Intraarterial chemotherapy as neoadjuvant treatment of oral cancer

Transcatheter arterial chemoembolization is safe and effective for patients with late-stage or recurrent oral carcinoma

OBJECTIVE

We reported the long-term outcomes of transcatheter chemoembolization (TACE) for patients with late-stage or recurrent oral carcinoma.

METHODS

This retrospective study enrolled 18 patients with late-stage or recurrent oral carcinoma between December 2015 and April 2021. The tumor-feeding artery was catheterized, and cisplatin/oxaliplatin and 5-FU/raltitrexed were infused with embolization using polyvinyl alcohol or gelatin sponge. Computed tomography was performed at about 1, 3, and 6 months after the procedure, and every 6 months after that. During the procedure and follow-up, procedure outcomes, complications, treatment efficacy, and overall survival were analyzed.

RESULTS

A total of 31 sessions of TACE were performed, with a technical success rate of 100%. Of 12 patients combined with oral hemorrhage, two patients showed rebleeding 35 and 37 days later, with a clinical efficiency of hemostasis of 88.9%. Mild complications were observed in 11 patients (61.1%). Severe complications or procedure-related deaths were not observed during or after the procedure. The objective response rate and disease control rate were 20.0% and 86.7%, 38.5% and 61.5%, and 25.0% and 50.0% at 1, 3, and 6 months later, respectively. Seventeen patients (94.4%) were followed up, with a median duration of 37.8 months (IQR 22.3-56.8). Nine patients died of tumor progression, one died of massive rebleeding, and one died of severe lung infection. The median overall survival was 23.8 months.

CONCLUSION

TACE is a safe and effective procedure with minimal invasiveness for treating late-stage or recurrent oral carcinoma. TACE can be recommended as a palliative treatment, particularly for patients with oral hemorrhage.

Risk of Free Flap Failure in Head and Neck Reconstruction: Analysis of 21,548 Cases From A Nationwide Database

BACKGROUND

Head and neck reconstruction is complicated and is made even more challenging by free flap failure. We identified risk factors associated with free flap failure in records extracted from a nationwide database of a 23 million populations.

METHODS

We used International Classification of Diseases, Ninth Version, codes 140 to 149 and 161 to identify patients in Taiwan's National Health Insurance Research Database with head and neck cancer between 2000 and 2013. Patient's age, sex, neoadjuvant treatment, comorbidities, and anticoagulation use were also retrieved. Free flap reconstruction twice, or free flap and pedicle flap reconstructions during the same hospitalization were recorded as free flap failure. Logistic regression was used to identify factors that increased risk of free flap failure.

RESULTS

A total of 21,548 patients with head and neck cancer were identified; 883 (4.1%) experienced free flap failure. Use of aspirin, clopidogrel, urokinase, prostaglandin (PGE1), low-molecular-weight heparin, and operation time were associated with free flap failure. However, some potential confounders could not be identified from the database.

CONCLUSIONS

Several statistically significant findings were prone to influence by potential confounders. The clinically applicable result was that longer operation time and preoperative chemotherapy could increase the likelihood of free flap failure. On the other hand, several factors were proved to be irrelevant to free flap failure.

Prognostic importance of pathological response to neoadjuvant chemotherapy followed by definitive surgery in advanced oral squamous cell carcinoma

Objective

The clinical importance of neoadjuvant chemotherapy (NAC) followed by definitive surgery was retrospectively investigated in clinical Stage III/IV oral squamous cell carcinoma (OSCC).

Methods

Surgery was performed for OSCC in 164 patients, including 72 patients who had received NAC (two cycles of cisplatin and fluorouracil) prior to surgery from January 2004 to December 2014. The clinical characteristics and survival parameters of the groups that received and did not receive NAC were evaluated. The pathological response was classified as Grade 0 (no effect), 1a (very slight effect), 1b (slight effect), 2 (moderate effect) or 3 (marked effect), and its correlation with prognosis was investigated.

Results

There were no statistical differences in survival indicators between patients who received NAC and those who did not (overall survival, P = 0.75). The proportion of patients who received NAC in the effective NAC group (Grades 1b, 2, and 3) was 52.8%. After a median follow-up of 35 months, overall survival (P = 0.01), disease-free survival (P = 0.002), locoregional disease-free survival (P = 0.003), and distant disease-free survival (P = 0.01) were significantly better in the effective NAC group than in the less effective NAC group (Grades 0 and 1a).

Conclusion

Although NAC had a limited effect on disease prognosis in OSCC, the pathological response to NAC could be an important prognostic indicator for advanced OSCC.

Long-term quality of life after intensified multi-modality treatment of oral cancer including intra-arterial induction chemotherapy and adjuvant chemoradiation

Background:

Quality of life (QoL) studies are well established when accompanying trials in head and neck cancer, but studies on long-term survivors are rare.

Aims:

The aim was to evaluate long-term follow-up patients treated with an intensified multi-modality therapy.

Setting and Design:

Cross-sectional study, tertiary care center.

Patients and Methods:

A total of 135 oral/oropharyngeal cancer survivors having been treated with an effective four modality treatment (intra-arterial induction chemotherapy, radical surgery, adjuvant radiation, concurrent systemic chemotherapy) filled European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and HN35 questionnaires. Mean distance to treatment was 6.1 (1.3–16.6) years. Results were compared with a reference patient population (EORTC reference manual). In-study group comparison was also carried out.

Statistical Analysis:

One-sample t-test, Mann–Whitney-test, Kruskal–Wallis analysis.

Results:

QoL scores of both populations were well comparable. Global health status, cognitive and social functioning, fatigue, social eating, status of teeth, mouth opening and dryness, and sticky saliva were significantly worse in the study population; pain and need for pain killers, cough, need for nutritional support, problems with weight loss and gain were judged to be significantly less. Patients 1-year posttreatment had generally worse scores as compared to patients with two or more years distance to treatment. Complex reconstructive measures and adjuvant (chemo) radiation were main reasons for significant impairment of QoL.

Conclusion

Subjective disease status of patients following a maximized multi-modality treatment showed an expectable high degree of limitations, but was generally comparable to a reference group treated less intensively, suggesting that the administration of an intensified multi-modality treatment is feasible in terms of QoL/effectivity ratio.

Accelerated fractionation radiotherapy and late intensification with 2 intra-arterial cisplatin infusions for locally advanced head and neck squamous cell carcinoma

BACKGROUND

This study was established to determine the maximum tolerated dose of intra-arterial cisplatin (IAC) concurrent with accelerated fractionation radiotherapy for locally advanced head and neck squamous cell carcinoma (HNSCC).

METHODS

We conducted a phase I study. Treatment consisted of 70 Gy/35 fractions/5.8 weeks and 2 weekly IAC infusions during the last 2 weeks.

RESULTS

Ten patients were recruited. Two patients had stage III, 1 had stage IVa, and 7 had stage IVb disease. Three patients received IAC at 100 mg/m(2), 3 at 125 mg/m(2), and 4 at 150 mg/m(2). Nine patients received both planned infusions. Dose-limiting toxicity occurred at 150 mg/m(2) as transient grade 4 leukopenia and prolonged grade 3 acute skin reactions. The maximum tolerated dose was 125 mg/m(2). Six patients survived disease-free at 39 to 67 months.

CONCLUSIONS

It was feasible to give IAC concurrent with accelerated fractionation radiotherapy for locally advanced HNSCC. The maximum tolerated dose of cisplatin was 125 mg/m(2).

Self assembled magnetic PVP/PVA hydrogel microspheres; magnetic drug targeting of VX2 auricular tumours using pingyangmycin

Chemotherapy in cancer treatment is associated with serious side effects and as a result there is great interest in research aimed at bringing down the level of systemic cytotoxicity. With advances in material science, magnetic drug targeting has emerged as one of the viable ways of attaining this. In this study, we used self assembled PVP/PVA magnetic hydrogel microspheres to deliver pingyangmycin (Bleomycin A5) to rabbit auricular VX2 tumours in the presence of a 0.5 T permanent magnet both during and 24 h after perfusion. A total of 22 New Zealand white rabbits ranging from 13 to 16 weeks and weighing 2.5-3.0 kg (2.46 +/- 0.2) successfully implanted with tumours 200-300 mm2 in size were used. In group D (1 mg pingyangmycin in 50 mg ferrofluid without a magnet) 2 weeks post treatment, there was statistically significant difference compared to the control (p = 0.05) in favor of group D. However, when compared to the group with 1 mg pingyangmycin(BLM) in 50 mg of ferrofluid and 0.5 mg (BLM) in 50 mg ferrofluid both with a permanent magnet in place for 24 h, the statistically significant difference was in favor of combined treatment, i.e. ferrofluid carrying drug in presence of a permanent magnet (p = 0.01). The microspheres in conjunction with the magnet did deliver pingyangmycin to the tumour and hence may be of use in future as far as magnetic drug targeting is concerned. However, more studies are still required to establish biodistribution and biostability not to forget drug release of ferrofluid of different chemotherapeutic agents available.

CT-Based Evaluation of Tumor Volume After Intra-Arterial Chemotherapy of Locally Advanced Carcinoma of the Oral Cavity: Comparison with Clinical Remission Rates

PURPOSE

To assess the volume of locally advanced tumors of the oral cavity and the oropharynx before and after intra-arterial (i.a.) chemotherapy by means of computed tomography and to compare these data with clinically determined treatment response of the same patient population.

METHODS

Eighty-eight patients with histologically proven, advanced carcinoma of the oral cavity and/or the oropharynx (local tumor stages T3/4) received neoadjuvant i.a. chemotherapy with cisplatin as part of a multimodal therapeutic regimen, comprising (1) local chemotherapy, (2) surgery, and (3) combined radio-chemotherapy. Three weeks after the intervention, residual disease was evaluated radiologically by measurement of the tumor volume and clinically by inspection and palpation of the primary tumor according to WHO criteria.

RESULTS

Comparison of treatment response according to radiological and clinical criteria respectively revealed complete remission in 5% vs. 8% (p < 0.05), partial remission in 30% vs. 31%, stable disease in 61% vs. 58%, and tumor progression in 5% vs. 2%.

CONCLUSION

Radiological volumetry and clinical evaluation found comparable response rates after local chemotherapy. However, in patients with good response after local treatment, volumetric measurement with CT may help to distinguish between partial and complete remission. Thus, radiological tumor volumetry provides precise and differentiated information about tumor response and should be used as an additional tool in treatment monitoring after local chemotherapy.

Reliability of CT-based tumor volumetry after intraarterial chemotherapy in patients with small carcinoma of the oral cavity and the oropharynx

INTRODUCTION

The aim of the study was to evaluate the feasibility and consistency of CT-based tumor volumetry in patients with early carcinoma of the oral cavity and the oropharynx before and after intraarterial (IA) chemotherapy, comparing these data with clinical remission rates.

METHODS

Included in the study were 61 patients (mean age 59.3 years; 47 men) with histologically proven small carcinoma of the oral cavity or the oropharynx (local tumor stages T1/2). Patients received IA chemotherapy with high-dose cisplatin as part of a multimodal therapeutic regimen and underwent both clinical and radiological examination before and 4 weeks after local chemotherapy.

RESULTS

Clinical evaluation of tumor response was possible in all patients (61/61). Radiological assessment of tumor volume was feasible in 42 of 61 patients (69%), but failed in 19 (31%) due to the absence of deep tumoral spread, lack of contrast enhancement or severe dental artifacts. Patients in whom evaluation was possible according to volumetric and clinical criteria revealed comparable remission rates: overall response 54.8% versus 52.4%, stable disease 40.4% versus 47.6%, and tumor progression 4.8% versus 0.0%.

CONCLUSION

Because volume calculation was not feasible in approximately one-third of the patients, it cannot be recommended as a reliable indicator for treatment response in patients with small carcinoma of the oral cavity.

[Local chemotherapy for squamous cell cancer of the oral cavity and oropharynx]

BACKGROUND

Modern treatment concepts for patients suffering from oral and oropharyngeal cancer include more and more adjuvant therapeutic options. Local chemotherapy offers the possibility to apply an extremely high drug concentration at the tumor site while minimizing possible side effects by systemic neutralization at the same time.

PATIENTS AND METHODS

A total of 289 patients with histologically proven carcinoma of the oral cavity and the oropharynx underwent neoadjuvant intra-arterial chemotherapy with high-dosage cisplatin within a multimodal therapeutic setting. Concerning the TNM classification, more than 70% of the patients were classified as stages III and IV. The mean age at the time of intervention was 60 years, and 71% of the patients were male.

RESULTS

After the first cycle 19.3% of the patients presented with complete remission (grade I); 35.4% and 41.5% showed partial remissions (grade II) or stable disease (grade III), respectively. The mean observation time after treatment was 28 months (median: 24.2 months). Of the 137 patients who completed the full multimodal therapeutic scheme, 11% developed local recurrence, and 12.4% developed lymph node or distant metastasis. At the time of evaluation, 72.5% of these patients were still alive.

CONCLUSION

Intra-arterial chemotherapy is a safe and highly effective procedure that should be considered as an important option in multimodal therapeutic concepts for oral and oropharyngeal cancer.

Maximized combined modality treatment of an unselected population of oral and oropharyngeal cancer patients. Final results of a pilot study compared with a treatment-dependent prognosis index

BACKGROUND

In an attempt to raise the survival of an unselected and representative population of oral and oropharyngeal squamous cell cancer patients, a pilot study of an integrated four-modality treatment was conceived. Final endpoints were compliance, loco-regional control, survival (after complete 5-year follow-up), and a concept of trial assessment using the treatment-dependent prognostic index TPI.

PATIENTS

Eighty-seven consecutive patients with histologically proven untreated stages I-IV disease presented in the period between 1997 and 1999 of whom 14 had to be considered uncurable and 73 were fit to be treated with the intention of achieving a cure.

METHODS

All patients received one cycle of neoadjuvant intraarterial chemotherapy with 150 mg/m(2) cisplatin (systemically neutralized with sodium thiosulphate), and, if possible, by consecutive treatment applying both surgery of the primary tumour and the neck lymphatics, as well as by adjuvant radiation over 5 weeks (51.3 Gy) plus concurrent chemotherapy (weekly systemic docetaxel 25 mg/m(2)).

RESULTS

Ninety per cent of all cases and 96% of the patients treated with curative intention received more than one modality due to study design. Patient non-compliance in the group treated with curative intention has been 18/73 (=25%), and protocol compliance has been 32/73 (=44%). The locoregional control rate for all cases was 71% (62/87 patients) and for the patients treated with curative intention 83.5% (61/73 patients). Thirteen/fourteen non-curable patients died after a mean period of 4 months. After a median observation time of 5 years, the final absolute survival of the unselected population was 53%, and of the patients treated with curative intention 62% (especially, 70% and 50% for patients with operable stages III and IV, respectively).

CONCLUSION

The multimodality regimen as presented proved feasible and showed high objective and relative survival rates in comparison with known data from tumour registries of unselected populations. Intra-arterial chemotherapy should be considered a valuable addition to treatment. The potential of survival benefit from this multimodality regimen in comparison with the prognosis index TPI should be investigated in further studies.

Response to intraarterial induction chemotherapy: A prognostic parameter in oral and oropharyngeal cancer

BACKGROUND

Patients with head and neck cancer and good pathologic response to neoadjuvant systemic induction chemotherapy have a better prognosis for survival than do those with stable or progressive disease. Thus, induction chemotherapy could theoretically help in stratifying further treatment, but toxicity is much too high. The prognostic implication of superselective intraarterial high-dose cisplatin administered by a femoral approach, which has much less toxicity, is not yet known.

METHODS

One hundred eighty-seven unselected consecutive patients with previously untreated oral and oropharyngeal squamous cell carcinoma received intraarterial high-dose cisplatin for induction and were assessed for response by visual examination and palpation. This treatment was followed by surgery and adjuvant radiation with concomitant systemic chemotherapy. Omission of a modality depended on individual contraindications and not on preselection. The consequence of omissions has been the constitution of several treatment arms. The overall and disease-free survival in relation to clinical local response after intraarterial induction chemotherapy was calculated using the Kaplan-Meier method. Additional analysis excluded bias caused by stages and treatment arms.

RESULTS

Explorative statistics using the log-rank and chi-square tests demonstrated a strong prognostic relevance of response to intraarterial chemotherapy irrespective of stage and treatment.

CONCLUSIONS

Our results are encouraging for prospective randomized studies and molecular genetic investigations with intraarterial chemotherapy.

Chemoembolization Using Cisplatin Crystals as Neoadjuvant Treatment of Oral Cancer

Chemoembolization for cancer of the head and neck has been used very rarely in the past owing to local characteristics and risks. By combining the antineoplastic activity and embolizing effect in the same drug, a more routine use seems possible. A cisplatin suspension in normal saline (5 mg in 1 mL) with precipitation of microembolizing cisplatin crystals and without additional drugs was prepared. The cisplatin dosage was 150 mg/m2, the maximum absolute dose 300 mg, and the maximum amount of fluid 60 mL. One hundred and three consecutive patients with previously untreated squamous cell carcinomas of the oral cavity and the anterior oropharynx were treated in a neoadjuvant setting with superselective chemoembolization using the cisplatin suspension. Acceptance by the patients has been excellent with no refusal. Overall response after one intervention has been 73%, with 18.5% showing pathological complete remissions. The highest response rates could be seen in T1-3 tumors and tumors of the oral tongue and floor of the mouth. Measurable acute systemic toxicity has been low. Postembolization syndrome, especially swelling, had to be observed carefully. There have been 3.5% interventional and 10% local complications, which could be significantly reduced by the use of this procedure only in cancers of the oral tongue, floor of the mouth, and mandibular alveolar ridge. Chemoembolization of cancer in the head and neck area can be carried out regularly and safely using this method, and it is highly effective. It could be used as an induction before definitive surgery or radiotherapy. Further investigation is mandatory to assess the potential of chemoembolization for the improvement of local control and survival.

Sentinel-Lymphonodektomie als Staging-Methode bei Kopf-Hals-Karzinomen

BACKGROUND

The excision of sentinel lymph nodes has a growing relevance in the diagnosis of oral and oropharyngeal cancer in cases of N0 necks. The validity of sentinel node biopsy (SNB) was examined as a single surgical staging tool.

PATIENTS AND METHODS

Within the framework of a multi-modal treatment scheme, SNB without elective neck dissection was carried out on 70 previously untreated patients in the same session as the surgery for the primary cancer. Control of accuracy was via observation of the manifestation of neck node metastases in 45 patients who were postoperatively irradiated.

RESULTS

A total of 94% of sentinel nodes could be excised; 9 patients (13%) had positive nodes and were treated with a therapeutic neck dissection (ND). There were 2 neck node metastases as second primaries, all other patients remained regionally inconspicuous (median observation time 26 months).

CONCLUSION

As a staging tool for N0 necks and T1-3 tumors, SNB could lead to a considerable reduction in the number of elective NDs. It could be well integrated into a multi-modal treatment scheme.

Pattern of drainage in sentinel lymph nodes after intra-arterial chemotherapy for oral and oropharyngeal cancer

PURPOSE

Prerequisite for lymphoscintigraphy-guided sentinel lymph node (SLN) biopsy in head and neck cancer patients has been a previously untreated primary tumor to avoid disturbance of the lymphatic flow. We evaluated the feasibility in a multimodality treatment approach to oral and oropharyngeal cancer comprising presurgical intra-arterial chemotherapy of the primary tumor.

PATIENTS AND METHODS

In a prospective study of 35 consecutive patients with primary oral and anterior oropharyngeal cancer T1-4N0 treated with superselective intra-arterial chemotherapy with high-dose cisplatin, SLN scintigraphy was performed on the day of surgery, including gamma camera imaging before and hand-held gamma probe identification of the SLN during surgery. SLN biopsy was performed in 50 neck sides, followed by radical resection of the primary in the same session. Elective neck dissection was not carried out. The pattern of lymphatic drainage was recorded and compared with the literature on well-known patterns found in lymphographic studies and metastatic disease in neck dissection specimens of patients without presurgical treatment.

RESULTS

Drainage patterns of SLN related to different primary locations mapped the mentioned comparison patterns. SLN drainage patterns gave strong evidence that there are SLN in levels 3 and 4 with direct drainage from the primary. After a median observation time of 24 months, no patients had a neck relapse.

CONCLUSIONS

The results suggest that intra-arterial chemotherapy of the primary tumor does not significantly alter lymphatic drainage and that SLN biopsy following intra-arterial chemotherapy is feasible and offers valid results comparable to those obtained from patients without presurgical treatment.

Positron Emission Tomography in Combination With Sentinel Node Biopsy Reduces the Rate of Elective Neck Dissections in the Treatment of Oral and Oropharyngeal Cancer

Purpose

To assess the impact of a diagnostic ladder including [18F]fluorodeoxyglucose positron emission tomography (PET) and lymphoscintigraphy guided sentinel node biopsy (LS/SNB) on neck treatment in patients with oral and oropharyngeal squamous cell carcinoma (OOSCC).

Patients and Methods

Prospectively, 62 patients with resectable T1-3 OOSCC underwent computed tomography (CT) and PET. Patients without neck uptake in PET were defined as cN0 and were accrued for LS/SNB. Results were correlated with histopathology. The traditional guidelines according to CT findings were compared to the actual regimen and the outcome.

Results

Sensitivity, specificity, validity, and positive and negative predictive value of PET versus CT were 72% v 89%, 82% v 77%, 79% v 80.5%, 62% v 61.5%, and 88% v 94.5% (not significant). Thirty-eight PET negative patients underwent LS/SNB. Sentinel lymph nodes were found in all 38 patients. Five patients had positive nodes (PET false-negatives) and underwent neck dissection (ND). Fifty-one neck sides in 36 patients who were CT-negative would have been treated with selective ND according to the guidelines, and at least 45 neck sides would have had to undergo extensive ND because of positive CT findings (96 of 124 neck sides). In contrast, PET in combination with LS/SNB spared 59 neck sides, and 41 of 124 neck sides actually underwent ND as a result of PET staging, LS/SNB, and intraoperative decision. After a median follow-up of 35 months, two patients (both cN+ve and pN+ve) suffered from neck relapses.

Conclusion

Diagnostics using PET in combination with LS/SNB considerably reduced the number of extensive ND in OOSCC as compared to CT without locoregional hazard.

Relevance of positive margins in case of adjuvant therapy of oral cancer

Positive or clean surgical margins are of great prognostic interest in the surgical treatment of oral and oropharyngeal cancer with poor survival of patients burdened with positive margins. The impact of postoperative treatment modalities on the survival of these patients is debated. The relevance of positive margins was investigated in three patient populations (a group treated by surgery only, a group with postoperative polychemotherapy, and a group with a multi-modality treatment comprising postoperative radiation with concurrent chemotherapy) which were compared retrospectively. Patients treated with adjuvant regimens following resection in healthy margins had a survival advantage as compared to the surgery only group possibly due to less local relapses and longer relapse latencies. Overall disease-free survival was better in the groups with adjuvant therapy irrespective of free or positive margins. Survival rates following positive surgical margins were worse in all three groups as compared to the respective subgroups with healthy margins. A second resection in patients with positive margins, executed in the group with postoperative radiation with concurrent chemotherapy, did not result in survival improvement. Therefore, radical resection at initial surgery in healthy and clear margins remains indispensable in multi-modality treatment strategies involving surgery. The combination of healthy margins and adjuvant treatment seems to be most favorable for patient survival.

Intra-arterial induction high-dose chemotherapy with cisplatin for oral and oropharyngeal cancer: long-term results

Intra-arterial (IA) chemotherapy for curative treatment of head and neck cancer experienced a revival in the last decade. Mainly, it was used in concurrent combination with radiation in organ-preserving settings. The modern method of transfemoral approach for catheterisation, superselective perfusion of the tumour-feeding vessel, and high-dose (150 mg m⁻²) administration of cisplatin with parallel systemic neutralisation with sodium thiosulphate (9 g m⁻²) made preoperative usage feasible. The present paper presents the results of a pilot study on a population of 52 patients with resectable stage 1–4 carcinomas of the oral cavity and the oropharynx, who were treated with one cycle of preoperative IA chemotherapy executed as mentioned above and radical surgery. There have been no interventional complications of IA chemotherapy, and acute side effects have been low. One tracheotomy had to be carried out due to swelling. The overall clinical local response has been 69%. There was no interference with surgery, which was carried out 3–4 weeks later. Pathological complete remission was assessed in 25%. The mean observation time was 3 years. A 3-year overall and disease-free survival was 82 and 69%, respectively, and at 5 years 77 and 59%, respectively. Survival results were compared to a treatment-dependent prognosis index for the same population. As a conclusion, it can be stated that IA high-dose chemotherapy with cisplatin and systemic neutralisation in a neoadjuvant setting should be considered a feasible, safe, and effective treatment modality for resectable oral and oropharyngeal cancer. The low toxicity of this local chemotherapy recommends usage especially in stage 1–2 patients. The potential of survival benefit as indicated by the comparison to the prognosis index should be controlled in a randomised study.

Rationale for Sentinel Node Biopsy to Stage N0 Head and Neck Squamous-Cell Carcinoma

Sentinel node biopsy is an evolving staging tool in the management of patients with squamous-cell carcinoma of the head and neck. This tool provides a more detailed understanding of the lymphatic pathways within the head and neck and the role of these pathways regarding tumor spreading. By targeting nodes that are most likely to harbor disease, a more detailed pathological evaluation of sentinel nodes is possible-thus improving staging by the identification of micrometastases. The rationale behind the use of sentinel node biopsy to stage the N0 neck are discussed within this paper.

Intralesional chemotherapy for head and neck carcinoma: a review of the literature

In the last decade chemotherapy has gained widespread acceptance in the treatment of oral and pharyngeal cancer. Current standard treatment for advanced lesions consists of concomitant radiation and chemotherapy. This approach has provided marginal improvement of prognosis for Stage III-IV disease. Recent studies have explored the idea that locally delivered cytotoxic drugs could further improve prognosis in this patient population. We review this literature with the objective of popularizing these data and suggesting future directions for treatment and clinical research for head and neck cancer.

Interventional neuroradiology of the head and neck

Vascular interventions are important and helpful for treatment of various pathologies of the head and neck. Interventional neuroradiology of the head and neck includes image-guided biopsies, vessel occlusion, and local chemotherapy. Knowledge of anatomy, functional relationships between intra- and extracranial vessels, and pathology are the basis for therapeutic success. The interventional neuroradiologist is responsible for appropriate selection of patients based on clinical information, indications, and risk assessment. Neuroradiologic imaging, especially CT and MR imaging, and appropriate analysis of angiographic findings help ensure indication for treatment and plan an intervention. Technical equipment, including an angiographic unit, catheters, needles, embolizing materials, and so forth, are important. Knowledge of hemodynamics is relevant to avoid complications and to find the optimal technique for solving the clinical problem. Indications for image-guided biopsies are preverterbal fluid-collections, spinal and paraspinal inflammations and abscesses, deep cervical malignancies, vertebral body, and skull base tumors. Special care should be taken to preserve critical structures in this region, including spinal nerve roots, cervical plexus, main peripheral nerves, and vessels. Indications for vessel occlusion are emergency situations to stop bleeding in vascular lesions (traumatic, malformation, or tumors) by reduction of pressure, preoperative reduction of blood flow to minimize the surgical risk, palliative occlusion of feeding vessels to produce tumor necrosis, or potential curative (or presurgical) occlusion of vascular malformations. Pressure reduction to support normal coagulation, such as epistaxis, in hereditary hemorrhagic telangiectasia can be achieved by proximal vessel occlusion with large particles or platinum coils. Prevention of intraoperative bleeding requires occlusion of the microvascular bed with small particles. Examples of these interventions are: a hemangioma of the hard palate, a juvenile angiofibroma, a hemangiopericytoma, a malignant meningioma, a malignant fibrous histiocytoma, and a glomus tumor. Effective treatment of vascular malformations, such as AV fistulas or angiomas, needs exact occlusion of the fistula or the angiomatous nidus, which is demonstrated in the case of an AV angioma of the base of the tongue. Chemotherapy with local intra-arterial cisplatin combined with intravenous administration of sodium thiosulfate as antidote is indicated as an adjuvant modality in a multimodal regimen of oropharyngeal squamous cell carcinoma or as palliative treatment of recurrent and otherwise untreatable malignant tumors of the head and neck. Examples are a carcinoma of the alveolar ridge, a squamous cell carcinoma of the floor of the mouth, and a nasopharyngeal lymphoepithelioma. Palliative treatment of a bleeding oropharyngeal cancer is another example of interventional treatment. Selective treatment, either occluding or pharmacologic, may be preoperative, palliative, or curative. The objective is reduction of surgical risk, improvement of quality of life, or curative therapy of a lesion. Thus, the interventional treatment should not be associated with morbidity or mortality. Major complications, such as cerebral stroke, blindness, or cranial nerve palsies, can result from application of inappropriate techniques or poor evaluation of angiographic findings and should be avoided in the majority of cases. Sometimes collateral lesions are unavoidable. These include inflammation, necrosis, and nerve damage. Based on neuroradiologic experience, most of those risks are predictable. The benefits, risks, and expected damages of neuroradiologic interventions must be balanced during the informed consent procedure with the patient. Avoiding complications, handling unavoidable problems, and dealing with complications is a skill founded on knowledge and experience. Continuing education is a firm basis to push the limits of interventions and expand benefits without increasing risk for the patient. Nevertheless, state-of-the-art external carotid intervention should, in skilled hands, have a permanent morbidity far below 1% and no mortality.

Combined modality treatment of oral and oropharyngeal cancer including neoadjuvant intraarterial cisplatin and radical surgery followed by concurrent radiation and chemotherapy with weekly docetaxel - three year results of a pilot study

BACKGROUND

A new four-modality treatment of primary oral and oropharyngeal squamous cell carcinomas was evaluated with regard to feasibility, tolerance, and survival.

PATIENTS AND METHODS

Seventy three operable patients (100%) with histologically proven untreated stage I to stage IV disease received at least one cycle of neoadjuvant intraarterial chemotherapy with 150 mg/m(2) cisplatin neutralized with sodium thiosulphate, followed by radical operation for the tumour with a simultaneous selective neck dissection (clinically negative neck), or modified radical neck dissection (nodal involvement), followed by adjuvant chemoradiation over 5 weeks (51.9 Gy, systemic docetaxel 25 mg/m(2), once every week).

RESULTS

Ninety-six per cent of patients were operated on, 68% had postoperative radiation, 57% concomitant chemotherapy; 44% fulfilled the complete protocol. There have been 11 local or regional recurrences to date, three of which were treated by salvage surgery. Eighteen patients died, in nine of them death was tumour-related. Seventy five per cent lived after a median observation time of 33 months. Cumulative survival was 74% calculated for 4 years.

CONCLUSION

The presented multimodality regimen proved feasible and showed better survival for the whole population and for all tumour stages when compared with the treatment-dependent prognosis index of the DOSAK (German-Austrian-Swiss Cooperative Group on tumours of the maxillofacial region).

Long-term complete remission of oral cancer after anti-neoplastic chemotherapy as single treatment modality: role of local chemotherapy

The impact of intra-arterial local chemotherapy on squamous cell carcinomas of the oral cavity is doubtful when considering long-term survival, especially in cases of nodal involvement. But even in patients with strictly local disease it is not possible to determine the effect of intra-arterial chemotherapy because it is mainly used as a neoadjuvant treatment modality. In the present paper, long-term courses of two patients are described who refused any further treatment after one cycle of intra-arterial chemotherapy with cisplatin followed by systemic chemotherapy with 5-fluorouracil and one cycle of intra-arterial chemotherapy with high-dose cisplatin, respectively. The aim of the paper is to demonstrate the potential of local chemotherapy in responders. The impact of this treatment modality in incurable patients is discussed, too. This may offer a point in favor of use of intra-arterial chemotherapy in combination treatment regimens.

In vitro cytotoxic dose-relation of cisplatin and sodium thiosulphate in human tongue and oesophageal squamous carcinoma cell lines

BACKGROUND

Intraarterial chemotherapy of oral and oropharyngeal cancer with cisplatin (cis-diamminedichloroplatinum [II]) has experienced a revival in the last decade. Side-effects of the therapy were very low with concomitant systemic infusion of the neutralizing agent sodium thiosulphate. The requisite dose of the chemotherapeutic agent which safely leads to apoptosis of oral cancer cells has not yet been assessed in vitro, nor has the combination of cisplatin and sodium thiosulphate been examined for the potential reduction of cytotoxicity in oral cancer cells.

STUDY DESIGN

In a panel of two tongue squamous cancer cell lines and an oesophageal cancer cell line as control and comparison, cisplatin (0.2-10 microgram/ml) was combined with sodium thiosulphate (0-0.5 mg/ml).

RESULTS

10 microgram/ml of cisplatin proved to be 100% antiproliferative, while any additional concentration of sodium thiosulphate decreased this effect. At the maximum dose of cisplatin, a sodium thiosulphate/cisplatin concentration relation of less than 6:1 still effected cytotoxic activity of >80%. An increase of cisplatin concentration led to higher cytotoxicity irrespective of sodium thiosulphate concentration. The oesophageal cell line was more sensitive to cisplatin and to sodium thiosulphate than the tongue cell lines.

CONCLUSIONS

In this study, it was found that high concentrations of cisplatin are necessary in oral cancer to reach cytotoxic levels which support high-dose intraarterial chemotherapy by which these levels might be reached. A sodium thiosulphate/cisplatin concentration ratio within the tumour of less than 6:1 may be allowed without compromising the cytotoxic activity of cisplatin.

Monocomponent chemoembolization in oral and oropharyngeal cancer using an aqueous crystal suspension of cisplatin

Intensification of intra-arterial chemotherapy with high-dose cisplatin and concomitant reduction of toxicity under the conditions of the head and neck was aimed at by combination of antineoplastic activity and embolizing effect in the same pharmacon. A cisplatin suspension in normal saline (5 mg in 1 ml) with precipitation of microembolizing cisplatin crystals was prepared. No additional pharmacons. Cisplatin dosage was 150 mg m(-2), maximum absolute dose 300 mg, maximum amount of fluid 60 ml. Thirty patients (UICC-Classification of tumours: I/2 patients, II/6, III/2; IV/20) were treated in a neoadjuvant setting with superselective chemoembolization using the cisplatin suspension. A control group (n=30) with the same tumour and nodal staging was treated with a usual cisplatin solution (150 mg m(-2) dissolved in 500 ml saline). In both groups, parallel intravenous infusion of sodium thiosulphate (9 g m(-2)). Endpoints were toxicity and response. Continuation of treatment by surgery or radiation. Overall remission was 70% in the study group and 46.7% in the control group after one cycle respectively. Systemic side-effects were very low (grade I WHO) in both groups. Side-effects were found to be similar to post-embolization syndrome (swelling, mild to moderate pain, leucocytosis without fever) in the study group. Chemoembolization in the head and neck area can be carried out routinely using this method.

[Factors affecting local and regional control and survival of carcinomas of the tongue and floor of mouth]

A retrospective study of 142 patients that had previous surgery for carcinoma of the tongue or floor of mouth looking into the factors that affect significantly the evolution of our patients and in which circumstances we could benefit from new therapeutic techniques. Cause specific survival at 3 and 5 years was 63.4% and 56.9% respectively. Recurrences were found locally in 32 patients (22.5%), regional in 32 (22.5%) and metastasis in 11 (7.4%). T staging had no did impact on local recurrence, but the presence of positive margins (p = 0.0323). Regional control for N0/N1 was 85% (90/106) versus 55.5% (20/36) for N2/N3 (p = 0.001). Regional control by N staging was 84.5% (73/86) for N0, 85% (17/20) for N1, 57% (30/35) for N2 and 0% for N3 (0/1). Both, N staging and number of positive nodes had a significant impact in specific survival. Positive margins and the presence of positive nodes have the greatest impact on survival and regional control. Adjuvant postoperative radiotherapy did not increase survival, but not prospective random selection was performed. To evaluate this.

Chemoembolization of oral and oropharyngeal cancer using a high-dose cisplatin crystal suspension and degradable starch microspheres

The aim of the study was to achieve intensification of intraarterial chemotherapy of head and neck cancer with high-dose cisplatin by establishing a new method of chemoembolization which can be routinely used without the earlier drawbacks of the method (low drug dosage due to early occlusion of the small head and neck vessels, danger of local damage). Thirty two patients with previously untreated oral and oropharyngeal squamous cell carcinomas of all stages were treated by at least one superselective chemoembolization via femoral approach using a new preparation format of 150 mg/m(2) cisplatin which is an aqueous crystal suspension. In defined cases, combination with the delivery of degradable starch microspheres (DSM). Systemic neutralization with sodium thiosulfate. Primary end points were tolerance and response. Subsequent treatment was surgery or radiation. Chemoembolization succeeded in all 37 interventions to date. Overall response after one cycle was 64.7% using the cisplatin crystal suspension only (n=17) and 86.6% using additional DSM chemoembolization (n=15), as assessed 3 weeks after treatment. Systemic toxicity was extremely low, local side-effects (pain, swelling, small necrosis) were pronounced after additional delivery of DSM. There have been three complications (tracheotomy due to swelling, temporary facial paralysis twice due to embolization of the geniculate ganglion). Using the high-dose cisplatin crystal suspension, chemoembolization can routinely be used in the head and neck area as neoadjuvant therapy. Response was better than with former comparable regimens. The additional delivery of DSM was complicated, restricted to certain areas and unreliable in the dosage needed and might be omitted, therefore.

Intra-arterial embolization of head-and-neck cancer with radioactive holmium-166 poly(L-lactic acid) microspheres: an experimental study in rabbits

A total of 22 NZW rabbits with VX2 squamous cell carcinomas transplanted into the auricles were intra-arterially (i.a.) embolized with radioactive or inactive holmium-labelled poly(L-lactic acid) (HoPLA) microspheres with a mean diameter of 38-80 microm. The effects on tumour growth, the efficiency of i.a. infusion, the efficacy of retention of microspheres in the primary tumour and the excretion of free holmium-166 were analyzed. Complete tumour remissions were obtained in 79% and 86% following embolization with radioactive and inactive microspheres, respectively. Over 95% of the microspheres were retained in the tumour and the leaching of holmium-166 in urine and faeces was less than 0.1% in 2 days. The injection efficiency was not optimal, as 40% of the microspheres were retained in the cannulation system. Arterio-arteriolar connections should be detected and closed prior to embolization to prevent stray emboli from entering the brain. It is concluded that 166HoPLA microspheres are promising candidates for further studies on radio-embolization of unresectable head-and-neck cancer.