A comparison of surgery and radiotherapy in the management of post-cricoid carcinoma

Post-cricoid and Upper Oesophagus Cancers Treated with Organ Preservation Using Intensity-modulated Image-guided Radiotherapy: a Phase II Prospective Study of Outcomes, Toxicity and Quality of Life

AIMS

To prospectively examine the outcomes, toxicity and quality of life (QoL) of patients with post-cricoid and upper oesophagus (PCUE) cancers treated with an organ-preservation approach of (chemo)-radiotherapy using intensity-modulated image-guided radiotherapy (IM-IGRT).

MATERIALS AND METHODS

This phase II prospective study was conducted at a tertiary cancer centre from February 2017 to January 2020. Forty patients with squamous cell carcinoma of PCUE of stage T1-3, N0-2, M0 were accrued. Gross exolaryngeal extension/dysfunctional larynx were major exclusion criteria. Patients received 63-66 Gy in once-daily fractions using volumetric modulated arc therapy with daily IGRT. Outcome measures included disease-related outcomes, patterns of failure, Radiation Therapy Oncology Group toxicities, feeding tube dependency and QoL.

RESULTS

The median follow-up was 22 months. Twenty-six (87.5%) patients had locoregionally advanced disease and 34 (85%) patients received (chemo)-radiotherapy. A complete response was observed in 26 (65%) patients. The 2-year locoregional control, event-free survival and cause-specific survival were 59.6%, 40.2% and 44.8%, respectively. The volume of primary tumour (GTVPvol) exceeding 28 cm³ had inferior overall survival (P = 0.005) on univariate analysis. Multivariable analysis showed GTVPvol and positron emission tomography-computed tomography maximum standardised uptake value to be independently predictive for event-free and overall survival. A feeding tube requirement at presentation was seen in 11 (27.5%) patients, whereas long-term feeding tube dependency at 6 months was seen in 10 (37%) patients. For QoL, a statistical improvement in pain, appetite loss and swallowing was observed over time.

CONCLUSION

Although the outcomes of PCUE cancers remain dismal, the use of state of the art diagnostic modalities, careful case selection and modern radiotherapy techniques improved outcomes as compared with before in this exclusive analysis of PCUE cancers.

A Prospective Study Comparing Laparoscopic vs. Conventional Stomach Pull Up in Total Pharyngo-Laryngo-Esophagectomy for Post Cricoid Cancer

The aim of this study is to compare laparoscopic and conventional techniques following Total Pharyngo-laryngo-esophagectomy (TPLE) with respect to perioperative morbidity and mortality and postoperative recovery in post cricoid cancer patients. This is a prospective study, which was undertaken in Gujrat Cancer Research Institute (GCRI) in the period of July 2007 to March 2010. Fifteen consecutive patients who underwent laparoscopic TPLE were compared to that of 18 consecutive patients who underwent open TPLE. Laparoscopic and open TPLE procedure were compared with respect to patient characteristics, intra operative and complications present. The average duration was observed to be 3.5 h in the MIS (Minimally Invasive Group) group and was 5.3 h in the open group. The average blood loss was 300 mL in the MIS group and 500 mL in the open group. Average duration of the hospital stay in the MIS group was 13 days and 16 days in the open group. In the MIS group, one patient (6.7%) had a pneumonic complication and two patients (13%) had wound complications. In the open group, six patients (33%) had pneumonic consolidation and four patients (22%) had wound infections. In both groups, one patient each suffered mortality. Laparoscopic TPLE has been found to be much safer with less morbidity as compared with open surgery.

Treatment patterns and survival outcomes of advanced hypopharyngeal squamous cell carcinoma

Background

This study evaluated the treatment outcomes of the primary surgery (PS) or concurrent chemoradiotherapy (CCRT) as the initial treatment for hypopharyngeal squamous cell carcinoma (HPSCC).

Methods

This retrospective cohort study included patients with stages III–IV HPSCC from four tertiary referral centers consecutively enrolled from 2003 to 2012; of them, 213 (32.6%) and 439 (67.4%) had received PS and CCRT as their primary treatments, respectively. The 5-year overall survival (OS) and disease-free survival (DFS) rates were analyzed using the Kaplan–Meier method and Cox regression models.

Results

In patients undergoing PS and CCRT, OS rates were 45.0% and 33.1% (p < 0.001), respectively, and DFS rates were 36.2% and 28.9% (p = 0.003), respectively. In subgroup analysis, in patients with stage IVA HPSCC, PS was associated with higher OS rate (p = 0.002), particularly in those with T4 or N2 classification (p = 0.021 and 0.002, respectively). Multivariate analysis indicated that stage IVA HPSCC, stage IVB HPSCC, and CCRT were independent adverse prognostic factors for OS rate (p = 0.004, < 0.001, and 0.014, respectively). Furthermore, in patients with stage IVA HPSCC aged ≥ 65 years and with N2 classification, CCRT was significantly associated with lower OS rates than was PS (p = 0.027 and 0.010, respectively).

Conclusions

In patients with advanced HPSCC, PS was significantly associated with better prognosis than CCRT. PS could be a favorable primary treatment modality for the management of patients with stage IVA HPSCC, particularly those aged ≥ 65 years and with T4 and N2 classification.

The Emerging Role of Robotic Surgery among Minimally Invasive Surgical Approaches in the Treatment of Hypopharyngeal Carcinoma: Systematic Review and Meta-Analysis

The aim of this systematic review with meta-analysis was to investigate the available literature on transoral approaches in the treatment of hypopharyngeal squamous cell carcinoma, with a special focus on transoral robotic surgery (TORS). A systematic review was conducted according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) check-list, and 15 studies were included. Five of the included studies evaluated TORS, while ten studies focused on transoral laser microsurgery (TLM) for the treatment of early or advanced stage hypopharyngeal cancer. Overall, survival rates of TLM and TORS studies, analyzed together in the cumulative meta-analysis, were 66.4% (95% confidence interval (CI) 54.3%–76.7%) at 36+ months of follow up. The TORS subgroup showed a higher cumulative survival rate (85.5%, 95% CI 55.8%–96.5%) compared to TLM (58.5%, 95% CI 46.6%–69.6%). Cumulative data showed that 29.3% (95% CI 24.0%–35.3%) of deaths were attributable to cancer. The results were similar between TLM and TORS studies. The larynx function preservation cumulative rate was 94.3% (95% CI 91.8%–96.1%). The results were similar among the two subgroups. The present review supports the use of transoral approaches in the treatment of hypopharyngeal cancer. TORS is oncologically sound and provides excellent functional results with low complication rates.

Detection of Human Papilloma Virus and Risk Factors among Patients with Head and Neck Squamous Cell Carcinoma Attending a Tertiary Referral Centre in South India

Background:

Head and Neck Squamous Cell Carcinomas (HNSCC) is the sixth most common cancer globally. In India, on an average 25-30% of all cancer cases affect the head and neck. The etiological factors associated with HNSCC are tobacco, alcohol and environmental carcinogens. However there are few cases, where there are no obvious risk factors involved. In western counties, there are many reports of human papilloma virus (HPV) association with HNSCC. Hence, we conducted a study to determine the role of HPV infection and risk factors among patients with HNSCC.

Materials and Methods:

A prospective, cross-sectional study was conducted in a tertiary referral centre from January 2014 to March 2016. 88 patients were enrolled in the study. Socio- demographic, behavioural data, site and subsite involvement, histopathology, staging and treatment were documented. Polymerase chain reaction (PCR) was performed to detect the presence of HPV DNA using consensus primers MY 09/11 and GP5+/GP6+ and further the samples were subjected to PCR for detecting HPV type 16 and 18.

Results:

The study included 88 participants with HNSCC. 57 had oral and oropharyngeal squamous cell carcinoma, 11 with laryngeal malignancy and 20 involving hypopharynx. Among the participants buccal mucosa (n=22) was the most common subsite involved, majority (50%) had moderately differentiated squamous cell carcinoma and 53.4% presented in stage IV. 2 (2.6%) cases were positive for HPV consensus and both were positive for HPV 16, one case each in larynx and hypopharynx. There was statistical significance in the association between betel nut chewing, cigarette smoking and alcohol intake as risk factors in the carcinogenesis of HNSCC.

Conclusion:

In our setting in South India, HPV does not play a major role in the carcinogenesis of HNSCC but betel nut chewing, tobacco exposure and alcohol consumption remain major risk factors for HNSCC.

Revisiting the gastric pull-up for pharyngoesophageal reconstruction: A systematic review and meta-analysis of mortality and morbidity

Gastric pull-up (GPU) is among the oldest techniques for reconstructing the pharyngoesophageal junction following cancer resection. This review examines morbidity and mortality rates following GPU pharyngoesophageal junction reconstruction from 1959 until present: 77 studies, 2,705 patients. The odds of mortality, anastomotic complications, and other complications decreased by 37.2% (95%CI = 28.0-45.3%; P < 0.0001), 8.0% (95%CI = -2.1 to 17.1%; P = 0.12), 21.0% (95%CI 3.5-35.2%; P = 0.021) per decade respectively. J. Surg. Oncol. 2016;114:907-914. © 2016 Wiley Periodicals, Inc.

Management algorithm for failed gastric pull up reconstruction of laryngopharyngectomy defects: case report and review of the literature

BACKGROUND

Gastric pull up remains a popular reconstructive option for pharyngoesophagectomy defects extending to thoracic inlet. Gastric necrosis is a dreaded complication of gastric pull up reconstruction and few studies report on management of this complication. MEDLINE, EMBASE, and Web of Science™ databases were searched for publications in the last 25 years on gastric pull up reconstruction following pharyngoesophagectomy. The rates of complications related to gastropharyngeal anastomosis were extracted, and methods of managing gastric necrosis were noted. Forty seven case series were identified reporting on the use of gastric pull up for reconstruction of pharyngoesophageal defects. Mortality rate varied from 0 to 33 % with a weighted average of 8.6 %. In 39 % of patients, mortality was either caused or directly related to failure of the gastropharyngeal anastomosis. The reported rate of gastric necrosis ranged from 0 to 24 % resulting in a 28 % mortality. Options for managing gastric necrosis included: temporary cervical diversion, free jejunum flap, colonic interposition, tubed radial forearm flap, deltopectoralis and pectoralis myocutaneous flaps.

CASE PRESENTATION

We present the first case of an anterolateral thigh flap rescue of gastric necrosis after gastric pull up reconstruction. The case report is followed by a review of literature on management of gastric pull up failures.

CONCLUSION

Based on the extracted information, we propose an algorithm for managing gastric pull up failure following pharyngoesophageal reconstruction.

Dysphagia as a cause of chest pain: an otolaryngologist's view

Dysphagia is an important alarm symptom, commonly associated with chest pain; it is often associated with reflux disease, xerostomia, or tumors of the head and neck. However, simple diagnoses such as aspiration of a foreign body can be overseen and may result in major complications, such as perforation and mediastinitis. It is thus of crucial importance that a thorough gastrointestinal, cardiac, and radiologic examination precede a rigid esophagoscopy by an otolaryngologist. In this article the differential diagnoses of dysphagia are discussed, and the otolaryngologist's approach to diagnosis and therapy are explained.

Treatment results and prognostic factors in locally advanced hypopharyngeal cancer

CONCLUSIONS

We suggest that concurrent chemoradiation (CCRT) is an effective definitive treatment for patients with advanced hypopharyngeal carcinoma who are unfit for or refuse surgery. A high dose of radiation (> 70 Gy) should be given to achieve acceptable local control rates and survival.

OBJECTIVES

The purpose of this retrospective study was to compare the treatment results of locally advanced hypopharyngeal carcinoma with two different protocols.

PATIENTS AND METHODS

From December 1995 to December 2004, 74 patients with locally advanced hypopharyngeal cancer were treated with CCRT or surgery plus postoperative radiotherapy (SRT). Their treatment results were reviewed by retrospective analysis. The study points included outcome, toxicity, and prognostic factors.

RESULTS

There was no significant difference in T and N status between the two treatment groups, nor were there significant differences in overall or disease-free survival or the incidence of distant metastasis (p >0.05). In the CCRT group and SRT group, the estimated 3-year overall survival was 39% and 44%, respectively. The SRT group had better local control than the CCRT group (p <0.05). Relatively, 27% patients retained their larynx function for more than 2 years in the CCRT group. Radiation doses >70 Gy yielded significantly better survival and local control than doses <70 Gy (p <0.05).

A clinical study of post-cricoid carcinoma

CONCLUSION

The local control rate following surgery was very high in patients with post-cricoid carcinoma; however, many of the patients undergoing surgery later developed distant metastasis. Therefore, establishment of chemotherapeutic regimens for preventing distant metastasis is desirable.

OBJECTIVES

To define the clinical course of the cancer, the problems that might be associated with its treatment, and the future course of treatment of this cancer at our hospital.

PATIENTS AND METHODS

This study included 21 patients with post-cricoid carcinoma who had undergone primary treatment at our hospital between 1989 and 2004. The present study was designed to retrospectively investigate the therapeutic outcome of post-cricoid carcinoma at our hospital.

RESULTS

The 5-year cause-specific survival rate was 52%. All the patients who eventually died did so within 3 years of the treatment. Seven patients had distant metastases, representing a higher frequency as compared with that of patients with recurrence of the primary focus and cervical lymph node metastasis. All of these patients who had been treated by surgery died of the cancer.

Minimally invasive pharyngo-laryngo-esophagectomy: a salvage procedure for recurrent postcricoid esophageal cancer

Hypopharyngeal and cervical esophageal tumors represent 5-10% of all esophageal neoplasms and are challenging for both surgeons and oncologists, because the choice of the adequate therapeutic strategy is not clearly defined and therefore difficult. In fact, although surgical treatment represents the gold standard of therapy, chemo-radiotherapy, previously used as adjuvant treatment, has been more recently adopted with curative intent, leaving to surgery a salvage role only. When surgery is required it is advisable to reduce patients' trauma. The present study reports on a personal technique for minimally invasive pharyngo-laryngo-esophagectomy and reconstruction with the whole stomach. We use a laparoscopic approach for mobilization of the stomach, transhiatal esophageal dissection and to follow transhiatal gastric transposition to the neck combined to a cervicotomy to perform pharyngo-laryngectomy, proximal esophageal mobilization, and pharyngo-gastric anastomosis. We performed this technique on four patients with recurrent disease after initially curative primary chemo-radiotherapy. Mean operative time was 345 min (range: 300-384). There were no intraoperative complications. All patients were extubated immediately after the operation and were managed in postoperative care unit for a mean time of 10 days (range: 7-12). Enteral nutrition was begun on post-operative day (POD) 1. The nasogastric tube and drainages were removed on POD 11, and patients immediately started oral nutrition. One patient had a TIA (transient ischemic attack) on POD 2. All patients were discharged within 20 days (18-20). Initial experience with this minimally invasive technique in selected patients is encouraging because it seems to minimize postoperative complications and allows early rehabilitation.

Management of the patients with hypopharyngeal cancer: eight-year experience of Miyagi Cancer Center in Japan

The aim of this study is to evaluate the results of treatment for hypopharyngeal cancer and indicate the future prospect of the treatment. Seventy-four patients with squamous cell carcinoma of the hypopharynx admitted to Miyagi Cancer Center from 1993 through 2000 are reviewed. Sixty-four patients received radical treatment, and 10 patients received palliative treatment or no treatment. The cancer was advanced (stages III and IV) in 82% of all the patients. The overall 5-year survival rate of all the patients was 38%. The overall 5-year survival rate of 64 patients received radical treatment was 43%. The ten patients who received palliative treatment or no treatment died of cancer within 16 months. Fifty-two out of the 74 patients underwent neck dissection for the neck lymph node involvement; forty of the 52 patients underwent ipsilateral neck dissection and 12 underwent bilateral neck dissection. Four out of the 40 patients, who underwent ipsilateral neck dissection alone, developed late contralateral regional recurrence but were successfully treated by contralateral neck dissection at the time of recurrence. Twenty-three out of 74 patients had multiple primary cancers synchronously or metachronously (31%). Cause of the death of six patients out of 74 patients was confirmed to be primary cancers other than hypopharyngeal cancer, as judged by physicians in other department or other hospitals. Most of the patients died due to distant metastasis from hypopharyngeal cancer or other primary cancers. We therefore conclude that contralateral elective neck dissection which is frequently chosen for the treatment of hypopharyngeal cancer surgery is unnecessary. Even if locoregional control is accomplished, distant metastasis or multiple primary cancers emerge and make prognosis poor. To improve the prognosis, we should develop some strategy against hypopharyngeal cancer for each patient. New strategies including chemoprevention and surgery against distant metasistasis are necessary.

Treatment of hypopharyngeal carcinoma: analysis of nationwide study in the Netherlands over a 10-year period

OBJECTIVE

To analyse different treatment strategies and treatment results of hypopharyngeal carcinoma in the Netherlands.

DESIGN

Retrospective study.

SETTING

Eight head and neck centres in the Netherlands.

PARTICIPANTS

A total of 893 patients were treated between 1985 and 1994. Patients were mostly treated with radiotherapy alone, combined surgery and radiotherapy and surgery alone.

RESULTS

The 5-year survival for the whole group was 26%. The 5-year survival for patients treated with curative intention was 32% and treated with palliative intention was 5%. The 5-year disease-free survival after radiotherapy alone was 37%, after surgery alone 41% and after combined therapy 47%. The role of chemotherapy could not be investigated because of a small number of patients treated with chemotherapy in this period.

CONCLUSION

Combined therapy with surgery and radiotherapy has a better survival for patients with a hypopharyngeal carcinoma in comparison with radiotherapy alone. The N-stage is more important for the prognosis than the T-stage.

[Reconstruction after total circular pharyngolaryngectomy: comparison between gastric interposition and free jejunal flap]

AIM OF THE STUDY

To elucidate hospital mortality, morbidity and actuarial survival rates of patients with carcinoma of the hypopharynx and cervical oesophagus and to identify the technique of choice for reconstruction after pharyngolaryngectomy.

PATIENTS AND METHODS

We reviewed the records of 209 patients who underwent total pharyngolaryngectomy between May 1982 and January 2000. The majority of patients had advanced cancer: hypopharyngeal in 131 cases and cervical oesophageal in 78 cases. Follow-up was complete for all patients. Chi 2 and log rank tests were used, with a limit of significance of 5%.

RESULTS

The postoperative mortality and morbidity rates were 4.8% and 38.3%, respectively. Alimentary continuity was achieved using the stomach (127 patients), colon (5 patients), or free jejunal autograft (77 patients). The 1-year and 5-year survival rates were 62% and 24%, respectively. There was no significant difference with regard to the survival between gastric transposition and free jejunal autograft, but there were fewer complications in the gastric pull-up group with regard to the respiratory complications (33% vs 47.0%, p < 0.05), local recurrences (15.8% vs 33.8%, p = 0.004) and survival without dysphagia (76% vs 89%, p < 10(-5)).

CONCLUSION

Surgical ablation is a viable option for advanced hypopharyngeal and cervical oesophageal neoplasms, and stomach interposition is the preferred method of reconstruction.

Advanced hypopharyngeal carcinoma treatment results according to treatment modalities

BACKGROUND

The purpose of this retrospective study is to compare the treatment results of locally advanced hypopharyngeal carcinoma according to treatment modalities.

METHODS

Seventy-three patients with locally advanced hypopharyngeal carcinoma treated at the Department of Therapeutic Radiology, Seoul National University Hospital, between August 1979 and July 1997 were retrospectively analyzed. Twenty-three patients were treated with radiotherapy (RT) alone, 18 patients were treated with surgery and postoperative RT, and 32 patients were treated with neoadjuvant chemotherapy (CTx) and RT. Median follow-up period was 28 months.

RESULTS

The overall 5-year survival rates were 15.7% for the RT alone group, 46.8% for surgery and postoperative RT group, and 43.0% for neoadjuvant CTx and RT group. The 5-year disease-free survival rates were 13.9%, 47.4%, and 30.7%, respectively. Surgery and postoperative RT or neoadjuvant CTx and RT showed superiority over RT alone in terms of both overall survival and disease-free survival rates. No significant differences were found in overall and disease-free survival rates between the surgery and postoperative RT group and neoadjuvant CTx and RT group (p =.15, p =.13). In the neoadjuvant CTx and RT group, 12 patients (38%) retained their larynx more than 5 years.

CONCLUSION

Neoadjuvant CTx and RT is an effective strategy to achieve organ preservation without compromising the survival of patients with locally advanced hypopharyngeal carcinoma.

Surgical treatment for hypopharynx carcinoma: feasibility, mortality, and results

This study seeks to evaluate treatment modalities, mortality after surgery, survival, and local control rates for a consecutive cohort of patients with cancer of the hypopharynx treated according to a prospective protocol that favors surgery as an initial approach to the disease. The charts of 228 consecutive patients with previously untreated hypopharyngeal squamous cell carcinoma were reviewed. Outcome measures (overall survival, disease specific survival, and local control) were calculated using the Kaplan-Meier estimator. Of 228 consecutive patients, 136 (59.6%) were found suitable for initial surgical treatment. Of the remaining 92 patients, 18 (7.9%) had nonresectable lymph node metastases, 16 (7.0%) had unresectable primary tumors, 13 (5.7%) refused surgery, and 13 (5.7%) presented distant metastases during initial diagnostic evaluation. Of those who had surgery, 46 had larynx-sparing procedures, 54 had total laryngectomy, and 36 had total laryngo-pharyngectomy. None of the patients who had surgery died postoperatively. Actuarial 5-year overall survival was 27.2% for all 228 patients, 39.5% for the 136 patients with surgical treatment, and 61.1% for the 46 patients who were treated with larynx-sparing procedures.

A comparison of surgery and radiotherapy in the management of advanced pyriform fossa carcinoma

This retrospective study analyses the outcome of treatment of 61 patients with advanced carcinoma of the pyriform fossa. Thirty-two patients (group 1) underwent surgery and postoperative radiotherapy and 29 patients (group 2) had induction chemotherapy followed by radiotherapy. The local recurrence-free survival at 5 years from the completion of therapy for group 1 was 54%, compared to 61% for group 2. The 5-year neck recurrence-free survival for groups 1 and 2 were 54% and 59%, respectively. The 5-year overall survival rates for groups 1 and 2 were 19% and 14%, respectively. Non-surgical therapy for advanced stage pyriform fossa cancer provides survival comparable with that achieved with the standard approach of surgery and postoperative radiotherapy. We advocate radical irradiation as the method of choice because it provides nodal coverage to the bilateral jugular chains and retropharyngeal nodes, all known to be at risk for metastases, and is associated with lower morbidity compared to surgery. But, however, despite the therapy, the outcome is poor.