Larynx preservation with combined chemotherapy and radiation therapy in advanced but resectable head and neck cancer

Pectoralis Major in Salvage Total Laryngectomy after Irradiation: Morbidity, Mortality, Functional, and Oncological Results in a Referral Center in Egypt

BACKGROUND

Nonsurgical organ preservation protocols have seen a large diffusion worldwide in the last decades. Their oncological and functional effectiveness in a real-world setting has been recently questioned because of the high morbidity of salvage procedures. The aim of this study is to review the outcomes of postirradiation salvage total laryngectomy (STL) and reconstruction with pectoralis major flap.

METHODS

This retrospective observational study included 37 cases of STL in the period from January 2015 to December 2021. Data for each patient were extracted from the hospital information system and reviewed.

RESULTS

The 3-year overall and disease-specific survival are, respectively, 28% and 51%. Only seven recurrences after salvage surgery were recorded and all of them died from the disease. The other 14 deaths derived from comorbidities, with diabetes being the most significant predictive parameter for overall survival. Also, lower postoperative albumin levels were associated with a higher risk of death.

CONCLUSIONS

Overall survival after STL and reconstruction with PMMF is low but most deaths are due to comorbidities and not to cancer progression or recurrence.

Pretherapeutic Assessment by Multidetector Computed Tomography for Thyroid Cartilage Invasion in Laryngeal Cancer: A Double‑edged Sword

Introduction:Almost one-fourth of head and neck cancers in India are laryngeal cancers. Both conservative and surgical therapeutic approaches are available. According to present tumor-node-metastasis staging protocol, thyroid cartilage invasion is a crucial criterion for diagnosing advanced stages of the disease. A major cartilage invasion depicts T4A stage of disease for which surgical treatment is required. Aims: The present study aims to evaluate the accuracy of multidetector computed tomography (MDCT) in evaluation thyroid cartilage invasion in T3 and T4 stage of laryngeal cancers. Materials and Methods: It is a retrospective analysis done in the Department of Radiology, Pramukhswami Medical College, Anand, Gujarat, on 22 patients of T3 and T4 stage of laryngeal cancer who presented for pretherapeutic MDCT neck evaluation. The MDCT results were retrospectively reviewed and compared with postoperative histopathological results. Statistical analysis was done for each parameter as positive predictive value (PPV) (main statistical parameter), negative predictive value, sensitivity, and specificity. Results: MDCT showed a PPV of 60.00% in detecting any type of thyroid cartilage invasion, 66.66% for major and 33.33% for minor cartilage invasion. Extralaryngeal spread of disease was the most specific marker for cartilage involvement. In total, 31.8% of cases were downgraded in staging by pathology. Conclusion: Overestimation of thyroid cartilage invasion by MDCT is a reality which should be in mind before making final therapeutic decisions. Although crucial, it should not be the sole criteria preventing while making a surgical versus conservative therapeutic call.

A comparison of concurrent cisplatin versus cetuximab with radiotherapy in locally-advanced head and neck cancer: A bi-institutional analysis

AIM

To present our experience comparing cisplatin- and cetuximab-based radiotherapy for locally-advanced head and neck squamous cell carcinoma.

BACKGROUND

The comparative effectiveness of cisplatin-based chemoradiotherapy (CRT) versus cetuximab-based bioradiotherapy (BRT) for locally-advanced head and neck squamous cell carcinoma (LAHNSCC) continues to be explored.

MATERIALS AND METHODS

Outcomes of LAHNSCC patients treated with CRT (125) or BRT (34) at two institutions were compared retrospectively, with attention to overall survival (OS), cancer-specific survival (CSS), locoregional control (LRC), and distant control (DC). Univariate analysis (UVA) using Cox regression was performed to explore the association of intervention with survival and disease control, and multivariate (MVA) Cox regression was then performed to assess the association of intervention with survival.

RESULTS

There were significant baseline differences between the CRT and BRT groups with respect to age, race, performance status, N-classification, tobacco history, and human papillomavirus status. UVA demonstrated inferiority of BRT versus CRT with respect to both OS (hazard ratio [HR] 2.19, 95% confidence interval [95%CI] 1.03-4.63, p = 0.04) and CSS (HR 3.33, 95%CI 1.42-7.78, p < 0.01), but non-significantly different outcomes in LRC (HR 0.99, 95%CI 0.37-2.61, p = 0.98) and DC (HR 2.01, 95%CI 0.78-5.37, p = 0.14). On MVA, there was no significant OS difference between interventions (HR 1.19, 95%CI 0.42-3.35, p = 0.74); there were too few events for the other outcomes to draw meaningful conclusions with MVA.

CONCLUSIONS

In our retrospective analysis, patients undergoing CRT experienced improved OS and CSS over those receiving BRT; however, disease control did not significantly differ. These findings may inform management of LAHNSCC patients.

Different clinical outcomes between locally advanced hypopharyngeal and oropharyngeal cancer treated with definitive concurrent chemoradiotherapy: implication for subgroup selection for induction chemotherapy

OBJECTIVE

The purpose of this study is to compare the long-term clinical outcome of hypopharynx cancer and oropharynx cancer treated with concurrent chemoradiotherapy.

METHODS

A total of 213 patients with locally advanced hypopharyngeal squamous cell carcinoma (n = 79) or oropharygeal squamous cell carcinoma (n = 134) were included. All patients were treated with upfront concurrent chemoradiotherapy between 1995 and 2012.

RESULTS

The median overall survival and progression-free survival differed significantly between the two groups (P < 0.05). Overall survival and progression-free survival rates at 3 years were 52% and 42% for hypopharynx cancer, and 75% and 72% for oropharynx cancer, respectively. There was no significant difference in the overall incidence of distant metastases but more locoregional recurrences occurred in patients with hypopharynx cancer compared with those with oropharynx cancer with a statistical significance (P < 0.001).

CONCLUSIONS

Patients diagnosed with locally advanced hypopharyngeal had relatively poor survival after upfront concurrent chemoradiotherapy. More intensive treatment such as induction chemotherapy before concurrent chemoradiotherapy might be needed to improve survival outcome in this subgroup of patients.

Evaluation of swallowing function after supracricoid laryngectomy as a primary or salvage procedure

The primary functional issues following conservative therapy for advanced laryngeal cancer concern swallowing. Here, we evaluated the recovery of swallowing after supracricoid partial laryngectomy (SCL) in patients with primary or recurrent laryngeal cancer. We evaluated the swallowing recovery in 27 SCL patients through oropharyngoesophageal scintigraphy, and we evaluated their quality of life using EORTC questionnaires. Four patients underwent total laryngectomy during follow-up. Patients who retained their larynges were able to feed without nutritional support and without tracheostoma. The only significantly different parameter between the primary and salvage cases was the time elapsed to the removal of nasogastric/PEG tubes, which was longer in salvage cases. SCL has been demonstrated as a valuable option for primary and recurrent laryngeal cancer patients. The present data demonstrate good functional results, particularly in terms of swallowing after previous treatments and in primary settings. The combination of oropharyngoesophageal scintigraphy and questionnaires appears to be an adequate, standardizable approach to assessing swallowing function after SCL.

RETRACTED: Laryngeal Function After Radiation Therapy

Laryngeal function after oncologic treatment is a key aspect and focus of interest in the contemporary management of head and neck cancers. Although historically the treatment of most locally advanced laryngeal cancers has been total laryngectomy, recent innovations in radiation therapy and combined chemotherapy and radiation therapy have shown that organ and function preservation can be achieved with good oncologic outcomes. Technical improvements, along with better understanding of tumor biology and dose tolerance of critical organs involved in speech and swallowing function, have paved the way for better outcomes. This article reviews in comprehensive detail the recent data of laryngeal function after radiotherapy.

Oncologic results of the surgical salvage of recurrent laryngeal squamous cell carcinoma in a multicentric retrospective series: emerging role of supracricoid partial laryngectomy

BACKGROUND

Several studies in the last decade evaluated conservative surgical procedures and, in particular, supracricoid operations as an alternative to total laryngectomy for the salvage of recurrences of laryngeal squamous cell carcinoma (SCC) after a first attempt of organ preservation.

METHODS

The clinical records of 68 consecutive patients primarily treated by irradiation or endoscopic surgery and surgically salvaged by total laryngectomy or supracricoid partial laryngectomy in 2 large university hospitals in Italy from 2004 to 2010 were reviewed.

RESULTS

The survival was not affected by the primary treatment or by salvage modality. The only parameter always keeping a prognostic value is the involvement of resection margins of salvage surgery. Patients with early relapse seem to have a worse prognosis than patients with a delayed relapse (p = .05 at Cox multivariate analysis and p = .048 at Wilcoxon test for overall survival [OS] from the primary treatment).

CONCLUSION

Supracricoid operations, if the indications are careful, can prove reliable salvage procedures.

Chemoselection: a paradigm for optimization of organ preservation in locally advanced larynx cancer

Definitive chemoradiation (CRT) and laryngectomy followed by postoperative radiotherapy (RT) are both considered standard-of-care options for the management of advanced laryngeal cancer. While organ preservation with chemoradiotherapy is often the preferred up-front approach for appropriately selected candidates, the functional benefits of organ preservation must be carefully balanced against the considerable morbidity of salvage laryngectomy in patients who fail primary chemoradiation. Up-front identification of patients who are likely to require surgical salvage, therefore, is an important aim of any organ preserving approach in order to minimize morbidity while maximizing organ preservation. To this end, a strategy of 'chemoselection', using the primary tumor's response after 1 cycle of induction chemotherapy as an in vivo method of selecting responders for definitive chemoradiation while reserving primary surgical management for non-responders, has been employed extensively at our institution. The rationale, treatment results and future directions of this approach are discussed.

Radiation-induced squamous cell carcinoma of the nasopharynx after radiotherapy for nasopharyngeal carcinoma

BACKGROUND

The purpose of this study was to investigate the treatment outcome of radiation-induced squamous cell carcinoma (SCC) of the nasopharynx after radiotherapy (RT) for nasopharyngeal carcinoma (NPC).

METHODS

We conducted a retrospective review of patients who underwent radiation therapy for NPC, which resulted in radiation-induced SCC of the nasopharynx.

RESULTS

Between 1998 and 2011, 24 patients had radiation-induced SCC of the nasopharynx. The median age of diagnosis was 68.2 years. The majority of patients (66.7%) presented with early-stage NPC initially, and they were treated with RT alone (n = 18) or concurrent chemoradiation (n = 6). The mean latency period for the second malignancy was 10.5 years. All the patients were treated with maxillary-swing nasopharyngectomy. Clear resection margin was achieved in 66.7%, and 75% of those with involved margin received adjuvant RT. The mean follow-up duration was 48.2 months. The overall 5-year actuarial local tumor control was 56% and the overall 5-year disease-free survival was 38%.

CONCLUSION

Radiation-induced SCC of the nasopharynx is rare after RT for NPC. The prognosis remained poor despite aggressive surgery and adjuvant RT.

Function and organ preservation in adult cancers of the head and neck

Treatment for primary head and neck cancer has evolved from the use of radical approaches to therapies preserving important functions. Essential to this concept is the maintenance of therapeutic efficacy. The advances of organ-sparing surgery, improved radiation techniques and fractionation, and the addition of chemotherapy and targeted systemic agents, have added to the number of patients who undergo organ-preservation therapy. Crucial functions that can be spared include speech, swallowing, vision, salivation and cosmesis. This paper examines advances in therapy that allow the preservation of these important functions, scenarios where organ and function preservation is indicated, given current technology and agents, and where there might be future improvements.

Inhibition of p38 mitogen-activated protein kinase ameliorates radiation-induced ototoxicity in zebrafish and cochlea-derived cell lines

Radiation is a widely used treatment for head and neck cancers, and one of its most severe side effects is ototoxicity. Radiation-induced ototoxicity has been demonstrated to be linked to the increased production of ROS and MAPK. We intended to investigate the effect of p38 inhibition on radiation-induced ototoxicity in cochlea-derived HEI-OC1 cells and in a zebrafish model. The otoprotective effect of p38 inhibition against radiation was tested in vitro in the organ of Corti-derived cell line, HEI-OC1, and in vivo in a zebrafish model. Radiation-induced apoptosis, mitochondrial dysfunction, and an increase of intracellular NO generation were demonstrated in HEI-OC1 cells. The p38-specific inhibitor, SB203580, ameliorated radiation-induced apoptosis and mitochondrial injury in HEI-OC1 cells. p38 inhibition reduced radiation-induced activation of JNK, p38, cytochrome c, and cleavage of caspase-3 and PARP in HEI-OC1 cells. Scanning electron micrography showed that SB203580 prevented radiation-induced destruction of kinocilium and stereocilia in zebrafish neuromasts. The results of this study suggest that p38 plays an important role in mediating radiation-induced ototoxicity and inhibition of p38 could be a plausible option for preventing radiation ototoxicity.

Survival patterns in treated cases of carcinoma larynx in north india - a 10 years followup study

Patients with stage I and II tumors had the best results with radical radiotherapy alone 5 years survival for patients with stage I and stage II tumors was 90-95% and 75-85% respectively Patients with advanced stage III & IV disease were treated Unoperable stage IV cancer patients had poor outcome and received only palliative treatment.

Comparison of total laryngectomy with surgical (cricohyoidopexy) and nonsurgical organ-preservation modalities in advanced laryngeal squamous cell carcinomas: A multicenter retrospective analysis

BACKGROUND

Functional outcome and quality of life (QOL) have become relevant endpoints in the field of laryngeal oncology, leading to the emergence of organ-preserving strategies.

METHODS

The medical records of 166 patients with advanced (stages III and IV) laryngeal squamous cell carcinoma (SCC) who were treated with a total laryngectomy, radiochemotherapy, or cricohyoidopexy (CHP) were reviewed.

RESULTS

In the whole series, no statistically significant differences among the 3 treatment arms with respect to the overall survival (OS) and disease-specific survival (DSS) rates were observed. The organ-preservation rate was 45% for radiotherapy and 76.7% for CHP (p = .0002). Among the cT4a cases, a longer survival was observed for the patients treated with total laryngectomy (3 yr-OS = 78% vs 68% for CHP and 54% for radiochemotherapy, p = .031).

CONCLUSIONS

In advanced laryngeal SCC, CHP shows survival rates comparable to those of radiochemotherapy and a higher larynx-preservation rate, although it may not replace radiochemotherapy because it can be recommended only in selected cases.

Oncologic outcomes in advanced laryngeal squamous cell carcinomas treated with different modalities in a single institution: a retrospective analysis of 65 cases

BACKGROUND

Treatment for laryngeal squamous cell carcinoma (SCC) has been predominantly surgical for decades, but in the last 20 years nonsurgical modalities (radiotherapy), with the aim of organ preservation, also became predominant among advanced stages. Retrospectively evaluating our series of stage III and stage IV laryngeal SCCs, we compared the 2 main therapeutic modalities.

METHODS

Medical records of 65 consecutive patients with advanced laryngeal SCC, from November 2005 to January 2009, were reviewed.

RESULTS

Among irradiated patients 2-year organ preservation was 86% for cT2, 43% for cT3, and 17% for cT4a (p = .037, Wilcoxon test). With respect to survival, the only significant differences between surgery and radiotherapy were detected among cT4a SCCs (p = .03, Wilcoxon test), in favor of surgery.

CONCLUSIONS

The present results confirm the surgical recommendation for cT4a laryngeal SCCs. On the other hand, for T < 4, our results confirm that radiochemotherapy warrants a survival similar to that of total laryngectomy, thus allowing us to preserve the larynx in a relevant number of cases.

Endoscopic horizontal partial laryngectomy by CO(2) laser in the management of supraglottic squamous cell carcinoma

BACKGROUND

The objective of this study was to evaluate the results of endoscopic horizontal supraglottic laryngectomy (EHSL) by CO(2) laser.

METHODS

Between 1996 and 2005, 78 patients underwent a horizontal supraglottic laryngectomy operation (HSL) with an external approach and 70 underwent laser EHSL, as treatment for supraglottic laryngeal squamous cell carcinoma (LSCC). We evaluated oncological endpoints, comparing the external and the endoscopic approach.

RESULTS

Among patients primarily treated by EHSL, the 5-year disease-specific survival (DSS) was 89% (vs 80% in the external approach group). Statistical analysis did not reveal significant differences between the 2 groups as for survival nor for organ preservation. The most significant clinical predictor for DSS is neck relapse (p < .0001).

CONCLUSIONS

This study confirms the effectiveness of laser EHSL in which oncological outcome is similar to the external approach and functional results are probably better. Neck management in this setting is fundamental to warrant the best survival.

Poor radiotherapy compliance predicts persistent regional disease in advanced head/neck cancer

OBJECTIVE

To determine if poor compliance to chemoradiation results in an increased rate of persistent neck disease.

STUDY DESIGN

Retrospective, cohort study in an urban, tertiary-care medical center.

METHODS

The study included patients with N+ stage III/IV squamous cell carcinoma of the upper aerodigestive tract treated with curative-intent chemoradiation, who underwent subsequent planned neck dissection. Main outcome measure was persistent regional disease evidenced by identifiable carcinoma in neck dissection specimens. Variables including age, gender, race, primary site, initial T, N staging, imaging results, and treatment compliance were assessed and correlated to positive neck dissection pathology.

RESULTS

Of 40 patients, 18 (45%) had persistent carcinoma in neck dissection specimens while 22 (55%) demonstrated complete response in the neck. There were 14 patients (35%) who were poorly compliant to radiotherapy (>or=14 days treatment interruption) and the remaining 26 patients (65%) were considered compliant (<14 missed days). Only 23% of compliant patients had positive pathology while 79% of noncompliant patients had positive pathology (hazard ratio: 9.9). Noncompliance was the only variable that had a statistically significant correlation to positive pathology results (P = .002). Multivariate logistic regression showed all other variables to be insignificant in predicting pathology.

CONCLUSIONS

This study found that poorly compliant patients are at significantly higher risk of persistent neck disease. Poor compliance may help identify patients who will most benefit from neck dissection after chemoradiation. This variable was more predictive than pretreatment variables and posttreatment CT scan. Further studies investigating patterns of failure after chemoradiotherapy in the poorly compliant patient population are warranted.

American Society of Clinical Oncology Clinical Practice Guideline for the Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer

Purpose

To develop a clinical practice guideline for treatment of laryngeal cancer with the intent of preserving the larynx (either the organ itself or its function). This guideline is intended for use by oncologists in the care of patients outside of clinical trials.

Methods

A multidisciplinary Expert Panel determined the clinical management questions to be addressed and reviewed the literature available through November 2005, with emphasis given to randomized controlled trials of site-specific disease. Survival, rate of larynx preservation, and toxicities were the principal outcomes assessed. The guideline underwent internal review and approval by the Panel, as well as external review by additional experts, members of the American Society of Clinical Oncology (ASCO) Health Services Committee, and the ASCO Board of Directors.

Results

Evidence supports the use of larynx-preservation approaches for appropriately selected patients without a compromise in survival; however, no larynx-preservation approach offers a survival advantage compared with total laryngectomy and adjuvant therapy with rehabilitation as indicated.

Recommendations

All patients with T1 or T2 laryngeal cancer, with rare exception, should be treated initially with intent to preserve the larynx. For most patients with T3 or T4 disease without tumor invasion through cartilage into soft tissues, a larynx-preservation approach is an appropriate, standard treatment option, and concurrent chemoradiotherapy therapy is the most widely applicable approach. To ensure an optimum outcome, special expertise and a multidisciplinary team are necessary, and the team should fully discuss with the patient the advantages and disadvantages of larynx-preservation options compared with treatments that include total laryngectomy.

Therapeutic Options in Advanced Laryngeal Cancer: An Overview

Historically, patients with advanced laryngeal cancer have been treated with radical surgery and adjuvant radiation therapy. Intensive surgical research has allowed surgeons to deal with almost any local extension and to propose an appropriate surgical procedure for each case. Several function-sparing surgical options are available to treat moderately advanced/advanced laryngeal cancer. Better understanding of the anatomy and biology of cancer in this anatomical site has enabled us to devise effective oncological strategies associated with a great effort to preserve laryngeal function. Numerous efforts have been made to augment the therapeutic armamentarium with the addition of chemotherapeutic agents combined with radiation therapy. For advanced laryngeal cancer, the debate is still open between partial/subtotal surgical procedures, which are more efficient but sacrifice parts of the larynx, and radiotherapy/chemoradiation protocols which can preserve the larynx and its function even though it requires radical surgery for salvage. Efforts should be made to select patients properly, in an individual basis, based on tumor characteristics, clinical aspects, patient's expectations, and the expertise of the head and neck oncologic team for the various therapeutic strategies in order to get better oncological results in association with the preservation of the laryngeal form and function, when possible.

Single-cycle induction chemotherapy selects patients with advanced laryngeal cancer for combined chemoradiation: a new treatment paradigm

PURPOSE

Primary chemoradiotherapy in patients with advanced laryngeal cancer can achieve high rates of organ preservation without sacrificing survival compared with radiation alone or conventional laryngectomy. Appropriate selection of patients for organ preservation approaches could enhance overall treatment outcome and quality of life. We conducted a phase II organ preservation trial for patients with stage III and IV larynx cancer to determine whether late salvage surgery rates could be decreased and survival improved by selecting patients for organ preservation based on response to a single cycle of induction chemotherapy.

PATIENTS AND METHODS

The chemotherapy was cisplatin 100 mg/m2 on day 1 and fluorouracil 1,000 mg/m(2)/d for 5 days. Patients who achieved less than 50% response had immediate laryngectomy. Patients who achieved more than 50% response went on to concurrent chemoradiotherapy. Histologic complete responders after chemoradiotherapy received two more cycles of chemotherapy. Patients with residual disease after chemoradiotherapy had planned salvage surgery.

RESULTS

Of 97 eligible patients, 73 (75%) achieved more than 50% response and received chemoradiotherapy. A total of 29 patients (30%) had salvage surgery; 19 patients (20%) had early salvage surgery after the single cycle of induction chemotherapy, three patients (3%) had late salvage surgery after chemoradiotherapy, six patients (6%) eventually had salvage surgery for recurrence, and one patient had laryngectomy for chondroradionecrosis. The median follow-up time was 41.9 months. The overall survival rate at 3 years is 85%. The cause-specific survival rate was 87%. Larynx preservation was achieved in 69 patients (70%).

CONCLUSION

These results confirm excellent larynx preservation and improved overall survival rates compared with historical results.

Survival patterns in treated cases of carcinoma larynx in North India: A 10-year follow-up study

Carcinoma of larynx is a common disease in North Indian population. It is seen commonly in smokers and alcoholics. It poses a serious health problem due to its tendency to cause airway obstruction and to make the patient aphonic if total larynxgectomy is done for curing this cancer. We conducted a retrospective analysis in 690 cases of carcinoma larynx presenting to Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh. Various aspects of this disease like predisposing factors, patterns of spread, histological types, various treatment modalities, their complications and response of this disease to these therapeutic options were studied in detail.

Phase II evaluation of 96-hour paclitaxel infusion in advanced (recurrent or metastatic) squamous cell carcinoma of the head and neck (E3395): a trial of the Eastern Cooperative Oncology Group

BACKGROUND

Paclitaxel (24-hour infusion) has yielded activity in advanced squamous cell carcinoma of the head and neck (SCCHN). Protracted exposure to paclitaxel may overcome resistance observed by using shorter infusions. Therefore we sought to evaluate paclitaxel by 96-hour infusion in both treatment-naïve and previously treated patients with SCCHN.

MATERIALS AND METHODS

Eligibility stipulated bi-dimensionally measurable, biopsy-documented, incurable SCCHN, Eastern Cooperative Oncology Group performance status (PS) 0-1, and adequate physiological indices. Patients were divided into three cohorts: 1) chemotherapy-naïve; 2) chemotherapy-exposed, paclitaxel-naïve; and 3) chemotherapy and paclitaxel exposed. Paclitaxel was dosed at 140 mg/m2 (96-hour infusion) every 3 weeks in treatment-naïve patients and at 120 mg/m2 (96 hours) every 3 weeks in previously treated patients.

RESULTS

Fifty patients were accrued between February 1997 and July 2000. The study was terminated because of low response rate. Eighty percent of patients were male, 75% PS 1. Nearly half the patients had oropharyngeal or hypopharyngeal primary sites. There was one treatment-related death due to neutropenic fever/pneumonia. Grade 4 toxicities included granulocytopenia in eight patients (20%), thrombocytopenia, and stomatitis in one patient each. Grade 3 or greater anemia occurred in 10 patients. There was no grade 2 or 3 peripheral sensory neuropathy. In 15 chemotherapy-naïve patients, two responses (13%) were observed. There were no responses in treatment-exposed patients. The overall median survival was 5.5 months, and 1-year survival rate 10%. Treatment-naïve patients had a median survival of 8.2 months and 1-year survival rate of 20%.

CONCLUSIONS

Paclitaxel by 96-hour infusion at a dose of 120-140 mg/m2/96 hours is only marginally active in the treatment of SCCHN. This dose and schedule cannot be recommended for further evaluation.

[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.

Larynx squamous cell carcinoma: concepts and future directions

The larynx is one of the most important structures in the upper aerodigestive tract. Functional impairment of the larynx is a bur-den to patients who suffer from laryngeal carcinoma, the second most common cancer of the head and neck region after the oral cavity.

Systemic chemotherapy for squamous cell head and neck cancer

Squamous cell head and neck cancer is a relatively uncommon malignancy in North America. Nonetheless, it has been of considerable interest to medical oncologists because of its remarkable sensitivity to systemic chemotherapy. Even in patients with relapsed or metastatic disease, meaningful tumour shrinkage can be achieved with systemic therapy. This has led to the performance of carefully conducted clinical trials exploring the role of systemic chemotherapy, not only in the palliative setting, but as part of definitive multi-modality treatment. Chemotherapy has been used as the initial (or induction) treatment, as an adjuvant treatment after definitive surgery and/or radiation, and concurrent with both definitive and adjuvant radiation therapy. Evidence-based conclusions have been drawn from these clinical trials and have led to significant changes in the current standards of care for this disease. In this article, the available data supporting the use of systemic chemotherapy as palliative treatment, and as part of the definitive management for this disease will be reviewed.

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.

Organ preservation trials for laryngeal cancer

Organ-preservation strategies include definitive radiation therapy alone, induction chemotherapy followed by radiotherapy, and concurrent chemoradiotherapy. Over the past decade, induction chemotherapy followed by radiotherapy has been the standard for the nonsurgical management of advanced laryngeal cancer. Over this same period, however, other nonsurgical strategies have been under evaluation. These approaches include radiotherapy with concurrent chemotherapy to take advantage of the radiosensitizing properties of most cytotoxic drugs with activity against squamous cell cancer, altered fractionation radiotherapy, and the incorporation of molecularly targeted therapeutics into multimodality treatment.

Accelerated hyperfractionated radiotherapy and concurrent protracted venous infusion chemotherapy in locally advanced head and neck cancer

Concurrent radiotherapy and chemotherapy result in a significant benefit with respect to induction chemotherapy followed by radiotherapy or radiotherapy alone, although with a significant increase of toxicity. To discover a more tolerated and effective chemoradiation regimen, the feasibility and efficacy of a hyperfractionated accelerated irradiation with concurrent protracted venous infusion chemotherapy was investigated. Sixty-five patients with advanced head and neck cancer underwent a definitive (53 patients) or a postoperative adjuvant (12 patients) chemoradiation treatment. Chemotherapy consisted of an intravenous protracted infusion of 5 and 200 mg/m /d cisplatin and 5-fluorouracil, respectively. Radiotherapy consisted of a split-course accelerated hyperfractionation of two 150-cGy (split twice a day) or three 100-cGy fractions per day (split three times a day) at more than 6-hour intervals, for 2 weeks followed, after a 1-week interruption, by 2-to-3-week treatment, with the same fractionation schedule, to a total dose of 60 Gy to 69 Gy. Confluent mucositis was tolerable and was the cause of treatment delay of more than 10 days in only 20% of patients. Grade 3 or greater systemic toxicity occurred only in 9 of 65 (14%) patients and was never the cause of drug dose reduction. Complete responses were observed in 69% of patients with gross diseases. At a median follow-up of 43.5 months, 45% of patients were alive and free of disease and 38% died of cancer. The 5-year actuarial local regional failure was 35%. The 5-year actuarial disease-specific survival was 50%. Preservation of larynx function was achieved in 47% of living patients and in 74% of all patients, with advanced tumors of the laryngopharynx. The long-term results of this study suggest that this chemoradiation regimen has the potential of achieving a significant improvement over standard therapy while avoiding significant toxicity.

Carcinoma of the supraglottic larynx: treatment results with radiotherapy alone or with planned neck dissection

PURPOSE

To present the results of radiotherapy with or without neck dissection for squamous cell carcinoma of the supraglottic larynx treated at the University of Florida and to compare these data with those obtained after conservation surgery.

METHODS AND MATERIALS

Continuous-course radiotherapy alone or combined with a planned neck dissection was used to treat 274 patients with squamous cell carcinoma of the supraglottic larynx between 1964 and 1998. All patients had follow-up for a minimum of 2 years, and 250 (91%) had follow-up for 5 years or more.

RESULTS

At 5 years, the actuarial probability of local control after radiotherapy according to T stage was as follows: T1, 100%; T2, 86%; T3, 62%; and T4, 62%. The probability of cause-specific survival at 5 years by AJCC stage was as follows: stage I, 100%; II, 93%; III, 81% IVA, 50%; and IVB, 13%. The risk of severe late complications was 4%. Of 57 patients undergoing planned postradiotherapy neck dissection, 7% experienced a severe complication.

CONCLUSIONS

On the basis of our data and the literature, early or moderately advanced supraglottic carcinomas may be treated successfully with either supraglottic laryngectomy or radiotherapy. Supraglottic laryngectomy probably produces a higher initial local control rate but, based on anatomic and coexisting medical constraints, is suitable for a smaller subset of patients and has a higher risk of complications compared with radiotherapy.

A phase II study of concomitant hyperfractionated radiation therapy and double dose intra-arterial cisplatin for squamous cell carcinoma of the head and neck

This successor phase II study evaluates the tolerability and efficacy of concomitant hyperfractionated radiation therapy (HFX-RT) and double dose intra-arterial (IA) cisplatin in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN). In doing so, this study represents further resurgence of the potential use of IA chemotherapy in the management of SCCHN. This has been enabled by the evolution of angiographic catheter/microcatherter technology. Between 1997 and 1999, 24 patients with locally advanced T4/T3 SCCHN were treated with HFX-RT (76.8- 81.6 Gy at 1.2 Gy bid over 6-7 weeks) and high-dose IA cisplatin (150mg/m2 given at the start of and during RT boost treatment [start of week 6 and 7]). Twenty-two patients (92%) had T4 disease and 14 (58%) N2/ N3 disease. Acute toxicity was limited to two grade 4 (8%) and 19 grade 3 (79%) mucosal events; and single grade 3 hematologic, infectious and skin events. Eight patients (33%) were unable to receive the second planned dose of IA cisplatin. Twenty-two patients had complete response (92%) at the primary site. Among 17 patients with positive neck disease 12 (71%) achieved complete response in the neck. Follow-up ranges from 7-30 months (median = 18 months) with 14 patients alive without disease, 2 alive with disease, 7 dead of disease and 1 dead of intercurrent disease. While concomitant HFX-RT and double dose IA cisplatin as used in this study is associated with encouraging response rates in this highly unfavorable subset of patients with locally advanced SCCHN it was not feasible. Future investigation of this novel treatment strategy utilizing modern angiographic catheter/microcatherter technology will involve a single dose of IA cisplatin with HFX-RT and dose intensification using neoadjuvant therapy.

Treatment results and prognostic factors of advanced T3--4 laryngeal carcinoma: the University of California, San Francisco (UCSF) and Stanford University Hospital (SUH) experience

PURPOSE

To review the UCSF-SUH experience in the treatment of advanced T3--4 laryngeal carcinoma and to evaluate the different factors affecting locoregional control and survival.

METHODS AND MATERIALS

We reviewed the records of 223 patients treated for T3--4 squamous cell carcinoma of the larynx between October 1, 1957, and December 1, 1999. There were 187 men and 36 women, with a median age of 60 years (range, 28--85 years). The primary site was glottic in 122 and supraglottic in 101 patients. We retrospectively staged the patients according to the 1997 AJCC staging system. One hundred and twenty-seven patients had T3 lesions, and 96 had T4 lesions; 132 had N0, 29 had N1, 45 had N2, and 17 had N3 disease. The overall stage was III in 93 and IV in 130 patients. Seventy-nine patients had cartilage involvement, and 144 did not. Surgery was the primary treatment modality in 161 patients, of which 134 had postoperative radiotherapy (RT), 11 had preoperative RT, 7 had surgery followed by RT and chemotherapy (CT), and 9 had surgery alone. Forty-one patients had RT alone, and 21 had CT with RT. Locoregional control (LRC) and overall survival (OS) were estimated using the Kaplan--Meier method. Log-rank statistics were employed to identify significant prognostic factors for OS and LRC.

RESULTS

The median follow-up was 41 months (range, 2--367 months) for all patients and 78 months (range, 6--332 months) for alive patients. The LRC rate was 69% at 5 years and 68% at 10 years. Eighty-four patients relapsed, of which 53 were locoregional failures. Significant prognostic factors for LRC on univariate analysis were primary site, N stage, overall stage, the lowest hemoglobin (Hgb) level during RT, and treatment modality. Favorable prognostic factors for LRC on multivariate analysis were lower N stage and primary surgery. The overall survival rate was 48% at 5 years and 34% at 10 years. Significant prognostic factors for OS on univariate analysis were: primary site, age, overall stage, T stage, N stage, lowest Hgb level during RT, and treatment modality. Favorable prognostic factors for OS on multivariate analysis were lower N stage and higher Hgb level during RT.

CONCLUSION

Lower N-stage was a favorable prognostic factor for LRC and OS. Hgb levels > or = 12.5 g/dL during RT was a favorable prognostic factor for OS. Surgery was a favorable prognostic factor for LRC but did not impact on OS. Correcting the Hbg level before and during treatment should be investigated in future clinical trials as a way of improving therapeutic outcome in patients with advanced laryngeal carcinomas.

High-dose intra-arterial cisplatin boost with hyperfractionated radiation therapy for advanced squamous cell carcinoma of the head and neck

PURPOSE

To evaluate the tolerance and efficacy of intra-arterial (IA) cisplatin boost with hyperfractionated radiation therapy (HFX-RT) in patients with advanced squamous cell carcinoma of the head and neck (SCCHN).

PATIENTS AND METHODS

Forty-two patients with locally advanced primary SCCHN were treated on consecutive phase I/II studies of HFX-RT (receiving a total of 76.8 to 81.6 Gy, given at 1.2 Gy bid) and IA cisplatin (150 mg/m(2) received at the start of and during RT boost treatment).

RESULTS

Acute grade 3 to 4 toxicities were as follows: grade 4 and grade 3 mucosal toxicity occurred in three (7%) and 31 patients (69%), respectively, and grade 3 hematologic, infectious, and skin events occurred in one patient each. Eight of 24 patients (33%) were unable to receive a second planned dose of IA cisplatin because of general anxiety (n = 5), nausea and/or emesis (n = 2), or asymptomatic occlusion of an external carotid artery (n = 1). Thirty-seven patients (88%) experienced complete response (CR) at primary site. Twenty-nine (85%) of 34 patients presenting with nodal disease experienced CR. The actuarial 2-year rates of locoregional control and disease-specific and overall survival are 73%, 63%, and 57%, respectively, with a median active follow-up of 30 months.

CONCLUSION

In this highly unfavorable subset of patients, these results seem superior to previously reported chemoradiation regimens in more favorable patients. Use of a second dose of IA cisplatin boost was associated with increased toxicity without obvious therapeutic gain. This novel strategy allows for an incremental increase in the treatment intensity of the HFX-RT regimen recently established as superior to once-a-day RT.

Chemotherapy in the management of squamous-cell carcinoma of the head and neck

Previously reserved for palliation, chemotherapy is now also a central component of several curative approaches to the management of patients with advanced-stage head and neck cancer. Here we review the results of both induction chemotherapy and chemoradiotherapy trials in patients with curable disease, and chemotherapy trials in patients with recurrent and metastatic disease, and we highlight current areas of investigation. Compared with traditional treatment modalities, chemotherapy given on induction schedules to patients with advanced laryngeal cancer allows greater organ preservation without compromise to survival; when given concomitantly with radiotherapy to patients with resectable or unresectable advanced disease, chemotherapy again improves survival.

ORGAN PRESERVATION FOR CARCINOMA OF THE LARYNX AND HYPOPHARYNX

Treatment of laryngeal and hypopharyngeal cancers often necessitates total laryngectomy. This article reviews approaches of curing patients with these diseases while preserving their larynx. Strategies include radiation alone, neoadjuvant chemotherapy with radiation for responders, or concurrent chemotherapy and radiation. Both retrospective experiences and randomized trials evaluating differing therapies in an effort to achieve voice preservation are reported and analyzed.

High-dose intra-arterial cisplatin and concurrent hyperfractionated radiation therapy in patients with locally advanced primary squamous cell carcinoma of the head and neck: report of a phase II study

BACKGROUND

This phase II study evaluates the tolerability and efficacy of concurrent hyperfractionated radiation therapy (HFX-RT) and high-dose intra-arterial (IA) cisplatin in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN).

METHODS

Between December 1995 and November 1997, 20 patients with locally advanced T4/T3 SCCHN were treated with HFX-RT (76.8-79.2 Gy at 1.2 Gy bid over 6-7 weeks) and high-dose IA cisplatin (150 mg/m(2) given at the start of RT boost treatment [start of week 6]). Seventeen patients (85%) had T4 disease, and 14 (70%) had N2/ N3 disease.

RESULTS

Grade 3-5 acute toxicity was limited to one grade 4 (5%) and 14 grade 3 (70%) mucosal events. No grade 3/4 hematologic toxicity was observed. Median weight loss during therapy was 9% (range, 2%-16%). Eighteen patients had complete response (90%) at the primary site; 14 were confirmed pathologically. Among 17 patients with positive neck disease, 16 (94%) achieved complete response in the neck, including 12 of 13 patients with N2/N3 disease who underwent planned neck dissection. Active follow-up ranges from 12 to 32 months (median, 20 months) with 11 patients alive without disease, 5 dead of disease, and 4 dead of intercurrent disease. Eighteen patients (90%) remained disease free at the primary site, and the locoregional control rate is 80%.

CONCLUSIONS

High-dose IA cisplatin and concurrent HFX-RT as used in this study is feasible and warrants further investigation. The high complete response rate and low grade 4 toxicity in this highly unfavorable subset of patients appears better than previously reported chemoradiation regimens for more favorable patients.

Induction chemotherapy and radiation therapy for T4 oropharyngeal carcinoma

Between 1964 and 1996, 123 patients were treated for T4 oropharyngeal carcinoma; 93 were treated with radiation therapy alone; 30 were treated with induction chemotherapy and radiation therapy. Patients who received induction chemotherapy and radiation therapy were treated between 1985 and 1996; during this time 39 patients were treated with radiation therapy alone. Five-year local control rates for patients undergoing chemotherapy and radiation therapy, radiation therapy alone (all patients), and radiation therapy alone (patients treated since September 1985) were 63%, 38%, and 48%, respectively. The five-year rates of freedom from distant metastasis were 87%, 73%, and 76%, respectively. The five-year actuarial cause-specific survival rates were 58%, 27%, and 37%, respectively, while the five-year absolute survival rates were 42%, 17%, and 23%, respectively. Improvements in local control and freedom from distant metastasis in those receiving chemotherapy were not statistically significant, while the improvements in cause-specific survival and absolute survival were significant at the P < or = 0.05 level. Induction chemotherapy may improve the cure rate for patients with T4 oropharyngeal carcinoma. Although encouraging, these data are nonrandomized and should be interpreted with caution.

Comparing treatment outcomes of radiotherapy and surgery in locally advanced carcinoma of the larynx: a comparison limited to patients eligible for surgery

PURPOSE

The use of radical radiotherapy and surgery for salvage (RRSS) in locally advanced squamous cell carcinoma (SCC) of the larynx is controversial. In the absence of randomized studies, it is unclear if RRSS can match the rates of locoregional control and survival reported for primary surgery in this setting. The aim of this study was to compare treatment outcomes of radiotherapy and surgery in comparable patients with CS III-IV SCC of the larynx.

METHODS AND MATERIALS

Eighty-two patients with untreated T2N+M0 or T3T4NM0 SCC of the larynx were treated with a policy RRSS at the Toronto-Sunnybrook Regional Cancer Centre between June 1980 and December 1990. The medical records at presentation were reviewed independently by a panel of three surgical oncologists blinded as to treatment outcome to determine patient suitability for laryngectomy and neck dissection using eligibility criteria adopted by recent clinical trials. Treatment outcomes for surgery-eligible patients were compared to results of comparably staged patients in the surgical literature since 1980.

RESULTS

Sixty-three patients (77%) were eligible for study. With a median follow-up of 3 years, radiotherapy controlled the primary in 8/20 evaluable glottic primaries and 21/41 evaluable supraglottic primaries. Forty-five percent of patients surviving 5 years retained a functional larynx. Sixteen of 29 relapsing patients were salvaged with surgery. Disease above the clavicles was controlled in 65% of T3T4N0N+ glottic primaries (compared to a published range of 53% to 79%) and 82% of T3N0 glottic primaries (compared to a published range of 69% to 84%). The 5-year overall survival of patients with T3T4 glottic cancer was 54% compared to a published range of 50% to 63%. The cause-specific survival (CSS) of patients with T3N0 glottic primaries (86% at 1 year and 73% at 2 years) was identical to the only published report of CSS in the surgical literature.

CONCLUSION

A policy of RRSS offers a good chance of laryngeal conservation without compromising ultimate locoregional control or survival when compared to primary laryngectomy and neck dissection in patients with locally advanced carcinoma of the larynx meeting the surgical eligibility of clinical trials.

Conservative surgery in T3-T4 pharyngolaryngeal squamous cell carcinoma: an alternative to radiation therapy and to total laryngectomy for good responders to induction chemotherapy

OBJECTIVE

To evaluate the possibility of preservation of the larynx after neoadjuvant chemotherapy by performing a conservative surgery instead of total laryngectomy initially planned, in patients with previously untreated laryngeal and piriform sinus squamous cell carcinoma (SCC).

STUDY DESIGN

Retrospective study.

METHODS

A total of 115 patients treated at Tenon Hospital with induction chemotherapy from 1985 to 1995, all with initial indication of radical surgery, were available for the study. The clinical tumor response was evaluated after three cycles of chemotherapy. According to this response, to preserve laryngeal functions, some patients had a modification of the treatment initially planned: radiation therapy essentially for complete responders, and conservative surgery for some partial responders.

RESULTS

Of 69 patients with laryngeal cancer, 14 were treated by partial laryngectomy and 19 by radiation therapy; of 46 patients with piriform sinus cancer, 8 were treated by partial surgery and 12 by radiation therapy; the other patients were treated as was initially planned (total laryngectomy with partial pharyngectomy). Overall survival rates, estimated by the Kaplan-Meier method, were not statistically different between the three treatment groups. The laryngeal functions were preserved in 54% of the patients who were alive at 3 years.

CONCLUSION

This report is a retrospective study, but these results suggest the possibility of using conservative surgery, instead of initially planned total laryngectomy, for good responders to induction chemotherapy with a small residual tumor.

The performance of SF-36 health survey in patients with laryngeal cancer. Head and Neck Cancer Italian Working Group

BACKGROUND

Interest in measuring health-related quality of life has increased together with the awareness that such humanistic outcomes require valid and reliable measures. Among the several generic questionnaires, the Short Form 36 Items Health Survey (SF-36) is recognized for its comprehensiveness, brevity, and high standards of reliability and validity. It has been translated and validated in several languages.

METHODS

In the framework of a larger, prospective, multicenter study aimed to produce and validate an Italian questionnaire tailored to laryngeal cancer patients, the SF-36 was administered to a sample of well-characterized cases. It was, therefore, possible to test its characteristics in terms of patients' acceptance, psychometric, and clinical validity.

RESULTS

Overall, findings show that in this sample of 165 consecutive patients with laryngeal cancer at various stage of disease, the SF-36 performance was very good. The patients' acceptance was satisfactory: all patients completed the questionnaire. All the questionnaire scales met the standards suggested in terms of grouping and scaling assumptions. The internal reliability coefficients actually replicate the satisfactory findings reported for the original SF-36. In terms of capability of the questionnaire scales to discriminate between groups expected to differ in a given health concept in relation to clinical variables, the results were also good.

CONCLUSIONS

This study showed that SF-36 was well accepted by patients and was able to detect the impact of different treatment approaches on health- related quality of life. It is likely that the sensitivity and the precision of the SF-36 can be further improved by integrating brief questionnaire modules specific for laryngeal clinical issues.

Carcinoma of the larynx treated with hypofractionated radiation and hyperbaric oxygen: long-term tumor control and complications

PURPOSE

To evaluate the long-term outcome with respect to local control, survival, and complications in a cohort of patients with locally advanced laryngeal carcinoma treated with hypofractionated radiation and hyperbaric oxygen at 4 atmospheres of pressure (HBO-4).

METHODS AND MATERIALS

Between January 1970 and August 1982, 45 patients with locally advanced carcinoma of the larynx were treated with primary radiation using a unique hypofractionated schedule of 2 fractions of 11 Gy separated by 21 days, with concomitant HBO-4 during each radiotherapy session. To avoid seizures, discomfort and other complications of HBO-4, each session was performed under general anesthesia. All patients had pathologically confirmed squamous cell carcinoma of the glottic (23) or supraglottic larynx (22) and were staged as follows: T2-5, T3-24, T-4-16; N0-26, N1-4, N2-13, N3-1. Patients were treated with opposed lateral wedged fields of 4-6 MV photons, with a median field size of 5.5 x 9.75 to a total median dose of 22.5 Gy.

RESULTS

As of February 1998, follow-up was complete on all but one patient, who relocated to another country after 8 years. Complete clinical responses were observed in 39 (87%) of the cases. The 10-year local control rate for all 45 patients was 58%, and local control for the complete responders was 69%. Three patients underwent laryngectomy for complications and were found to have no pathological evidence of disease in the laryngectomy specimen. The 10-year survival of the overall population was 27%. The 10-year voice preservation rate for the the 39 complete responders was 55%. Acute mucosal and skin reactions were modest and acceptable. Significant late complications occurred in 14 patients consisting of severe fibrosis, necrosis, pharyngeal fistula, with 3 patients requiring laryngectomy for complications. The actuarial rate of severe complications at 5 years was 42%.

CONCLUSIONS

The response rate and long-term tumor control rate obtained with this treatment program were comparable to more protracted radiation schedules with or without systemic chemotherapy. The complication rate was high resulting in an adverse therapeutic ratio. The radiobiologic interpretation of this clinical data, and implications for hypoxia directed therapy, are discussed.

Clinical economics of head and neck malignancies

With the continued increase in medical expenditures and the growing awareness that resources are not limitless, there is increasing pressure to curb health care costs and to establish priorities. As potential solutions are proposed and implemented, there is understandable concern that policy choices may adversely affect both the access to and the quality of care. Economic analyses are one tool used to optimize resource allocation decisions. The primary goal of these analyses is to maximize value and efficiency, not necessarily to decrease spending. The current focus on cost cutting is often associated with a more truncated, nonsocietal perspective (e.g., that of the payer or provider). To be most useful, these analyses must be methodologically rigorous. Standard guidelines, such as those established by Eisenberg, are helpful. As shown in the reports applicable to head and neck malignancies that have been discussed here, many articles published in the clinical literature must be interpreted cautiously, because fundamental methodological concerns (e.g., using costs rather than charges, discounting to a common base year) were frequently not addressed. Economic investigations are one aspect of the broader fields of outcomes and health services research. It is easy to underestimate how greatly economic studies depend on the availability of high quality noneconomic data. In that context, current initiatives in evidence-based medicine (EBM), using the best available evidence (considering for example, the type of trial, the quality of the research, and the credentials of the researcher) to help clinicians practice in situations where doubt may exist in the diagnosis, treatment, or prognosis of patients, will likely grow in importance. Evidence-based clinical practice guidelines and systematic literature reviews are manifestations of this trend. Historically, disease control measures and survival have been the primary and points in clinical cancer studies. Economic analyses and studies evaluating other end points (e.g., function, quality of life) will likely play a larger role in the future in evaluating the diagnosis, treatment, and follow-up of head, neck and other malignancies.

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.

The changing role of surgery in the diagnosis and treatment of cancer

Many changes have occurred in the surgical treatment of the cancer patient. For many tumors, surgery has been modified or eliminated. These changes are due to the realization that, for some cancers, more extensive surgical procedures are not more beneficial, to improvements in radiation therapy and chemotherapy, to the availability of better noninvasive or less invasive diagnostic and therapeutic techniques, and to improved surgical equipment (such as videoscopic surgery).

Management of the clinically positive neck in organ preservation for advanced head and neck cancer

BACKGROUND

To investigate clinicopathologic predictive criteria for the optimal management of neck metastases in patients with advanced head and neck cancers treated with combined chemoradiotherapy.

METHODS

Prospective study, 48 patients. Mean length follow-up, 23 months.

RESULTS

Neck stage predicted neck response to chemoradiotherapy; N3 necks showed more partial responses (P = 0.04), and N1 necks showed more complete responses (P = 0.12). Primary tumor site strongly predicted the pathologic response found on neck dissection in patients with a clinical partial response (cPR) following chemoradiotherapy. There was no difference in survival between patients with a clinical complete response (cCR) after chemoradiotherapy, and patients with a pathologic complete response (pCR) after neck dissection (P = 0.20); however, when grouped together, these patients survived longer than did patients with a pPR at neck dissection (P = 0.06).

CONCLUSIONS

Clinical response to induction chemotherapy is a poor predictor of ultimate neck control. Induction chemotherapy followed by chemoradiotherapy, and planned neck dissection for patients with persistent cervical lymphadenopathy, provides good regional control.

Medical oncology in the management of head and neck cancers

General approaches and therapeutic goals of medical oncology for head and neck cancer are presented. The effectiveness of chemotherapy for the treatment of different stages of head and neck cancer in specific anatomic sites is discussed, as well as complications associated with chemotherapy, and approaches to the prevention and management of these stages. Systemic side effects that may occur with specific therapeutic agents are presented in a tabular format. Future directions and evolving approaches to head and neck cancer therapy are summarized.