Is a surgical resection leaving positive margins of benefit to the patient with locally advanced squamous cell carcinoma of the head and neck: a comparative study using the intergroup study 0034 and the Radiation Therapy Oncology Group head and neck database

Comparative Survival Function in Patients with Positive Surgical Margins Following Laryngectomy

Aims: This study aims to make a comparative analysis of disease-free survival (DFS) and overall disease-specific survival (OS) in patients with laryngeal carcinoma. Materials and methods: The study was designed retrospectively. Sixteen patients with postoperative PSM and 30 with negative surgical margins (NSM) were included. Survival analysis and Long-Rank comparisons was performed for DFS and OS between groups. Results: PSM was a significant independent risk factor for loco-regional recurrence and disease-related mortality (p = 0.004, HR: 1.6, p = 0.002, HR: 3.2, respectively). DFS and OS were significantly longer in NSM group (p = 0.001 and 0.003, respectively). For PSM group, 2- and 5-year DFS rates were 57%; OS rates were 80% and 34% respectively. In NSM group, 2- and 5-year DFS rates were 96% and 83%; OS rates were found to be 96%. Conclusion: PSM had significant relation with poor prognosis.

Value of lingual lymph node metastasis in patients with squamous cell carcinoma of the tongue

OBJECTIVES

To investigate the role of lingual lymph node (LLN) metastasis on locoregional control (LRC) in patients with locally advanced tongue squamous cell carcinoma (SCC).

METHODS

A total of 231 patients were prospectively enrolled. Analyses focused on the association between the LLN metastasis and clinical pathologic variables as well as the significance of LLN metastasis in predicting prognosis.

RESULTS

LLNs were noted in 58 patients, 33 of whom were positive for LLN metastasis. LLN metastasis was significantly related to adverse pathologic characteristics. In patients with LLN metastasis, the 5-year LRC rate was 45%. In patients without LLN metastasis, the 5-year LRC rate was 65% and the difference was significant (P = 0.013). Further, Cox model analysis confirmed the independence of LLN metastasis from prognosis prediction.

CONCLUSION

LLN metastasis in locally advanced tongue SCC is relatively uncommon; however, LLNs should be routinely dissected because they could significantly decrease locoregional control.

LEVEL OF EVIDENCE

2b. Laryngoscope, 129:2527-2530, 2019.

Data Set for the Reporting of Carcinomas of the Hypopharynx, Larynx, and Trachea: Explanations and Recommendations of the Guidelines From the International Collaboration on Cancer Reporting

The International Collaboration on Cancer Reporting is a nonprofit organization whose mission is to develop evidence-based, universally available surgical pathology reporting data sets. Standardized pathologic reporting for cancers facilitates improved communication for patient care and prognosis and the comparison of data between countries to progressively improve clinical outcomes. Laryngeal cancers are often accompanied by significant morbidity, although surgical advances (such as transoral endoscopic laser microresection and transoral robotic surgery) provide new alternatives. The anatomy of the larynx is complex, with an understanding of the exact anatomic sites and subsites, along with recognizing anatomic landmarks, being crucial to classification and prognostication. This review outlines the data set developed for the histopathology reporting in Carcinomas of the Hypopharynx, Larynx and Trachea and discusses the main elements required and recommended for reporting.

Pitfalls in determining head and neck surgical margins

Accurate assessment of surgical margins in the head and neck is a challenge. Multiple factors may lead to inaccurate margin assessment such as tissue shrinkage, nonstandardized nomenclature, anatomic constraints, and complex three dimensional specimen orientation. Excision method and standard histologic processing techniques may obscure distance measurements from the tumor front to the normal tissue edge. Arbitrary definitions of what constitutes a "close" margin do not consider the prognostic significance of resection dimensions. In this article we review some common pitfalls in determining margin status in head and neck resection specimens as well as highlight newer techniques of molecular margin assessment.

Relapse patterns after transoral laser microsurgery and postoperative irradiation for squamous cell carcinomas of the tonsil and tongue base

OBJECTIVES

We evaluated relapse patterns after transoral laser microsurgery (TLM) in squamous cell carcinoma (SCC) of the tonsil and tongue base and evaluated the indications for adjuvant irradiation.

METHODS

Between December 1, 1996, and December 31, 2005, 79 patients with previously untreated SCC of the tonsil or tongue base underwent TLM with or without neck dissection. Thirty-eight patients (48%) underwent postoperative irradiation (median, 62 Gy) to the primary site and the neck. Analysis of relapse patterns was performed on the basis of adverse risk factors and the presence or absence of adjuvant irradiation.

RESULTS

The median follow-up for living patients was 47 months (range, 10 to 107 months), and patients were monitored for at least 2 years or until recurrence or death. Local, regional, and distant treatment failures numbered 4, 6, and 4 for surgery alone (n = 41) and 0, 2, and 6 for adjuvant irradiation (n = 38), respectively. Patients with high-risk features (extracapsular extension or at least 2 adverse factors) had locoregional control rates at 2 or more years of 66% and 94% for TLM alone and TLM plus adjuvant irradiation, respectively.

CONCLUSIONS

Adjuvant irradiation after TLM resection of oropharyngeal SCC with intermediate- or high-risk features improves locoregional control compared with TLM alone.

From wide excision to a compartmental approach in tongue tumors: what is going on?

PURPOSE OF REVIEW

Surgical approaches to tongue cancer have not changed substantially over the years. The literature proposes some indications for tumor excision even though type of intervention, resection margins, neck dissection, and 'en bloc' resection versus separate excision of tumor and lymph nodes do not seem to be standardized. The purpose of this review is to describe the evolution of surgical management of tongue carcinoma with particular attention to recent reports focusing on compartmental tongue surgery.

RECENT FINDINGS

The current literature usually describes resection of tongue carcinoma within wide disease-free margins, ranging from 1.5 to 2 cm. In case of advanced-stage tumors, performing concomitant neck dissection is recommended; otherwise, a deferred neck dissection is indicated if depth of neoplastic infiltration exceeds 4 mm. In recent years, a new technical approach has been formulated based on anatomy of the tongue, thus, introducing the concept of an anatomy-based, function sparing, compartmental surgery.

SUMMARY

Applying such a proposal to clinical practice aims at standardizing a surgical procedure that otherwise might be arbitrary. Compartmental surgery improves overall survival, does not seem to worsen functional outcomes of the residual tongue, and allows comparison of case studies.

Palliative surgery for head and neck cancer with extensive skin involvement

OBJECTIVES/HYPOTHESIS

To evaluate the role of regional and free tissue transfer for the palliative management of head and neck cancer with extensive skin involvement.

STUDY DESIGN

Case Series.

METHODS

A retrospective review was performed of patients treated for head and neck cancer with involvement of the skin at the Mount Sinai Medical Center over a 5-year period (2006-2010). Only patients with extensive skin involvement and unresectable tumors who underwent palliative resection and reconstruction were included in the review. Subjects were analyzed for age, gender, performance status, primary site, tumor histology, extent of invasion, type of reconstruction, hospital course, wound complications, adjuvant therapy, survival, and cause of death.

RESULTS

Twenty-five patients met the inclusion criteria for the review. Fourteen patients (56%) underwent regional flap reconstruction, and 11 patients (44%) underwent free flap reconstruction. The average length of stay was 7 days. Twenty-four patients (96%) had a medically uncomplicated postoperative hospital course. Nineteen patients (76%) were treated with adjuvant palliative radiotherapy and/or chemotherapy. Long-term follow-up was achieved for 19 patients. The median follow up in this group was 9.5 months. Eleven of the 21 patients (52%) developed wound complications postoperatively. Eight of these were minor wound dehiscences, while three developed major wound complications. Four patients (16%) had distant metastasis at the time of surgery, and the median time to develop distant metastases after surgery was 6 months. Median survival time was 9.5 months. Twenty-two patients (88%) were discharged in the care of their families with appropriate pain management and without the need for extensive wound care.

CONCLUSIONS

For unresectable tumors with extensive skin involvement, palliative resection and reconstruction is a reasonable treatment option. Although survival may not be affected, addressing the odor, bleeding, pain, and infection associated with skin involvement has the potential to improve a patient's quality of life.

LEVEL OF EVIDENCE

4.

Compartmental tongue surgery: Long term oncologic results in the treatment of tongue cancer

Compartmental tongue surgery (CTS) is a surgical technique that removes the compartments (anatomo-functional units) containing the primary tumor, eliminating the disease and potential muscular, vascular, glandular and lymphatic pathways of spread and recurrence. Compartment boundaries are defined as each hemi-tongue bounded by the lingual septum, the stylohyoid ligament and muscle, and the mylohyoid muscle. In this non-randomized retrospective study we evaluated the oncologic efficacy of CTS in patients with squamous cell carcinoma (SCCA) of the tongue treated from 1995 to 2008. We evaluated 193 patients with primary, previously untreated cT2-4a, cN0, cN+, M0 SCCA with no contraindication to anesthesia and able to give informed consent. Fifty patients treated between October 1995 and July 1999 received standard surgery (resection margin >1cm); 143 patients treated between July 1999 and January 2008 received CTS. Study endpoints were: 5-year local disease-free, locoregional disease-free and overall survival. After 5years, local disease control was achieved in 88.4% of CTS patients (16.8% improvement on standard surgery); locoregional disease control in 83.5% (24.4% improvement) and overall survival was 70.7% (27.3% improvement). The markedly improved outcomes in CTS patients, compared to those treated by standard surgery, suggest CTS as an important new approach in the surgical management of tongue cancer.

Status of primary tumour surgical margins in squamous head and neck cancer: prognostic implications

PURPOSE OF REVIEW

To look at the current published literature on squamous-cell carcinoma of the head and neck, at the microscopic level, and the implications of molecular and genetic research.

RECENT FINDINGS

The goal of surgical treatment is still complete eradication of the primary tumour with a 'safe margin'. To achieve this 'safe margin' is not always possible, however. Currently, there is no agreed consensus as to how to submit tissue for frozen section, or how to define a 'clear margin'. Histopathologically, there are two margins requiring analysis, the mucosal margin and the 'deep margin'. Margins declared histopathologically 'tumour free' can be found to be positive for malignant/premalignant cells when molecular markers are applied. When the presence of genetically altered cells is suggested in the margins, there is an increased risk of a recurrent or new tumour. There is limited application of such knowledge and further trials are awaited.

SUMMARY

Standard histopathology has limitations for examining surgical margins. The probability of recurrent malignant disease is explained and this is much increased when molecular markers are identified in the resected margins. Further studies are required.

Paclitaxel, carboplatin, and concomitant radiotherapy for resected patients with high risk head and neck cancer

Many resected patients with locally advanced head and neck cancer are found on pathological assessment to have high-risk features for recurrence. We thus performed a feasibility trial of post-operative radiotherapy with paclitaxel and carboplatin in high-risk carcinoma of the head and neck. All patients were planned for 6 cycles of weekly paclitaxel (40 mg/m2) and carboplatin (AUC=1) and concomitant radiotherapy, 60 Gy in 6 weeks. The most common side effect was grade 3 and 4 mucositis in 5/6 patients and g-tube placement in 4/6 patients. Five out of 6 patients remain alive without evidence of disease at a mean time of 19 months since completion of therapy. Our pilot study treated 6 postoperative patients. Since 4 of 6 enrolled patients were unable to complete the treatment as prescribed, we conclude that this regimen is not feasible. With an 83% grade 3 or 4 mucositis rate and 67% of patients enrolled requiring feeding tube placement, this regimen is not tolerable.

Chemoradiation after Surgery for High‐Risk Head and Neck Cancer Patients: How Strong Is the Evidence?

Patients with locally advanced, operable head and neck squamous cell carcinoma (HNSCC) are known to be at high risk of treatment failure, ranging from local regrowth to lymphatic spread to systemic dissemination. Attacking specifically each of these patterns of failure implies the use of a multimodal approach. Throughout the past two decades the management of stages III/IV HNSCC remained a matter of debate, especially with regards to treatment intensity and sequencing. Surgery and/or radiotherapy were the mainstay of local-regional treatment in patients with locally advanced disease, but treatment outcome often remained disappointing. In the hope of improving the prognosis after radical surgery, cisplatin-based combinations have been administered before surgery, in the interval between surgery and radiotherapy, or after radiotherapy. Until very recently these combinations, at best, decreased systemic failures without having a real impact on local outcome or survival. Indeed, until the mid-1990s, most trials that had tested postoperative combinations of chemotherapy and radiotherapy did not show any significant benefit. In 2004 level I evidence was established with the publication of the results of two large-scale, independent but similar trials conducted in Europe and the U.S. Both studies demonstrated that, compared with postoperative irradiation alone, adjuvant concurrent chemoradiation was more efficacious in terms of local-regional control and disease-free survival. With the publication of these two trials the evidence demonstrating the potential value of concurrent postoperative chemoradiotherapy in high-risk operable head and neck cancer is strong; however, additional studies and comparative analysis of the selection criteria and treatment outcomes across these two trials will be needed to gain a more accurate assessment of benefit and risk levels in specific patients with operable, locally advanced disease.

Concurrent chemo-radiotherapy with mitomycin C compared with porfiromycin in squamous cell cancer of the head and neck: Final results of a randomized clinical trial

PURPOSE

Previous randomized trials have shown a benefit with concurrent use of the hypoxic cell cytotoxin mitomycin C (MC) and radiation (RT) in the management of squamous cell cancer of the head and neck (SCCHN). We conducted a randomized trial comparing MC with porfiromycin (POR) in combination with RT in the management of SCCHN.

METHODS AND MATERIALS

Between 1992 and 1999, 128 patients with SCCHN were enrolled in this prospective randomized trial. Patients were stratified by management intent, and balanced with respect to stage and site of disease. They were randomized to receive MC (15 mg/M(2)) or POR (40 mg/M(2)) on Days 5 and 47 (or last day) of RT. Of 121 evaluable patients, 61 were randomized to MC and 60 to POR. Patients were treated with standard daily RT to a total median dose of 64 Gy over 47 days. Patients were well balanced with respect to management intent, stage, site, age, sex, hemoglobin levels, tumor grade, radiation dose, and days on treatment.

RESULTS

There were no significant differences between the two arms with respect to acute hematologic or nonhematologic toxicities. As of January 2003 with a median follow-up of 6.3 years, there have been 19 local relapses (4 MC vs. 15 POR), 21 regional relapses (7 MC vs. 14 POR), 24 distant metastases (11 MC vs. 13 POR), and 66 deaths (33 MC vs. 33 POR). MC was superior to POR with respect to 5-year local relapse-free survival (91.6% vs. 72.7%, p = 0.01), local-regional relapse-free survival (82% vs. 65.3%, p = 0.05), and disease-free survival (72.8% vs. 52.9%, p = 0.026). There were no significant differences between the two arms with respect to overall survival (49.2% vs. 54.4%) or distant metastasis-free rate (79.9% vs. 75.9%).

CONCLUSIONS

Despite promising preclinical data, and an acceptable toxicity profile, POR was inferior to MC as an adjunct to RT in the management of SCCHN. This randomized trial emphasizes the need for randomized studies to evaluate new agents in the management of SCCHN.

Intraoperative radiotherapy for head and neck and skull base cancer

BACKGROUND

The purpose of this study was to evaluate the use of intraoperative electron beam radiotherapy (IORT) as an adjuvant modality in the treatment of advanced head and neck and skull base cancer.

METHODS

Between 1991 and 1996, 34 patients with squamous cell carcinoma (SCCA) and 10 patients with non-SCCA were enrolled in this prospective nonrandomized clinical trial. Most patients had been previously treated with combinations of surgery, external beam radiotherapy, and chemotherapy. The most frequent sites treated were the skull base (56%) and the neck (44%). IORT was delivered in a dedicated operating room suite with energies of 6 to 15 MeV (6 MeV most commonly used) at doses of 12.5 to 22.5 Gy.

RESULTS

At 2 years overall and disease-free survival was 32% and 21%, respectively, for the SCCA patients and 50% and 40%, respectively, for the non-SCCA patients. Tumor control rates at 2 years in the IORT field were 46% for the SCCA patients and 52% for the non-SCCA patients. For squamous cell histology, survival in patients with microscopic residual tumor did not differ from those with no residual tumor, but they both had significantly longer disease-free survival than those patients with gross residual at the time of IORT (p =.03), with a trend toward longer overall survival (p =.09). The only complication directly attributable to IORT was a neuropathy in a patient who received an IORT dose of 22.5 Gy (cumulative dose 130.1 Gy).

CONCLUSIONS

IORT at a dose of 12.5 Gy is safe and produces tumor control and survival for patients likely to have microscopic residual disease in sites difficult to resect such as the skull base.

Time-dose-response relationships in postoperatively irradiated patients with head and neck squamous cell carcinomas

BACKGROUND AND PURPOSE

To define the influence of the dose and time on the response to treatment in postoperatively irradiated head and neck cancer patients and to establish a good prediction of failure.

METHODS AND MATERIALS

From January 1985 to December 1995, 214 patients with histologically proven head and neck squamous cell carcinomas were irradiated after radical surgery or single tumour resection according to surgical and histopathological findings. The total doses given ranged between 50 and 75 Gy to the primary bed tumour and between 42 and 56 Gy to the neck with fraction sizes of 1.7-2 Gy/day. The median length of the time interval between surgery and radiotherapy, time of irradiation and total treatment time were 81, 59 and 139 days, respectively. The end-point analyzed was the local-regional tumour control rate at the primary tumour bed and neck for 5 years from the beginning of radiotherapy. Univariate and multivariate analyses were used to determine predictors of failure from among the following studied variables: (i), clinical stage (T/N) of the patients; (ii), tumour grade; (iii), neck surgery; (iv), tumour margins; (v), histological tumour nodal extension; (vi), chemotherapy; (vii), normalized total dose; (viii), time interval between surgery and radiotherapy; (ix), time of irradiation; and (x), total treatment time.

RESULTS

The actuarial 5-year tumour control rate for the entire group was 72%, and 92% of the patients who achieved local control are currently alive without disease. Tumour control was inversely related to T stage (83% for T2 vs. 57% for T4) and the probability of local control within each stage was dependent on the N status (> or =71% for T3-T4/N0 vs. 31-44% for T3-T4/N1-N3). Histological N status and tumour margins, but not tumour grade, impacted significantly on tumour control. When local control was analyzed as a function of the dose to the primary, a non-significant negative dose-response relationship was found. The total treatment time was a significant prognostic factor, and the time interval between surgery and irradiation proved to be an independent predictor of failure.

CONCLUSIONS

Despite the absence of a statistically significant dose-response relationship, the present results suggest that postoperative irradiation treatment given to patients with head and neck squamous cell carcinomas should not be unduly prolonged, in order to minimize the amount of tumour cell proliferation. In these patients, nodal involvement, positive margins of the resected specimens and time interval between surgery and irradiation were the most important prognostic factors.

Adjuvant chemotherapy in head and neck cancer

Chemotherapy for head and neck cancer in the adjuvant setting is still experimental at the present time. In general, chemotherapy, given as an adjuvant to surgery and radiation therapy, has not been effective in improving local control or overall survival. Many of the regimens tested would be considered suboptimal by today's standards, and the experimental patient population in these studies have been heterogenous without stringent application of "high-risk" features. Concurrent radiation and chemotherapy seems to be promising and is the focus of ongoing research efforts. The true role of this approach will have to await the completion and analysis of currently active trials, such as the intergroup high-risk adjuvant trial.

[Simultaneous radiochemotherapy with carboplatin in patients with inoperable advanced stage III and IV head and neck tumors]

BACKGROUND

The results of treating advanced tumors in the head and neck region with radiotherapy alone are disappointing. Concurrent radiotherapy and chemotherapy may improve this situation. The treatment results of concurrent radiochemotherapy at the University of Rostock were analyzed retrospectively.

PATIENTS AND METHODS

From 1991 to 1996 92 patients with head and neck tumors were treated with concurrent radiochemotherapy (1.8 to 63 Gy; 70 mg/m2 carboplatin day 1 to 5 and 29 to 33) with palliative tumor resection (n = 37) or without surgical treatment (n = 55). Remission rate, overall survival and disease-free survival, local control and acute toxicity were analyzed.

RESULTS

Six weeks after radiochemotherapy 56.5% of patients had a complete remission, 36% a partial remission and 7.5% "no change". With a median follow-up of 42 months (6 to 74 months) overall survival, disease-free survival and local control were 24.3%, 28.9%, 18.0% 5 years after treatment. All these criteria were significantly better in patients with palliative tumor resection compared to no surgical treatment (uni- and multivariate) and in patients with Stage III than in patients with Stage IV carcinomas (univariate), overall survival was significantly better in patients with Stage III (multivariate). A pretherapeutic Hb level below 7.0 mmol/l (11.27 g/dl) reduced the local control significantly (uni- and multivariate). Grade III and IV mucositis was detected in 10%, Grade III leucopenia in 12% of treated patients. Grade IV leucopenia and Grade III thrombopenia were observed in 1 patient each.

CONCLUSION

The toxicity of this treatment is tolerable. However, additional trials must be conducted before considering the palliative tumor resection as standard therapy.

Indications, techniques and results of postoperative brachytherapy in cancer of the oral cavity

PURPOSE/OBJECTIVE

We tried to reduce the number of local recurrences after surgery and external beam irradiation (EBI) in carcinoma of the oral cavity, when margins were positive or close.

MATERIAL AND METHODS

From 1980 to 1992, we treated 97 cases of carcinomas of the oral cavity by postoperative brachytherapy. Surgery was combined with EBI+brachytherapy in 51 cases and with brachytherapy alone in 46 cases. We treated 29 T1, 34 T2, 30 T3T4 and four Tx (73% were N0 at first examination and 23% had positive nodes). The type of surgery is analysed. Brachytherapy was performed in one or two planes along the surgical scar. If the mandibular rim was resected, especially when the tongue or the remaining floor were sutured to the internal face of the inferior lip or to the buccal mucosa, the bridge technique was used. To decrease the dose to the inferior part of the mandible, the bridge was modified thanks to experimental dosimetry.

RESULTS

At 5 years, the local control (LC) is 89%, the locoregional control (LRC) 82%, the specific survival (SS) 74% and the overall survival (OS) 67%.

COMPLICATIONS

We noted 19% of grade 1 (minor), 12% of grade 2 (moderate) and 6% of grade 3 (major) complications.

CONCLUSION

Compared with the results of the literature, we think that postoperative brachytherapy can improve classical radiosurgical results in selected cases with a risk of local recurrence.

An analysis of radiotherapy in the management of 104 patients with parotid carcinoma

A retrospective analysis was made of 104 patients with parotid carcinoma treated with radical radiotherapy between 1977 and 1986. Eighty-seven patients received postoperative radiotherapy and 17 had radiotherapy alone. The 5- and 10-year survival figures, corrected for intercurrent deaths, were 60% and 49% respectively, with primary control rates of 68% and 58%. Local control was significantly better for patients initially presenting with T1/T2 disease, but local relapse still occurred in 23% of these patients. Of 13 patients with acinic cell tumours, four developed local recurrence and a further two had metastatic disease. These patterns of relapse suggest that patients with parotid carcinoma should receive postoperative radiotherapy irrespective of disease stage or histological type.