Postoperative radiotherapy for squamous cell carcinoma of the head and neck

Early Death in T3-T4 Head and Neck Cancer: NCDB Comparison of Surgical vs. Non-Surgical Approaches

BACKGROUND

Surgeries for T3-T4 head and neck squamous cell carcinoma (HNSCC) are often complex and high-risk with the potential for early death, which is both clinically devastating and a negative quality indicator for health systems. This study aims to compare surgical and non-surgical approaches in an aggressive subset of HNSCC for early death.

METHODS

This is a retrospective analysis of the National Cancer Database (NCDB) v2018 for advanced T3-T4 HNSCC patients from 2004 to 2018. Univariate and multivariate logistic regression analyses were performed with the primary goal of comparing 30-day mortality in patients undergoing primary surgery (PS) versus radiation with or without chemotherapy (CRT). Subgroup analysis between treatment groups was performed with respect to HPV status.

RESULTS

A total of 79 677 advanced head and neck cancer patients with a mean (SD) age of 62.5 (12.0) years, predominantly male (74.0%), were included in the analysis. Patients with T3-T4 HNSCC undergoing upfront surgery had an early death rate of 1.1%, compared to 4.7% for CRT (p < 0.001). This translated to significantly lower odds of early death with PS compared to CRT (OR = 0.25, 95% CI 0.22-0.28), adjusting for age, comorbidity index, stage III or IV, subsite, insurance status, and grade. Subset analysis showed survival benefits of PS irrespective of HPV status. Age ≥ 65 years, T4 tumors, higher Charlson Comorbidity Index (CCI), and uninsured status were consistently associated with increased mortality risk.

CONCLUSION

This study suggests that an upfront surgical approach is associated with decreased early death compared to non-surgical treatment for HNSCC. HPV-based subgroup analysis has shown a more focused predictor of early death. Cancer treatment paradigms should account for the observation of these findings for advanced HNSCC.

Postoperative complications following salvage neck dissection after (chemo)radiotherapy for head and neck squamous cell carcinoma: which patients are at high risk?

BACKGROUND

Salvage neck dissection (ND) is the treatment of choice for residual neck disease after (chemo)radiotherapy for head-and-neck squamous cell carcinoma (HNSCC). Although ND is a relatively safe surgical procedure, several studies have shown that salvage ND will increase the morbidity of (chemo)radiotherapy with possible increase in acute and late toxicity and deterioration of quality-of-life. Therefore, unnecessary salvage ND need to be avoided. However, the available literature could not identify potential groups at higher risk of post-operative complications because of the missing demographic information and the heterogeneity in studies and outcome data. We aim to report on the types, rates, and severity of postoperative complications and to identify groups of patients at high risk of these complications.

METHODS

Of 908 patients with node-positive HNSCC primarily treated with (chemo)radiotherapy between 2008 and 2022, 130 (14%) underwent salvage ND. Endpoints of the study are the incidence of G ≥ 2 and G3 postoperative complications, identification of risk factors for these complications and the oncologic outcomes.

RESULTS

Of all patients who underwent salvage ND, 41% still had vital tumor in ND-specimen (pN +). No G4-5 complications were reported. The incidence of G3 and G ≥ 2(CTCAE.v5) postoperative complications were 18% and 52%, respectively. Events reported as G3 complications were wound infection/dehiscence (n = 9), fistula (n = 4), bleeding (n = 4), tracheotomy (n = 6), dysphagia (n = 4), severe pneumonia and septicemia (n = 2), and frozen shoulder (n = 1). Seven patients had more than one type of G3 complications. Logistic regression showed that extent of salvage ND, size of the largest node and HPV-negative disease were independent predictors for G ≥ 2 complications. Multivariable analysis showed that G ≥ 2 complications was not associated with worse OS while HPV-negative and N3-disease were independent predictors for worse survival.

CONCLUSIONS

Of all patients who underwent salvage ND, 41% still had residual neck disease while 52% developed G ≥ 2 and 18% G3 complications. Although OS was not worse in these patients, accurate detection of residual neck disease is essential to spare considerable number of patients from unnecessary salvage ND with its possible complications. Patients with lymph nodes larger than 3 cm, HPV-negative disease and those treated by (modified)radical ND were at high risk of G ≥ 2 complications.

The Single-Cell Landscape of Peripheral and Tumor-infiltrating Immune Cells in HPV- HNSCC

Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer worldwide. HPV-negative HNSCC, which arises in the upper airway mucosa, is particularly aggressive, with nearly half of patients succumbing to the disease within five years and limited response to immune checkpoint inhibitors compared to other cancers. There is a need to further explore the complex immune landscape in HPV-negative HNSCC to identify potential therapeutic targets. Here, we integrated two single-cell RNA sequencing datasets from 29 samples and nearly 300,000 immune cells to investigate immune cell dynamics across tumor progression and lymph node metastasis. Notable shifts toward adaptative immune cell populations were observed in the 14 distinct HNSCC-associated peripheral blood mononuclear (PBMCs) and 21 tumor-infiltrating immune cells (TICs) considering disease stages. All PBMCs and TICs revealed unique molecular signatures correlating with lymph node involvement; however, broadly, TICs increased ligand expression among effector cytokines, growth factors, and interferon-related genes. Pathway analysis comparing PBMCs and TICs further confirmed active cell signaling among Monocyte-Macrophage, Dendritic cell, Natural Killer (NK), and T cell populations. Receptor-ligand analysis revealed significant communication patterns shifts among TICs, between CD8+ T cells and NK cells, showing heightened immunosuppressive signaling that correlated with disease progression. In locally invasive HPV-negative HNSCC samples, highly multiplexed immunofluorescence assays highlighted peri-tumoral clustering of exhausted CD8+ T and NK cells, alongside their exclusion from intra-tumoral niches. These findings emphasize cytotoxic immune cells as valuable biomarkers and therapeutic targets, shedding light on the mechanisms by which the HNSCC sustainably evades immune responses.

Role of Nanoformulations in the Treatment of Lung Cancer

Lung cancer is the second deadliest disease in the world. A major portion of deaths related to cancer are due to lung cancer in both males and females. Interestingly, unbelievable advances have occurred in recent years through the use of nanotechnology and development in both the diagnosis and treatment of lung cancer. Due to their in vivo stability, the nanotechnology-based pharmacological system gained huge attractiveness, solubility, absorption from the intestine, pharmacological effectiveness, etc. of various anticancer agents. However, this field needs to be utilized more to get maximum results in the treatment of lung cancer, along with wider context medicines. In the present review, authors have tried to concentrate their attention on lung cancer`s difficulties along with the current pharmacological and diagnostic situation, and current advancements in approaches based on nanotechnology for the treatment and diagnosis of lung cancer. While nanotechnology offers these promising avenues for lung cancer diagnosis and treatment, it is important to acknowledge the need for careful evaluation of safety, efficacy, and regulatory approval. With continued research and development, nanotechnology holds tremendous potential to revolutionize the management of lung cancer and improve patient outcomes. The review also highlights the involvement of endocrine systems, especially estrogen in lung cancer proliferation. Some of the recent clinical trials and patents on nanoparticle-based formulations that have applications in the treatment and diagnosis of lung cancer are also discussed.

Factors Contributing to Postoperative Radiotherapy Delays in Head and Neck Cancer: A Comprehensive Review

Head and neck cancer encompasses a diverse group of malignancies that pose significant challenges in their management due to their heterogeneity in clinical behavior and treatment response. Postoperative radiotherapy (PORT) is a critical component in the treatment regimen for head and neck cancer, aimed at reducing local recurrence and improving overall survival (OS). However, delays in the initiation of PORT can significantly compromise patient outcomes. This comprehensive review explores the factors contributing to such delays, categorizing them into patient-related, treatment-related, and systemic factors. Patient-related factors include health status, comorbidities, socioeconomic barriers, and psychological issues. Treatment-related factors involve surgical complications, complexities in treatment planning, and coordination challenges between surgical and radiation oncology teams. Systemic and institutional factors encompass hospital resources, staffing levels, administrative and insurance issues, and geographic barriers. The review also examined the impact of these delays on patient outcomes, highlighting the increased risk of recurrence and reduced survival rates. Strategies to mitigate delays are discussed, including improved preoperative and postoperative planning, enhanced multidisciplinary coordination, patient education, and systemic policy changes. Additionally, case studies and real-world examples of successful interventions are presented. Future directions for research and policy recommendations are also outlined, emphasizing the need for continued efforts to ensure timely PORT for head and neck cancer patients. This review aims to provide a comprehensive analysis that can inform clinical practice and policy, ultimately improving the standard of care and patient outcomes in head and neck cancer treatment.

[French national standard for the treatment of squamous cell carcinoma of upper aero-digestive tract - General principles of treatment]

OBJECTIVES

The management of upper aerodigestive tract cancers is a complex specialty. It is essential to provide an update to establish optimal care. At the initiative of the INCa and under the auspices of the SFORL, the scientific committee, led by Professor Béatrix Barry, Dr. Gilles Dolivet, and Dr. Dominique De Raucourt, decided to develop a reference framework aimed at defining, in a scientific and consensus-based manner, the general principles of treatment for upper aerodigestive tract cancers applicable to all sub-locations.

METHODOLOGY

To develop this framework, a multidisciplinary team of practitioners was formed. A systematic analysis of the literature was conducted to produce recommendations classified by grades, in accordance with the standards of the French National Authority for Health (HAS).

RESULTS

The grading of recommendations according to HAS standards has allowed the establishment of a reference for patient care based on several criteria. In this framework, patients benefit from differentiated care based on prognostic factors they present (age, comorbidities, TNM status, HPV status, etc.), conditions of implementation, and quality criteria for indicated surgery (operability, resectability, margin quality, mutilation, salvage surgery), as well as quality criteria for radiotherapy (target volume, implementation time, etc.). The role of medical and postoperative treatments was also evaluated based on specific criteria. Finally, supportive care must be organized from the beginning and throughout the patients' care journey.

CONCLUSION

All collected data have led to the development of a comprehensive framework aimed at harmonizing practices nationally, facilitating decision-making in multidisciplinary consultation meetings, promoting equality in practices, and providing a state-of-the-art and reference practices for assessing the quality of care. This new framework is intended to be updated every 5 years to best reflect the latest advances in the field.

Role of combined surgical and radiotherapy treatment in nonmetastatic WHO I nasopharyngeal carcinoma patients

BACKGROUND

Keratinizing squamous cell carcinoma (KSCC) is recognized as WHO I nasopharyngeal carcinoma (NPC). Current guidelines for treating nasopharyngeal cancer do not delineate specific strategies for individual pathologic subtypes.

OBJECTIVES

To explore the optimal treatment for KSCC of the nasopharynx.

MATERIAL AND METHODS

Data on patients were extracted from the SEER database. Survival differences between patients treated with radiotherapy alone and combined surgery were assessed using Kaplan-Meier and Cox regression models and compared using propensity score matching (PSM). In addition, we explored the survival differences between the two groups of patients in different risk stratifications.

RESULTS

In our study, 165 patients underwent surgical intervention, while 1238 patients did not. In both univariate (CSS: p = .001, HR = 0.612; OS: p < .001, HR = 0.623) and multivariate (CSS: p = .004, HR = 0.655; OS: p < .001, HR = 0.655) analyses, combined surgery was identified as a significant prognostic factor. These findings were consistent after PSM. Using RPA, patients were categorized into two groups. CSS improved in the high-risk group, whereas the difference in low-risk patients was not significant.

CONCLUSIONS AND SIGNIFICANCE

For patients diagnosed with WHO I nasopharyngeal carcinoma, the combination of radiotherapy and surgery has significant clinical advantages, especially for patients at high risk.

Electrochemotherapy for head and neck cancers: possibilities and limitations

Head and neck cancer continues to be among the most prevalent types of cancer globally, yet it can be managed with appropriate treatment approaches. Presently, chemotherapy and radiotherapy stand as the primary treatment modalities for various groups and regions affected by head and neck cancer. Nonetheless, these treatments are linked to adverse side effects in patients. Moreover, due to tumor resistance to multiple drugs (both intrinsic and extrinsic) and radiotherapy, along with numerous other factors, recurrences or metastases often occur. Electrochemotherapy (ECT) emerges as a clinically proven alternative that offers high efficacy, localized effect, and diminished negative factors. Electrochemotherapy involves the treatment of solid tumors by combining a non-permeable cytotoxic drug, such as bleomycin, with a locally administered pulsed electric field (PEF). It is crucial to employ this method effectively by utilizing optimal PEF protocols and drugs at concentrations that do not possess inherent cytotoxic properties. This review emphasizes an examination of diverse clinical practices of ECT concerning head and neck cancer. It specifically delves into the treatment procedure, the choice of anti-cancer drugs, pre-treatment planning, PEF protocols, and electroporation electrodes as well as the efficacy of tumor response to the treatment and encountered obstacles. We have also highlighted the significance of assessing the spatial electric field distribution in both tumor and adjacent tissues prior to treatment as it plays a pivotal role in determining treatment success. Finally, we compare the ECT methodology to conventional treatments to highlight the potential for improvement and to facilitate popularization of the technique in the area of head and neck cancers where it is not widespread yet while it is not the case with other cancer types.

Submandibular Gland-Sparing Technique Versus En-Bloc Level IB Dissection in Oral Cavity Cancers with N0 Neck Status: A Randomized Controlled Trial

IMPORTANCE

Metastases to the submandibular gland (SMG) from oral cavity primaries are very rare. Hence, a gland-preserving level IB dissection technique is a feasible option without compromising the lymph node yield (LNY).

OBJECTIVE

To assess the feasibility and noninferiority of the SMG-preserving dissection technique to the conventional en bloc removal of level IB in terms of LNY in patients with cN0 oral squamous cell carcinoma (OSCC) undergoing elective neck dissection.

DESIGN

Parallel-design, single-center, open-label, randomized controlled trial.

SETTING

Tertiary care health care center-Department of Otorhinolaryngology-Head & Neck Surgery, AIIMS Rishikesh.

PARTICIPANTS

Thirty-eight (n = 38) participants with 46 (n = 46) neck dissection specimens of OSCC were randomly allocated (1:1) into gland-preserving (n1 = 23) and en bloc (n2 = 23) dissection groups.

INTERVENTION

Elective neck dissection comparing SMG-sparing level IB dissection technique versus en bloc level IB dissection.

MAIN OUTCOME MEASURES

LNY, lymph node density, and level IB operative time in both groups were compared between groups (α < .05).

RESULTS

Median LNY (P = .543) and lymph node density (P = 1.000) in level IB did not show significant differences between the groups. LNY in level IB by gland-preserving technique is also not inferior to the conventional en bloc dissection technique (mean difference = 0.217; 95% CI: [-0.597, 1.032]; P = .593). The mean level IB operative time is significantly longer in the gland-preserving group (P < .001).

CONCLUSIONS AND RELEVANCE

None of the examined SMGs were involved by the tumor. SMG-preserving technique is noninferior to the traditional technique of level IB clearance and can be used in elective neck dissections without compromising the LNY. Functional neck dissection has greatly evolved to decrease patient morbidity, and this method can be adopted in case-specific situations.

TRIAL REGISTRATION

The trial was registered in the Clinical Trials Registry-India (CTRI/2022/05/042344) on May 2, 2023, https://ctri.nic.in/.

The Remove-the-Mask Open-Source head and neck Surface-Guided radiation therapy system

Background and Purpose

Surface Guided Radiotherapy (SGRT) for head and neck radiotherapy is challenging as obstructions are common and non-rigid facial motion can compromise surface accuracy. The purpose of this work was to develop and benchmark the Remove the Mask (RtM) SGRT system, an open-source system especially designed to address the challenges faced in radiotherapy of head and neck cancer.

Materials and Methods

The accuracy of the RtM SGRT system was benchmarked using a head phantom positioned on a robotic motion platform capable of sub-millimetre accuracy which was used to induce unidirectional shifts and to reproduce three real head motion traces. We also assessed the accuracy of the system in ten humans volunteers. The ground truth motion of the volunteers was obtained using a commercial motion capture system with an accuracy < 0.3 mm.

Results

The mean tracking error of the RtM SGRT system for the ten volunteers was of -0.1 ± 0.4 mm -0.6 ± 0.6 mm and 0.3 ± 0.2 mm, and 0.0 ± 0.2° 0.0 ± 0.1° and 0.0 ± 0.2° for translations and rotations along the left-right, superior-inferior and anterior-posterior axes respectively and we also found similar results in measurements with the head phantom. Forced facial motion was associated with lower tracking accuracy. The RtM SGRT system achieved submillimetre accuracy.

Conclusion

The RtM SGRT system is a low-cost, easy to build and open-source SGRT system that can achieve an accuracy that meets international commissioning guidelines. Its open-source and modular design allows for the development and easy translation of novel surface tracking techniques.

Genetic Polymorphisms of XPC, XPD, XPG Genes and their Association with Radiotherapy Induced Toxicity among Head and Neck Cancer Patients: A Hospital Based Study from Maharashtra

BACKGROUND

The present study was planned to investigate possible association of single nucleotide polymorphisms (SNPs) of nucleotide excision repair (NER) genes such as XPC, XPD, XPG with acute radiation induced toxicities such as skin reactions and oral mucositis in normal tissue from head and neck cancer (HNC) patients receiving radiotherapy.  Methods: Two hundred and fifty HNC patients receiving radiotherapy were enrolled in this study and the acute toxicity reactions and radiation response were recorded. Association of SNPs rs2228001 of XPC, rs238406, rs13181 of XPD and rs17655 of XPG gene with normal tissue reactions in the form of dermatitis and mucositis were studied by PCR-RFLP and direct DNA sequencing.

RESULTS

The results of univariate analysis of SNPs of XPC, XPD and XPG showed that XPC polymorphism at codon 939 of exon 15 (A>C) was not associated with dermatitis (OR=0.30, 95% CI: 0.06-1.39; p=0.125), or oral mucositis (OR=1.14, 95% CI: 0.41-3.20; p=0.793). The XPD codon 156 of exon 6 (C>A) and codon 751 of exon-23 A>C) polymorphism showed no association with radiosensitivity in HNC patients (OR=1.50, 95% CI: 0.60-3.71; p=0.080) for dermatitis, (OR=1.54, 95% CI: 0.66-3.61; p=0.312) for oral mucositis. The 1104 Asp variant genotype or allele of XPG (OR=1.35 95% CI: 0.50-3.64; p=0.541) showed no association with degree of radiotherapy associated dermatitis or mucositis (OR=0.80, 95% CI: 0.32-2.03; p=0.648) in HNC patients. The variant C allele of 2920 A/C genotype of XPC gene at codon 939 of exon 15, found protective with developing skin reactions with grade >1 (OR=0.60, 95% CI: 0.36-0.97; p=0.039) in HNC patients treated with radiotherapy.

CONCLUSION

The results obtained in this study concluded that the SNPs rs2228001of XPC, rs238406, rs13181 SNPs of XPD and rs17655 SNP of XPG are not associated with normal tissue toxicity in HNC patients treated with radiotherapy. Radiotherapy with high radiation dose was significantly associated with oral mucositis in response to radiotherapy.

Crosstalk between Non-Coding RNAs and Wnt/β-Catenin Signaling in Head and Neck Cancer: Identification of Novel Biomarkers and Therapeutic Agents

Head and neck cancers (HNC) encompass a broad spectrum of neoplastic disorders characterized by significant morbidity and mortality. While contemporary therapeutic interventions offer promise, challenges persist due to tumor recurrence and metastasis. Central to HNC pathogenesis is the aberration in numerous signaling cascades. Prominently, the Wnt signaling pathway has been critically implicated in the etiology of HNC, as supported by a plethora of research. Equally important, variations in the expression of non-coding RNAs (ncRNAs) have been identified to modulate key cancer phenotypes such as cellular proliferation, epithelial-mesenchymal transition, metastatic potential, recurrence, and treatment resistance. This review aims to provide an exhaustive insight into the multifaceted influence of ncRNAs on HNC, with specific emphasis on their interactions with the Wnt/β-catenin (WBC) signaling axis. We further delineate the effect of ncRNAs in either exacerbating or attenuating HNC progression via interference with WBC signaling. An overview of the mechanisms underlying the interplay between ncRNAs and WBC signaling is also presented. In addition, we described the potential of various ncRNAs in enhancing the efficacy of chemotherapeutic and radiotherapeutic modalities. In summary, this assessment posits the potential of ncRNAs as therapeutic agents targeting the WBC signaling pathway in HNC management.

Comparative Survival Function in Patients with Positive Surgical Margins Following Laryngectomy

Aims: This study aims to make a comparative analysis of disease-free survival (DFS) and overall disease-specific survival (OS) in patients with laryngeal carcinoma. Materials and methods: The study was designed retrospectively. Sixteen patients with postoperative PSM and 30 with negative surgical margins (NSM) were included. Survival analysis and Long-Rank comparisons was performed for DFS and OS between groups. Results: PSM was a significant independent risk factor for loco-regional recurrence and disease-related mortality (p = 0.004, HR: 1.6, p = 0.002, HR: 3.2, respectively). DFS and OS were significantly longer in NSM group (p = 0.001 and 0.003, respectively). For PSM group, 2- and 5-year DFS rates were 57%; OS rates were 80% and 34% respectively. In NSM group, 2- and 5-year DFS rates were 96% and 83%; OS rates were found to be 96%. Conclusion: PSM had significant relation with poor prognosis.

Investigating Predictive Factors of Dysphagia and Treatment Prolongation in Patients with Oral Cavity or Oropharyngeal Cancer Receiving Radiation Therapy Concurrently with Chemotherapy

Radiation therapy (RT) treatment for head and neck cancer has been associated with dysphagia manifestation leading to worse outcomes and decrease in life quality. In this study, we investigated factors leading to dysphagia and treatment prolongation in patients with primaries arising from oral cavity or oropharynx that were submitted to radiation therapy concurrently with chemotherapy. The records of patients with oral cavity or oropharyngeal cancer that received RT treatment to the primary and bilateral neck lymph nodes concurrently with chemotherapy were retrospectively reviewed. Logistic regression models were used to analyze the potential correlation between explanatory variables and the primary (dysphagia ≥ 2) and secondary (prolongation of total treatment duration ≥ 7 days) outcomes of interest. The Toxicity Criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC) were used to evaluate dysphagia. A total of 160 patients were included in the study. Age mean was 63.31 (SD = 8.24). Dysphagia grade ≥ 2 was observed in 76 (47.5%) patients, while 32 (20%) experienced treatment prolongation ≥ 7 days. The logistic regression analysis showed that the volume in the primary site of disease that received dose ≥ 60 Gy (≥118.75 cc, p < 0.001, (OR = 8.43, 95% CI [3.51-20.26]) and mean dose to the pharyngeal constrictor muscles > 40.6 Gy (p < 0.001, OR = 11.58, 95% CI [4.84-27.71]) were significantly associated with dysphagia grade ≥ 2. Treatment prolongation ≥ 7 days was predicted by higher age (p = 0.007, OR = 1.079, 95% CI [1.021-1.140]) and development of grade ≥ 2 dysphagia (p = 0.005, OR = 4.02, 95% CI [1.53-10.53]). In patients with oral cavity or oropharyngeal cancer that receive bilateral neck irradiation concurrently with chemotherapy, constrictors mean dose and the volume in the primary site receiving ≥ 60 Gy should be kept below 40.6 Gy and 118.75 cc, respectively, whenever possible. Elderly patients or those that are considered at high risk for dysphagia manifestation are more likely to experience treatment prolongation ≥ 7 days and they should be closely monitored during treatment course for nutritional support and pain management.

Functional swallowing outcomes related to radiation exposure to dysphagia and aspiration-related structures in patients with head and neck cancer undergoing definitive and postoperative intensity-modulated radiotherapy

BACKGROUND

The relationship between swallowing outcomes and radiotherapy dose to dysphagia and aspiration-related structures (DARS) may be different following definitive versus postoperative radiotherapy (PORT) for mucosal head and neck cancer (HNC) and has not been well-studied.

METHOD

Patient- and clinician-reported swallowing measures were prospectively collected at six time points from baseline to 24 months postradiotherapy HNC. Radiotherapy plans were retrospectively analyzed to assess dose delivered to DARS. The association between swallowing outcomes and participant demographics, tumor characteristics, and radiotherapy dose in definitive and postoperative treatment cohorts was assessed.

RESULTS

Ninety-three participants who received radiotherapy for HNC were included in the analysis (n = 49 definitive radiotherapy for laryngeal/pharyngeal primary tumors and n = 44 postoperative PORT for predominantly oral cavity/salivary gland tumors). Participants undergoing PORT had lower doses to DARS than those undergoing definitive RT. High dose to the pharyngeal constrictors and base of tongue for definitive RT and the esophageal inlet, supraglottic larynx and cervical esophagus for the PORT group were associated with worse swallowing function.

CONCLUSION

Radiation dose to DARS is associated with post-treatment swallowing outcomes. These dose/outcome relationships may vary between the definitive and postoperative settings.

An Updated Review on Head and Neck Cancer Treatment with Radiation Therapy

The complexity of head and neck cancers (HNC) mandates a multidisciplinary approach and radiation therapy (RT) plays a critical role in the optimal management of patients with HNC, either as frontline or adjuvant treatment postoperatively. The advent of both definitive and post-operative RT has significantly improved the outcomes of patients with HNC. Herein, we discuss the role of postoperative RT in different subtypes of HNC, its side effects, and the importance of surveillance. The treatment regions discussed in this paper are the oral cavity, nasopharynx, paranasal sinus cavity, oropharynx, larynx and hypopharynx. Multiple studies that demonstrate the importance of definitive and/or postoperative RT, which led to an improved outlook of survival for HNC patients will be discussed.

Management of Laryngeal Dysplasia and Early Invasive Cancer

OPINION STATEMENT

Dysplasia and early laryngeal cancer lie on a spectrum of cellular changes. These start with early changes to the cells including epithelial hyperplasia and expand to dysplasia, squamous cell carcinoma in situ and finally developing in to invasive cancer. Dysplasia can range from low to high grade, with each being treated in a different manner. Treatment options are typically determined by where the dysplasia/invasive cancer lie on this spectrum along with the site within the larynx. Hyperkeratosis, mild dysplasia and moderate dysplasia typically involve primary endoscopic excision. Severe dysplasia and squamous cell carcinoma in situ involve primary endoscopic resection with the addition of possible laser resection and/or ablation. At this stage, surgery will be followed by close surveillance. Finally, early laryngeal cancer such as T1 and T2 lesions is typically more involved. Treatment depends on the site and degree of involvement of the structures, along with spread to surrounding structures. Typical treatment options of more involved early laryngeal cancer can range from radiation therapy, endoscopic transoral laser resection, endoscopic transoral robotic resection to open resection. Often times, my choice of treatment will be aimed at voice preservation but patient preference will also play a role in the decision making between treatment modalities. Chemotherapy and immunotherapy are typically not used in early stage laryngeal cancer.

Relevance of Combined Electron and Photon Beams in Radiotherapy of Head and Neck Cancers in the Era of Intensity-Modulated Radiotherapy

Introduction External beam radiotherapy (EBRT) for head and neck (H&N) cancers continues to be delivered using varied technologies, ranging from the old two-dimensional conventional radiotherapy (2DRT) techniques to the modern three-dimensional conformal radiotherapy (3DCRT), intensity-modulated radiotherapy (IMRT), and volumetric modulated arc therapy (VMAT) in different centers in India. Due to limitations of spinal cord tolerance, electron and photon beams are combined in 2DRT and 3DCRT techniques for treating nodal volume of the H&N cases. However, many centers having modern technology practice IMRT/VMAT in place of electron beams. The purpose of this study is to analyze the role of combined electron and photon beams in radiotherapy of H&N cancers and its relevance in the modern era of IMRT/VMAT.

Materials and Methods Data were collected through a survey conducted on cancer centers in India where radiotherapy is being given by 2DRT, 3DCRT, and IMR/VMAT for the treatment of head and neck cancers.

Results The mean percentage of H&N (H&N) cases among all cases were 39.2% (standard deviation [SD]: 14.22), out of which 16.63% (SD: 20.83) were treated with a combination of photon and electron beams and 49.73% (SD: 37.41) were treated with IMRT/VMAT. The average percentage of H&N cases of government institutes was 38.39% (SD: 14.11) and that of private institutes was 40.14% (SD: 14.11). Patients treated with photon and electron combination and IMRT/VMAT were 22.19% (SD: 11.24) and 24.05% (SD: 23.99), respectively, in government institutes, and 10.29% (SD: 11.24) and 79.09% (SD: 26.75) in private institutes.

Conclusion As per this study, we conclude that despite the availability of IMRT/VMAT, a combination of electron and photon beams is still relevant in India. Since a large proportion of the patients are still treated with the electron and photon combination, it is imperative that further studies on field–junction dosimetry should be conducted to ensure accurate dose delivery.

Current Role of Radiotherapy in the Management of Oral Cavity Squamous Cell Carcinoma

Study Design

Literature review.

Objective

To review the current role of radiotherapy (RT) in the management of oral cavity squamous cell carcinoma (SCC).

Methods

Review of selected literature.

Results

T1-T2N0 SCCs may be treated with either RT alone or surgery with a high likelihood of cure. The pendulum swung toward surgery with postoperative RT (PORT) added depending on the pathological findings in the mid 1980s. Patients with positive margins, extranodal extension (ENE), and/or 4 or more positive nodes receive concomitant chemotherapy (POCRT). Patients with T3-T4 and/or positive regional nodes are treated with surgery and PORT alone or POCRT. The likelihood of cure is moderate to low depending on extent of disease. The likelihood of major complications ranges from 10% to 30% depending on the method of reconstruction and the aggressiveness of postoperative PORT/POCRT. Patients with very advanced disease are treated with palliative RT, chemotherapy, or supportive care.

Conclusions

The role of RT in the management of oral cavity SCC is primarily in the postoperative setting with palliative RT being reserved for those with very advanced disease where the likelihood of cure is remote.

Utility of 3-Month Surveillance F-18 FDG PET/CT in Surgically Resected Oral Squamous Cell Carcinoma

OBJECTIVES

To evaluate the performance of surveillance F-18 fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) 1 year after imaging in oral squamous cell carcinoma (OSCC) patients treated with definitive surgery and adjuvant (chemo)radiotherapy (RT).

METHODS AND MATERIALS

Surveillance PET/CT accuracy was retrospectively evaluated in OSCC patients receiving surgical resection and (chemo)RT. Pathologic risk factors were assessed for influence on accuracy of the post-RT PET/CT.

RESULTS

Fifty-four patients with median follow-up of 3.8 years met inclusion criteria. A PET/CT obtained a median of 3.4 months after RT revealed 11 (20.4%) instances of true disease recurrence: 4 locoregional alone, 6 distant alone, and 1 patient with locoregional and distant disease. Locoregional detection sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 55.6%, 75.0%, 33.3%, and 88.2%, respectively. For distant recurrence, the respective values were 100%, 95.2%, 77.8%, and 100%. Absence of bone invasion, absence of pT4 disease, and disease within the tongue were independently associated with higher sensitivity ( P = .048). Perineural invasion was associated with increased specificity ( P = .027), and tumor location in the tongue was associated with a higher PPV ( P = .007) on surveillance PET/CT.

CONCLUSIONS

Post-RT PET/CT accuracy information for surgically managed OSCC patients demonstrates significant associations with pathologic factors.

Postoperative radiotherapy dose requirement in standard combined-modality practice for head and neck squamous cell carcinoma: Analysis of salient surgical and radiotherapy parameters in 2 cohorts

BACKGROUND

This study compared 2 sequential cohorts to identify the postoperative radiotherapy (PORT) dose requirement for head and neck squamous cell carcinoma (HNSCC).

METHODS

Two distinct PORT dose regimens were prescribed over 11 years; group 1 received 56 Gy or less, and group 2 received 60 Gy or more. The 2D and 3D techniques were used.

RESULTS

Two sequential cohorts consisted of 478 patients, with mean and median follow-up for group 1 and 2 as: 37.0 versus 28.5 months and 13.8 versus 13.1 months, respectively. Grades 3-4 mucosal toxicities (11.4% vs 28.3%), hospitalization (3.2% vs 17.4%), and nasogastric feeding (11.9% vs 29.7%) were higher in group 2. The 2-year disease-free survival (DFS) was higher with PORT >60 Gy for the following factors: age ≤ 50 years (P = .041); ≥ 4 positive nodes (P = .029); and overall treatment time (OTT) ≥ 100 days (P = .042).

CONCLUSION

Except for the benefit of doses >60 Gy for limited parameters, a lower PORT dose did not compromise the results and can potentially reduce the morbidities and healthcare costs.

Delayed postoperative radiation therapy in local control of squamous cell carcinoma of the tongue and floor of the mouth

Objective

To evaluate the effect of time between surgery and postoperative radiation therapy on local recurrence of squamous cell carcinoma of the tongue and floor of the mouth.

Methods

A total of 154 patients treated between 1996 and 2007 were selected considering local recurrence rate and time of the adjuvant radiotherapy.

Results

Local recurrence was diagnosed in 54 (35%) patients. Radiation therapy reduced the rate of local recurrences, although with no statistical significance. The time between surgery and initiation of postoperative radiotherapy did not significantly influence the risk of local recurrence in patients referred to adjuvant treatment (p=0.49).

Conclusion

In the presence of risk factors for local recurrence, a short delay in starting the adjuvant radiation therapy does not contraindicate its performance.

Improved survival in HPV/p16-positive oropharyngeal cancer patients treated with postoperative radiotherapy

INTRODUCTION

In the literature, HPV infection and/or p16 positivity have been consistently demonstrated to correlate with improved response rates in oropharyngeal squamous cell carcinoma (OPSCC) patients treated with primary radiotherapy (RT) alone and in combination with chemotherapy. However, the exact role of HPV/p16 positivity in patients treated with postoperative RT is still unclear.

METHODS

We analyzed tumor samples for HPV-DNA and p16 expression and correlated these variables with treatment outcome in a series of 63 consecutively treated oropharyngeal cancer patients (95% stage III/IV). HPV and p16 analysis were performed using validated test systems. Survival was estimated by the Kaplan-Meier method. Cox proportional hazard regression models were applied to compare the risk of death among patients stratified according to risk factors.

RESULTS

Expression of p16 or high-risk HPV-DNA was detected in 60.3% and 39.6% of the tumors, respectively. p16 expression [overall survival (OS) at 2 years: 91%] as well as HPV infection (OS at 2 years: 95%) was associated with improved OS. Mean survival in p16-positive patients was 112 months compared to 64.6 months in case of p16 negativity. All HPV-positive tumors stained positive for p16. In a multivariable analysis, p16 positivity was associated with improved OS and with disease-free survival.

CONCLUSION

p16 expression and HPV infection are strongly associated with the outcome of postoperatively irradiated OPSCC patients. HPV and p16 double-negative OPSCC patients should be regarded as a distinct "very high-risk patient group" that may benefit from intensified or novel treatment combinations.

Distribution of circulating natural killer cells and T lymphocytes in head and neck squamous cell carcinoma

OBJECTIVE

Natural killer (NK) cells are capable of eliminating malignantly transformed cells without prior sensitization. In contrast to NK-cells, T lymphocytes possess antitumourous activity that is restricted to major histocompatibility complex (MHC) recognition. The aim of this study was to determine the causes of the different distributions of these cell types in the peripheral blood of patients with head and neck squamous cell carcinomas (HNSCC).

METHODS

A cohort of 105 subjects was divided into three clinical groups: non-treated HNSCC patients, treated relapse-free HNSCC patients and healthy control subjects. Peripheral blood mononuclear cells (PBMC) were isolated from venous blood, subsets were depleted, flow cytometric counts were made and subsequently correlation analyses with clinical parameters were performed.

RESULTS

Treated relapse-free HNSCC patients have a significantly increased mean proportion of NK-cells in PBMC of 26.39% (p<0.001), whereas T lymphocytes and natural killer-T-(NKT) cells of treated patients have a significantly decreased mean proportion in PBMC of 55.15% (p<0.05) at least 12 months after treatment. This inverse redistribution of these two subsets is reflected in a significantly increased mean NK/T-ratio of 0.54 (p<0.05) in treated patients. The NK/T-ratio correlates with the systemic invasiveness of the type of therapy patients undergo and is highest after surgery with adjuvant radiochemotherapy (0.64, rs=0.334, p<0.01). This appears to be a post-therapeutic long-term effect in treated patients, as they had a mean relapse-free period until venous puncture of 47.9 months in our study. We also demonstrated age-dependent changes in the peripheral distribution of T- and NK-cells.

CONCLUSION

These findings reveal new aspects in understanding tumour biology and interactions with the cellular immune system which provide novel starting points for further research.

Cisplatin superior to carboplatin in adjuvant radiochemotherapy for locally advanced cancers of the oropharynx and oral cavity

BACKGROUND AND PURPOSE

The optimal radiochemotherapy regimen for squamous cell carcinoma of the head and neck (SCCHN) is controversial. In most cases, platin-based chemotherapy regimens are used. However, uncertainty exists whether cisplatin or carboplatin is the better choice. This retrospective study compared radiochemotherapy with either cisplatin or carboplatin in patients with locally advanced SCC of the oropharynx and oral cavity.

PATIENTS AND METHODS

Concurrent chemotherapy consisted of two courses of cisplatin (20 mg/m(2) on days 1-5 and days 29 - 33; n = 65) or two courses of carboplatin (AUC 1.5 on days 1-5 and days  29 - 33; n = 41). Both regimens were retrospectively compared for locoregional control (LRC), overall survival (OS), and toxicity. Thirteen additional potential prognostic factors were evaluated including age, gender, ECOG performance status, tumor site, histologic grade, T/N category, AJCC stage, year of treatment, extent of resection, interval between surgery and RT, completion of chemotherapy, and radiotherapy breaks.

RESULTS

The 3-year LRC rates were 85% in the cisplatin group and 62% in the carboplatin group, respectively (p = 0.004). The 3-year OS rates were 78% and 51%, respectively (p = 0.001). Acute toxicity (mucositis, skin toxicity, nausea/vomiting, renal toxicity, hematologic toxicity) and late toxicity (xerostomia, neck fibrosis, skin toxicity, lymph edema) rates were not significantly different between the two groups. On multivariate analysis, better LRC was significantly associated with cisplatin (p < 0.001), an ECOG performance status of 0-1 (p = 0.001), and an interval between surgery and RT of ≤ 6 weeks (p = 0.001). Improved OS was significantly associated with cisplatin (p < 0.001) and completion of chemotherapy (p = 0.002).

CONCLUSION

For adjuvant radiochemotherapy of patients with locally advanced cancer of the oropharynx and oral cavity, cisplatin appears preferable to carboplatin as it resulted in better outcomes without increased toxicity.

Radical surgery and postoperative radiotherapy in patients with advanced squamous cell carcinoma of the larynx

Background: The aim of this study is to analyze the results of radical surgery followed by postoperative radiotherapy in patients with advanced laryngeal cancer. Methods: Seventy-seven patients with advanced laryngeal cancer were treated with postoperative radiotherapy following total laryngectomy with or without neck dissection. Median age of patients at the diagnosis was 57 years (range, 43-76). The median follow-up was 41 months (range, 11-70). Radiotherapy was performed using three-dimensional conformal technique. Results: Median duration of overall radiation treatment time was 5.9 weeks (range, 5.4-7.6). Median total dose delivered was 60 Gy (range, 50-66). Locoregional relapse was the most frequent pattern of failure. A 5-year locoregional control (LRC) and overall survival (OS) rates were 72.3% and 66.2%, respectively. A 5-year LRC and OS rates were significantly higher in patients without nodal disease (N0) as compared to patients with metastatic involvement of the neck lymph nodes (N+) (p=0.009 and p=0.002, respectively). Confluent mucositis was developed in 16 patients (20.8%). Late toxicity most frequently occurred in the skin as well as in the mucous membrane and in the subcutaneous tissue and was grade 1 reaction (74.0%, 67.5%, and 72.7%, respectively). Conclusion: In order to improve treatment results in terms of LRC and OS and following evidence-based treatment recommendations for patients with advanced laryngeal cancer whose initial treatment was radical surgery, we strongly advocate the acceptance of postoperative concurrent chemoradiotherapy in cases with surgical specimen demonstrating high-risk pathological features.

Intraoperative radiotherapy (IORT) with low-energy photons as a boost in patients with early-stage oral cancer with the indications for postoperative radiotherapy : treatment feasibility and preliminary results

PURPOSE

To evaluate the feasibility and preliminary results of intraoperative radiotherapy (IORT) with low-energy photons as a boost in patients with early-stage oral cancer with the indications for postoperative radiotherapy.

PATIENTS AND METHODS

Between 2003 and 2006, 16 patients with early-stage cancer of mobile tongue (n = 10 [63%]) or floor of the mouth (n = 6 [37%]) treated at Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland, were evaluated for IORT boost with the INTRABEAM®System (Carl Zeiss Surgical GmbH; IORT-PRS) because of the high risk of local recurrence due to positive margins on frozen pathologic section. After tumor resection, the applicator was positioned in the tumor bed. The applicator's diameter (range: 1.5-5 cm) was selected to encompass high-risk area of tumor recurrence. The dose (5 Gy, 7 Gy, or 7.5 Gy) was applied according to tumor volume and bone proximity. External-beam radiotherapy (EBRT) was provided to the tumor bed in all patients (50 Gy) and to the nodal area, when needed. Toxicity and local tumor control were assessed.

RESULTS

Median follow-up was 36 months. IORT did not increase acute mucosal reaction. Local tumor control was found in all cases. Early mucosal reaction did not exceed 3 according to the RTOG scale and healed in median time of 35 days after completion of EBRT. No late adverse effects were observed.

CONCLUSION

This preliminary report has demonstrated the feasibility of IORT-PRS for patients with early oral cancer with the indications for postoperative radiotherapy. This method may be considered an alternative boost technique, although additional studies are needed to establish long-term results in a larger group of patients.

Postoperative strategies after primary surgery for squamous cell carcinoma of the head and neck

This review discusses the role of adjuvant treatment after curative surgery for patients with head and neck squamous cell carcinoma (HNSCC). In general, patients with unfavourable prognostic factors have a high-risk of loco-regional recurrence and subsequent worse survival after surgery alone and are therefore considered proper candidates for adjuvant treatment by either postoperative radiotherapy alone or postoperative chemoradiation. Selection of the most optimal adjuvant treatment strategy should be based on the most important prognostic factors. In this review, the different treatment strategies will be discussed in general. More specifically, we will discuss the role of the interval between surgery and radiotherapy, the overall treatment time of radiation, the selection of target volumes for radiation and the value of adding concomitant chemotherapy to postoperative radiation.