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PubMed2006

Benefit of postoperative chemoradiotherapy for patients with unknown primary squamous cell carcinoma of the head and neck.

BACKGROUND: Postopertative adjuvant chemoradiotherapy recently became an established modality for patients with selected high-risk locally advanced head and neck cancers. The optimal treatment of unknown primary squamous cell cancer of the head and neck (SCCHN) continues to be controversial, since major randomized studies excluded those patients. METHODS: We conducted a retrospective review of patients treated during 1995 to 2002 for unknown primary SCCHN. All patients were treated with a neck dissection followed by concurrent high-dose cisplatin (100 mg/m(2)) and bilateral neck radiotherapy. RESULTS: Thirty-seven patients were identified with nodal disease distribution of N1 (5%), N2a (22%), N2b (41%), N2c (8%), N3 (22%), and Nx (3%). Modified neck dissection was done on the majority (30/37 = 81%) of patients. With a median follow-up of 42 months among the survivors, very few patients had regional recurrence (5%) or distant failure (11%), and 89% of patients were alive. The actuarial 5-year overall survival rate could not be estimated because there were no deaths beyond 20 months after surgery. Substantial yet acceptable acute and late morbidities were demonstrated in this cohort of patients. CONCLUSIONS: Postoperative chemoradiotherapy is of potential benefit to patients with unknown primary SCCHN by improving survival and reducing failures. This treatment warrants further prospective evaluation.

Adult↗
PubMed2006

Rate of pathologic complete responses to docetaxel, cisplatin, and fluorouracil induction chemotherapy in patients with squamous cell carcinoma of the head and neck.

OBJECTIVE: To report the rate of pathological complete response after induction chemotherapy with the docetaxel, cisplatin, and fluorouracil (TPF) combination. DESIGN: Retrospective cohort analysis. SETTING: Tertiary care academic cancer center, between June 1999 and May 2004. PATIENTS: Seventy-two patients with newly diagnosed squamous cell carcinoma of the head and neck; 68 (95%) of the patients had stage IV, locally advanced disease. INTERVENTIONS: Three cycles of induction chemotherapy followed by a biopsy of the primary site. All patients subsequently underwent chemotherapy with 3 cycles of TPF. MAIN OUTCOME MEASURE: Rate of pathological complete response at the primary site after induction chemotherapy with 3 cycles of TPF. RESULTS: Biopsy results were negative for cancer in 64 patients (89%) and positive in 8 patients (11%). The median follow-up was 2 years. In the positive biopsy result group, 2 (25%) of 8 patients died of disease vs 3 (4%) of 64 patients in the negative biopsy result group. Twenty-nine neck dissections were performed; results were positive in 7 patients (all alive with no evidence of disease) and negative in 22 patients (21 alive with no evidence of disease). The overall 2- and 5-year progression-free survival is currently projected at 85% and 85%, respectively; the overall 2- and 5-year survival, at 95% and 90%, respectively. Importantly, T4 presentation did not predict a positive biopsy result at the primary site or a positive neck dissection result (P = .60 and P = .56, respectively). N3 presentation (12 patients) did not predict a positive biopsy result at the primary site (P = .87) but did correlate with positive neck dissection results in 6 of 12 patients (P<.001). CONCLUSIONS: Induction chemotherapy with the TPF regimen results in a high pathological complete response rate (89%). This rate is higher than with the cisplatin plus fluorouracil combination therapy, which was reported to be between 25% and 50% in previous studies. Chemoradiotherapy is currently an accepted standard of care, but induction chemotherapy continues to be investigated. Based on recent phase 3 trial results and the data presented herein, we propose that the 3-drug combination be used as the new platform when administering induction chemotherapy.

Adult↗
PubMed1998

Treatment of the N+ neck in squamous cell carcinoma of the upper aerodigestive tract.

This article discusses the following aspects of the management of the N+ neck: evolution of neck dissection; specificity of staging of the clinically N+ neck; limitations of neck dissection in patients with adverse histologic features; management of bilateral nodal metastases, fixed nodes, and nodes with involvement of skin, nerves or the carotid artery; retropharyngeal nodes; and salvage treatment of the N+ neck following prior irradiation. A summary of the author's own approach is then presented.

Carcinoma, Squamous Cell↗
PubMed2001

Base-of-tongue cancer: survival, function, and quality of life after external-beam irradiation and brachytherapy.

OBJECTIVE: Base-of-tongue cancer has traditionally been treated by surgical resection followed by radiation therapy. Primary radiation therapy with brachytherapy has recently been proposed as an alternative. In a prior analysis, we found that patients with advanced tongue-base cancer treated by total glossectomy and postoperative radiation therapy can be cured while potentially maintaining good quality of life. Therefore, we designed the current study to assess survival, function, and quality of life in our patients with tongue-base cancer who were treated with primary radiation therapy and brachytherapy with neck dissection as indicated. STUDY DESIGN: Consecutive case series. METHODS: Twenty patients were treated between 1993 and 1997 using the approach just named. The T stages were T1 (3), T2 (10), T3 (6), and T4 (1). The N stages were N0 (3), N1 (3), N2 (11), and N3 (3). At the time of brachytherapy catheter placement, neck dissections were performed in all 14 patients with N2 or N3 disease. Surviving patients completed a functional status survey and quality of life questionnaire. RESULTS: The 3- and 5-year Kaplan-Meier corrected actuarial survival rates were 57% and 38%, respectively. Eight patients remained alive at the time of this writing and completed the functional status survey and quality of life assessment. Function and quality of life were well maintained in patients treated with external-beam irradiation followed by brachytherapy and neck dissection. However, none of our patients with T3 disease had long-term survival. CONCLUSION: Although we do not endorse external-beam irradiation and brachytherapy for advanced tongue-base cancers, this treatment should be strongly considered for patients with T1 or T2 tumors in whom preservation of function and quality of life is a priority.

Adult↗
PubMedDate not supplied

[Latero-cervical metastasis of N0 laryngeal cancer].

The authors report a pathological study of functional neck dissection performed on 145 N0 laryngeal carcinoma patients from 1982 to 1988. The incidence of occult latero-cervical metastases in N0 was evaluated in relation to site and extension of the primitive tumor. A total of 108 supraglottic, 25 glottic and 12 transglottic tumors were observed. Among the cases treated the incidence of occult metastases was 28.3% while capsular rupture accounted for 3.4%. Diagnostic error, calculated on the number of neck dissections, was 20.2%. A greater incidence of occult metastases was found in supraglottic tumors (29.6%) than in either glottic (24%) or transglottic (25%) tumors. Furthermore, incidence of occult metastases proved proportional to the extension of the primitive tumor. There was a single metastases in 35 cases while only 6 cases proved multiple. Some final considerations are given on the importance of performing precautionary functional neck dissection in N0 laryngeal cancer.

Adult↗
PubMed1990

Current management of cancer of the lip.

Carcinoma of the lip is the most common cancer of the oral cavity, occurring most frequently on the lower lip of elderly males. Less advanced neoplasms may be treated equally successfully by surgery or irradiation, and results are cosmetically acceptable by both methods. Reconstruction of the lip following surgical ablation of tumor usually consists of primary repair. Larger defects require flaps from the opposite lip, adjacent cheek, or more distant tissue. Although prophylactic neck dissection is usually not indicated, the presence of neck metastases from carcinoma of the lip is best managed by neck dissection followed by postoperative radiotherapy. The prognosis for curing lip cancer is dependent upon the size of the primary tumor and whether cervical metastasis has occurred. The overall five-year cure rate of lip cancer approximates 80%. The cure rate of patients with neck metastases is approximately 50%.

Carcinoma↗
PubMed1983

Treatment of epidermoid and undifferentiated carcinomas from occult primaries presenting in cervical lymph nodes.

We treated 83 patients with epidermoid or undifferentiated carcinoma in cervical neck nodes without an obvious primary at our institution between 1964 and 1979. All patients received radiotherapy and 29 patients had radical neck dissection (RND) or total excisional biopsy (TEB) as well. Actuarial survival was 38% at 5 years for the entire group and 25% at 10 years. Fifty-four patients with neck control had significantly better survival (p = .0001) at 5 and 10 years than those whose neck was uncontrolled. Factors associated with improved neck control were initial size of the neck mass and the addition of surgery (RND or TEB). Analysis of failures showed that 50% of patients failed only in the primary or neck and 50% developed distant metastases. Tumor was the major cause of death. We recommend more aggressive treatment with both XRT and neck dissection in patients with large resectable neck masses to prevent regrowth of tumor in the neck.

Actuarial Analysis↗
PubMed2005

The value of frozen section analysis of the sentinel lymph node in clinically N0 squamous cell carcinoma of the oral cavity and oropharynx.

OBJECTIVE: To determine the feasibility and accuracy of fine-sectioned frozen-section analysis of the sentinel lymph node (SLN) in cN0 oral cavity and oropharynx squamous cell carcinoma. STUDY DESIGN: Thirty-one patients were included and underwent lymphoscintigraphy a day before surgery and marking of the SLN. Intraoperatively, the SLNs were identified using a gamma probe, excised, and analyzed using fine-sectioned frozen section. The remaining SLN tissue was fixed in formalin for further staining and immunohistochemical analysis. An elective neck dissection was performed in all patients and all excised lymph nodes were examined for metastatic disease. RESULTS: SLNs were identified preoperatively by lymphoscintigraphy as well as by gamma probe intraoperatively in all patients. A total of 82 sentinel lymph nodes were excised and analyzed by fine-sectioned frozen section. Micrometastases were found in 16 out of the 82 SLNs, upstaging 14 out of 31 patients (45%) from cN0 to pN+. Furthermore, a total of 1295 lymph nodes from the neck dissection specimens were analyzed, confirming only one more metastatic disease. Sensitivity and negative predictive value of SLN biopsy were 93% and 94% respectively for frozen section analysis. CONCLUSION: Our study shows that SLN biopsy in cN0 neck of patients with oral cavity and oropharyngeal carcinoma is both feasible and accurate. Provided that larger studies confirm our results, an elective neck dissection may become unnecessary if fine-sectioned frozen-section analysis of the SLN shows no nodal metastases in patients with cN0 oral cavity and oropharynx carcinoma.

Aged↗
PubMed1998

A review of neuroendocrine neoplasms of the larynx: update on diagnosis and treatment.

Neuroendocrine neoplasms of the larynx have been divided into those of epithelial or neural origin. The latter consist of paragangliomas while the epithelial origin group can be divided into the typical and atypical carcinoids and small cell neuroendocrine carcinomata, the latter consisting of the oat cell type, the intermediate cell type and the combined cell type. There are now over 500 cases of neuroendocrine neoplasms of the larynx in the literature. The diagnosis is primarily based on light microscopy, and, in some instances, it may be supported by special histochemical studies. It should be confirmed by immunocytochemical and/or ultrastructural investigation. The different biological behaviour of neuroendocrine neoplasms of the larynx makes a specific diagnosis of paramount importance, since treatment depends on diagnostic accuracy. Typical carcinoid is an extremely rare lesion. It is treated preferably by conservative surgery; elective neck dissection is not necessary because of the lack of lymph node metastases at diagnosis. Chemotherapy and/or radiotherapy have not been effective in the limited number of patients treated thus far. Prognosis is excellent with cure following surgery. Atypical carcinoid is the most frequent non-squamous carcinoma of the larynx. The mainstay of treatment is surgery. Elective neck dissection should be performed because of the high likelihood of cervical lymph node metastases. Primary radiation therapy with adjuvant chemotherapy is not indicated. The survival rate is 48 per cent at five years and 30 per cent at 10 years. Although the larynx is one of its most common extrapulmonary sites, small cell neuroendocrine carcinoma is still a rare tumour. Surgical results for this tumour have been disappointing and is reserved for cases of local relapse with no evidence of metastasis. Chemotherapy and radiotherapy currently appear to offer the least disabling and most effective forms of therapy. The two- and five-year survival rates are 16 per cent and five per cent, respectively. Paraneoplastic syndromes have occasionally been reported in association with carcinoid tumours (typical and atypical) and small cell neuroendocrine carcinoma. There have been also rare reports of an elevated neuropeptide serum level. Paraganglioma is the only laryngeal neuroendocrine neoplasm with a female preponderance (3:1). Confusion with atypical carcinoid has led to incorrect diagnosis and inappropriate classification schemes, erroneously suggesting that laryngeal paraganglioma has the potential for aggressive behaviour. Conservative surgery represents the treatment of choice; elective neck dissection is not necessary, and the prognosis is excellent.

Carcinoid Tumor↗
PubMed2003

Is neck ultrasound necessary for early stage oral tongue carcinoma with clinically N0 neck?

OBJECTIVES: To define the necessity of neck ultrasound for investigation of T1 and T2 oral tongue carcinoma with N0 neck. METHODS: The medical records of all patients with early stage (T1-2 N0) oral tongue cancer treated surgically between January 1985 and December 2000 were reviewed. Patients with 30 neck dissections were identified for analysis. The result of neck ultrasound examination was correlated with the histological examination. RESULTS: The sensitivity, specificity and overall accuracy of ultrasound examination were found to be 47%, 93% and 70%, respectively. The implication of ultrasound examination with respect to elective neck treatment was discussed in the management of the N0 neck. CONCLUSIONS: It is concluded that ultrasound alone is inadequate for making decisions regarding neck management of patients with T1 and T2 N0 carcinoma of the tongue and cannot replace a policy of elective neck dissection.

Carcinoma↗
PubMed1991

Occult metastatic neck disease: detection with US and US-guided fine-needle aspiration cytology.

The authors performed a prospective study of the value of ultrasonography (US) and US-guided fine-needle aspiration cytology (FNAC) for assessment of N0 lesions in the neck. Preoperative US was performed in 107 patients with squamous cell carcinoma of the head and neck, who underwent 132 elective neck dissections. During the US examination of the last 54 patients, who underwent 70 elective neck dissections, US-guided FNAC was performed. US alone was found to be an unreliable method for detecting occult lymph node metastasis; the accuracy never exceeded 70% (93 of 132), with a sensitivity of 60% (32 of 53) and a specificity of 77% (61 of 79). In contrast, US-guided FNAC had an accuracy of 89% (62 of 70), a sensitivity of 76% (25 of 33), and a specificity of 100% (37 of 37). Because of the high sensitivity and specificity of US-guided FNAC for the assessment of the N0 neck, this modality may play an important role in directing treatment of these patients in the future.

Biopsy, Needle↗
PubMed1996

Management of carcinoma of the supraglottic larynx: evolution, current concepts, and future trends.

The treatment of cancer of the supraglottic larynx has undergone an evolution. Better understanding of the anatomy and biology of cancer in this anatomic site has enabled surgeons to devise effective oncologic strategies while making every effort to preserve the function of the larynx. Certain recent concepts and changing trends have emerged in the treatment of cancer of the supraglottic larynx, including the treatment of the neck, significance of extracapsular spread of tumor in cervical lymph nodes, and conservation laser surgery. In 1985, Snyderman et al. reported the prognostic significance of extracapsular spread in patients with cancer of the supraglottic larynx. In 1990, Lutz et al. reported the results of our experience with the treatment of 202 patients. The review verified the significant risk of bilateral neck disease in these patients, even with adjuvant radiation therapy. Accordingly, since 1990 all patients having cancer of the supraglottic larynx have been treated in the Department of Otolaryngology at the University of Pittsburgh with bilateral neck dissections. The use of adjuvant radiation therapy has been based on the presence of extracapsular spread. This study documents the oncologic effectiveness of this treatment and confirms the efficacy of bilateral neck dissections in an attempt to control neck disease and the prognostic significance of extracapsular spread. We review the evolution of the treatment of cancer of the supraglottic larynx, present our results, and consider innovative surgical approaches.

Adult↗
PubMed1981

Radical irradiation for carcinoma of the pyriform sinus.

Radiation therapy is sometimes prescribed as an alternative to partial or total laryngopharyngectomy in the initial management of carcinoma of the pyriform sinus. Forty-two patients were irradiated for cure and have a follow-up period of 2-14 years. Local control by irradiation alone was 11 of 14 for T1, 6 of 10 for T2, 3 of 6 for T3, and 1 of 7 T4. Three T2 failures were salvaged by laryngopharyngectomy for an ultimate control of 9 of 10 for T2. Management of the neck is critical since 79% of the patients presented with clinically positive necks, and many had substantial neck disease. Complete or partial neck dissection was added after irradiation on an individualized basis. In spite of the extensive degree of neck disease, only three patients died of uncontrolled neck disease with the primary controlled. The two-year absolute survival for Stages I and II was 83%, Stage III 62% and Stage and Stage IV 52%. The five-year absolute survival for Stages I and II was 66%, Stage III 38%, and Stage IV 10%. Complications of irradiation, neck dissection, and surgical salvage procedures are reviewed.

Head and Neck Neoplasms↗
PubMed1979

Voice preservation in treatment of carcinoma of the pyriform sinus.

A retrospective analysis of 175 patients having a histopathologic diagnosis of epidermoid carcinoma of the pyriform sinus presenting between January 1, 1964 and December 31, 1973 was undertaken to establish the effectiveness of conservation surgery in preserving voice. Patients were treated by three separate methods: 1. preoperative radiation therapy, partial laryngopharyngectomy and radical neck dissection (PLP and RND) (N = 85); 2. preoperative radiation therapy, total laryngopharyngectomy and radical neck dissection (TLP and RND), (N = 57); and 3. palliation, which consisted of palliative radiation therapy alone or combinations of radiation therapy and chemotherapy or palliative surgery (N = 33). Of the 85 patients treated with the expectation of cancer cure and voice preservation (PLP and RND), 44 or 52% actually had their voice preserved. Of course, in none of the patients treated by TLP and RND was voice preserved, but 2 of the 33 patients treated palliatively retained ability to speak. Overall, 46 of 175 patients (26%) with carcinoma of the pyriform sinus were afforded voice preservation. The ability to preserve voice is correlated with stage and an analysis of operative complications is presented.

Carcinoma, Squamous Cell↗
PubMed2002

Metastasis of maxillary carcinoma to the parapharyngeal space: rationale and technique for concomitant en bloc parapharyngeal dissection.

PURPOSE: En bloc resection of the primary tumor and regional lymph nodes is the classic method of surgery in cases of head and neck cancer, but it is not performed in cases of carcinoma of the maxillary gingiva or antrum for anatomic reasons. One of the reasons for the poor prognosis of patients with maxillary cancer and N+ stage necks is thought to be recurrence in the parapharyngeal space, which is out of the surgical field in radical neck dissection. The purpose of this study was to discuss the rationale and indication for en bloc resection and parapharyngeal dissection for maxillary cancer. PATIENTS AND METHODS: Ninety-nine patients with maxillary cancer (54 in the gingiva and 45 in the antrum) treated at our institution between 1980 and 2000 were studied retrospectively. RESULTS: In 4 patients, there was recurrence in the parapharyngeal spaces despite good control of tumors in the maxilla and the neck. These 4 patients had all undergone resection of maxilla and neck lymph nodes separately. We also report the case of a patient with carcinoma of the maxillary antrum who underwent en bloc resection of the maxilla and neck. After radical neck dissection, parapharyngeal dissection was performed with a mandibular ramus osteotomy approach, and the maxilla and neck tissue were resected en bloc. CONCLUSIONS: Although en bloc resection causes more extensive surgical damage, it may be useful in patients with maxillary cancer who have metastasis in the upper jugular lymph nodes.

Adult↗
PubMed1993

Management of occult neck metastases in oral cavity squamous carcinoma.

A large experience with patients who had radical neck dissection for oral squamous carcinoma has been reviewed in order to compare elective lymphadenectomy results with those achieved when neck dissection was delayed until metastases appeared or was performed initially for limited N1 neck disease. No significant difference in survival rates was observed, but neck failure was a more significant problem when treatment was delayed. This was most obvious in patients treated for tongue cancer. Although the impact of elective neck treatment on "cure" rates will require prospective studies, it seems clear that elective lymphadenectomy can enhance regional control of cancer and improve the quality of the patients' survival.

Adult↗
PubMed1996

Quality of life outcomes after primary radiotherapy for squamous cell carcinoma of the base of tongue.

PURPOSE: To determine quality of life functional outcome after primary radiotherapy for carcinoma of the base of tongue. METHODS AND MATERIALS: At the University of Florida, essentially all patients with squamous cell carcinoma of the base of tongue are treated with primary continuous-course, external-beam radiotherapy alone or followed by a neck dissection. Fifty-three patients who remained continuously free of disease at 2 to 23 years were eligible to participate in an assessment of the posttreatment quality of their lives. Three patients could not be located for quality of life assessment, and one patient refused to participate, leaving 49 evaluable patients. Radiotherapy doses were 60 to 75 Gy in once daily fractions, or 74 to 79 Gy in twice daily fractions. The subjective Performance Status Scale for Head and Neck Cancer, which assigns a functional score ranging from 0 to 100, was completed by each of the patients during routine follow-up appointments. The scale measures ability to eat in public, understandability of speech, and normalcy of diet. RESULTS: Patients treated with external-beam radiotherapy alone had excellent results with regard to eating in public though scores showed a decline as T stage increased (average scores were T1: 90.6%; T2: 88.1%; T3: 82.8%; T4: 75.0%). Results for understandability of speech were T1: 93.75%; T2: 100%; T3: 82.8%; and T4: 87.5%. Fixation of the tongue at diagnosis was not a predictor of poor function. Normalcy of diet scores likewise decreased with increasing T stage: T1: 93.8%; T2: 89.5%; T3: 71.3%; T4: 60.0%. The addition of a neck dissection had no impact on the functional outcomes that were evaluated. Functional results did not deteriorate with prolonged follow-up of more than 5 years. Results were compared with those from the literature for patients treated by surgery plus postoperative radiotherapy or external-beam irradiation plus interstitial 192Ir implant. The functional results of high-dose external-beam irradiation alone in the present series were similar to those reported after external plus interstitial irradiation. The functional results after both types of radiation treatment were superior to results for patients who underwent surgery. CONCLUSIONS: Functional outcomes after external-beam radiotherapy were similar to those after external-beam plus 192Ir implant, and were superior to the results of surgical resection. Planned postradiotherapy neck dissection did not affect the analyzed functional endpoints. Function appeared to be stable by 5 years without subsequent change.

Adult↗
PubMed1998

Treatment of oropharyngeal carcinoma by irradiation or by surgery.

Of previously untreated patients with squamous cell carcinoma of the oropharynx, 145 are reviewed in this study. All were treated in the Department of Head and Neck Surgery at the University of Liverpool from 1990 to 1997. Seventy-seven patients were treated with irradiation, 28 patients by surgery and 40 patients were deemed not suitable for any curative treatment. Univariate analysis showed no difference in the two groups treated by curative modalities but multivariate analysis did suggest that the surgical group tended to have larger neck node metastases. The 5-year tumour specific actuarial survival for all patients was 53%, 65% for the radiotherapy group and 51% for the surgery group. The difference was not statistically significant (chi (1)2 = 1.5070). The modality of treatment had no affect on either the development of a primary or neck node recurrence or the survival after such a recurrence. Where neck node disease was present it was treated as appropriate. As is generally standard practice, lymph nodes over 2 cm were treated with radical neck dissection whether the patient was having irradiation therapy or surgery. If the patient was having irradiation therapy, the neck dissection was carried out before and irradiation after operation, both on the primary and on the neck, if appropriate. It is concluded that irradiation therapy in properly selected cases in combined head and neck clinics is a safe and effective treatment for squamous cell carcinoma of the oropharynx. Neck node disease should be treated appropriately, but there is no support for the old adage that whatever form of treatment is being used for the neck node should also be used for the primary site.

Analysis of Variance↗