Combined neck dissection and postoperative radiation therapy in the management of the high-risk neck: a matched-pair analysis

[French national standard for the treatment of squamous cell carcinoma of upper aero-digestive tract - General principles of treatment]

OBJECTIVES

The management of upper aerodigestive tract cancers is a complex specialty. It is essential to provide an update to establish optimal care. At the initiative of the INCa and under the auspices of the SFORL, the scientific committee, led by Professor Béatrix Barry, Dr. Gilles Dolivet, and Dr. Dominique De Raucourt, decided to develop a reference framework aimed at defining, in a scientific and consensus-based manner, the general principles of treatment for upper aerodigestive tract cancers applicable to all sub-locations.

METHODOLOGY

To develop this framework, a multidisciplinary team of practitioners was formed. A systematic analysis of the literature was conducted to produce recommendations classified by grades, in accordance with the standards of the French National Authority for Health (HAS).

RESULTS

The grading of recommendations according to HAS standards has allowed the establishment of a reference for patient care based on several criteria. In this framework, patients benefit from differentiated care based on prognostic factors they present (age, comorbidities, TNM status, HPV status, etc.), conditions of implementation, and quality criteria for indicated surgery (operability, resectability, margin quality, mutilation, salvage surgery), as well as quality criteria for radiotherapy (target volume, implementation time, etc.). The role of medical and postoperative treatments was also evaluated based on specific criteria. Finally, supportive care must be organized from the beginning and throughout the patients' care journey.

CONCLUSION

All collected data have led to the development of a comprehensive framework aimed at harmonizing practices nationally, facilitating decision-making in multidisciplinary consultation meetings, promoting equality in practices, and providing a state-of-the-art and reference practices for assessing the quality of care. This new framework is intended to be updated every 5 years to best reflect the latest advances in the field.

Advances in Proton Therapy for the Management of Head and Neck Tumors

Proton therapy (PBRT) is a form of external beam radiotherapy with several dosimetric advantages compared with conventional photon (x-ray) radiotherapy. Unlike x-rays, protons deposit most of their dose over a finite range, with no exit dose, in a pattern known as the Bragg peak. Clinically, this can be exploited to optimize dose to tumors while delivering a lower integral dose to normal tissues. However, the optimal role of PBRT is not as well-defined as advanced x-ray-based techniques such as intensity-modulated radiotherapy.

Need for adjuvant radiotherapy in oral cancer: depth of invasion rather than tumor diameter

PURPOSE

The 8th edition of the TNM Cancer Staging Manual incorporates depth of invasion (DOI) into the pathologic tumor classification for oral squamous cell carcinoma (OSSC). While deep invading tumors with small tumor diameters (TD) have been categorized as early stage tumors in the 7th edition, they are now upstaged, potentially influencing the decision to initiate adjuvant radiotherapy (RT).

METHODS

OSCC patients surgically treated with curative intent between 2010 and 2019 were consecutively included. Tumors were staged based on TD only (according to the 7th edition TNM Cancer Staging Manual), then restaged based solely on DOI.

RESULTS

Of the 133 included patients, 58 patients (43.6%) had a different pT-stage when using DOI instead of TD for staging (upstaging in 23.3%). Overall survival (OS) was significantly worse in patients who were upstaged with DOI. In addition, stratification by adjuvant RT showed significant worse OS in upstaged patients without receiving adjuvant RT.

CONCLUSIONS

DOI seems to be an import indicator for adjuvant RT in OSCC-patients.

PTCOG Head and Neck Subcommittee Consensus Guidelines on Particle Therapy for the Management of Head and Neck Tumors

Purpose

Radiation therapy is a standard modality in the treatment for cancers of the head and neck, but is associated with significant short- and long-term side effects. Proton therapy, with its unique physical characteristics, can deliver less dose to normal tissues, resulting in fewer side effects. Proton therapy is currently being used for the treatment of head and neck cancer, with increasing clinical evidence supporting its use. However, barriers to wider adoption include access, cost, and the need for higher-level evidence.

Methods

The clinical evidence for the use of proton therapy in the treatment of head and neck cancer are reviewed here, including indications, advantages, and challenges.

Results

The Particle Therapy Cooperative Group Head and Neck Subcommittee task group provides consensus guidelines for the use of proton therapy for head and neck cancer.

Conclusion

This report can be used as a guide for clinical use, to understand clinical trials, and to inform future research efforts.

Intraoperative marking of the tumour resection surface for improved radiation therapy planning in head and neck cancer: preclinical evaluation of a novel liquid fiducial marker

OBJECTIVE

To evaluate a novel liquid fiducial marker for intraoperative marking of the tumour resection surface in oral cancer patients to facilitate precise postoperative delineation of the interface between the tumour resection border and reconstructed tissue for intensity-modulated radiation therapy.

METHODS

A total of 200 markers were created by injecting the volumes of 10 µl, 20 µl, 30 µl, 40 µl and 50 µl of a liquid marker composed of sucrose acetoisobutyrate (SAIB) and iodinated sucrose acetoisobutyrate (x-SAIB) into the soft tissue of porcine mandible segments. Visibility of the resulting markers was quantified by threshold-based segmentation of the marker volume in CT- and CBCT imaging and by a comparison of signal intensities in MRI.

RESULTS

Even the lowest volume of SAIB-/x-SAIB investigated (10 µl) resulted in a higher visibility (CT_{Soft tissue}: 88.18 ± 13.23 µl; CT_Bone: 49.55 ± 7.62 µl; CBCT: 54.65 ± 12.58 µl) than observed with the incorporation of titanium ligature clips (CT_{Soft tissue}: 50.15 ± 7.50 mm³; CT_Bone: 23.90 ± 3.39 mm³; CBCT: 33.80 ± 9.20 mm³). Markers created by the injection of 10 µl and 20 µl could reliably be delineated from markers created by the injection of higher volumes.

CONCLUSION

SAIB/x-SAIB, which has recently become available as a Conformité Européenne (CE)-marked fiducial marker, provides an option for fast and reliable production of markers with excellent visibility in imaging modalities used in oral cancer radiation therapy (RT) planning routine.

Preservation of swallowing in resected oral cavity squamous cell carcinoma: examining radiation volume effects (PRESERVE): study protocol for a randomized phase II trial

BACKGROUND

Patients with resected oral cavity squamous cell carcinoma (OCSCC) are often treated with adjuvant radiation (RT) ± concomitant chemotherapy based on pathological findings. Standard RT volumes include all surgically dissected areas, including the tumour bed and dissected neck. RT has significant acute and long-term toxicities including odynophagia, dysphagia, dermatitis and fibrosis. The goal of this study is to assess the rate of regional failure with omission of radiation to the surgically dissected pathologically node negative (pN0) hemi-neck(s) compared to historical control, and to compare oncologic outcomes, toxicity, and quality of life (QoL) profiles between standard RT volumes and omission of RT to the pN0 neck.

METHODS

This is a multicentre phase II study randomizing 90 patients with T1-4 N0-2 OCSCC with at least one pN0 hemi-neck in a 1:2 ratio between standard RT volumes and omission of RT to the pN0 hemi-neck(s). Patients will be stratified based on overall nodal status (nodal involvement vs. no nodal involvement) and use of concurrent chemotherapy. The primary endpoint is regional failure in the pN0 hemi-neck(s); we hypothesize that a 2-year regional recurrence of 20% or less will be achieved. Secondary endpoints include overall and progression-free survival, local recurrence, rate of salvage therapy, toxicity and QoL.

DISCUSSION

This study will provide an assessment of omission of RT to the dissected pN0 hemi-neck(s) on oncologic outcomes, QoL and toxicity. Results will inform the design of future definitive phase III trials.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03997643 . Date of registration: June 25, 2019, Current version: 2.0 on July 11 2020.

Transoral robotic surgery and neck dissection for HPV-positive oropharyngeal carcinoma: Importance of nodal count in survival

BACKGROUND

In this study we determine the survival in patients with HPV-positive oropharyngeal carcinoma treated with transoral robotic surgery (TORS), neck dissection and risk-adapted adjuvant therapy.

METHODS

We retrospectively identified 122 patients with HPV-positive oropharyngeal carcinoma treated with TORS and neck dissection between 2011 and 2018. Survival probability was calculated. We determined the effect of the type of neck dissection performed (modified radical neck dissection-MRND vs. selective neck dissection - SND), extranodal extension (ENE), margin status, and presence of ≥ 5 metastatic nodes on survival.

RESULTS

Our patient population had a five-year overall survival of 91.0% (95% C.I. 85-97%). The five-year probability of recurrence or cancer-associated death was 0.0977 (95% C.I. 0.0927-0.1027). The five-year probability of cancer-associated death was 0.0528 (95% C.I. 0.048-0.0570). All patients who died of their disease had distant metastasis. Our PEG dependence rate was 0%. Patients with ENE and positive margins who underwent adjuvant chemoradiation did not have worse survival. Presence of ≥ 5 metastatic nodes portended worse survival after controlling for age, positive ENE and margins. Low yield (<18 nodes) on neck dissection worsened DFS on multivariable analysis. Furthermore, patients who underwent SND did not have worse OS than those who underwent MRND.

CONCLUSION

Our study demonstrates that surgery could be simplified by performing TORS with SND rather than MRND. The one true poor prognostic factor in HPV-positive oropharyngeal carcinoma patients who undergo surgery is high nodal burden. Patients with high nodal burden are much more likely to die from their disease.

Timing factors as prognostic variables in patients with head and neck squamous cell carcinoma treated with adjuvant radiotherapy: a literature review

INTRODUCTION

Radiotherapy (RT) plays an important role in the treatment of patients with head and neck neoplasia, and is frequently used as postoperative adjuvant therapy. This study aimed to review the literature about timing factors that may influence the clinical outcomes of patients with advanced head and neck neoplasia treated with adjuvant RT.

RESULTS

Timing factors such as total treatment time, length of adjuvant RT, and the absence of interruptions during RT may influence the clinical outcome of these patients.

CONCLUSIONS

In the same way that certain tumor factors can affect the prognosis of patients with squamous cell carcinoma of the head and neck, some therapeutic timing factors are also prognostic factors and therefore, must be carefully orchestrated in order to avoid loss at therapeutic outcomes for these patients.

Implications of Tumor Size, Subsite, and Adjuvant Therapy on Outcomes in pT4aN0 Oral Cavity Carcinoma

Objective

To determine if tumor size, subsite, and adjuvant radiation therapy (AXRT) are associated with overall survival (OS) in patients with pT4aN0 oral cavity squamous cell carcinoma (OSCC) who underwent mandibulectomy with negative surgical margins (NSMs).

Study Design

Retrospective cohort study.

Setting

National Cancer Database (NCDB).

Subjects and Methods

Retrospective analysis of the NCDB that included patients diagnosed with pT4aN0 OSCC who underwent mandibulectomy with NSMs between 2004 and 2015. The association of age, Charlson-Deyo score (CDS), tumor size, subsite, and AXRT with OS was analyzed. The cases were divided into 3 subgroups based on maximal tumor dimension for subgroup analysis; tumors ≤2.0 cm, tumors 2.1 to 4.0 cm, and tumors >4.0 cm.

Results

For the entire cohort; age ( P < .001; hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.02-1.03), CDS ( P = .013; HR, 0.57; 95% CI, 0.37-0.89), tongue subsite ( P = .003; HR, 2.01; 95% CI, 1.27-3.40), floor of mouth subsite ( P = .001; HR, 1.76; 95% CI, 1.28-2.42), tumor size ( P < .001; HR, 0.57; 95% CI, 0.45-0.72), and AXRT ( P < .001; HR, 1.46; 95% CI, 1.24-1.72) were associated with OS on multivariate analysis. On subgroup analysis, AXRT not significantly associated with OS in patients with gingival, hard palate, retromolar trigone, and not specified tumors ≤2.0 cm ( P = .323; HR, 1.29; 95% CI, 0.78-2.15).

Conclusions

In patients with pT4aN0 OSCC who underwent mandibulectomy with NSMs, age, CDS, tongue subsite, floor of mouth subsite, tumor size, and AXRT are associated with OS. AXRT was not significantly associated with overall survival in patients with gingival, hard palate, retromolar trigone, and not specified tumors ≤2.0 cm.

The Evolving Role of Radiotherapy for Head and Neck Cancer

The length and quality of head and neck cancer survivorship continues to meaningfully improve. Radiotherapy has been central to this process through advances in treatment delivery, fractionation schemas, radiosensitizing systemic therapy, and thoughtful interplay with technical surgical improvements. The future looks brighter still, with ongoing progress in targeted biologic therapy, immuno-oncology, and molecular-genetic tumor characterization for personalized treatment. Head and neck cancer, a disease once fraught with nihilism and failure, is evolving into a major success story of modern multidisciplinary cancer care.

Association of Survival With Shorter Time to Radiation Therapy After Surgery for US Patients With Head and Neck Cancer

Importance

Shortening the time from surgery to the start of radiation (TS-RT) is a consideration for physicians and patients. Although the National Comprehensive Cancer Network recommends radiation to start within 6 weeks, a survival benefit with this metric remains controversial.

Objective

To determine the association of delayed TS-RT with overall survival (OS) using a large cancer registry.

Design, Setting, and Participants

In this observational cohort study, 25 216 patients with nonmetastatic stages III to IV head and neck cancer were identified from the National Cancer Database (NCDB).

Exposures

Patients received definitive surgery followed by adjuvant radiation therapy, with an interval duration defined as TS-RT.

Main Outcomes and Measures

Overall survival as a function of TS-RT and the effect of clinicopathologic risk factors and accelerated fractionation.

Results

We identified 25 216 patients with nonmetastatic squamous cell carcinoma of the head and neck. There were 18 968 (75%) men and 6248 (25%) women and the mean (SD) age of the cohort was 59 (10.9) years. Of the 25 216 patients, 9765 (39%) had a 42-days or less TS-RT and 4735 (19%) had a 43- to 49-day TS-RT. Median OS was 10.5 years (95% CI, 10.0-11.1 years) for patients with a 42-days or less TS-RT, 8.2 years (95% CI, 7.4-8.6 years; absolute difference, -2.4 years, 95% CI, -1.5 to -3.2 years) for patients with a 43- to 49-day TS-RT, and 6.5 years (95% CI, 6.1-6.8 years; absolute difference, -4.1 years, 95% CI, -3.4 to -4.7 years) for those with a 50-days or more TS-RT. Multivariable analysis found that compared with a 42-days or less TS-RT, there was not a significant increase in mortality with a 43- to 49-day TS-RT (HR, 0.98; 95% CI, 0.93-1.04), although there was for a TS-RT of 50 days or more (HR, 1.07; 95% CI, 1.02-1.12). A significant interaction was identified between TS-RT and disease site. Subgroup effect modeling found that a delayed TS-RT of 7 days resulted in significantly worse OS for patients with tonsil tumors (HR, 1.22; 95% CI, 1.05-1.43) though not other tumor subtypes. Accelerated fractionation of 5.2 fractions or more per week was associated with improved survival (HR, 0.93; 95% CI, 0.87-0.99) compared with standard fractionation.

Conclusions and Relevance

Delayed TS-RT of 50 days or more was associated with worse overall survival. The multidisciplinary care team should focus on shortening TS-RT to improve survival. Unavoidable delays may be an indication for accelerated fractionation or other dose intensification strategies.

A prognostic nomogram for predicting risk of recurrence in laryngeal squamous cell carcinoma patients after tumor resection to assist decision making for postoperative adjuvant treatment

BACKGROUND

This study aimed to create a nomogram for postoperative prediction of the risk of recurrence in laryngeal squamous cell carcinoma patients who received laryngectomy alone and to assess indications for postoperative adjuvant treatments (POAT).

METHODS

A retrospective analysis of 1571 newly diagnosed laryngeal carcinoma patients was conducted. Those patients were divided into two groups-the development cohort (n = 1102) and the validation cohort (n = 469). Patients were classified into three subgroups according to their individual points calculated from the nomogram. The efficiency of POAT was examined among various subgroups.

RESULTS

Five variables, including pT classification, pN classification, surgical margin, tumor differentiation, and primary location, were included in the nomogram. The C-index was 0.753 in development cohort and 0.744 in validation cohort. Patients were classified into three subgroups with incremental risks of recurrence. In the high-risk group, patients receiving POAT showed significantly better recurrence-free survival (RFS) than did those receiving surgery alone, while POAT was not significantly associated with RFS in either the low- or moderate-risk groups.

CONCLUSIONS

The risk of tumor recurrence in patients with laryngeal carcinoma was quantified by our newly constructed nomogram. Patients categorized as high-risk were found to benefit from POAT in RFS.

Definitive radiotherapy vs. postoperative radiotherapy for lower gingival carcinomas of the mandible : A single-center report about outcome and toxicity

PURPOSE

To assess radiotherapy (RT) outcomes in patients with gingival carcinoma and growth up to or involvement of the lower jaw bone.

METHODS

This was a retrospective analysis of 51 patients with squamous cell carcinomas of the gingiva. Patients received definitive (group 1, 31.4%) or postoperative (group 2, 66.7%) RT between 2005 and 2017 at the Department of Radiation Oncology, University Hospital Heidelberg. The primary endpoint was overall survival (OS) in both treatment groups. Other endpoints were local-disease-free survival (LDFS), progression-free survival (PFS) and treatment-related toxicity (Common Terminology Criteria for Adverse Events, CTCAE, Version 4.03).

RESULTS

Median age at first diagnosis was 63 years. All patients had a local advanced disease (American Joint Commission on Cancer [AJCC] stage III-IV). After a median follow-up of 22 months (range 3-145 months), 20 patients (39.2%) were still alive. At 5 years, OS rate was 36.6%. No significant differences in OS (p = 0.773), PFS (p = 0.350) and LDFS (p = 0.399) were observed between the two groups. Most common higher-grade acute RT-related complications (≥ grade 3) were dermatitis (78.2%), oral mucositis (61.7%), xerostomia (51.5%), and loss of taste (74.6%). Three cases (5.8%) of osteoradionecrosis (ORN) of the lower jaw were detected after 15-31 months.

CONCLUSIONS

Definitive and postoperative RT have similar treatment outcomes for patients with lower gingiva carcinomas of the lower jaw. The most common acute complications (grade ≥3) were dermatitis, oral mucositis, xerostomia and loss of taste.

Postoperative Radiation Therapy for Metastatic Cervical Adenopathy

The management of cancers of the head and neck focuses on primary site and regional (neck) disease control. Many patients are treated with surgery as the principal mode of treatment, and surgery often includes an elective or therapeutic neck dissection. Risk factors assessed for recurrence subsequent to neck dissection include nodal size, number, levels, and the presence of extranodal spread. Adjuvant radiation therapy (with or without chemotherapy) is offered to patients deemed at sufficient risk of recurrence based on assessment of these factors. However, randomized trials have not been performed to test the need and/or benefit of adjuvant postoperative radiation. The necessity of adjuvant radiation has been based on decades of clinical observations, retrospective studies, and indirect randomized trials. The case for postoperative radiation for patients with adverse features in the neck, and recommendations are made in the accompanying article.

Role of postoperative adjuvant radiotherapy for locally advanced laryngeal cancer: a meta-analysis

BACKGROUND

Studies have shown mixed results on the role of postoperative adjuvant radiotherapy (PORT) in surgically managed locally advanced laryngeal cancer.

OBJECTIVES

The aim of this study is to review and investigate the role of PORT in patients with locally advanced laryngeal cancer using meta-analysis.

MATERIALS AND METHODS

Relevant studies were searched using PubMed and eligible information has been extracted. Then, meta-analysis of hazard ratio (HR) was performed to evaluate the role of PORT in locally advanced laryngeal cancer.

RESULTS

This meta-analysis included 7 published studies containing 2007 patients. For overall survival (OS), patients of locally advanced laryngeal cancer who were treated with PORT have a combined hazard ratio (HR) of 0.67 with 95%CI (0.56, 0.79), compared to those who were not treated with PORT, which was significantly associated with better survival. PORT was also associated with a better disease-free survival (DFS) and local control rate (LCR) in patients with locally advanced laryngeal cancer. The pooled HR and 95%CI for DFS and LCR were 0.72 (0.53, 0.99) and 0.29 (0.09, 0.99), respectively.

CONCLUSIONS AND SIGNIFICANCE

This study suggested that PORT could improve the survival of patients with surgically managed locally advanced laryngeal cancer.

The effect of treatment package time in head and neck cancer patients treated with adjuvant radiotherapy and concurrent systemic therapy

Objectives

In patients with head and neck carcinoma, “treatment package time” (TPT) was proven to impact outcomes in cases receiving adjuvant radiotherapy alone. Its impact in patients receiving radiotherapy with concurrent systemic therapy has not been studied previously. The TPT influence on survival endpoints for patients treated with surgery followed by radiation and concurrent systemic therapy was analyzed.

Methods

Institutional database to identify head and neck carcinoma cases treated with definitive surgery followed by concomitant chemo(bio) radiotherapy (CRT) was used. TPT was the number of days elapsed between surgery and the last day of radiation. %FINDCUT SAS macro tool was used to search for the cutoff TPT that was associated with significant survival benefit. Kaplan–Meier curves, log-rank tests as well as univariate and multivariate analyses were used to assess overall survival (OS) and recurrence free survival (RFS).

Results

One hundred and three cases with a median follow up of 37 months were included in the study. Oropharyngeal tumors were 43%, oral cavity 40% and laryngeal 17% of cases. Concurrent systemic therapy included platinum and cetuximab in 72% and 28%, respectively. Optimal TPT was found to be < 100 days with significantly better OS (P = 0.002) and RFS (P = 0.043) compared to TPT ≥100 days. On multivariate analysis; TPT<100 days, extracapsular nodal extension, high-risk score, lymphovascular space and perineural invasion were independent predictors for worse OS (P < 0.05). T4, extracapsular nodal extension and high-risk score were all significantly detrimental to RFS (P < 0.05).

Conclusions

Addition of concomitant systemic therapy to adjuvant radiotherapy did not compensate for longer TPT in head and neck squamous cell carcinoma. Multidisciplinary coordinated care must be provided to ensure the early start of CRT with minimal treatment breaks.

Postoperative (chemo) radiation in patients with squamous cell cancers of the head and neck - clinical results from the cohort of the clinical cooperation group "Personalized Radiotherapy in Head and Neck Cancer"

BACKGROUND

Postoperative (chemo) radiation improves tumor control and survival in high-risk patients with head and neck squamous cell carcinoma based on established risk factors. The clinical cooperation group "Personalized Radiotherapy in Head and Neck Cancer" focuses on the identification and validation of new biomarkers, which are aimed at eventually stratifying and personalizing the therapy concept. Hence, we reviewed all patients with head and neck squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx, treated with postoperative (chemo) radiation from 06/2008 until 06/2015 at the Department of Radiation Oncology in the University Hospital, LMU Munich. Here we report the clinical results of the cohort, laying the foundation for further research within the framework of a clinical cooperation group.

METHODS

Patient data were retrospectively (until 2013) and prospectively (from 2013) collected and analyzed for outcome and treatment failures with regard to previously described and established risk factors.

RESULTS

We identified 302 patients (median follow-up 45 months, average age 60.7 years), having received postoperative (chemo)radiation (median 64 Gy). Chemotherapy was added in 58% of cases, mostly Cisplatin/5- Fluorouracil in concordance with the ARO 96-3 study. The 3-year overall survival, local, locoregional and distant failure estimates were 70.5, 9.7, 12.2 and 13.5%, respectively. Human papillomavirus-associated oropharyngeal cancer was associated with a significant improved overall survival, locoregional, distant and overall tumor control rates in multivariate analysis. Additionally, in multivariate analysis, for local failure, resection status and perineural invasion, for locoregional and distant failure extracapsular extension and for overall survival the presence of nodal disease were significant adverse factors. Moreover, 138 patients have been treated in concordance with the ARO 96-3 protocol, corroborating the results of this study.

CONCLUSIONS

Our cohort represents a large unselected cohort of patients with head and neck squamous cell carcinoma treated with postoperative (chemo)radiation. Tumor control rates and survival rates are consistent with the results of previously reported data.

Personalizing Postoperative Treatment of Head and Neck Cancers

Head and neck cancer (HNC) treatment is a complex multidisciplinary undertaking. Although overtreatment can result in functional and cosmetic defects, undertreatment can result in cancer recurrence. Surgery and chemoradiotherapy are both accepted standards for the curative intent treatment of locally advanced mucosal squamous cell carcinoma of the head and neck, but are often prioritized differently depending on the site of tumor origin (e.g., oral cavity/sinonasal vs. oropharynx/larynx), tumor burden, tumor biology, quality-life considerations, and patient preference. Regardless of modalities chosen, failure to cure remains a considerable problem in locally advanced disease. For patients treated with primary surgery, high-risk pathologic features portend higher recurrence rates, and adjuvant therapy can reduce these rates and improve outcomes. This report details which tumor- and nodal-related factors are indications for adjuvant therapy, examines the impact of tumor HPV status on adjuvant treatment paradigms, and considers which systemic therapies should be used for which patients when trimodality therapy is indicated.

Role of adjuvant chemoradiotherapy in T4N0 stage IV head and neck cancer: A National Cancer Database analysis

BACKGROUND

The purpose of this study was to evaluate the role of postoperative adjuvant radiotherapy (surgery + adjuvant RT) versus adjuvant chemoradiotherapy (surgery + adjuvant CRT) in patients with T4N0M0, stage IV head and neck squamous cell carcinoma (HNSCC).

METHODS

Between 1998 and 2011, 3518 and 885 patients were treated with surgery + adjuvant RT and surgery + adjuvant CRT, respectively. Three-year overall survival (OS) rates were determined and crude and adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were computed.

RESULTS

Median follow-up was 41.8 months with 2193 reported deaths. The 3-year OS was 67.5% for surgery + adjuvant RT and 70.5% for surgery + adjuvant CRT (P = .013). For negative margins, the corresponding 3-year OS was 70.1% and 74.9% (P = .005). For positive margins, the corresponding 3-year OS was 56.0% and 60.6% (P = .079). On multivariate analysis, the beneficial effect for adjuvant CRT over adjuvant RT was not significant (HR 0.90; CI 0.79-1.03; P = .124).

CONCLUSION

In this cohort of patients with T4N0 HNSCC treated with surgery, there was no observed survival benefit of adjuvant CRT over adjuvant RT on multivariate analysis.

Patterns of Postoperative Radiotherapy for Head and Neck Cancer in Italy: A Prospective, Observational Study by the Head and Neck Group of the Italian Association for Radiation Oncology (AIRO)

Aims and background

Our previous survey showed that the patterns of postoperative radiotherapy (PORT) for head and neck cancer (HNC) in Italy might be suboptimal. A prospective observational study was therefore designed to evaluate this issue in greater detail.

Methods

All radiotherapy centers involved in the HNC Working Group of the Italian Radiation Oncology Association were asked to enter into the study all patients treated with PORT during a 6-month period.

Results

A total of 200 patients were accrued by 24 centers from December 2008 to May 2009. Larynx (38%) and oral cavity (34%) were the most common primary sites. The median time between surgery and the start of radiotherapy was 69 days (range, 25–215 days). Seventy-nine percent of cases with no evidence of risk factors for local recurrence were treated with high-dose radiotherapy to the primary site. In about 75% of cases the pN0 neck was included in the target volume. Concomitant chemotherapy was delivered to about 60% of patients with major risk factors and 21% of patients with no risk factors.

Conclusions

Three issues emerged from our study as potential targets for future investigations: the impact on clinical outcome of the interval between surgery and the start of PORT; factors driving radiation oncologists to overtreat volumes at low risk of recurrence; and problems associated with the delivery of concomitant chemotherapy.

Yoga as an Integrative Approach for Prevention and Treatment of Oral Cancer

Despite tremendous advancements in medicine, the number of oral cancer cases continues to increase, and the need for integrating alternate medicine or adopting an integrative approach has become a compelling cost-effective requirement for the management and treatment of diseases. Conventional treatment of oral cancer involves surgery followed by radiotherapy with or without chemotherapy which causes several complications including poor quality of life and high chances of recurrence of cancer. Oral cancer is often linked with obesity which is major risk factors in other cancers. Apart from obesity, oral cancer is thought to have an inverse relation with neurodegenerative disorders presumably because cell death decreases in the former case and increases in the latter. Ancient mind-body techniques such as yoga have not been adequately tested as a tool to synergize the cellular equilibrium pertaining to the treatment of oral cancer. Nerve growth factor (NGF), tumor necrosis factor-alpha (TNF-α), and interleukin-6 (IL-6) are among the early experimental cellular biomarkers that may be used to probe the modulation of oral cancer, obesity, and neurodegenerative disorders. Yoga has been reported to influence these molecules in healthy individuals but whether their expression can be altered in patients of oral cancer by yoga intervention is the subject of this research being discussed in this review article. Therefore, the present article not only reviews the current status of research studies in oral cancer, obesity, and neurodegenerative disorders but also how these are linked to each other and why the investigations of the putative NGF pathway, involving TNF-α and IL-6, could provide useful clues to understand the molecular effects brought about by yoga intervention in such patients.

Efficacy of postoperative neck irradiation for regional control in patients with pN0 oral tongue cancer: Propensity analysis

BACKGROUND

The purpose of this study was to investigate whether adjuvant radiotherapy (RT) is efficacious for regional control and survival in patients with pN0 oral tongue cancer.

METHODS

Clinicopathological features of 166 patients with pN0 oral tongue cancer were compared between those who underwent adjuvant RT to the neck (neck RT-positive) and those who did not (neck RT-negative). Study endpoints were isolated regional recurrence and 3-year regional recurrence-free survival (RRFS). Propensity score matching was also performed.

RESULTS

Cox regression analysis did not reveal any significant predictor of isolated regional recurrence, including RT field. Three-year RRFS showed modest improvement in neck RT-positive group compared to neck RT-negative group before (92.2% vs 91.9%) and after propensity analysis (93.8% vs 83.3%), without statistical significance (log-rank P = .85 and .37, respectively).

CONCLUSION

Despite more frequent unfavorable factors, the neck RT-positive group had a comparable oncologic outcome to the neck RT-negative group, suggesting that a marginal benefit in regional control might be expected from extending the RT field to the neck for pN0 oral tongue cancer.

Radiation Therapy for Oral Cavity and Oropharyngeal Cancers

Radiotherapy is a key therapeutic modality used in the treatment of oral cavity and oropharyngeal cancers, whether as definitive treatment or postoperatively for those with high-risk factors after surgery. Although radiotherapy is a proven, effective treatment of cancer control, it can result in significant acute and late toxicities. Pretreatment patient education, supportive care, and posttreatment adherence to rehabilitative and preventive care can help mitigate toxicities. Advances in radiation delivery, such as through continued technological advances, or novel approaches to customizing radiation dose and volume, to maximize the therapeutic efficacy while minimizing side effects, are warranted.

Oral squamous cell carcinoma: the impact of stage-dependent therapy regimes on postoperative disease recurrence

OBJECTIVE

To investigate disease recurrence among patients with oral squamous cell carcinoma (OSCC) and positive lymph node lesions receiving different therapy for different stages of the disease.

STUDY DESIGN

One hundred sixty-one patients with biopsy-proven pN1 and pN2+ carcinomas were reviewed retrospectively. We investigated postoperative disease recurrence when using surgery alone (SA), adjuvant radiotherapy (RT), or adjuvant radiochemotherapy (RCT) and compared our results with the 2012 German guidelines.

RESULTS

Among the study population, 60 (37%) experienced postoperative disease recurrence, 38% with SA, 42% with adjuvant RT, and 39% with adjuvant RCT (P = .420). In the case of pN1, the recurrence rate was 14% with SA, 32% with RT, and 33% with RCT (P = .156); and in pN2+, 60%, 49%, and 29%, respectively (P = .012).

CONCLUSIONS

Surgery plus adjuvant therapy has benefits with respect to postoperative disease recurrence in pN2+ OSCC. In pN1, surgery alone might be as effective as adjuvant RT or RCT.

Oral Cavity Carcinoma: Current Management, Controversies, and Future Directions

Oral cavity carcinoma (OCC) remains a major cause of morbidity and mortality in patients with head and neck cancer. Although the incidence has decreased over the last decade, outcomes remain stagnant with only a 5% improvement in overall survival in the last 20 years. Although surgical resection remains the primary treatment modality, several areas of controversy exist with regard to work-up, management of the primary and neck tumors, and adjuvant therapy. As surgical techniques evolve, so has the delivery of radiotherapy and systemic treatment, which have helped to improve the outcomes for patients with advanced disease. Recently, the addition of cetuximab has shown promise as a way to improve outcomes while minimizing toxicity, and this remains an active area of study in the adjuvant setting. Advances in microvascular free-flap reconstruction have extended the limits of resection and enabled enhanced restoration of function and cosmesis. While these advances have led to limited survival benefit, evaluation of alternative modalities has gained interest on the basis of success in other head and neck subsites. Organ preservation with definitive chemoradiotherapy, though proven in the larynx and pharynx, remains controversial in OCC. Likewise, although the association of human papillomavirus is well established in oropharyngeal carcinoma, it has not been proven in the pathogenesis or survival of OCC. Future study of the molecular biology and pathogenesis of OCC should offer additional insight into screening, treatment selection, and novel therapeutic approaches.

An expression analysis of markers of radiation-induced skin fibrosis and angiogenesis in wound healing disorders of the head and neck

BACKGROUND

Radiation-induced fibrosis (RIF) is one of the severe long-term side effects of radiation therapy (RT) with a crucial impact on the development of postoperative wound healing disorders (WHD). The grades of fibrosis vary between mild to severe depending on individual radiosensitivity. In this study, we have investigated the molecular pathways that influence RIF and have correlated data from immunohistochemistry (IHC) for von -Willebrand Factor (vWF) and from Real-Time Polymerase Chain Reaction (RT-PCR) concerning markers such as Transforming Growth Factor (TGF)-β 1, and vWF, with clinical data concerning the occurrence of WHD during follow-up.

METHODS

Expression profiles of the genes encoding TGF-β 1, vWF, and α-procollagen (PC) were analyzed, by RT-PCR, in specimens from patients with (n = 20; 25.6 %) and without (n = 58; 74.4 %) a history of previous RT to the head and neck. Moreover, IHC against vWF was performed. Clinical data on the occurrence of cervical WHDs were analyzed and correlated.

RESULTS

A statistically significant increase in the expression profiles of α-PC and TGF-β 1 was observed in previously irradiated skin samples (occurrence of RT >91 days preoperatively). vWF showed a statistically significant increase in non-irradiated tissue. Moreover, analysis of expression profiles in patients with and without WHDs during follow-up was performed. IHC showed a reduced amount of vessels and structural changes in epidermal tissue post-RT.

CONCLUSIONS

The expression of markers of fibrosis and angiogenesis was analyzed in order to gain insight into molecular pathways that account for structural changes in irradiated skin and that eventually lead to WHDs. The results are congruent with reports from the literature and are a possible starting point for further research, as anti-TGF-β 1 treatment, for example, could represent new therapeutic opportunities in the management of previously irradiated patients.

The use of proton therapy in the treatment of head and neck cancers

External beam radiation therapy is a commonly utilized treatment modality in the management of head and neck cancer. Given the close proximity of disease to critical normal tissues and structures, the delivery of external beam radiation therapy can result in severe acute and late toxicities, even when delivered with advanced photon-based techniques, such as intensity-modulated radiation therapy. The unique physical characteristics of protons make it a promising option in the treatment of advanced head and neck cancer, with the potential to improve sparing of normal tissues and/or safely escalate radiation doses. Clinical implementation will require the continued development of advanced techniques such as intensity-modulated proton therapy, using pencil beam scanning, as well as rigorous methods of quality assurance and adaptive techniques to accurately adjust to changes in anatomy due to disease response. Ultimately, the widespread adaptation and implementation of proton therapy for head and neck cancer will require direct, prospective comparisons to standard techniques such as intensity-modulated radiation therapy, with a focus on measures such as toxicity, disease control, and quality of life.

A retrospective analysis to determine factors contributing to the survival of patients with oral squamous cell carcinoma

The clinical outcome of patients with OSCC is assessed based on TNM system and currently it is the most reliable indicator on which therapeutic decisions are made. The patients with advanced disease are managed with combined treatment modalities. The aim of this retrospective study was to identify the factors which influence survival of patients with OSCC in Sri Lanka. Four hundred and thirty patients who have been managed surgically using either (1) local excision, (2) local excision+supraomohyoid neck dissection, (3) local excision+modified radical neck dissection, (4) local excision+radical neck dissection, (5) local excision+contra-lateral neck dissection depending on TNM stage, with or without post-operative radiotherapy. Patients with incompletely excised tumours showed statistically significant poor survival which improved with radiotherapy (stage II P=0.002, stage III P=0.017). With reference to TNM stage IV tumours, the patients who had received surgical option 4, showed poor survival compared to surgical options 2, 3, and 5 (P=0.001). However, within the group of patients who had received surgical option 4, those who had nodal metastasis showed poorer survival compared to patients without nodal metastasis. In addition, survival improved in patients who had been treated with surgical option 4, with radiotherapy. Furthermore, margin status was also found to significantly influence the survival of patients with TNM stage IV tumours (P=0.003). The main factors that had significant impact on the survival were TNM stage, nodal metastasis and the state of excision margins.

The diagnosis and treatment of oral cavity cancer

BACKGROUND

About 10,000 persons are diagnosed as having carcinoma of the oral cavity or the throat in Germany every year. Squamous-cell carcinoma accounts for 95% of cases.

METHODS

We systematically reviewed the pertinent literature on predefined key questions about these tumors (which were agreed upon by a consensus of the investigators), concerning imaging, the removal of cervical lymph nodes, and resection of the primary tumor.

RESULTS

246 clinical trials were selected for review on the basis of 3014 abstracts. There was only one randomized, controlled trial (evidence level 1-); the remaining trials reached evidence levels 2++ to 3. Patients with mucosal changes of an unclear nature persisting for more than two weeks should be examined by a specialist without delay. The diagnosis is made by computed tomography or magnetic resonance imaging along with biopsy and a standardized histopathological examination. Occult metastases are present in 20% to 40% of cases. Advanced disease (stages T3 and T4) should be treated by surgery followed by radiotherapy, with or without chemotherapy. 20% of the patients overall go on to have a recurrence, usually within 2 to 3 years of the initial treatment. The 5-year survival rate is somewhat above 50%. Depending on the radicality of surgery and radiotherapy, there may be functional deficits, osteoradionecrosis, and xerostomia. The rate of loss of implants in irradiated bone is about 10% in 3 years.

CONCLUSION

The interdisciplinary planning and implementation of treatment, based on the patient's individual constellation of findings and personal wishes, are prerequisites for therapeutic success. Reconstructive measures, particularly microsurgical ones, have proven their usefulness and are an established component of surgical treatment.

The treatment of oral cancer: an overview for dental professionals

Oral cancer is a serious life-threatening disease. Dental professionals may be the first individuals to identify/suspect these lesions before referring to oral and maxillofacial surgeons and oral medicine specialists. Because the general dentist will likely follow on with the patient's future oral health, it is important that he or she has a basic understanding of the various treatments involved in treating oral malignancies and their respective outcomes. The four main modalities discussed in this review include surgery alone, radiotherapy alone, surgery with radiotherapy, and chemotherapy with or without surgery and radiotherapy. Chemotherapy has become an area of great interest with the introduction of new 'targeted therapies' demonstrating promising results in conjunction with surgery. Despite these results, the toxicities associated with chemotherapy regimens are frequent and can be severe, and therefore may not be suitable for all patients. Treatment modalities have improved significantly over the decades with overall decreases in recurrence rates, improved disease-free and overall survival, and an improved quality of life. Prognosis, however, is still ultimately dependent on the clinical stage of the tumour at the initial diagnosis with respect to size, depth, extent, and metastasis as recurrence rates and survival rates plummet with disease progression.

Current management of advanced resectable oral cavity squamous cell carcinoma

The oral cavity is the most common site of head and neck squamous cell carcinoma, a disease which results in significant morbidity and mortality worldwide. Though the primary modality of treatment for patients with oral cavity cancer remains surgical resection, many patients present with advanced disease and are thus treated using a multi-disciplinary approach. Patients with extracapsular spread of lymphatic metastasis and surgical margins that remain positive have been found to be at high risk for local-regional recurrence and death from disease, and are most often recommended to receive both post-operative radiation as well as systemic chemotherapy. The basis for this approach, as well as scientific developments that underly future trials of novels treatments for patients with high-risk oral cavity cancer are reviewed.

Postoperative elective nodal irradiation for squamous cell carcinoma of the head and neck: outcome and prognostic factors for regional recurrence

BACKGROUND

This study describes the results of elective irradiation in the N0 neck and tries to identify prognostic factors for regional recurrence.

MATERIALS AND METHODS

Between 1985 and 2000, 785 cN0 or pN0 necks were treated with elective nodal irradiation in 619 head and neck squamous cell carcinoma patients.

RESULTS

Regional control at 3 years was 94% in the cN0 (nondissected) neck compared with 97% in the pN0 (dissected) neck and 90% in the ipsilateral compared with 96% in the contralateral neck (P = 0.08 and P = 0.006, respectively). Regional control in the ipsilateral cN0 neck was 78% compared with 96% in the contralateral cN0 neck. Surgical margin of the primary tumor was an additional prognostic factor in all N0 and pN0 necks.

CONCLUSIONS

Neck control rates in electively irradiated N0 necks were excellent. Regional control was worse in the cN0 neck compared with the pN0 neck and in the ipsilateral neck compared with the contralateral side. Additionally, in case of positive surgical margins of the primary tumor, elective nodal irradiation should be applied, even in case of a pN0 neck.

Matched survival analysis in patients with locoregionally advanced resectable oropharyngeal carcinoma: platinum-based induction and concurrent chemoradiotherapy versus primary surgical resection

PURPOSE

The outcome of a prospective case series of 47 patients with newly diagnosed resectable locoregionally advanced oropharyngeal squamous cell carcinoma treated with platinum-based induction-concurrent chemoradiotherapy (IC/CCRT) was compared with the outcome of 47 matched historical control patients treated with surgery and postoperative RT.

METHODS AND MATERIALS

A total of 47 control patients with locoregionally advanced oropharyngeal squamous cell carcinoma were identified from review of a prospectively compiled comprehensive computerized head-and-neck cancer database and were matched with a prospective case series of patients undergoing IC/CCRT by disease stage, nodal status, gender, and age (± 5 years). The IC/CCRT regimen consisted of one cycle of induction chemotherapy followed by conventionally fractionated RT to a total dose of 66-70 Gy concomitantly with two cycles of chemotherapy. Each cycle of chemotherapy consisted of cisplatinum, 100 mg/m(2), and a continuous infusion of 5-fluorouracil, 1,000 mg/m(2)/d for 5 days. The survival analysis was performed using Kaplan-Meier estimates. Matched-pair survival was compared using the Cox proportional hazards model.

RESULTS

No significant difference was found in the overall survival or progression-free survival rates between the two groups. The matched analysis of survival did not show a statistically significant greater hazard ratio for overall death (hazard ratio, 1.35; 95% confidence interval, 0.65-2.80; p = .415) or progression (hazard ratio, 1.44; 95% confidence interval, 0.72-2.87; p = .301) for patients undergoing IC/CCRT.

CONCLUSION

Although the sample size was small and not randomized, this matched-pair comparison between a prospective case series and a historical cohort treated at the same institution showed that the efficacy of IC/CCRT with salvage surgery is as good as primary surgical resection and postoperative RT.

Postoperative strategies after primary surgery for squamous cell carcinoma of the head and neck

This review discusses the role of adjuvant treatment after curative surgery for patients with head and neck squamous cell carcinoma (HNSCC). In general, patients with unfavourable prognostic factors have a high-risk of loco-regional recurrence and subsequent worse survival after surgery alone and are therefore considered proper candidates for adjuvant treatment by either postoperative radiotherapy alone or postoperative chemoradiation. Selection of the most optimal adjuvant treatment strategy should be based on the most important prognostic factors. In this review, the different treatment strategies will be discussed in general. More specifically, we will discuss the role of the interval between surgery and radiotherapy, the overall treatment time of radiation, the selection of target volumes for radiation and the value of adding concomitant chemotherapy to postoperative radiation.

Postoperative Radiotherapy in Head and Neck Cancer

Though early stage head and neck cancers can be cured either by surgery or radiation, patients with locally advanced disease continues to pose a therapeutic challenge. Locoregional failure is the major cause of death in head and neck cancers. As the outcome of locally advanced head and neck cancer is less than promising, a combined modality approach is generally undertaken in this group of patients. The combination of surgery, radiation and more recently, chemotherapy and targeted therapy can improve outcomes in locally advanced head and neck cancer patients. This overview discusses the rationale and role of postoperative radiotherapy (PORT) in advanced head and neck cancers, the radiotherapy technique in brief and methods of enhancing the efficacy of postoperative RT by altering the fractionation schedules and adding chemotherapy and targeted therapy.

Effectiveness of adjuvant radiotherapy in patients with oropharyngeal and floor of mouth squamous cell carcinoma and concomitant histological verification of singular ipsilateral cervical lymph node metastasis (pN1-state)--a prospective multicenter randomized controlled clinical trial using a comprehensive cohort design

Background

Modern radiotherapy plays an important role in therapy of advanced head and neck carcinomas. However, no clinical studies have been published addressing the effectiveness of postoperative radiotherapy in patients with small tumor (pT1, pT2) and concomitant ipsilateral metastasis of a single lymph node (pN1), which would provide a basis for a general treatment recommendation.

Methods/Design

The present study is a non-blinded, prospective, multi-center randomized controlled trial (RCT). As the primary clinical endpoint, overall-survival in patients receiving postoperative radiation therapy vs. patients without adjuvant therapy following curative intended surgery is compared. The aim of the study is to enroll 560 adult males and females for 1:1 randomization to one of the two treatment arms (irradiation/no irradiation). Since patients with small tumor (T1/T2) but singular lymph node metastasis are rare and the amount of patients consenting to randomization is not predictable in advance, all patients rejecting randomization will be treated as preferred and enrolled in a prospective observational study (comprehensive cohort design) after giving informed consent. This observational part of the trial will be performed with maximum consistency to the treatment and observation protocol of the RCT. Because the impact of patient preference for a certain treatment option is not calculable, parallel design of RCT and observational study may provide a maximum of evidence and efficacy for evaluation of treatment outcome. Secondary clinical endpoints are as follows: incidence and time to tumor relapse (locoregional relapse, lymph node involvement and distant metastatic spread), Quality of life as reported by EORTC (QLQ-C30 with H&N 35 module), and time from operation to orofacial rehabilitation. All tumors represent a homogeneous clinical state and therefore additional investigation of protein expression levels within resection specimen may serve for establishment of surrogate parameters of patient outcome.

Conclusion

The inherent challenges of a rare clinical condition (pN1) and two substantially different therapy arms would limit the practicality of a classical randomized study. The concept of a Comprehensive Cohort Design combines the preference of a randomized study, with the option of careful data interpretation within an observational study.

Trial registration

ClinicalTrials.gov: NCT00964977