Larynx preservation with combined chemotherapy and radiation therapy in advanced hypopharynx cancer

Efficacy of Voice Therapy in Rehabilitation of Muscle Tension Dysphonia in Patients of Nonlaryngeal Head and Neck Cancer: A Sequelae of Chemoradiotherapy

The association of voice disorders in laryngeal cancers has been studied extensively; however Dysphonia associated with chemo-radiation in non laryngeal Head and Neck cancer (HNC) is a new area of practice in voice clinics. This study thus aimed to evaluate the efficacy of voice rehabilitation among non-laryngeal HNC survivors who were treated with curative RadioTherapy (RT)/Chemoradiotherapy (CRT) in adjunct with or without surgery. This tertiary institutional assessor blinded quasi experimental study after inclusion and exclusion criteria consisted of a study cohort of 128 patients who within 1-3 months of completion of treatment for HNC reported to the laryngology clinic for voice complaints and throat discomfort. All patients underwent documentation of laryngeal endoscopic imaging, acoustics assessment, Aronson's Laryngeal Palpatory Method (LPM) and Voice Handicap Index (VHI). Thereafter they were subjected to Vocal Rehabilitation Therapy (VRT) which constituted of Manual circumlaryngeal therapy, SOVTE, and vocal hygiene program. Re-evaluation of the vocal parameters was done at 6 weeks and 3 months from the start of the VRT. All parameters were significantly altered at 6 weeks and 3 months follow-up. Post VRT the videolaryngoscopic findings showed reduction in abnormal supraglottic MTPs with subsequent good approximation of true cords and reduction of involvement of supralaryngeal activities. The Dysphonia Severity Index (DSI) impairment levels and VHI scores showed significant improvement from the baseline to both at 6 weeks and 3 months of VRT (p < 0.001). DSI and VHI scores even showed significant improvement between 6 weeks to 3 months of therapy. There was highly significant correlation of VRT with/without surgery, with CRT and in non-smokers at 6 weeks and 3 months of VRT. In non-laryngeal head and neck malignancies, VRT offered as early as within 1-3 months of completion of treatment of HNC ameliorates surgical and chemo-radiation induced Muscle Tension Dysphonia.

Muscle Tension Dysphonia: A Sequeale of Chemoradiotherapy in Patients of Head and Neck Cancer

It's very important to demarcate that voice is the production of sound by the larynx while speech is articulation of the produced sound by tongue movements, soft palate and the lips. Mucositis, dysphagia, change in speech and voice are the common sequelae of Radiotherapy (RT) alone or in combination with chemotherapy (CRT) which is commonly used in the treatment of head and neck cancer (HNC). The aim of this study was to investigate the patient-reported voice impairment among non laryngeal head and neck cancer survivors who were treated with curative RT/CRT with or without surgery. This tertiary institutional assessor blinded study consists of a study cohort of 128 patients who after of completion of treatment for HNC reported to the laryngology clinic for voice complaints and throat discomfort. The assessment included laryngeal endoscopic and stroboscopic imaging, acoustics assessment and VHI (Vocal handicap index). This study cohort consisted of 89.8% males and 11.2% females. There was hyperadduction and strain of ventricular bands in almost all the cases. There was hyperactivity and compression of both true and false cords in 80.5% of the cases. DSI impairment level showed significant association with gender, VHI, GRBAS score and RT/CRT and it did not show significant association with smoking and surgery, while VHI showed significant association with DSI and RT/CRT and it did not show significant association with gender, smoking and surgery. Muscle tension is a very common effect of RT/RCT and dysphonia can be easily associated with it. Future research needs to focus on specific voice treatment regimens in HNC treated with RT/CRT to improve the quality of life of these patients.

The Effect of Supraclavicular Radiotherapy on Acoustic Voice Quality Index (AVQI), Spectral Amplitude and Perturbation Values

OBJECTIVE

The Acoustic Voice Quality Index (AVQI), spectral amplitude, and voice perturbation parameters are objective assessment methods that are used in clinical settings and for research purposes. The aim of this study was to demonstrate the effect of supraclavicular RT on the physiology and function of the vocal fold.

METHODS

A total of 29 female patients were included in the study. The voices of the patients, who were diagnosed with breast cancer and underwent supraclavicular RT, were recorded before and after the treatment (1 and 6 months). AVQI, spectral amplitude (H1-H2, H1-A1, H1-A2, H1-A3) and acoustic analyses of the voice perturbation parameters were performed.

RESULTS

AVQI was significantly higher in the first month (P < 0.05). Of the voice perturbation parameters, shimmer was found to be significantly high in the first month (P < 0.05). However, not all spectral amplitude values showed a significant change (P > 0.05).

CONCLUSION

In this study, AVQI and shimmer values were found to be higher following the application of supraclavicular RT. These results showed that nonlaryngeal RT might cause changes in the acoustic values of the voice in the early stage.

Combined Surgery and Radiation Therapy for Squamous Cell Carcinoma of the Hypopharynx

Squamous cell carcinoma of the hypopharynx remains a highly lethal disease. This article documents our experience with 132 patients undergoing surgical management of squamous cell carcinoma of the hypopharynx, of whom 80% received postoperative radiation therapy. Local-regional control was obtained in 61% of the patients. Five-year overall and disease-free survival rates were 30% and 41%, respectively. Prognosis was better in patients with limited disease: local disease permitting larynx-sparing surgery, N0/N1 clinical neck, and stage I/II/III disease. Cancer of the hypopharynx remains an aggressive entity associated with poor prognosis. Novel strategies stressing improved local-regional control with prevention of distant metastasis are warranted.

Neck dissection: cause and effect

OBJECTIVE

This study aimed to evaluate changes in neck dissection procedures over time in a tertiary university hospital to determine their influence on residency training.

METHODS

Neck dissections performed in a recent decade (2003-2012) were retrospectively analysed and compared with those of an earlier decade (1981-1990).

RESULTS

Nowadays, neck dissections are most frequently performed for thyroid (2003-2012 vs 1981-1990: 60.7 per cent vs 25 per cent, p = 0.002) and less often for epithelial malignancies (23.2 per cent vs 53.5 per cent, p = 0.002). Compared with dissections for thyroid spread, more dissections for epithelial malignancies are extensive (epithelial vs thyroid malignancies, 66 per cent vs 4.9 per cent) and more are performed after chemoradiation failures (25.6 per cent vs 0 per cent).

CONCLUSION

This study demonstrates changes in neck dissection procedures over time. There is an increasing preference for conservative treatment for epithelial cancers. In addition, there is a large increase in both the diagnosis and surgical treatment of thyroid cancer. This shift may have a great effect on residents' learning curves and on their ability to achieve competency in performing neck dissections.

Effects of chemoradiotherapy on voice and swallowing

PURPOSE OF REVIEW

Chemotherapy has been found to result in comparable survival rates to surgery for head and neck cancer. However, toxicity can often be worse after chemoradiotherapy, with impairment in voice, swallowing, nutrition, and quality of life. Investigators are attempting to modify radiotherapy treatment regimens to spare organs that have an impact on swallowing. This review will highlight voice and swallowing impairment seen after chemoradiotherapy, as well as treatment for voice and swallowing disorders in this population. Results of newer radiotherapy regimens will also be highlighted.

RECENT FINDINGS

Specific oropharyngeal swallowing motility disorders after chemoradiotherapy have been identified. Damage to specific structures has been correlated with specific pharyngeal phase swallow impairment. Swallowing function and quality of life have been examined over time, with improvement seen in both. Preventive/prophylactic swallow exercise programs have been encouraging. Chemoradiotherapy effects on voice have been identified in terms of acoustic, aerodynamic, and patient and clinician-rated perception of function. Improvement in voice has also been observed over time after chemoradiotherapy. Voice therapy has been found to have a positive impact on voice and perceptual measures in this population.

SUMMARY

Current studies show some improvement in swallow function after swallow and voice therapy in patients treated with chemoradiotherapy. Further, there is a suggestion of improved swallow function with sparing of organs with specific radiotherapy protocols. Future research needs to focus on specific voice and swallow treatment regimens in the head and neck cancer patient treated with chemoradiotherapy, specifically, timing, frequency, duration, and specific treatment types.

Hypopharyngeal cancer treatment based on definitive radiotherapy: who is suitable for laryngeal preservation?

Aims:

To investigate prognostic factors for survival and locoregional control in patients with stage I–IVA hypopharyngeal cancer treated with laryngeal preservation radiotherapy.

Methods:

This study was a retrospective analysis of 108 patients with stage I–IVA squamous cell carcinoma of the hypopharynx, treated with laryngeal preservation radiotherapy. Actuarial survival, disease-specific survival and local relapse-free survival were calculated, and multivariate analyses were performed using Cox's proportional hazards model.

Results:

After a median follow-up duration of 39 months, the five-year local relapse-free survival rate was 35 per cent for all patients, 66 per cent for those with stage I–II disease, 46 per cent for those with stage III disease and 20 per cent for those with stage IVA disease (p = 0.004). Multivariate analyses showed that tumour and node stages were independent prognostic factors.

Conclusions:

Patients with stage I–II disease were suitable for laryngeal preservation radiotherapy. For most patients with stage III–IVA disease, other than those who were T1 N1 or T2 N1, the treatment results were poor.

Accelerated Radiotherapy and Larynx Preservation in Favorable-risk Patients with T2 or Worse Hypopharyngeal Cancer

OBJECTIVE

To evaluate the advantage of accelerated fractionation radiotherapy for patients with hypopharyngeal cancer requiring total laryngectomy.

METHODS

Seventy patients with previously untreated, technically resectable hypopharyngeal cancer who received larynx-preserving treatment with radiotherapy between April 1992 and June 2004 were analyzed. No patients had previous history of other malignancy or poor performance status that would possibly affect the outcomes. A total RT dose of > or = 60 Gy/6 weeks was determined depending on the tumor clearance during treatment before December 1998, and fixed to 70 Gy in all patients thereafter. Accelerated fractionation (70 Gy/<49 days) was completed in 35 patients during the latter period. Concomitant platinum-based chemotherapy was used in 41 patients after May 1998.

RESULTS

Local control rates at 2 years were 72 and 68% for patients with T2 and T3/T4 disease, respectively. Patients who had received 70 Gy/<49 days achieved a better local control rate than those who had received other, more conservative total dose/overall treatment time with statistical significance (91% versus 50% at 2 years, P < 0.001). Multivariate analysis involving 70 Gy/<49 days of radiotherapy, T-classification (T2 versus T3/4), and use of chemotherapy revealed that administering 70 Gy/<7 weeks was the only independent prognostic factor (P = 0.007) for better local control.

CONCLUSIONS

Our experience in radiotherapy for hypopharyngeal cancer mirrored the results of previously conducted large randomized trials for various head and neck cancers. Encouraging local control in this study warrants prospective study to test the long-term oncological and functional outcome of larynx-preserving treatment in patients with advanced but resectable volume of this disease.

Effects of Cisplatin, 5-Fluorouracil, and Radiation on Cell Cycle Regulation and Apoptosis in the Hypopharyngeal Carcinoma Cell Line

In head and neck cancer including hypopharyngeal cancer, cisplatin and 5-fluorouracil (5-FU) usually have been used as neoadjuvant chemotherapeutic agents. We investigated the effects of cisplatin, 5-FU and radiation on p53 protein expression and cell responses (cell cycle arrest and/or apoptosis) in the hypopharyngeal carcinoma cell line (PNUH-12; mutant type p53). PNUH-12 cells were treated with cisplatin, 5-FU and radiation. The changes in the cells were assessed by a cell cytotoxicity assay, Western blotting (p53 and p21(WAF1/CIP1) proteins), a DNA fragmentation assay, propidium iodide (PI) staining and DNA flow cytometry. The expression of p53 protein was increased after treatment with cisplatin and 5-FU, but not radiation. The expression of p21(WAF1/CIP1) protein was increased only after treatment with 5-FU, not cisplatin or radiation. With cisplatin and radiation, we observed apoptosis both by DNA fragmentation and PI staining and increased S phase in cisplatin and G2 phase in radiation by DNA flow cytometry. But, with 5-FU, we could not observe apoptosis by DNA fragmentation and PI stain but only an increased G1 phase by DNA flow cytometry. In PNUH-12, radiation induced p53-independent apoptosis and p21(WAF1/CIP1)-independent G2-phase cell cycle arrest. Cisplatin induced p53-dependent apoptosis and p21(WAF1/CIP1)-independent S-phase cell cycle arrest and 5-FU induced p53 and p21(WAF1/CIP1)-dependent G1-phase cell cycle arrest, not apoptosis. Cisplatin and 5-FU induced p53-dependent pathways, but radiation p53-independent pathway. The cell responses by cisplatin, 5-FU and radiation were all different pathways.

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.

Conservation laryngeal surgery for selected pyriform sinus cancer

AIMS

This study reports the treatment of a cohort of patients with pyriform sinus squamous cell carcinoma, using conservative surgery and radiotherapy.

METHODS

Thirty-four patients with pyriform sinus SCC were treated between 1986 and 2001, using partial laryngopharyngectomy with or without complementary radiotherapy. Seventy-six percent had stage III-IV lesions. Quality of life questionnaire and clinical examination were used for evaluation of laryngeal function.

RESULTS

Conservation surgery was undertaken. All patients underwent neck dissection. Two thirds of the patients received post-operative radiotherapy. Reconstruction was achieved by local muscular flap in 13 cases, radial forearm free flap in 18 and pectoralis major flap in three. Five-year overall and disease-specific survival rates were 50 and 65%, respectively. Successful laryngeal function preservation with local control was achieved in 80% of the patients.

CONCLUSION

Partial laryngopharyngectomy is a suitable treatment for early and selected advanced stage pyriform sinus carcinoma with a good functional and oncologic outcome.

Imaging of the hypopharynx and cervical esophagus

Cross-sectional imaging with CT and MR imaging plays a crucial role in the evaluationof cancers of the hypopharynx and cervical esophagus. Clinical examination, includingendoscopy, often fails to detect the full extent of this tumor as it has high propensity togrow in submucosal fashion. Detailed description of the cross-sectional anatomy and ofthe tumor growth pattern will aid in the detection and evaluation of the full extent of thelesion. Post-treatment imaging findings are addressed.

[Hypopharyngeal cancer: analysis of the evolution and surgical results]

OBJECTIVE

Hypopharyngeal carcinoma is an aggressive malignancy that usually presents at a late stage, thereby resulting in an overall poor prognosis for these patients. The aim of this study is to determine the evolution and postoperative results of patients treated in our department for hypopharyngeal cancer.

METHODS

We retrospectively reviewed 60 patients who had undergone surgery followed by radiation therapy between 1980-1999. Most of them were advanced stage (III-IV) and 75% patients showed regional metastases at presentation.

RESULTS

The 5-year survival rate was 38.4%. The overall incidence of distant metastases and second neoplasms was 12.5% and 10.4%.

CONCLUSIONS

Hypopharyngeal cancer remains one of the most lethal ones in head and neck cancer. The poor survival rate is related primary to advanced stage disease and particularly to lymph node metastases.

Carcinoma of the hypopharynx

Despite advances in surgical and nonsurgical treatment, overall survival rates for patients who have hypopharyngeal carcinoma have not improved,and this disease still has a poor prognosis. The best results are obtained with multimodality therapy. but at best, two thirds of patients are palliated rather than cured of disease. Radical surgery with postoperative radiation therapy remains the standard of care. Organ preservation strategies have not been as successful in hypopharyngeal cancer as for cancers of other head and neck sites. Chemoradiation is an effective alternative method of aggressive treatment but may be associated with significant dysfunction of the end organ when preservation is possible. Because of poor long-term survival rates, local control remains the most important factor in planning treatment, to provide meaningful palliation and best possible quality of life.

Reconstruction of circumferential pharyngoesophageal defects with laryngotracheal flap and pectoralis major myocutaneous flap

BACKGROUND

Hypopharyngeal cancer often presents at an advanced stage. Radical surgery has played an important role in the treatment of these cases; however, it always results in a large, or even a circumferential, defect of the pharyngoesophageal segment (PES) that causes some difficulties during reconstruction.

MATERIALS AND METHODS

Twelve patients with advanced hypopharyngeal cancer and cervical esophageal invasion received surgery resulting in a circumferential defect of PES, which was reconstructed with the contralateral unaffected laryngotracheal flap and a patch-on pectoralis major myocutaneous flap (PMMCF).

RESULTS

The operation time of this method was shorter compared with free flap reconstruction. Only two minor complications and no pharyngocutaneous fistulas were found postoperatively. Nine patients can resume a regular diet. During the follow-up period (median, 38 months), there were no local recurrences and only one contralateral neck recurrence.

CONCLUSIONS

The preliminary result shows this technique is a simple and effective method with low morbidity and satisfactory oncologic and functional results.

Imaging of the hypopharynx and cervical esophagus

Cross-sectional imaging with CT and MR imaging plays a crucial role in the evaluation of cancers of the hypopharynx and cervical esophagus. Clinical examination, including endoscopy, often fails to detect the full extent of this tumor as it has high propensity to grow in submucosal fashion. Detailed description of the cross-sectional anatomy and of the tumor growth pattern will aid in the detection and evaluation of the full extent of the lesion. Post-treatment imaging findings are addressed.

Sequential induction chemotherapy and concomitant chemoradiotherapy in the management of locoregionally advanced laryngeal cancer

PURPOSE

To determine overall survival, progression-free survival, rate of voice preservation, and patterns of failure in locoregionally advanced laryngeal cancer treated with induction chemotherapy with or without surgery followed by concomitant chemoradiation.

BACKGROUND

Locoregionally advanced laryngeal cancer has been conventionally treated with either surgery and adjuvant radiotherapy or radiotherapy alone, and clinical and functional outcomes have been poor. Chemoradiotherapy has been demonstrated to improve functional outcome and disease control over conventional treatment in recent randomized head and neck trials.

PATIENTS AND METHODS

Advanced head and neck cancer patients were enrolled onto two consecutive phase II studies. Induction treatment consisted of three cycles of cisplatin, 5-fluorouracil (5-FU), leucovorin, and interferon-alpha 2b (PFL-IFN) followed by surgery for residual disease. Surgical intent was to spare the larynx when possible. All patients then proceeded to concomitant chemoradiation consisting of seven or eight cycles of 5-FU, hydroxyurea, and a planned total radiotherapy dose of 7000 cGy (FHX).

RESULTS

A subset of thirty-two laryngeal cancer patients with predominantly stage IV disease comprises the study group for this report. Clinical CR was observed in 59% of patients following induction therapy. The median follow-up was 63.0 months for surviving patients and 44.5 months for all patients. At five years, overall survival is 47%, progression-free survival is 78%, and locoregional control is 78%. No distant failures were observed. Voice preservation with disease control was 75% at five years. Only two total laryngectomies were performed during the course of treatment and follow-up. Treatment-related toxicity accounted for two deaths.

CONCLUSIONS

The addition of concomitant chemoradiotherapy to induction chemotherapy for locoregionally advanced laryngeal cancer appears to increase locoregional control and survival rates. PFL-IFN-FHX resulted in high rates of disease cure and voice preservation in a group of patients that has traditionally fared poorly in both clinical and functional outcome.

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.

Surveillance for recurrent head and neck cancer using positron emission tomography

PURPOSE

Earlier detection of head and neck cancer recurrence may improve survival. We evaluated the ability of [(18)F]fluorodeoxyglucose positron emission tomography (FDG-PET) to detect recurrence in a prospective trial using sequential PET scans.

PATIENTS AND METHODS

Serial posttherapy FDG-PET was prospectively performed in 44 patients with stage III or IV head and neck cancer. PET was performed twice during the first posttreatment year (at 2 and 10 months after therapy) and thereafter as needed. After therapy, patients were grouped, based on tissue biopsies, into those who achieved a complete response (CR) and those who had residual disease (RD). Patients who achieved a CR were further grouped into those without evidence of disease and those who had recurrence by 1 year after completion of therapy. Disease status as determined by physical examination (PE), PET, and correlative imaging was compared.

RESULTS

Eight patients were lost to follow-up and six had RD after therapy. Of the remaining 30 patients with a CR, 16 had recurrence in the first year after therapy. Five of these 16 patients had recurrence detected by PET only, four by PET and correlative imaging only, five by PE and PET only, and two by PE, correlative imaging, and PET. Only PET detected all recurrences in the first year. PET performed better than correlative imaging (P =.013) or PE (P =.002) in the detection of recurrence.

CONCLUSION

PET can detect head and neck tumor recurrence when it may be undetectable by other clinical methods. FDG-PET permits highly accurate detection of head and neck cancer recurrence in the posttherapy period.

Sequential chemotherapy and radiotherapy for organ preservation in advanced resectable nonlaryngeal head and neck cancer

Although there is no definite survival advantage to the use of sequential induction chemotherapy (CT) followed by radiotherapy (RT) in advanced resectable laryngeal cancer, this approach does succeed in preserving the larynx in many of these patients. The authors performed this study to analyze their results using a similar approach for patients with advanced resectable cancer located outside the larynx who would have required a total laryngectomy for oncologic or functional reasons. A retrospective study was performed at a single institution that included all patients with advanced resectable nonlaryngeal head and neck cancer treated with induction CT between January 1990 and August 1995. A total of 19 patients were included, with primary cancers located in the oropharynx in 14 patients, the hypopharynx in four, and the oral cavity and oropharynx in one. Eight patients had clinical stage III disease, and 11 patients had stage IV disease. Our treatment protocol consisted of two cycles of induction CT with cisplatin and 5-fluorouracil, followed by a third cycle of CT and subsequent RT in patients who achieved at least a clinical partial response (PR) after two courses of induction CT. Eighteen of 19 patients were evaluable for response. Overall, 13 patients (72%) had a major response (PR or CR) to induction CT at the primary site, and eight patients (57%) had a major response to chemotherapy in the neck. With a mean follow-up of 53 months (range, 24-71 months), the disease-specific survival was 57% for those patients with cancer of the oropharynx and oral cavity. In the subset of patients with hypopharynx cancer, 3 of 4 patients died of cancer despite achieving major response to induction CT. Organ preservation using sequential CT and RT for advanced resectable nonlaryngeal head and neck cancer is feasible, and the results in our experience with cancer of the oropharynx were similar to those reported for primary laryngeal cancer. Our limited experience using this protocol for cancer of the hypopharynx has been disappointing.

Intraoperative brachytherapy, laryngopharyngoesophagectomy, and gastric transposition for patients with recurrent hypopharyngeal and cervical esophageal carcinoma

OBJECTIVE

To evaluate the role of laryngopharyngoesophagectomy (LPE), intraoperative 125I brachytherapy (IOBT), and gastric transposition (GT) in patients with recurrent carcinoma involving the hypopharynx, or cervical esophagus.

METHODS

Between 1988 and 1994 a total of 21 patients were managed with LPE/IOBT/GT. All patients had documentation of recurrent disease at the hypopharynx or cervical esophagus and had previously been treated with external-beam radiation (EBRT) to a total median dose of 60 Gy. Median age was 67 years, with 17 male patients and four female. IOBT was performed in all cases with permanent 125I implantation. Medical records were retrospectively reviewed. Overall survival, local control, and complications were evaluated. Median follow-up was 6 months.

RESULTS

The median activity of 125I was 36 mCi, with a median dose of 80 Gy to the region at risk. Fifteen patients had lymph node dissections performed in conjunction with LPE, and 10 patients had nodal involvement on pathologic examination. Margins were microscopically positive in nine patients, and lymphvascular space invasion noted in 13. Actuarial survival at 1 and 3 years was 32% and 14%, respectively, with patients alive and with local control at 6, 24, 36, and 48 months (negative margins). Actuarial local control at 1 and 3 years was 63%. Complications included fistula in five patients, facial edema in four, protracted facial pain in two, cervical abscess in one, and mucosal hemorrhage in one.

CONCLUSION

Patients with recurrent carcinoma of the hypopharynx or cervical esophagus after EBRT have an extremely poor prognosis. LPE, IOBT, and GT may provide very good local control for all candidates and prolonged survival for a small percentage of patients with an acceptable risk profile.

Evaluation of chemotherapy response in patients with advanced head and neck cancer using [F-18]fluorodeoxyglucose positron emission tomography

BACKGROUND

[F-18]Fluorodeoxyglucose (FDG)-positron emission tomography (PET) can measure the metabolic activity of tissues; FDG-PET may be able to predict response to chemotherapy by identifying changes in tumor metabolism. Measurement of response to treatment may help improve survival in the management of advanced head and neck cancer. We evaluated this particular use of FDG-PET in patients participating in a neoadjuvant organ-preservation protocol using taxol and carboplatin and compared pathologic response after chemotherapy with changes in tumor metabolism measured by FDG-PET.

METHODS

Serial FDG-PET studies (n = 56) were performed in patients (n = 28) with stage III/IV head and neck cancer participating in a neoadjuvant organ-preservation protocol. The FDG-PET studies were performed before and after chemotherapy. All patients had tissue biopsies before and after chemotherapy. Patients were classified as pathologic complete response (PCR) or residual disease (RD) based on tissue biopsies. Visual analysis of PET scans was performed to identify patients with complete response by PET, and these findings were compared with pathology results. Metabolic changes were also evaluated using standardized uptake ratios (SUR) of FDG.

RESULTS

The sensitivity and specificity of PET for residual cancer after therapy was 90% (19/21) and 83% (5/6), respectively. Two patients had initially negative biopsies and positive PET studies for persistent disease. Pathology review and rebiospy led to confirmation of the PET results in these cases, giving a sensitivity of 90% for initial tissue biopsy.

CONCLUSIONS

In this preliminary analysis, FDG-PET was accurate in classifying response to chemotherapy in most patients. Fluorodeoxyglucose-PET may identify residual viable tumor when it is otherwise undetectable.

Preservation of the larynx after resection of a carcinoma of the posterior wall of the hypopharynx: versatility of a free flap patch graft

BACKGROUND

Preservation of the larynx after resection of a pharyngeal tumor remains a challenging problem for the head and neck surgeon.

METHODS

Nine patients with T1 or T2 carcinoma of the posterior wall of the hypopharynx (UICC 1987), who were treated surgically between 1984 and 1994, were studied. All patients underwent surgical resection of the tumor with laryngeal preservation and immediate reconstruction with free flap transfer. A free forearm flap was transferred in four patients and a free jejunal patch graft, in five patients.

RESULTS

There was one flap loss, due to venous thrombosis. Successful larynx preservation was achieved in the remaining eight patients (89%). Although there was one local control failure, three patients remained free of disease for more than 5 years.

CONCLUSIONS

Laryngeal preservation surgery using a free flap patch graft has proven very beneficial in selected cases with a carcinoma of the posterior wall of the hypopharynx.

Combined chemotherapy and radiotherapy versus surgery and postoperative radiotherapy for advanced hypopharyngeal cancer

BACKGROUND

Although the standard therapy for locally advanced hypopharyngeal cancer remains surgery and postoperative radiotherapy (RT), alternative treatment approaches include induction chemotherapy and RT. The purpose of this retrospective study was to compare the long-term outcome of these treatments performed in a single institution.

METHODS

Twenty-six patients with advanced, resectable, squamous cell carcinoma of the hypopharynx were treated with induction chemotherapy and definitive RT (group I), reserving laryngectomy for salvage. The induction phase of therapy consisted of 2-3 cycles of cisplatin-based chemotherapy followed by conventional fractionated RT to doses of 66-70 Gy. The outcomes of this group of patients were compared with the outcomes of 30 patients with hypopharyngeal cancer who were treated at our institution with surgery and postoperative RT (group II). The median follow-up times of the surviving patients in groups I and II were 5 and 9 years, respectively.

RESULTS

The local recurrence-free survival at 5 years from the completion of therapy for group I was 50%, compared with 69% for group II (p = .41). Among patients with T3-T4 primary tumors, the 5-year local control rates were 58% and 59% for groups I and II, respectively (p = .78). The likelihood of larynx preservation, free of local disease at 5 years for group I, was 52%. The 5-year neck recurrence-free survival for groups I and II were 47% and 69%, respectively (p = .66). Among patients with N2-N3 stage disease, the 5-year incidence of neck failure for groups I and II were 73% and 68%, respectively (p = .74). The 5-year distant metastases-free survival for groups I and II were 67% and 57%, respectively (p = .19). The 5-year disease-free survival rates for groups I and II were 30% and 42%, respectively (p = .9). The 5-year overall survival rates for groups I and II were 15% and 22%, respectively (p = .65).

CONCLUSIONS

Nonsurgical therapy for advanced stage hypopharyngeal cancer provides survivorship comparable with that achieved with standard approaches of surgery and postoperative RT. However, despite the therapy, the outcome is poor. Future studies will need to explore new treatment strategies in an effort to improve upon the outcome for this group of patients.

Chemotherapy of squamous cell carcinoma of head and neck: the future is now

In 1996, there is an established role for chemotherapy in head and neck cancer. Patients with recurrent disease will be offered combination chemotherapy. In this setting, investigations of new drugs or combinations and the pursuit of concomitant chemo-reirradiation are of interest. In patients with locoregionally advanced disease, induction chemotherapy can be used with the goal of larynx preservation. In addition, a role for chemotherapy in nasopharyngeal cancer appears to be emerging with increased survival as therapeutic goal. The combination of cisplatin and 5-FU does not need to be tested further, however, a more definitive evaluation of a biochemically modulated PF regimen might be of interest. Furthermore, induction chemotherapy represents an ideal investigational tool in which to further evaluate the activity of several new drugs in head and neck cancer patients. Finally, concomitant chemoradiotherapy has resulted in increased survival in several randomized clinical studies. Given the poor outcome of standard radiotherapy in patients with unresectable disease, we favor the administration of concomitant chemoradiotherapy in this group of patients as a standard therapy. In our opinion, the use of radiation therapy alone in this group of patients should be restricted to patients with poor performance status or other high medical risks that render the administration of chemotherapy unadvisable. Finally, given the high incidence of second malignancies and general medical complications in cured head and neck cancer patients, studies of chemoprevention and good preventive medical care by a medical oncologist should be made available to all patients.

Salvage laryngectomy for unsuccessful larynx preservation therapy

From 1983 to 1991, 31 patients underwent salvage laryngectomy for persistent or recurrent squamous carcinoma of the larynx (14), hypopharynx (15), or oropharynx (2) as part of a larynx preservation protocol. Laryngectomy was performed as a consequence of poor response to induction chemotherapy in 13 and for recurrent disease after completion of chemotherapy and irradiation in 18. Postoperative pharyngocutaneous fistula occurred in 39%, resulting in prolonged hospitalization. Local control was achieved in 68%, more often in patients with laryngeal as opposed to nonlaryngeal primaries (86% versus 53%; p = .05). The overall actuarial survival and disease-specific survival at 2 years were 32% and 38%, respectively. Disease-specific survival at 2 years was better in patients with laryngeal as compared to nonlaryngeal primaries (56% versus 24%; p = .02). There were no long-term survivors among the nonlaryngeal primary patients. In selected patients in whom larynx preservation failed, salvage laryngectomy was associated with acceptable local control and survival. Palliation was obtained in patients who were not cured by their laryngectomy. Future investigation will focus on identification of factors predicting complications and strategies to reduce the incidence and severity.