[The value of qualitative regression grading as a prognostic factor for survival after preoperative radiochemotherapy in patients with advanced head and neck cancer]

Neoadjuvant radiotherapy plus radical surgery for locally advanced stage III/IV oral cancer: Analysis of prognostic factors affecting overall survival

OBJECTIVES

Preoperative radiotherapy followed by surgery is an effective treatment option for solid tumors including locally advanced squamous cell cancers of the head and neck region. Histopathologic response to radiation has been shown to be associated with survival. However, the relative prognostic importance of regression grade compared to other potential biomarkers has not been established yet.

MATERIALS AND METHODS

One-hundred forty-four oral squamous cell carcinoma patients with stage III/IV disease were included in this analysis. Patients had received preoperative radiotherapy (RT) up to 50Gy total dose in combination with 5-Fluorouracil (5-FU)/Mitomycin C (MMC) or with Cetuximab, followed by radical surgery six to eight weeks later. Outcome data were obtained from the patient's files. Survival rates were estimated by the Kaplan-Meyer method. Cox-proportional-hazard regression models were used to compare the risk of death among patients stratified according to risk factors.

RESULTS

Five-year overall survival (OS) was 58% in the presented collective. Regression grade 4 (HR 3.58; p<0.001) was most significantly associated with reduced survival, followed by elevated neutrophils (HR 2.22; p=0.01), the combination of elevated neutrophils plus elevated CRP (HR 2.40; p=0.01), and elevated CRP alone (HR 1.74; p=0.03). In a multivariate analysis, the regression grade remained the most influential predictor of outcome (HR 4.23; p<0.001).

CONCLUSION

In a comparative analysis, tumor response to pre-operative radiotherapy remains the strongest prognostic factor for treatment outcome, while elevated CRP, as well as neutrophils, were also found to be of significance.

Histopathologic tumor response after induction chemotherapy and stereotactic body radiation therapy for borderline resectable pancreatic cancer

BACKGROUND

While clinical outcomes following induction chemotherapy and stereotactic body radiation therapy (SBRT) have been reported for borderline resectable pancreatic cancer (BRPC) patients, pathologic response has not previously been described.

METHODS

This single-institution retrospective review evaluated BRPC patients who completed induction gemcitabine-based chemotherapy followed by SBRT and surgical resection. Each surgical specimen was assigned two tumor regression grades (TRG), one using the College of American Pathologists (CAP) criteria and one using the MD Anderson Cancer Center (MDACC) criteria. Overall survival (OS) and progression free survival (PFS) were correlated to TRG score.

RESULTS

We evaluated 36 patients with a median follow-up of 13.8 months (range, 6.1-24.8 months). The most common induction chemotherapy regimen (82%) was GTX (gemcitabine, docetaxel, capecitabine). A median SBRT dose of 35 Gy (range, 30-40 Gy) in 5 fractions was delivered to the region of vascular involvement. The margin-negative resection rate was 97.2%. Improved response according to MDACC grade trended towards superior PFS (P=061), but not OS. Any neoadjuvant treatment effect according to MDACC scoring (IIa-IV vs. I) was associated with improved OS and PFS (both P=0.019). We found no relationship between CAP score and OS or PFS.

CONCLUSIONS

These data suggest that the increased pathologic response after induction chemotherapy and SBRT is correlated with improved survival for BRPC patients.

Neoadjuvant radiotherapy of head and neck carcinoma: an obstacle for plastic reconstruction?

Head and neck carcinomas often are at an advanced stage at the time of diagnosis and therefore frequently primarily hardly operable. A downstaging achieved by neoadjuvant radiotherapy can facilitate a radical tumor resection. Because of radiogenic tissue alterations like scarring and impairment of blood supply, elaborate operations, such as microsurgical reconstructions, are aggravated to a degree, and most surgeons consider them impossible. In this paper, we report our experiences with plastic-surgical reconstruction in patients with neoadjuvant pretreated head and neck carcinoma.In the last 6 years, eight patients with an advanced head and neck carcinoma were subjected to neoadjuvant radiotherapy followed by a radical tumor resection and reconstruction within the same session. Therefore, pedicled pectoralis flaps (in three patients), microvascular radialis flaps (two), lateral upper arm flaps (one), parascapular flaps (one), and a microsurgical anastomosed jejunal graft were used. The mean follow-up period was 44.5 months.The surgical postoperative course was uneventful in 75 % of patients (six out of eight). An anastomosis venous thrombose in one patient and a wound dehiscence in another required revision. In the end, a satisfactory result could be achieved in all the patients.Sophisticated reconstructions in irritated patients with ENT carcinoma are challenging; therefore, efficient interdisciplinary cooperation can overcome this obstacle.

Histologic tumor type and the rate of complete response after neoadjuvant therapy for esophageal cancer

A review of the literature demonstrated that clinical evaluation cannot be used to determine ‘complete response’. The different classification systems of the histopathologic response grading after neoadjuvant radiochemotherapy of esophageal carcinoma are summarized in this report. A systematic review of studies analyzing preoperative chemoradiation of squamous cell carcinoma (SCC) or adenocarcinoma (AC) of the esophagus demonstrated no significant difference in pathologic complete response (pCR) rates between the AC and SCC studies. Analyzing only the applied dose of radiation demonstrated that patients with AC required a higher dose than patients with SCC to achieve complete response. Incorporating chemotherapy administration does not markedly change the difference in required radiation dose. However, when the tumor does respond, the rate of pCR with increasing dosage of chemoradiotherapy increases more rapidly in AC patients than in SCC patients.

Outcome and histopathologic regression in oral squamous cell carcinoma after preoperative radiochemotherapy

BACKGROUND AND PURPOSE

Preoperative radiochemotherapy has been reported to enhance tumor response and to improve long-term survival in advanced squamous cell carcinoma of the head and neck. This retrospective study evaluates regression rate and long-term survival in 228 patients with primary oral squamous cell carcinoma treated by neoadjuvant radiochemotherapy and radical surgery.

PATIENTS AND METHODS

All patients with biopsy-proven, resectable oral squamous cell carcinoma - TNM stages II-IV without distant metastasis - received preoperative treatment consisting of fractioned irradiation of the primary and the regional lymph nodes with a total dose of 40 Gy and additional cisplatin (n = 160) or carboplatin (n = 68) during the 1st week of treatment. Radical surgery and neck dissection followed after a delay of 10-14 days. The study only included cases with histologically negative resection margins.

RESULTS

After a median follow-up of 5.2 years, 53 patients (23.2%) had experienced local-regional recurrence. The median 2-year disease-specific survival (DSS) rate was 86.2%. 5-year DSS and 10-year DSS were 76.3% and 66.7%, respectively. Complete histological local tumor regression after surgery (ypT0) was observed in 50 patients (21.9%) and was independent of pretreatment tumor classification. Uni- and multivariate survival analysis revealed that ypT- and ypN-stage were the most decisive predictors for DSS.

CONCLUSION

Preoperative radiochemotherapy with cisplatin/carboplatin followed by radical surgery attains favorable long-term survival rates. This applies especially to cases with complete histological tumor regression after radiochemotherapy, which can be assumed for one of five patients.

Preoperative chemoradiotherapy in the management of oral cancer: a review

INTRODUCTION

Multi-modality treatment concepts involving preoperative radiotherapy (RT) or chemoradiotherapy (CRT) and subsequent radical resection are used much less frequently than postoperative treatment for oral and oropharyngeal squamous cell carcinomas. In some centres, however, the preoperative approach has been established for several years.

MATERIAL

The present review is a compilation of the existing evidence on this subject.

METHODS

In a literature-based meta-analysis, the survival data of 1927 patients from 32 eligible publications were analysed.

RESULTS

The calculated survival rates of documented patients show remarkably good results with preoperative CRT and radical surgery. However, the findings of this analysis are based on data with a large proportion of studies using consecutive patient series.

CONCLUSION

Hard evidence providing sufficient data from prospective randomised studies is as yet missing for preoperative CRT. Prospective randomised studies are mandatory in this area.

Mortality and Causes of Death After Multimodality Treatment for Advanced Oral and Oropharyngeal Cancer

PURPOSE

To analyze mortality and causes of death in patients who received preoperative radiochemotherapy and underwent radical surgery for advanced oral or oropharyngeal cancer.

PATIENTS AND METHODS

A total of 222 patients who underwent multimodality treatment from 1990 to 2000 were included in the study. The inclusion criterion was International Union Against Cancer (UICC) disease stage II to IV (T2, 33.3%; T3, 12.6%; T4, 54.1%). Patients received preoperative radiotherapy 50 Gy and concomitant chemotherapy with mitomycin and 5-fluorouracil. Radical local-regional en bloc resection was performed in all patients. Survival status and causes of death were ascertained from the National Health Registry. Death certificates and autopsy reports were consulted when hospital files failed to provide reliable data.

RESULTS

After a median surveillance period of 72.3 months (range, 24 to 152 months), 59% of patients were alive, 21% had died of recurrence, 5% had died perioperatively, and 15% had died from other causes. Of these, a second cancer in the head and neck region or the lower respiratory tract or the upper digestive tract was found in 7.3%. Although 93% of deaths related to recurrent disease occurred within the first 36 months after surgery, the remaining causes of death did not reveal a specific temporal pattern.

CONCLUSION

Favorable survival data were registered for patients with advanced squamous cell carcinoma of the oral cavity who underwent combined treatment protocols. These patients frequently die of comorbidities. Because recurrent disease is a less common cause of mortality than are other causes, the latter should receive attention during surveillance.

Preoperative radiochemotherapy and radical resection for stages II to IV oral and oropharyngeal cancer: grade of regression as crucial prognostic factor

The purpose of this study was to assess the prognostic value of histological response to preoperative radiochemotherapy in an established multimodal therapy concept for advanced oral and oropharyngeal cancer. Two hundred and twenty-two patients who underwent preoperative radiochemotherapy (RCT: 50 Gy, mitomycin C and fluorouracil) and radical surgery were retrospectively evaluated. Resected tumours of all patients were histologically analysed and response to RCT was classified in histopathological grades of regression (RG). In a multivariate statistical analysis, RG was compared with established factors regarding their predictive value for overall and disease-specific survival. The 5-year overall survival probability in the different groups of histopathological regression grades were: RG1 (no vital tumour): 73.4%, RG2 (minimal tumour remnants encompassing less than 5%): 72.1%, RG3 (5-50% vital tumour cells): 41.9%, RG4 (more than 50% vital tumour): 37.9%. For disease-specific survival probability no significant differences were found between both groups of "responders" (RG1 and RG2) nor between "non-responders" (RG3 and RG4), whereas responders and non-responders differed significantly from each other (log-rank test; p < 0.001). T-classification, N-classification and disease stage, histological grading, tumour site, age, and sex had less prognostic value than RG in a Cox regression model. In the neoadjuvant multimodal therapy concept, histological response to preoperative RCT is a crucial prognostic factor even when surgical R0-resection is accomplished. Thus, non-responders have to be regarded as high-risk patients for recurrence and may benefit from further therapy.

Regression von �sophaguskarzinomen nach neoadjuvanter Radiochemotherapie

Following surgical resection locally advanced oesophageal carcinomas exhibit a bad prognosis and therefore neoadjuvant therapeutic strategies were developed. Because success of therapy is associated with the extent of tumor regression in this context, the introduction of objective histopathological criteria seems to be very important. This study included 67 patients with oesophageal carcinomas (cT2-cT4 cNx cM0) that were treated with a cisplatin- and 5-fluorouracil-containing simultaneous radiochemotherapy. In 43 patients squamous cell, in 24 cases adenocarcinomas were diagnosed. After completion of therapy, a surgical resection and a histopathological examination of the tissue specimens were performed. The extent of tumor regression was histologically evaluated and therapy-induced alterations were graded semiquantitatively. Thereby, a significantly favorable prognosis was observed in the group of patients that showed a regression of carcinomas of 90% or more. Additionally, the extent of a resorptive-histiocytic reaction, giant cells and lymphocytic infiltrates correlated with the grade of regression. These results underline the importance of an exact examination and histomorphological evaluation of the response for the assessment of survival probability after neoadjuvant radiochemotherapy of oesophageal carcinomas.

Neoadjuvant radiochemotherapy of oral cavity and oropharyngeal cancer: evaluation of tumor response by CT differs from histopathologic response assessment in a significant fraction of patients

BACKGROUND

Our aim was to compare and assess the predictive value of CT and histopathologic grading of tumor regression at primary tumor sites in patients with squamous cell carcinoma of the oral cavity and oropharynx after neoadjuvant (preoperative) radiochemotherapy (RCT).

METHODS

We investigated 55 patients with carcinomas of the oral cavity and oropharynx who underwent RCT before curative surgery. Two blinded observers measured RCT-induced reduction of tumor volume in pretherapeutic and posttherapeutic CT scans. Volume changes were compared with histopathologic findings obtained at surgery.

RESULTS

Histopathologic response evaluation revealed 31 complete remissions, 12 cases of partial response, and 12 nonresponders. We performed a logistic regression analysis to evaluate whether measured volume reduction could predict the likelihood of belonging to a certain response group. Taken together, we found 35 correct, 12 false-negative, and seven false-positive predictions.

CONCLUSIONS

The extent of remission as assessed by CT scans 4 to 5 weeks after completion of neoadjuvant RCT leads to false predictions in a significant percentage of patients.