraction/5 fractions per week. Concurrent chemotherapy consisted of weekly cisplatin (30 mg/m(2)) started at the first day of radiotherapy.

RESULTS

Median age was 57 years (range, 36 to 69 years) and 59 (90.8%) patients were male. Complete composite response was achieved in 47 patients (72.3%). Local and/or regional recurrence was the most frequent treatment failure present in 19 out of 25 patients (76.0%). At a median follow-up of 14 months (range, 5 to 72 months), 2-year local relapse-free, regional relapse-free, locoregional relapse-free, disease-free, and overall survival rates were 48.8%, 57.8%, 41.7%, 33.2% and 49.7%, respectively.On multivariate analysis the only significant factor for inferior regional relapse-free survival was the advanced N stage (p = 0.048). Higher overall stage was independent prognostic factor for poorer local relapse-free survival, locoregional relapse-free survival and disease-free survival (p = 0.022, p = 0.003 and p = 0.003, respectively). Pre-treatment haemoglobin concentration was an independent prognostic factor for local relapse-free survival, regional relapse-free survival, locoregional relapse-free survival, disease-free survival, and overall survival (p = 0.002, p = 0.021, p = 0.001, p = 0.002 and p = 0.002, respectively).

CONCLUSIONS

Poor treatments results of this study suggested that introduction of intensity-modulated radiotherapy, use of induction chemotherapy followed by concurrent radiochemotherapy, accelerated radiotherapy regimens, and molecular targeted therapies could positively influence treatment outcomes. The incorporation of reversal of anaemia should be also expected to provide further improvement in locoregional control and survival in patients with advanced squamous cell carcinoma of the oropharynx.

Current issues in combined modality therapy in locally advanced head and neck cancer

Curative treatment for patients with locally advanced squamous cell carcinomas of the head and neck (SCCHN) is complex and multidisciplinary. Our understanding of the optimal management of this disease has improved over the years, incorporating refined surgical approaches, better radiotherapy delivery methods, and greater use of systemic therapies. Investigation into shifting epidemiology patterns has uncovered two biologically and clinically distinct diseases: the smoking-related entity and the increasingly common malignancy associated with human papilloma virus (HPV). Prognosis favors the latter, driving newer investigations into dose de-intensification to limit toxicities in patients with HPV-driven disease, and alternatively intensifying treatment to improve tumor control in those with a significant smoking history. In this review, I describe the most recent progress in the multi-modal integration of radiotherapy and chemoradiotherapy, and the role of targeted agents and personalized therapy, and conclude with a discussion of the relevance of these innovations with respect to HPV tumor status.

Cervical osteomyelitis after placement of a self-expanding plastic stent for palliation of dysphagia associated with chemoradiation-induced esophageal strictures

BACKGROUND

Esophageal strictures are a common sequela of chemoradiation and/or surgery to the head and neck cancers and can lead to stenosis and significant dysphagia. Endoscopic dilation endoscopic and placement of self-expanding stents are often to used relieve dysphagia symptoms. However, these stents are not without risks and complications.

METHODS

We present a case of a 58-year-old man who had the rare complication of cervical osteomyelitis as a result of plastic esophageal stent placement for palliation of chemoradiation-induced strictures.

RESULTS

The patient was successfully managed with immobilization of the cervical spine in a halo vest and appropriate antibiotics.

CONCLUSION

To the best of our knowledge, this is the first reported case of cervical spine osteomyelitis after self-expanding plastic stent (SEPS) placement for esophageal stricture. It was successfully treated with immobilization and antibiotic therapy. The treating physician should be aware of this rare complication to make an early diagnosis. Literature on esophageal stent-induced cervical osteomyelitis is reviewed.

Long-term functional and oncologic results of transoral robotic surgery for oropharyngeal squamous cell carcinoma

OBJECTIVE

To examine the long-term functional and oncologic results in patients who underwent transoral robotic surgery (TORS) as primary therapy or as part of combined therapy for oropharyngeal squamous cell carcinoma arising in the tonsil or base of tongue.

PATIENTS AND METHODS

We reviewed a prospective TORS database of patients with squamous cell carcinoma arising in the tonsil or base of tongue treated between March 2007 and February 2009 to determine oncologic outcomes at 24 months or more of follow-up. The presenting tumor stage, histopathologic factors, surgical margins, and adjuvant treatment extent were evaluated. Functional outcomes included gastrostomy tube dependence and tracheostomy dependence. Oncologic outcomes included local, regional, and distant control and disease-specific and recurrence-free survival.

RESULTS

A total of 66 TORS patients were followed up for a minimum of 2 years. Most (97.0%; 64 of 66) were able to eat orally within 3 weeks after surgery before starting adjuvant therapy. Long-term gastrostomy tube use was required in 3 of the 66 (4.5%) and long-term tracheotomy in 1 (1.5%). Three-year estimated local control and regional control were 97.0% and 94.0%, respectively. Two-year disease-specific survival and recurrence-free survival were 95.1% and 92.4%, respectively.

CONCLUSION

With appropriate adjuvant therapy, TORS achieves excellent functional results for patients with oropharyngeal squamous cell carcinoma. Oncologic outcomes are equivalent or superior to results of other surgical and nonsurgical treatments.