Metachronous cancer: prognostic factors including prior irradiation

A 22 years survival and prognostic factors analysis in a homogeneous series of 64 patients with advanced cancer of the tongue and the floor of the mouth

PURPOSE

The aim of this study is to evaluate patients with advanced tongue and floor of the mouth carcinoma evaluating clinical and histopathologic parameters as prognostic factors for survival.

METHODS

We studied retrospectively 64 patients with squamous cell carcinomas of the tongue and floor of the mouth in stage III and IV, treated by surgery at first and followed them for at least 22 years or until death, with a median follow-up of 67 months (range, 3-290 months). The prognosis factors evaluation included tumor, patient and treatment related factors using univariate and multivariate statistical analysis.

RESULTS

The overall 5-year and 22-year survival rates were 34.4% and 6.3%, respectively; and the specific 5-year and 22 years survival rates 35.9%. Eleven patients (17.2%) had died of a second primary tumor and 8 (12.5%) of intercurrent diseases. Multivariable Cox regression analysis showed node capsular invasion, number of metastatic nodes and malignancy grading as the main factors associated with survival (p < 0.001).

CONCLUSION

A very long-term follow-up allowed for the observation of the specific and the overall survival, influenced by age and comorbidities. The prognosis was strongly influenced by the ganglionar status and the histopathological characteristics of the primary tumor.

Survivorship--competing mortalities, morbidities, and second malignancies

Mortality of head and neck cancer has declined in the United States over the past 20 years. This improvement has been linked to use of multimodality treatment of advanced disease. Despite this improvement, disease-specific survival remains low. Patients who survive head and neck cancer are exposed to morbidity and mortality secondary to the same factors as the general population. Factors related to cancer and cancer treatment predispose them to increased risk of mortality. Improvements in head and neck cancer treatment have led to a scenario where an increasing proportion of patients die from causes other than the primary cancer, called competing mortalities.

A comparative study of isolated and metachronous oesophageal squamous cell carcinoma with antecedent upper aerodigestive tract cancer

OBJECTIVES

Metachronous oesophageal squamous cell carcinoma (OSCC) has been increasing in long-term survivors of upper aerodigestive tract (UADT) cancers in recent years, but the treatment of such cases is not well established. The aim of this study was to compare the prognosis between patients with metachronous OSCC who had antecedent UADT cancers and patients with isolated OSCC.

METHODS

From January 1995 to December 2009, we retrospectively compared the data from 84 patients with metachronous OSCC who had antecedent UADT cancers (metachronous group) with the data from 527 patients with isolated OSCC (isolated group) according to their treatment modalities at Kaohsiung Chang Gung Memorial Hospital.

RESULTS

Overall, the metachronous group had significantly (P = 0.03) worse overall survival than the isolated group. For patients receiving surgery or preoperative chemoradiotherapy followed by surgery, the overall survival rates and incidence of postoperative complications were not significantly different. For patients receiving definite chemoradiotherapy or radiotherapy alone, the metachronous group had significantly (P = 0.02) inferior overall survival compared with the isolated group.

CONCLUSIONS

Offering a radical approach for the treatment of patients with metachronous OSCC who had antecedent UADT cancers is justifiable, with survival rates similar to those of patients with isolated OSCC.

Second, third, and fourth head and neck tumors. A progressive decrease in survival

BACKGROUND

Patients with a first head and neck carcinoma have a high risk of successive neoplasms, many of which appear again in the head and neck. Second head and neck tumors have a poorer prognosis than first tumors, but data about the prognosis of third and fourth tumors in the head and neck are lacking.

METHODS

We carried out a retrospective study of 4298 patients with a primary head and neck carcinoma. Survival and the characteristics of the first tumor, second tumor, and any successive tumors in the head and neck were analyzed.

RESULTS

Second and successive tumors showed a tendency to appear more frequently in the oral cavity and oropharynx and had a lower stage than that of index tumors. Five-year survival rates after a first, second, third, and fourth tumors in the head and neck were 67.6%, 56.1%, 45.0%, and 32.1%, respectively.

CONCLUSION

Survival decreased progressively with every new head and neck tumor.

[Diagnosis of laryngeal carcinoma]

DIAGNOSTICAL PROBLEMS OF LARYNGEAL CARCINOMA: Carcinoma of the larynx is still a prognostic serious disease associated with high mortality. Survival rates for these tumors vary and depend on the presence of early symptoms, anatomic accessibility and lymphatic supply. Despite advances in therapy and novel surgical and non-surgical approaches, early diagnosis remains the best predictor of survival.

STRATEGY AND NOVEL DIAGNOSTICAL PROCEDURES

This article reviews the diagnosis for laryngeal carcinoma in an effort to heighten the clinical and endoscopic recognition of these lesions, providing also global overview of clinical conventional and recent endoscopic diagnostic tools for squamous cell type of carcinoma of the larynx. Screening of asymptomatic individuals would detect tumors at an early enough stage to patients' benefit.

CONCLUSION

The progress in the elucidation of the molecular genetic changes in these tumors should soon bring novel diagnostic procedures into the clinical practise. The review higlights the important advances of endoscopic, radilogical and molecular methods in detection of the tumor which may help clinicians to diagnose tumors as early as possible. TNM staging, biopsy and histopathological grading remain the gold standard for diagnosis of laryngeal carcinoma. A great number of novel endoscopical methods are only supplementary tools to microlaryngoscopy. Some of the most significant biological markers might be integrated with the evaluation of behavioural factors, clinical and histopathological examinations for a new clinicomolecular approach to laryngeal cancer.

[Second primary tumors development in head and neck region. Case report]

Tumours of head and neck present 12.2% of the pernicious tumours' morbidity rate in Poland. Annually, the number of new cases is around 6500. The authors of this work present a case of a 65-year-old farmer who has been smoking for 40 years and occasionally abusing alcohol. The medical history of the patient includes: arterial hypertension, ureterolithiasis, obesity. The patient's brother suffered from knee cancer. In 1998 the patient underwent ablation of carcinoma (2x2 cm) from the left auricle. The result of histopathological examination was Carcinoma planoepitheliale keratodes. In 2003, due to Carcinoma planoepitheliale laryngis, horizontal surgery of the larynx was performed. In the same year the patient had superficial lobe of the left parotid gland removed (due to Carcinoma planoepitheliale glandulae parotis sinisti). After the surgery, supplementary treatment was introduced (irradiation Co60; dose--60Gy on the treated area). Currently the patient is under systematic supervision. He is in a good clinical condition. There have been no features of local growth in the treated organs nor any remote metastasis reported.

Segundos tumores primarios en el cáncer escamoso de cabeza y cuello

INTRODUCTION

The development of second primary tumors (SPT) in patients with head and neck squamous cell carcinoma (HNSCC) has become an increasingly important factor in clinical treatment decisions.

PURPOSE

To define favourable clinical characteristics for overall survival, in patients with SP head and neck cancer.

MATERIAL AND METHOD

Records of 633 patients with SCC treated from 1984 to 2004 were reviewed to describe clinical characteristics of the SPT.

RESULTS

The overall incidence of SPT was 11%. The incidence of the index tumors was as follows: supraglottic cancer 21% and oral cancer 16%. The most common SPT occurred in head and neck area in 47%, lung in 32% and esophagus in 11%. Second primary was associated with a poor 5 years survival in patients with HN-SCC (23 versus 53% in control group).

CONCLUSION

Because of the high rate of second primary tumors, protocols including chemoprophylaxis should be investigated. Prevention and early detection are indicated.

Survival outcomes for second primary head and neck cancer: a matched analysis

OBJECTIVE

Determine whether survival for second primary head and neck cancer is truly poorer than survival for first primaries.

METHODS

From the Surveillance, Epidemiology and End Results database, 2 cohorts were constructed. One cohort consisted of patients with exactly 1 head and neck primary malignancy; the second cohort consisted of patients with exactly 2 head and neck primaries, restricted to second primaries of the tongue, tonsil, glottic larynx, and hypopharynx with squamous cell carcinoma (SCCA) histology. Demographic and extent of disease data were extracted. For each primary site, matched Kaplan-Meier survival analysis was conducted comparing overall survival between the two cohorts matching for primary site, year of diagnosis, age, gender, and cancer stage.

RESULTS

A total of 242 cases of second head neck primary were successfully matched to patients with single primary disease. Among 96 patients with oral tongue SCCA, mean (median) survival was 40.1 (28) months after the second primary diagnosis versus 52.2 (32) months for matched single primary patients ( P = 0.552, log-rank test). Among 45 tonsillar carcinomas, mean survival was 42.8 (30) versus 90.9 (NA) months for the second primary and single primary cohorts, respectively ( P = 0.028). Among 52 matched glottic carcinomas, mean survival was 46.4 (27) versus 103.5 (120) months for the 2 cohorts, respectively ( P < 0.001). Among 49 hypopharyngeal carcinomas, mean survival was 35.6 (19) versus 53.9 (21) months, respectively ( P = 0.373).

CONCLUSIONS

Survivals for second primary head and neck malignancies may be poorer than survivals for comparable first primaries, but in this analysis we did not find this difference to be statistically significant for all subsites. Second primary survival will vary from site to site.

EBM RATING

B-3.

Second primary malignancies in patients with cancer of the head and neck

OBJECTIVE: Clinical study of second primary malignancies (SPM) in patients with cancer of the head and neck (HNC).

STUDY DESIGN AND SETTING: Retrospective study over 48 patients with SPMs culled from 636 with HNC seen in 122 months. The minimum follow-up was 18 months, and the setting for the study was the institutional referral center.

RESULTS: There was association between the sites of first and second tumor. The SPMs were diagnosed with a constant rate throughout the period of study. Five year-survival rate was 29%. SPM in an advanced stage either outside of the head and neck or synchronous had poor survival.

CONCLUSION: The SPMs are a growing problem with better survival after treatment of the first malignancy.

SIGNIFICANCE: Regular follow-up is necessary in HNC patients to improve their survival, giving special attention to the development of SPM.

Metachronous second primary cancers after successful partial laryngectomy for invasive squamous cell carcinoma of the true vocal cord

The current retrospective studies documented the incidence, sites of occurrence, risk factors, and outcome of metachronous second primary cancers (MSPCs) among an inception cohort of 410 patients with invasive squamous cell carcinoma of the true vocal cord successfully treated with partial laryngectomy at a single institution. The Kaplan-Meier actuarial life-table method was used to document the relationship between the incidence of MSPCs and survival data. Univariate analysis was performed for potential statistical relationships among the incidence of MSPCs, the site of occurrence, and different variables. The overall incidence of MSPCs was 23.9% (98/410). The 10-year actuarial survival estimate for MSPCs was 20.4%. The incidence curve of MSPCs was linear, resulting in a 2%/y rate of development for MSPCs. In univariate analysis, the only variable that demonstrated a statistical correlation with the incidence of MSPCs was smoking, with MSPCs being statistically more likely to occur in smokers than in nonsmokers (p = .04). The main sites of origin for MSPCs were the lung (25.5% of cases), other non-upper aerodigestive tract sites (32.7%), and the upper aerodigestive tract (41.8%). The 10-year actuarial estimates for MSPCs were 9.1% in the upper aerodigestive tract, 7.1% in sites other than the lung or upper aerodigestive tract, and 6.6% in the lung. The incidence curve for MSPCs was linear, whatever the site of origin, resulting in 1 %/y, 0.7%/y, and 0.6%/y rates of development for MSPCs in the upper aerodigestive tract, sites other than the lung or upper aerodigestive tract, and the lung, respectively. Survival was statistically reduced when an MSPC developed; the 10-year actuarial survival estimates were 76.8% in patients who did not develop an MSPC and 43.7% in patients who developed an MSPC (p < .0001). Overall, 68.4% of patients who developed an MSPC (67/98) died of this disease. The 10-year actuarial survival estimates were 24% for lung MSPCs, 43.7% for non-lung, non-upper aerodigestive tract MSPCs, and 63.4% for upper aerodigestive tract MSPCs.

Can cure be achieved in patients with head and neck carcinomas? The problem of second neoplasm

The improvement in locoregional control of head and neck carcinomas over the last few decades does not appear to modify the final survival of these patients, mainly due to the appearance of distant metastases and second neoplasms. This article reviews the topic of second neoplasm in patients with an index tumor in the head and neck, making a special point of the incidence and epidemiology of second neoplasms, the influence on prognosis, etiopathogenic theories and the possibility of prevention.

Systematic esophageal endoscopy screening in patients previously treated for head and neck squamous-cell carcinoma

BACKGROUND

An attempt was made to improve metachronous oesophageal cancer prognosis through bi-annual systematic esophageal endoscopy screening in patients treated for head and neck cancer.

PATIENTS AND METHODS

Bi-annual esophageal endoscopy, without a staining procedure, was performed in 1560 patients from 1987 to 1997. The distribution of previous head and neck cancer was oral cavity (20%), oropharynx (30%), hypopharynx (34%), and larynx (16%). All patients had initial panendoscopic inspection before HNSCC treatment. Esophageal tumors were considered to be second synchronous primaries when discovered within the first six months of initial tumor diagnosis.

RESULTS

Fifty metachronous esophageal asymptomatic cancers (42 T1 and 7 in situ carcinomas) were diagnosed by endoscopy. The median time between the HNC and the esophageal carcinoma was 43 months (7-137 months). Metachronous esophageal carcinoma was discovered in 2.6% of patients with oral cavity tumor, 5.7% of patients with oropharynx tumor, 2.3% of patients with hypopharynx tumor, and 1.7% of patients with larynx tumor. Causes of death were: 41.1% related to esophageal tumor with tumor progression, metastatic evolution, or treatment toxicity; 28.9% related to non malignant causes; 26.6% related to a cancer that was not of esophageal origin.

CONCLUSIONS

Over a 10-year period, systematic bi-annual esophageal endoscopy uncovered metachronous esophageal tumors in 3.2% of 1560 patients originally treated for head and neck carcinoma, developing in a median time of 47 months. Patients with initial oropharyngeal tumors had a significantly higher risk of metachronous esophageal SCC, compared to the other tumor sites (P < 0.02 with Fisher exact test). Given the elevated death rate not related to the esophageal cancer and the median survival of 16 months, any potential benefit from this time-consuming procedure is debatable.