Preoperative chemotherapy-sensitized radiation therapy for cervical metastases in head and neck cancer

Prognostic role of extracapsular spread in planned neck dissection after chemoradiotherapy

BACKGROUND

The purpose of this study is to evaluate the prognostic significance of nodes with extracapsular spread (ECS) in patients treated with a planned neck dissection after chemoradiotherapy.

METHODS

We carried out a retrospective study of 109 cN+ patients who achieved a complete response in the primary location after chemoradiotherapy and treated with a planned neck dissection.

RESULTS

The 5-year disease-specific survival for patients without residual metastatic nodes in the neck dissection (pN0, n = 69) was 75.7% (95% CI: 64.4%-87.0%). For patients with metastatic nodes without ECS (pN+/ECS-negative, n = 17), the corresponding figure was 74.0% (95% CI: 48.2%-99.8%), and for patients with metastatic neck nodes with ECS (pN+/ECS-positive, n = 23) it was 8.7% (95% CI: 0.0%-24.3%) (P = .0001).

CONCLUSION

The presence of ECS in the pathologic study of the planned neck dissections carried out after chemoradiotherapy in patients with human papillomavirus-negative (HPV-negative) head and neck squamous cell carcinoma (SCC) allows identification of a group of patients with a high risk of failure.

Radiation treatment of head and neck cancer

Radiation therapy plays a central and continuously evolving role in the treatment of head and neck cancer. In this review, some basic principles of radiation oncology are explained and common clinical scenarios are addressed in which radiation therapy forms part of the treatment course, with a focus on issues most pertinent to the interaction of radiation oncology with surgical treatment. These issues include refinement of the indications guiding the choice of adjuvant radiation therapy or chemoradiotherapy, sequencing and timing of therapies before or after definitive surgical management, and scientific and technical advances with the potential to reduce radiation-related toxicity.

Postradiotherapy neck dissection for head and neck squamous cell carcinoma: pattern of pathologic residual carcinoma and prognosis

BACKGROUND

For patients with head and neck cancer who were treated using primary radiotherapeutic approaches, the pattern of pathologic residual carcinoma in the neck dissection specimen and its effect on clinical outcome remains unknown.

METHODS

Medical records of 65 patients who underwent 71 neck dissections a median 7 weeks after radiotherapy were reviewed. Median follow-up was 33 months.

RESULTS

Residual cancer, identified in 28 patients (43%), diminished locoregional control (p = .018), recurrence-free (p = .018), and overall survival (p = .02). Thirteen patients (20%) had 2 or more pathologically involved lymph nodes. Nine (13%) involved level V. Four (6%) had pathologic involvement of nodal levels not clinically involved by cancer before treatment. In N2-3 patients with positive pathologic specimens, the presence of these factors diminished recurrence-free survival (p = .01). The outcome of patients with pathologic carcinoma but without such ominous factors approached those with negative pathology.

CONCLUSIONS

For patients with residual carcinoma in the neck following radiation, the pattern of residual disease is an effective predictor of recurrence.

Preliminary results of pre-radiation neck dissection in head and neck cancer patients undergoing organ preservation treatment

CONCLUSION

Pre-RT ND in patients with HNSCC undergoing organ preservation treatment is safe, advantageous, poses no additional morbidity owing to the elective neck dissection, and may possibly improve survival outcomes.

OBJECTIVE

Establish the role of pre-radiation neck dissection (pre-RT ND) in patients with head & neck squamous cell carcinoma (HNSCC) undergoing organ preservation treatment.

MATERIALS AND METHODS

Fourteen patients with histologically confirmed HNSCC in stages III approximately IV with proven regional metastasis were enrolled in the organ preservation approach incorporating pre-RT ND at a tertiary referral center between May 1998 and August 2004. Site matched patients treated with organ preservation intent in the conventional fashion were used as controls. Data were collected for their diagnosis, management, treatment outcome, and follow up.

RESULTS

Disease free survival was significantly better for the pre-RT ND group. There was no significant difference in overall survival, pattern of recurrence, and primary organ preservation rate between the two groups. No significant morbidity owing to neck dissection was noted in patients who underwent neck dissection. Although the delivery of radiation to the primary site was delayed for patients in the pre-RT ND group, it did not influence the major outcomes.

The role of positron emission tomography scans in the management of the N-positive neck in head and neck squamous cell carcinoma after chemoradiotherapy

OBJECTIVE

The objective of this study was to determine the sensitivity, specificity, and predictive value of 18-fluorodeoxyglucose positron emission tomography (PET) in predicting residual cervical metastatic disease in patients with N-positive necks undergoing curative radiotherapy and chemoradiotherapy for squamous cell carcinoma (SCC) of the upper aerodigestive tract.

METHODS

The authors studied a prospective case series of patients (2003-2005) of patients undergoing radiotherapy and chemoradiotherapy for advanced head and neck SSC. Study entry criteria included N-positive neck disease, a complete response to treatment at the primary tumor site, posttreatment PET scan (8-12 weeks after completion of treatment), followed by salvage neck dissection. The posttreatment PET scan neck findings were correlated to the salvage neck dissection pathology report. The sensitivity, specificity, and predictive values of the PET scan to predict residual cervical metastatic disease after curative chemoradiotherapy were calculated.

RESULTS

Twenty-one neck dissections (pretreatment N1 = 5, N2a = 2, N2b = 8, N3 = 6) were entered into the protocol. Four (19.0%) of the 21 neck specimens were positive for residual cervical metastatic disease, whereas the remaining 17 (80.9%) specimens demonstrated no residual carcinoma. The overall sensitivity and specificity were 75.0% and 64.7%, respectively. The positive predictive value was 33% and the negative predictive value was 91.7%.

CONCLUSIONS

Although the role of posttreatment neck dissection remains controversial, the surgeon must rely on clinical examination and imaging studies. Our practice has been to perform planned staged neck dissections on all N2 and N3 necks, as well as N1 necks with an incomplete response to treatment. Based on this small prospective study, it appears that PET imaging lacks adequate sensitivity and specificity to reliably predict the presence of residual cervical metastatic disease after completion of chemoradiotherapy. With a negative predictive value of 91.7%, however, a negative PET scan appears to be a reliable predictor of the absence of residual tumor.

Role of planned neck dissection for advanced metastatic disease in tongue base or tonsil squamous cell carcinoma treated with radiotherapy

OBJECTIVE

At the conclusion of this article, the reader should be able to discuss the need for planned neck dissection for advanced cervical diseases in the tongue base and tonsil cancer after treatment with radiotherapy.

BACKGROUND

In the past 5 years, we have treated patients with squamous cell carcinoma of the tonsil and tongue base with radiotherapy as the primary therapeutic modality. A planned complete neck dissection was performed on all patients with N2 or greater cervical disease regardless of response to radiotherapy. Composite resection was performed when there was persistent disease at the primary site. Although the "radiation-first" therapeutic approach for tongue base and tonsil cancer is widely accepted, the planned neck dissection for neck metastases remans controversial. The objective of the study was to determine the validity of planned neck dissection after radiotherapy for N2 disease.

METHODS

Medical records of patients with primary squamous cell carcinoma of the tongue base and tonsil with neck metastasis staged N2 or greater were reviewed. Between 1994 and 1999, 36 such patients were treated with curative radiation therapy. Response was assessed 6 to 8 weeks after completion of treatment with clinical examination and CT imaging. All patients underwent planned neck dissection. We reviewed the clinical and radiographic response of neck disease to radiotherapy as it correlated with the histopathologic findings.

RESULTS

Of the 36 patients, 17 had clinical and CT evidence of persistent disease. In this group, 65% had pathologically confirmed diseases at surgery. Of the 9 patients with no evidence of disease on clinical examination, negative biopsy at the primary site, and a negative CT scan, 33% (three of nine) still had residual disease in the neck dissection specimen.

CONCLUSIONS

Positive findings on clinical examination and CT can predict the presence of malignancy after radiation therapy. However, a negative CT and clinical examination are limited in predicting a complete response. These data lend support to the role of planned neck dissection after radiotherapy of N2 neck disease.

Combined radiotherapy with planned neck dissection for small head and neck cancers with advanced cervical metastases

BACKGROUND

We have previously described our treatment algorithm for patients with small head and neck cancers with advanced cervical metastases (stage N2 or greater). Primary radiotherapy is given to the primary site and neck, followed 6 weeks later with endoscopy and biopsy of the primary site. If biopsy of the primary site is negative by frozen section, an immediate neck dissection is performed even when no clinical residual neck disease is present. Our initial review found that 36% of patients with a complete clinical response to radiotherapy had positive nodes on histological examination.

STUDY DESIGN

Retrospective.

METHODS

The medical records of 71 patients treated at UCLA Medical Center from 1986 to 1999 by this algorithm were reviewed.

RESULTS

After radiotherapy, 69 of 71 patients had a complete response at their primary site. Forty-two patients had a complete clinical response in the neck. Seventy-one neck dissections were performed. Overall, 31 of 71 neck dissections (44%) had positive nodes. Among the 42 patients with a complete response to radiotherapy, 13 (31%) had positive histological nodes. Among the 29 patients with a partial response to radiotherapy, 17 (59%) had positive nodes. Follow-up and incidence of neck recurrence are discussed.

CONCLUSION

Planned neck dissection for advanced cervical metastases remains controversial for patients with a complete clinical response to radiotherapy. However, our results suggest that clinical assessment after radiotherapy cannot assure the absence of neck disease. Until there are reliable methods to distinguish which patients are truly free of neck disease, we believe the benefits of a planned neck dissection outweigh the low morbidity of this procedure.

Efficacy of concomitant chemoradiation and surgical salvage for N3 nodal disease associated with upper aerodigestive tract carcinoma

OBJECTIVES/HYPOTHESIS

To determine whether an aggressive approach using trimodality therapy would improve the outcome in head and neck cancer patients with advanced (N3) nodal disease.

STUDY DESIGN

In this retrospective, nonrandomized review, we analyzed a subset of patients who were treated in a targeted chemoradiation therapy protocol, consisting of 31 patients who received treatment between June 1993 and June 1997.

METHODS

Patients received selective intra-arterial infusions of cisplatin (150 mg/m2/wk for 4 weeks) and concomitant radiation therapy (2 Gy/fraction x 35 daily fractions over a 7-wk period) to the primary and clinically positive nodal disease. The patients were re-evaluated 2 months later and underwent salvage neck dissections if there was any residual disease.

RESULTS

Classification of disease in the primary site was as follows: T1 in 2 patients, T2 in 6 patients, T3 in 14 patients, and T4 in 9 patients. Among the 31 patients who were assessed for response at the nodal site, 4 of 31 (13%) had a complete response, 21 of 31 (68%) had a partial response, and 1 of 31 (3%) had no response. Excluding the 5 patients who could not be evaluated, 4 of 26 patients (15%) had a complete response, 21 of 26 (81%) had a partial response, and 1 of 26 (4%) had no response. Nineteen patients subsequently underwent neck dissection, and five patients had histological evidence of residual disease. The remaining seven patients included four who had a complete response in their necks and three who died of intercurrent disease before re-staging. Among the 23 patients who were rendered disease free, there were no recurrences within the neck, whereas 1 patient had recurrence at the primary site and 11 patients had recurrence at distant sites. With a median follow-up of 15 months (range, 4-41 mo), the 3-year overall survival and disease-specific survival were 41% and 43%, respectively.

CONCLUSIONS

Targeted chemoradiation therapy followed by surgical salvage is a highly effective approach for regional control of patients with N3 nodal disease, whereas additional strategies are required to address the problem of distant metastases.