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Oebel L, Mayer A, Kaufmann J, Wollschläger D, Hagemann J, Krüger M, Schmidberger H. Is bilateral radiotherapy necessary for patients with unilateral squamous cell carcinoma of unknown primary of the head and neck region? Clin Transl Radiat Oncol 2024; 45:100713. [PMID: 38192301 PMCID: PMC10772399 DOI: 10.1016/j.ctro.2023.100713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/24/2023] [Accepted: 12/06/2023] [Indexed: 01/10/2024] Open
Abstract
Background and Purpose Squamous cell carcinoma of unknown primary (SCC-CUP) of the head and neck region remains a clinical challenge, with uncertainty surrounding the necessity of contralateral irradiation of cervical lymphatic drainage in cases of unilateral involvement. Materials and Methods A retrospective study was conducted at the Department of Radiation Oncology, University Medical Center Mainz, on a cohort of 50 patients with unilateral SCC-CUP of the head and neck region treated between 2005 and 2019. 30 patients received bilateral and 20 received unilateral cervical radiotherapy. The majority (n = 38, 76 %) were treated with modern IMRT/ VMAT (Intensity-modulated Radiation Therapy/ Volumetric Modulated Arc Therapy) techniques. Results After a median follow-up of 64.5 months, locoregional recurrences occurred in 26 % of cases (n = 13/50), all of which were ipsilateral and predominantly within the volume of the previous irradiated CTV (clinical target volume) (85 %, n = 11/13). No patient treated unilaterally developed a contralateral recurrence in the neck. After 3 years, we observed 7 locoregional recurrences in the bilateral irradiated group (n = 7/30, 23 %), and 5 locoregional recurrences in the unilateral irradiated group (n = 5/20, 25 %). After 3 years, 12 patients had died in the bilateral irradiated group (n = 12/30, 40 %), and 7 in the unilateral irradiated group (n = 7/20, 35 %). 7 Patients showed distant metastases after 3 years in the bilateral irradiated group (n = 7/30, 23 %), and 2 in the unilateral irradiated group (n = 2/20, 10 %). Locoregional control (LRC) at 5 years was 66.2 % in the bilaterally irradiated group, and 70.0 % in the unilaterally irradiated group. Overall survival (OS) was 52.6 % (bilateral) and 64.0 % (unilateral). Distant metastasis-free survival (DMFS) was 74.7 % (bilateral) and 84.4 % (unilateral). No significant differences were observed in OS (p = 0.37), LRC (p = 0.91), and DMFS (p = 0.91) between the groups.Acute toxicity ≥ °2 accordingly CTCAE (Common Terminology Criteria of Adverse Events) was high with 97% while late toxicity ≥ °2 was moderate with 31%. There was no statistically significant difference between the group of unilateral and bilateral irradiated patients. Conclusion These data suggest that contralateral cervical irradiation may be of limited benefit in patients with SCC-CUP, as recurrences occured ipsilaterally, and predominantly within the area of prior irradiation. Unilateral irradiation seems to be adequate for carefully selected patients.
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Affiliation(s)
- Laura Oebel
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Arnulf Mayer
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Justus Kaufmann
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Daniel Wollschläger
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Jan Hagemann
- Department of Head and Neck Surgery, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Maximilian Krüger
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Heinz Schmidberger
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
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Chen AM. Management of unknown primary head and neck cancer with radiation therapy in the era of human papillomavirus (HPV): No longer cutting down the tree to get an apple. Radiother Oncol 2023; 189:109952. [PMID: 37844736 DOI: 10.1016/j.radonc.2023.109952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE Given the central role that radiation has in the management of head and neck squamous cell carcinoma of unknown primary origin, it is imperative to review how treatment paradigms have been refined and continue to evolve in the modern era. METHODS AND MATERIALS This study was designed based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement. A literature search of peer-reviewed publications was undertaken to identify works pertaining to the use of radiation for squamous cell carcinoma of unknown primary origin presenting as cervical lymph node metastases. Articles published from January 2002 to January 2023 with full text available on PubMed and restricted to the English language and human subjects were included. The full bibliographies of identified articles were reviewed and irrelevant studies were removed. RESULTS While such breakthroughs as intensity-modulated radiotherapy, positron emission tomography, biomarker testing with immune-histochemistry, and minimally invasive surgical techniques such as transoral robotic surgery have fundamentally changed the approach to this disease in recent decades, controversies still exist with respect to the manner in which radiation is delivered. Although the incidence of head and neck unknown primary cancer is relatively low, questions regarding the necessity of comprehensive radiation using the age-old standard method of targeting the bilateral necks and entire pharyngeal axis to encompass all putative sites of mucosal disease persist. CONCLUSIONS Prospective evidence is lacking, and the available studies have been complicated by such factors as the relatively limited sample sizes, as well as the variability in work-up, treatment, inclusion criteria, and follow-up. Regardless, advances in science and technology have ushered in more precise approaches with a high degree of customization, particularly given the increased proportion of patients presenting with human papillomavirus-related disease.
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Affiliation(s)
- Allen M Chen
- Department of Radiation Oncology, University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA 92868, USA.
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3
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Pala M, Novakova P, Pechacova Z, Vesela L, Vrana A, Sukova J, Holeckova P, Drbohlavova T, Podlesak T, Petruzelka L. Long-term results of radio(chemo)therapy in metastatic carcinoma to cervical lymph nodes from an unknown primary. Adult Comorbidity Evaluation 27 score as a predictor of survival. Strahlenther Onkol 2023; 199:149-159. [PMID: 35943554 DOI: 10.1007/s00066-022-01983-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 07/10/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE To evaluate the effectiveness and toxicity of curative (chemo)radiotherapy in patients with metastatic carcinoma to cervical lymph nodes from an unknown primary. METHODS Retrospective study of 90 consecutive patients, treated with curative radiotherapy from 2003 to 2018 (median age 59 years; current/former smokers 76%) was conducted. The distribution of nodal staging was as follows: N1: 12%, N2a: 21%, N2b: 43%, N2c: 10%, N3: 13%. In 62% of patients, neck dissection was performed before radiotherapy. Concomitant chemotherapy was given to 64% of patients. RESULTS The median follow-up of surviving patients was 86 months. The median total radiotherapy dose achieved was 70 Gy. The 5‑ and 10-year locoregional control were 84% in both cases, while 5‑ and 10-year distant control were 90% and 89%, respectively. A primary tumor in the head and neck area was detected in only 2 patients. No patient had an initial failure in the pharyngeal axis or contralateral cervical nodes. The 5‑ and 10-year overall survival were 55% and 42%, respectively. Severe early toxicity occurred in 71%; severe late toxicity in 33% of patients. Multivariate analysis demonstrated N‑status (hazard ratio [HR] 2.424; 95% confidence interval [CI] 1.121-5.241; p = 0.024) and comorbidity scores assessed by ACE-27 (Adult Comorbidity Evaluation; HR 3.058; 95% CI 1.489-6.281; p = 0.002) as two independent prognostic factors for overall survival. CONCLUSION The results of our work study demonstrate the high effectiveness of curative (chemo)radiotherapy on the pharyngeal axis and bilateral cervical nodes with long-term locoregional and distant control in 3/4 of the treated patients. N‑status and comorbidity scores were shown as strong prognostic factors influencing overall survival.
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Affiliation(s)
- Miloslav Pala
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic.
| | - Pavla Novakova
- Radiophysics Department, Bulovka University Hospital, Prague, Czech Republic
| | - Zdena Pechacova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Lucie Vesela
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Antonin Vrana
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Jarmila Sukova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Petra Holeckova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Tereza Drbohlavova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Tomas Podlesak
- Department of Otorhinolaryngology, Bulovka University Hospital, Prague, Czech Republic
| | - Lubos Petruzelka
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
- Department of Oncology of the 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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Brenet E, Philouze P, Schiffler C, Pommier P, Crozes C, Benzerdjeb N, Monchet E, Boulagnon-Rombi C, Ton Van J, Podeur F, Servagi-Vernat S, Liem X, Merol JC, Ceruse P, Serre AA, Chabaud S, Julieron M, Deneuve S. Influence of postoperative radiotherapy target volumes in unilateral head and neck carcinoma of unknown primary: A multicentric study using propensity score. Radiother Oncol 2021; 160:1-8. [PMID: 33845043 DOI: 10.1016/j.radonc.2021.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/22/2021] [Accepted: 04/01/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the impact of two radiation modalities on loco-regional control, survival and tumour emergence, after node dissection for an unilateral head and neck carcinoma of unknown primary (HNCUP). MATERIALS AND METHODS This is a multicentric retrospective study of 138 patients with unilateral HNCUP treated between 2002 and 2017. The absence of primary tumour was assessed by a systematic panendoscopy and positron emission tomography. Neck dissection was initially performed for all patients. Radiation Therapy was delivered on ipsilateral lymph node areas in 62 cases (44%: UL-RT group) and on bilateral lymph node areas and the entire pharyngeal mucosa in 77 cases (56%: COMP-RT group). Impact of radiation modalities on locoregional control and overall survival was assessed using propensity score matching method in order to balance baseline characteristics between the two groups. RESULTS The population included 80.4% men, 80.4% smokers, 32.6% P16 positive tumours and 71.0% extracapsular extension. After a median follow-up of 5 years, the locoregional control rate was 80.3% in the UL-RT group and 75.3% in the COMP-RT group (p = 0.688). The corresponding rate of contralateral lymph node recurrence was 0% versus 2.6% (p = 0.503) and the rate of tumour emergence was 11.5% versus 9.1% (p = 0.778). No significant difference was observed between the UL-RT and the COMP-RT groups for overall survival (p = 0.9516), specific survival (p = 0.4837) or tumour emergence (p = 0.9034). CONCLUSION UL-RT seems to provide similar outcomes as COMP-RT in unilateral HNCUP post-operative management.
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Affiliation(s)
- Esteban Brenet
- Head and Neck Surgery Department, Centre Hospitalo Universitaire Reims, France
| | - Pierre Philouze
- Head and Neck Surgery Department, Centre Hospitalo Universitaire Lyon Sud, France
| | | | - Pascal Pommier
- Radiotherapy Department, Centre Léon Bérard, Lyon, France
| | - Carole Crozes
- Pathological Anatomy Department, Centre Léon Bérard, Lyon, France
| | - Nazim Benzerdjeb
- Pathological Anatomy Department, Centre Hospitalo Universitaire Lyon Sud, France
| | - Elodie Monchet
- Head and Neck Surgery Department, Centre Oscar Lambret, Lille, France
| | | | - Jean Ton Van
- Head and Neck Department, Centre Oscar Lambret, Lille, France
| | - Fabien Podeur
- Oncologic Surgery Department, Centre Léon Bérard, Lyon, France
| | | | - Xavier Liem
- Radiotherapy Department, Centre Oscar Lambret, Lille, France
| | - Jean-Claude Merol
- Head and Neck Department, Centre hospilato Universitaire Reims, France
| | - Philippe Ceruse
- Head and Neck Surgery Department, Centre Hospitalo Universitaire Lyon Sud, France
| | | | - Sylvie Chabaud
- Biostatistics Department, Centre Léon Bérard, Lyon, France
| | - Morbize Julieron
- Head and Neck Surgery Department, Centre Oscar Lambret, Lille, France
| | - Sophie Deneuve
- Oncologic Surgery Department, Centre Léon Bérard, Lyon, France.
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Moy J, Li R. Approach to the Patient with Unknown Primary Squamous Cell Carcinoma of the Head and Neck. Curr Treat Options Oncol 2020; 21:93. [DOI: 10.1007/s11864-020-00791-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/18/2022]
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Maghami E, Ismaila N, Alvarez A, Chernock R, Duvvuri U, Geiger J, Gross N, Haughey B, Paul D, Rodriguez C, Sher D, Stambuk HE, Waldron J, Witek M, Caudell J. Diagnosis and Management of Squamous Cell Carcinoma of Unknown Primary in the Head and Neck: ASCO Guideline. J Clin Oncol 2020; 38:2570-2596. [PMID: 32324430 DOI: 10.1200/jco.20.00275] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To provide evidence-based recommendations to practicing physicians and other health care providers on the diagnosis and management of squamous cell carcinoma of unknown primary in the head and neck (SCCUP). METHODS The American Society of Clinical Oncology convened an Expert Panel of medical oncology, surgery, radiation oncology, radiology, pathology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 2008 through 2019. Outcomes of interest included survival, local and regional disease control, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS The literature search identified 100 relevant studies to inform the evidence base for this guideline. Four main clinical questions were addressed, which included subquestions on preoperative evaluations, surgical diagnostic and therapeutic procedures, appropriate pathology techniques, and adjuvant therapy. RECOMMENDATIONS Evidence-based recommendations were developed to address preoperative evaluation for patients with a neck mass, surgical diagnostic and therapeutic procedures, appropriate treatment options in unilateral versus bilateral SCCUP.Additional information is available at www.asco.org/head-neck-cancer-guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce Haughey
- Advent Health Medical Group, Otolaryngology, Head and Neck Surgery, Celebration, FL, and University of South Florida, Tampa, FL
| | - Doru Paul
- Weill Cornell Medical College, New York, NY
| | | | - David Sher
- University of Texas Southwestern, Dallas, TX
| | | | - John Waldron
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Matt Witek
- University of Wisconsin School of Medicine and Public Health, Madison, WI
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7
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Radiotherapeutic management of cervical lymph node metastases from an unknown primary site - experiences from a large cohort treated with modern radiation techniques. Radiat Oncol 2020; 15:80. [PMID: 32293497 PMCID: PMC7158130 DOI: 10.1186/s13014-020-01529-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/02/2020] [Indexed: 11/10/2022] Open
Abstract
Purpose To analyze management and outcomes following (chemo)radiation therapy in patients with cervical lymph node metastases from an unknown primary site (CCUP) in a large single-center cohort. Methods Between 2008 and 2019, 58 patients with CCUP were treated with (chemo)radiation therapy at the University of Freiburg Medical Center and were included in this analysis. Overall survival (OS), locoregional progression-free survival (PFS) and distant metastasis-free survival (DMFS) were calculated using the Kaplan-Meier method. The use of diagnostic procedures and their impact on oncological outcomes was analyzed by Cox regression, and treatment-related toxicities were quantified. Results Median follow-up was 29.9 months (range 4.6–121.9). Twenty-one patients (36.2%) received definitive RT, 35 (60.3%) underwent adjuvant RT, and 2 (3.4%) were treated for oligometastatic disease. Concurrent chemotherapy was prescribed in 40 patients (69.0%). 89.6% of patients completed the prescribed RT, and 65.0% completed the prescribed simultaneous chemotherapy. Locoregional recurrence was observed in 7 patients (12.1%) and distant metastases in 13 cases (22.4%). OS was 81,1, 64.9% and 56,6% after 1, 3 and 5 years, respectively. Univariate analysis of age, gender, extracapsular spread, tumor grading, neck dissection, diagnostic utilization of 18F-fluorodeoxyglucose positron-emission tomography and concomitant chemotherapy showed no effect on OS (p > 0.05 for all), while smoking was significantly associated with decreased survival (p < 0.05). There was a trend towards impaired OS for patients with advanced nodal status (pN3) (p = 0.07). Three patients (5.2%) experienced grade 3 radiation dermatitis, and 12 (22.4%) developed grade 3 and 1 (1.7%) grade 4 mucositis. Conclusions RT of the panpharynx and cervical lymph nodes with concurrent chemotherapy in case of risk factors demonstrated good locoregional control, but the metachronous occurrence of distant metastases limited survival and must be further addressed.
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8
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Platek A, Mix M, Chowdhry V, Farrugia M, Lacombe MA, Bogart JA, Degraaf L, Iovoli A, Arshad H, Wooten K, Gupta V, Hicks WL, Platek ME, Hahn SS, Singh AK. Evaluation of radiation treatment volumes for unknown primaries of the head and neck in the era of FDG PET. PLoS One 2020; 15:e0231042. [PMID: 32275670 PMCID: PMC7147765 DOI: 10.1371/journal.pone.0231042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/13/2020] [Indexed: 11/20/2022] Open
Abstract
Objectives Positron-emission tomography (PET) has improved identification of the primary tumor as well as occult nodal burden in cancer of the head and neck. Nevertheless, there are still patients where the primary tumor cannot be located. In these situations, the standard of care is comprehensive head and neck radiation therapy however it is unclear whether this is necessary. This study examines the effects of radiation treatment volume on outcomes among using data from two cancer centers in unknown primary carcinoma of the head and neck. Methods Patients received unilateral (n = 34), or bilateral radiation (n = 28). Patient factors such as age, gender, smoking history, and patterns of failure were compared using Mann Whitney U and Chi Square. Overall survival (OS) and disease free survival (DFS) trends were estimated using Kaplan-Meier survival curves. Effect of treatment volume on survival was examined using multivariate cox proportional hazard regression model. Results No significant differences were observed in the frequency of local (p = 0.32), regional (p = 0.50), or distant (p = 0.76) failures between unilateral and bilateral radiation therapy. By Kaplan-Meier estimates, OS (3-year OS bilateral = 71.67%, unilateral = 77.90%, p = 0.50) and DFS (3-year DFS bilateral = 77.92%, unilateral = 69.43%, p = 0.63) were similar between the two treatment approaches. Lastly, multivariate analysis did not demonstrate any significant differences in outcome by treatment volumes (OS: HR = 0.74, 95% CI: 0.31, 1.81, p = 0.51; DFS: HR: 0.68, 95% CI: 0.24, 1.93, p = 0.47). Conclusions Unilateral radiation therapy compared with bilateral produced similar survival.
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Affiliation(s)
- Alexis Platek
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, United States of America
| | - Michael Mix
- Department of Radiation Oncology, Upstate Medical University, Syracuse, NY, United States of America
| | - Varun Chowdhry
- Roswell Park Comprehensive Cancer Center, Department of Radiation Medicine, Buffalo, NY, United States of America
| | - Mark Farrugia
- Roswell Park Comprehensive Cancer Center, Department of Radiation Medicine, Buffalo, NY, United States of America
| | - Michael A Lacombe
- Department of Radiation Oncology, Upstate Medical University, Syracuse, NY, United States of America
| | - Jeffrey A Bogart
- Department of Radiation Oncology, Upstate Medical University, Syracuse, NY, United States of America
| | - Luke Degraaf
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, United States of America
| | - Austin Iovoli
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, United States of America
| | - Hassan Arshad
- Roswell Park Comprehensive Cancer Center, Department of Head and Neck/Plastic and Reconstructive Surgery, Buffalo, NY, United States of America
| | - Kimberly Wooten
- Roswell Park Comprehensive Cancer Center, Department of Head and Neck/Plastic and Reconstructive Surgery, Buffalo, NY, United States of America
| | - Vishal Gupta
- Roswell Park Comprehensive Cancer Center, Department of Head and Neck/Plastic and Reconstructive Surgery, Buffalo, NY, United States of America
| | - Wesley L Hicks
- Roswell Park Comprehensive Cancer Center, Department of Head and Neck/Plastic and Reconstructive Surgery, Buffalo, NY, United States of America
| | - Mary E Platek
- Roswell Park Comprehensive Cancer Center, Department of Biostatistics, Buffalo, New York, United States of America.,Department of Dietetics, D'Youville College, Buffalo, New York, United States of America
| | - Seung S Hahn
- Department of Radiation Oncology, Upstate Medical University, Syracuse, NY, United States of America
| | - Anurag K Singh
- Roswell Park Comprehensive Cancer Center, Department of Radiation Medicine, Buffalo, NY, United States of America
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9
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Straetmans JMJAA, Stuut M, Wagemakers S, Hoebers F, Kaanders JHAM, Speel EJM, Melchers WJG, Slootweg P, Kremer B, Lacko M, Takes RP. Tumor control of cervical lymph node metastases of unknown primary origin: the impact of the radiotherapy target volume. Eur Arch Otorhinolaryngol 2020; 277:1753-1761. [PMID: 32100130 DOI: 10.1007/s00405-020-05867-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 02/12/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Debate on the extent of treatment of neck metastasis of cancer of unknown primary tumors (CUPs) is still ongoing. In two Dutch tertiary referral centers, the post-surgical radiation target volume changed from the bilateral neck including the pharyngeal axis to the unilateral neck only, in the course of the last decade. This study aims to investigate the outcome of patients with CUP before and after de-escalation of post-surgical radiotherapy. METHODS Data of two Dutch tertiary referral centers were merged. Disease-free survival (DFS), overall survival (OS), and regional control rate (RCR) of 80 patients diagnosed with CUP (squamous cell and undifferentiated carcinomas) between 1990 and 2009 were retrospectively analyzed. RESULTS Thirty patients received bilateral neck and pharyngeal axis radiotherapy and 42 patients ipsilateral radiotherapy only. In another eight patients, the postsurgical radiation target volume was expanded to the contralateral neck or to the pharyngeal axis, due to suspicious lesions on imaging. The 5-year DFS, OS and RCR were 60%, 51.2%, and 80%, respectively, in the total patient population. RCR did not differ in patients treated with ipsilateral as compared to bilateral radiotherapy nor did 5-year OS and DFS. No tumors occurred in the pharyngeal axis. CONCLUSION In this study, omitting elective treatment of the contralateral neck and pharyngeal axis did not lead to a decrease in locoregional control or survival rates when treating patients with CUP.
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Affiliation(s)
- Jos M J A A Straetmans
- Department of Otorhinolaryngology and Head and Neck Surgery, Research Institute GROW, Maastricht University Medical Center, P.O. BOX 5800, 6202 AZ, Maastricht, The Netherlands. .,Department of Otorhinolaryngology and Head and Neck Surgery, Zuyderland Medical Center, H. Dunantstraat 5, 6419 PC, Heerlen, The Netherlands.
| | - Marijn Stuut
- Department of Otorhinolaryngology and Head and Neck Surgery, Research Institute GROW, Maastricht University Medical Center, P.O. BOX 5800, 6202 AZ, Maastricht, The Netherlands
| | - Sanne Wagemakers
- Department of Otorhinolaryngology and Head and Neck Surgery, Research Institute GROW, Maastricht University Medical Center, P.O. BOX 5800, 6202 AZ, Maastricht, The Netherlands
| | - Frank Hoebers
- Department of Radiation Oncology (MAASTRO), Research Institute GROW, Maastricht University, Maastricht, The Netherlands
| | - Johannes H A M Kaanders
- Department of Radiation Oncology, Radboud University Medical Center Nijmegen, Geert Grooteplein-Zuid 22, 6525 GA, Nijmegen, The Netherlands
| | - Ernst Jan M Speel
- Department of Pathology, Research Institute GROW, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Center Nijmegen, Geert Grooteplein-Zuid 22, 6525 GA, Nijmegen, The Netherlands
| | - Piet Slootweg
- Department of Pathology, Radboud University Medical Center Nijmegen, Geert Grooteplein-Zuid 22, 6525 GA, Nijmegen, The Netherlands
| | - Bernd Kremer
- Department of Otorhinolaryngology and Head and Neck Surgery, Research Institute GROW, Maastricht University Medical Center, P.O. BOX 5800, 6202 AZ, Maastricht, The Netherlands
| | - Martin Lacko
- Department of Otorhinolaryngology and Head and Neck Surgery, Research Institute GROW, Maastricht University Medical Center, P.O. BOX 5800, 6202 AZ, Maastricht, The Netherlands
| | - Robert P Takes
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center Nijmegen, Geert Grooteplein-Zuid 22, 6525 GA, Nijmegen, The Netherlands
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10
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Dou S, Li R, Zhang L, Wang Z, Xie L, Zhang C, Zhu G. Long-term results of elective mucosal irradiation for head and neck cancer of unknown primary in Chinese population: The EMICUP study. Cancer Med 2020; 9:1712-1720. [PMID: 31953927 PMCID: PMC7050068 DOI: 10.1002/cam4.2856] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 12/14/2019] [Accepted: 01/05/2020] [Indexed: 12/24/2022] Open
Abstract
Objective Controversy still exists regarding the volume of radiation for head and neck cancer of unknown primary (HNCUP). Theoretically, elective mucosal irradiation (EMI) should achieve a balance between survival and toxicity. This prospective study was conducted to evaluate the long‐term benefit of EMI in Chinese HNCUP patients. Methods A phase II, single‐arm trial was performed at two centers in China. HNCUP patients with pathologically confirmed metastatic squamous cell carcinoma or poorly differentiated carcinoma were enrolled. Patients with metastatic lymph nodes limited to level IV and/or the supraclavicular fossa were excluded. The EMI approach was specifically customized to Chinese patients by differentiating HNCUP as putative nasopharyngeal carcinoma (NPC) or non‐putative NPC. The primary endpoint was 3‐year mucosal recurrence‐free survival (MRFS). Results A total of 48 patients were enrolled between 02/02/2010 and 08/01/2018; 46 patients were analyzed, including 24 putative NPC and 22 non‐putative NPC patients. No primary recurrence was observed during a median follow‐up period of 70 months, and only 1 patient experienced out of field recurrence in the contralateral neck. The 3‐year MRFS was 90.6% (95%CI: 76.4%‐96.4%). The 5‐year MRFS, regional‐recurrence free survival (RRFS) and overall survival (OS) were 90.6% (95%CI: 76.4%‐96.4%), 86.0% (95%CI: 71.1%‐93.7%), and 90.6% (95%CI: 76.4%‐96.4%), respectively. No grade 4 acute or late toxicities occurred, and the most frequent grade 3 acute toxicity was oral mucositis (45.7%). Conclusion To the best of our knowledge, this is the first prospective study to evaluate the long‐term outcomes of EMI in Chinese HNCUP patients. Excellent MRFS and OS rates were observed. Further randomized studies are warranted.
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Affiliation(s)
- Shengjin Dou
- Radiotherapy Division, Department of Oral and Maxillofacial-Head Neck Oncology, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,National Clinical Research Center for Oral Diseases, Shanghai, China.,Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai, China
| | - Rongrong Li
- Radiotherapy Division, Department of Oral and Maxillofacial-Head Neck Oncology, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,National Clinical Research Center for Oral Diseases, Shanghai, China.,Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai, China
| | - Lin Zhang
- Radiotherapy Division, Department of Oral and Maxillofacial-Head Neck Oncology, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,National Clinical Research Center for Oral Diseases, Shanghai, China.,Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai, China
| | - Zhuoying Wang
- Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Li Xie
- Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chenping Zhang
- National Clinical Research Center for Oral Diseases, Shanghai, China.,Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai, China.,Department of Oral and Maxillofacial-Head Neck Oncology, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guopei Zhu
- Radiotherapy Division, Department of Oral and Maxillofacial-Head Neck Oncology, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,National Clinical Research Center for Oral Diseases, Shanghai, China.,Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai, China
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11
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Podeur F, Pommier P, Crozes C, Monchet E, Ton Van J, Roux P, Poupart M, Zrounba P, Julieron M, Deneuve S. Management of unilateral head and neck carcinoma of unknown primary: Retrospective analysis of the impact of postoperative radiotherapy target volumes. Head Neck 2019; 42:302-311. [DOI: 10.1002/hed.26007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/20/2019] [Accepted: 10/18/2019] [Indexed: 01/27/2023] Open
Affiliation(s)
- Fabien Podeur
- Oncologic Surgery DepartmentCentre Léon Bérard Lyon France
| | | | - Carole Crozes
- Pathological Anatomy DepartmentCentre Léon Bérard Lyon France
| | - Elodie Monchet
- Head and Neck Surgery DepartmentCentre Oscar Lambret Lille France
| | - Jean Ton Van
- Head and Neck Surgery DepartmentCentre Oscar Lambret Lille France
| | | | - Marc Poupart
- Oncologic Surgery DepartmentCentre Léon Bérard Lyon France
| | | | - Morbize Julieron
- Head and Neck Surgery DepartmentCentre Oscar Lambret Lille France
| | - Sophie Deneuve
- Oncologic Surgery DepartmentCentre Léon Bérard Lyon France
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12
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Rassy E, Nicolai P, Pavlidis N. Comprehensive management of HPV‐related squamous cell carcinoma of the head and neck of unknown primary. Head Neck 2019; 41:3700-3711. [DOI: 10.1002/hed.25858] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 04/09/2019] [Accepted: 06/12/2019] [Indexed: 01/19/2023] Open
Affiliation(s)
- Elie Rassy
- Department of Medical OncologyInstitut Gustave Roussy Villejuif France
- Department of Medical OncologyHotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University Beirut Lebanon
| | - Piero Nicolai
- Department of OtorhinolaryngologyHead and Neck Surgery, University of Brescia Brescia Italy
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13
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Unknown primary of the head and neck: a new entry in the TNM staging system with old dilemmas for everyday practice. Curr Opin Otolaryngol Head Neck Surg 2019; 27:73-79. [DOI: 10.1097/moo.0000000000000528] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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14
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Inter-observer variability of clinical target volume delineation in definitive radiotherapy of neck lymph node metastases from unknown primary. A cooperative study of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) Head and Neck Group. Radiol Med 2019; 124:682-692. [PMID: 30852793 DOI: 10.1007/s11547-019-01006-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 02/11/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND This study, promoted by Italian Association of Radiotherapy and Clinical Oncology (AIRO) Head and Neck Group, aimed to assess the current national practice of target volume delineation on a case of neck lymph node metastases from unknown primary evaluating inter-observer variability, in a setting of primary radiotherapy. MATERIALS AND METHODS A case of metastatic neck lymph node from occult primary was proposed to 17 radiation oncologists. A national reference RT center was identified and considered as benchmark. Participants were requested to delineate target volumes. A structured questionnaire was administered. A comparison between following parameters of the CTVs was performed: centroids distances, Dice similarity index (DSI), Jaccard index and mean distance to agreement (MDA). Volume expressed in cubic centimeters and CTVs cranio-caudal extension were evaluated. RESULTS Sixteen of 17 radiation oncologists recommended three CTVs dose levels. (CTV HD, CTV ID and CTV LD); CTV ID was not delineated by one of the participants and by the reference center. The distance between the reference centroid and the mean centroid of CTVs HD was 1.09 cm (0.36-3.99 cm); for CTV LD, a mean centroids distance of 2.45 (0.27-4.83 cm) was found, and for CTV HD, mean DSI is 0.48 and mean Jaccard index is 0.32 and MDA was 8.89 mm. CTV LD showed a mean DSI of 0.46, mean Jaccard index of 0.31 and MDA of 14.87 when compared to the reference. CONCLUSION Many aspects concerning treatment optimization of cervical nodes metastases from occult primary remain unclear, and we found a notable heterogeneity of global radiotherapy management reporting discordances both in target volume delineation and volume prescription.
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15
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Le N, Janik S, Simmel H, Erovic BM. Bilateral vs ipsilateral adjuvant radiotherapy in patients with cancer of unknown primary of the head and neck: An analysis of the clinical outcome and radiation‐induced side effects. Head Neck 2019; 41:1785-1794. [DOI: 10.1002/hed.25637] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 10/14/2018] [Accepted: 12/10/2018] [Indexed: 11/11/2022] Open
Affiliation(s)
- Nguyen‐Son Le
- Department of Otorhinolaryngology and Head and Neck SurgeryMedical University of Vienna Vienna Austria
| | - Stefan Janik
- Department of Otorhinolaryngology and Head and Neck SurgeryMedical University of Vienna Vienna Austria
| | - Helmut Simmel
- Department of Radio‐Oncology, Kaiser‐Franz‐Josef Hospital Vienna Austria
| | - Boban M. Erovic
- Department of Head and Neck Diseases, Evangelical Hospital Vienna Vienna Austria
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16
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Cabrera Rodríguez J, Cacicedo J, Giralt J, García Miragall E, Lloret M, Arias F, González Ruiz MA, Contreras J. GEORCC recommendations on target volumes in radiotherapy for Head Neck Cancer of Unkown Primary. Crit Rev Oncol Hematol 2018; 130:51-59. [PMID: 30196912 DOI: 10.1016/j.critrevonc.2018.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/16/2018] [Accepted: 07/17/2018] [Indexed: 12/22/2022] Open
Abstract
Head Neck Cancer of Unknown Primary (HNCUP) is a rare condition, representing approximately 5-10% of all head neck cancers. Radiotherapy, adjuvant or radical, is usually employed in the treatment of those patients. To date, no specific guidelines for the optimal definition of the target volume to be irradiated have been published. In recent years, there have been advances in the knowledge of the molecular biology of HNCUP, its diagnostic imaging and the implementation of sophisticated radiotherapy techniques with enhanced precision in target localization and treatment delivery. These progresses have provided valuable information about the natural history of HNCUP that will allow for establishment of the best treatment for each patient, including standardized, consistent and reproducible target volumes definitions. Several recommendations regarding how to choose volumes when contouring HNCUP in clinical practice are reported, in order to achieve a high rate of loco-regional control while avoiding unnecessary toxicity.
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Affiliation(s)
- Joaquín Cabrera Rodríguez
- Radiation Oncology Department, Hospital Universitario Infanta Cristina, Avenida de Elvas, s/n, 06080 Badajoz, Spain.
| | - Jon Cacicedo
- Radiation Oncology Department, Hospital Universitario de Cruces, Plaza de Cruces, s/n, 48903 Baracaldo, Spain
| | - Jordi Giralt
- Radiation Oncololgy Deparment, Hospital General Vall D'Hebron, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - Enrique García Miragall
- Radiation Oncology Department, Hospital General Universitario Valencia- ERESA, Avenida Blasco Ibáñez, 17, 46010 Valencia, Spain
| | - Marta Lloret
- Radiation Oncology Department, Hospital Universitario Doctor Negrín, c/ Barranco de la ballena, s/n, 35010, Las Palmas de Gran Ganaria, Spain
| | - Fernando Arias
- Radiation Oncology Department, Complejo Hospitalario de Navarra, C/ Irunlarrea, 4, 31008 Pamplona, Spain
| | - María Angeles González Ruiz
- Radiation Oncology Department, Hospital Universitario Infanta Cristina, Avenida de Elvas, s/n, 06080 Badajoz, Spain
| | - Jorge Contreras
- Radiation Oncology Department, Complejo Hospitalario Carlos Haya, Avenida de Carlos Haya, s/n, 29010 Málaga, Spain
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17
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Müller von der Grün J, Bon D, Rödel C, Balermpas P. Patterns of care analysis for head & neck cancer of unknown primary site: a survey inside the German society of radiation oncology (DEGRO). Strahlenther Onkol 2018; 194:750-758. [DOI: 10.1007/s00066-018-1308-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 04/23/2018] [Indexed: 11/30/2022]
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18
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Dharmawardana N, Campbell JM, Carney AS, Boase S. Effectiveness of primary surgery versus primary radiotherapy on unknown primary head and neck squamous cell carcinoma: a systematic review protocol. ACTA ACUST UNITED AC 2018; 16:308-315. [PMID: 29419616 DOI: 10.11124/jbisrir-2017-003476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION The review question is: what is the effectiveness of primary surgery versus primary radiotherapy on disease-free survival and quality of life in adults with an unknown primary, head and neck squamous cell carcinoma?
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Affiliation(s)
| | - Jared M Campbell
- The Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
| | - A Simon Carney
- Department of Surgery, Flinders University, Adelaide, Australia
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19
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Müller von der Grün J, Tahtali A, Ghanaati S, Rödel C, Balermpas P. Diagnostic and treatment modalities for patients with cervical lymph node metastases of unknown primary site - current status and challenges. Radiat Oncol 2017; 12:82. [PMID: 28486947 PMCID: PMC5424363 DOI: 10.1186/s13014-017-0817-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 05/03/2017] [Indexed: 11/29/2022] Open
Abstract
Background and Purpose This review aims to provide a comprehensive overview of the literature and elucidate open questions for future clinical trials concerning diagnostics and treatment modalities for cervical cancer of unknown primary (CUP). Methods A literature search for head and neck CUP was performed with focus on diagnostics and therapies as well as molecular markers. Results High level evidence on CUP is limited. However, it seems that a consensus exists regarding the optimal diagnostic procedures. The correct implementation of biomarkers for patient stratification and treatment remains unclear. An even greater dispute dominates about the ideal treatment with publications ranging from sole surgery to surgery with postoperative bilateral radiotherapy with inclusion of the mucosa and concomitant chemotherapy. Conclusions Cervical CUP represents a very heterogeneous malignant disease. On this account many aspects concerning treatment optimization remain unclear, despite a considerable number of publications in the past. Future research in form of prospective randomized trials is needed in order to better define patient stratification criteria and enable tailored treatment.
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Affiliation(s)
- Jens Müller von der Grün
- Department of Radiation Oncology, University Hospital, Johann Wolfgang Goethe University, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Aykut Tahtali
- Department of Otolaryngology and Head and Neck Surgery, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Shahram Ghanaati
- Department of Maxillofacial Surgery, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Claus Rödel
- Department of Radiation Oncology, University Hospital, Johann Wolfgang Goethe University, Theodor Stern Kai 7, 60590, Frankfurt, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Frankfurt, Germany
| | - Panagiotis Balermpas
- Department of Radiation Oncology, University Hospital, Johann Wolfgang Goethe University, Theodor Stern Kai 7, 60590, Frankfurt, Germany. .,German Cancer Research Center (DKFZ), Heidelberg, Germany. .,German Cancer Consortium (DKTK), Frankfurt, Germany.
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