The patterns and treatment of recurrence following radiotherapy for carcinoma of the oral cavity

Interstitial high-dose-rate brachytherapy combined with cervical dissection on head and neck cancer

BACKGROUND

The literature is scarce regarding the use of interstitial high-dose-rate brachytherapy (I-HDR) as adjuvant treatment of the cervical region, and most reports are focused on primary tumors of the mobile tongue and oropharynx. We evaluated the outcome and morbidity related to an institutional treatment policy, using I-HDR as the sole adjuvant treatment or in combination with external beam radiotherapy (EBRT) at the Departments of Radiation Oncology and Head and Neck Surgery, Hospital do Cancer, Sao Paulo, Brazil.

METHODS

From October 1994 to December 2003, charts of 42 patients who had biopsy-proven cervical head and neck cancer, with a median follow-up of 36 months (range, 8-111 months), were reviewed. The median age of the patients was 55 years (range, 31-76 years), and the male/female ratio was 4.25:1.00. Thirty-five patients had previous irradiation with EBRT, with doses ranging from 30 Gy to 65 Gy (median, 52 Gy). The total dose of I-HDR ranged from 12 Gy to 48 Gy (median, 24 Gy), given in three to 14 fractions (median, 6 fractions) in 2 to 8 days (median, 4 days).

RESULTS

The total treatment time ranged from 19 to 83 days (median, 35 days). The 5- and 8-year overall survival (OS) rates were 52.5% and 48.1%, respectively; and the relapse-free survival (RFS) rates were 48.5% and 38.1%, respectively. The only statistically significant prognostic factor for RFS and OS at 5 and 8 years was margin status (p = .0050). Four patients (9.5%) had late adverse side effects, such as local dehiscence (n = 2), local ulcer (n = 1), and extensive neck fibrosis (n = 1), not related to a higher dose to the skin or graft.

CONCLUSION

These results suggest that I-HDR can be recommended in selected patients with first presentation lesions, local recurrences, or second primary carcinomas, even with a previous course of EBRT, but further studies are eagerly awaited to delineate the optimum schedule for this combination-treatment modality.

Salvage treatment for recurrent squamous cell carcinoma of the oral cavity

BACKGROUND

Squamous cell carcinoma (SCCA) of the oral cavity recurs with a frequency of 25%-48%, a fact that usually portends a poor prognosis. Recent studies have reported salvage cure rates as high as 67%. Investigators have also claimed that restaging recurrent tumors provides useful prognostic information, although this has not been demonstrated with tumors of the oral cavity. The purposes of this study were: (1) to report the patterns of recurrent SCCA of the oral cavity; (2) to examine the benefit of restaging oral cavity tumors, and (3) to compare different treatment modalities in the management of recurrent SCCA of the oral cavity. Materials and Methods Thirty-eight patients who developed recurrent SCCA of the oral cavity were reviewed. Salvage treatment consisted of surgery, chemotherapy, radiation therapy, or a combination of these modalities. Survival analysis was based on the stage of the primary and recurrent tumors and the type of salvage treatment received.

RESULTS

The overall recurrence rate was 28%. Local recurrence was most common (58%) followed by locoregional (27%) and regional recurrence (16%). Patients who recurred more than 6 months after completion of their primary treatment had improved survival compared with those who recurred within 6 months of initial treatment. Individuals with stage I-II primary tumors had significantly improved salvage time and total survival time compared with those with stage III-IV primary tumors (p < 0.005 and p < 0.001). Conversely, the stage of the recurrent tumor was not predictive of either improved salvage time or total survival time. Patients who underwent salvage surgery had significantly improved salvage time and total survival time compared with those who received chemotherapy and/or radiation therapy (p < 0.001 and p < 0.002). The overall salvage cure rate was 21%. Neither the stage of the primary or recurrent tumors nor the type of salvage treatment received significantly correlated with an improved cure rate. However, the group of patients who underwent salvage surgery approached a statistically significant improvement in cure rate (p = 0.08).

CONCLUSIONS

Squamous cell carcinoma of the oral cavity is most likely to recur at the primary site. The stage of the primary tumor is significantly correlated with survival even after recurrence, but the stage of the recurrent tumor is not significantly correlated with survival. Patients most likely to benefit from retreatment are those who (1) have primary tumors stage I-II, (2) recur greater than 6 months after their initial treatment, and (3) develop recurrences that are amenable to salvage surgery.

Surgical management of head and neck cancer

Head and neck cancer surgery continues to evolve through the years and undergo improvement and refinement. In this article, the current state of head and neck cancer surgery is summarized in a site-by-site basis. The most important developments include organ-sparing surgery and microvascular free-tissue transfer for reconstruction.

Radical radiotherapy for squamous cell carcinoma of the larynx, oropharynx and hypopharynx: patterns of recurrence, treatment and survival

The present study investigates 1085 previously untreated patients with squamous cell carcinoma of the head and neck for factors that influence recurrence following treatment with definitive radiotherapy. In the second part of this study, those diagnosed with recurrence were studied with regard to treatment and were further analysed with regard to identification of prognostic factors which may affect outcome in the patient who actually develops a recurrence.

Radical external beam radiotherapy for 333 squamous carcinomas of the oral cavity--evaluation of late morbidity and a watch policy for the clinically negative neck

BACKGROUND AND PURPOSE

The aims of this study were to examine local control/morbidity for all cases and a 'watch policy' for the node-negative neck.

PATIENTS/METHODS

333 patients with squamous cell carcinoma of the oral cavity were treated with a short radical radiotherapy regime to the primary site and involved lymph node groups at the Christie Hospital, Manchester, between 1980 and 1987. Only 10 of 278 node-negative patients received elective neck node irradiation.

RESULTS

Actuarial cancer-free survival and local control rates at 5 years for the whole group were 55% and 61%, respectively. Control at the primary site was adversely related to increasing T-stage, node positivity and bone involvement at presentation. Osteonecrosis was seen in 14 (5.9%) of 237 cases without bone involvement at presentation. Taking all patients, late morbidity (non-healing soft tissue injury or bone necrosis) was seen in 45 patients (13.6%) at a median time of 21 months from treatment. The factors contributing to late morbidity were: (1) bone involvement at presentation, (2) synchronous MTX chemotherapy, (3) the contribution of scattered radiation from elective neck treatment, (4) increasing radiation dose, (5) increasing target volume for doses less than 55 Gy and (6) dental extractions. Eighty-four (31%) patients who were initially node-negative developed disease in the untreated neck during follow-up. Salvage neck dissections controlled neck disease in half of the node-only recurrences (21/42 cases).

CONCLUSION

These results have influenced our treatment policy, with lowering of the primary tumour dose in some cases and addition of elective neck irradiation for T2-T4 No patients.

Elective neck irradiation versus observation of the clinically negative neck of patients with oral cancer

PURPOSES

A retrospective study was conducted to determine the efficacy of elective neck irradiation (ENI) versus observation of patients with oral tumors of varying T stages and clinically negative necks, and to statistically evaluate outcome in the two groups with regard to the subsequent development of neck disease.

PATIENTS AND METHODS

Seventy-three patients were treated with surgery of their primary site; 31 received ENI, and 42 of the necks were observed. Of the ENI patients, 3.2% developed neck disease compared with 31% of those observed. When the two groups were evaluated by the T stage of the primary tumor, the results for ENI versus observation were as follows: T1 (0% vs 31%), T2 (5.9% vs 26.7%), T3 + 4 (0% vs 31%), respectively (P < .0000, adjusted odds ratio = 13.73, 95% confidence interval). The difference between the two groups was highly statistically significant. One hundred fourteen patients were treated with only radiation therapy alone at the primary site. In this group, 88 received ENI, and 16 necks were observed. Eight percent of the ENI group developed neck disease, compared with 3.8% of the observational group. Further evaluation by T stage of ENI versus observation showed T1 (3% vs 0%); T2 (9.3% vs 7.7%); T3 + 4 (5.6% vs 0%), respectively. The difference between these groups was not found to be statistically significant.

RESULTS

The 5-year disease-free survival rate for the surgical group was 90% for patients who received ENI and 40% for those observed. This difference was statistically significant (P = .0007). No statistical difference was found in 5-year disease-free survival for the radiation group between ENI and observation.

CONCLUSIONS

When comparing the above data for ENI versus observation, the survival advantages of elective neck irradiation in patients whose primary tumor was treated surgically is striking for all T stages. These results make the decision to observe the neck in such patients difficult to justify. Lack of statistical difference between ENI and observation in the radiation cohort likely reflects selection bias. If radiation therapy is being used to treat the primary disease, only low-risk sites or histologically favorable tumors would not, on a routine basis, have the neck fields treated as well.

Head and neck cancer

This synthesis of the literature on radiotherapy for head and neck cancer is based on 424 scientific articles, including 3 meta-analyses, 38 randomized studies, 45 prospective studies, and 246 retrospective studies. These studies involve 79174 patients. The literature review shows that radiotherapy, either alone or in combination with surgery, plays an essential role in treating head and neck cancers. When tumors are localized, many tumor patients can be cured by radiotherapy alone and thereby maintain full organ function (1, 2). Current technical advancements in radiotherapy offer the potential for better local tumor control with lower morbidity (3). This, however, will require more sophisticated dose planning resources. To further improve treatment results for advanced tumors, other fractionation schedules, mainly hyperfractionation, should be introduced (5). This mainly increases the demands on staff resources for radiotherapy. The combination of radiotherapy and chemotherapy should be subjected to further controlled studies involving a sufficiently large number of patients (4, 5). Interstitial treatment (in the hands of experienced radiotherapists) yields good results for selected cancers. The method should be more generally accessible in Sweden. Intraoperative radiotherapy should be targeted for further study and development.