Human papillomavirus modifies the prognostic significance of T stage and possibly N stage in tonsillar cancer

BACKGROUND

Despite the association with more advanced nodal stage, patients with human papillomavirus (HPV) positive oropharyngeal cancers have better outcomes. We examined whether the HPV can modify the effect of known prognostic factors in tonsillar cancer.

PATIENTS AND METHODS

A total of 489 patients from 10 centres were followed up for recurrence or death for a median of 3.2 years. Determinants of the rate of locoregional recurrence, death from tonsillar cancer and overall survival were modelled using Cox regression.

RESULTS

The prognostic value of T and N stages were modified by HPV as indicated by statistically significant interaction terms. After adjusting for age, gender and treatment, T stage appeared relevant only for HPV-positive cancers (where a higher T stage was associated with worse outcomes). There was some evidence that N stage was a more relevant prognostic factor for HPV-negative than -positive cancers. There was no evidence that the HPV modifies the effect of age, gender or grade on outcomes.

CONCLUSIONS

This study suggests that the prognostic significance of the conventional staging system in tonsillar cancer is modified by HPV.

Prognostic factors and treatment options for paediatric ependymomas

The aim of this study was to determine factors of prognostic relevance for paediatric ependymomas, and evaluate the efficacy of treatment modalities. This is a retrospective study of 43 patients with ependymoma (<18 years) who underwent a combination of surgical excision, chemotherapy, and/or radiotherapy treatment at The Prince of Wales Cancer Centre between 1969 and 2009. Statistical analysis was performed to assess the prognostic relevance of various parameters affecting the two-year and five-year overall survival (OS) and progression-free survival (PFS). The five-year OS and PFS were 50.3% and 44.8% respectively (median follow-up 50 months). Eighteen patients (41.9%) experienced tumour recurrence: 13 had a local recurrence (LR) and five had both LR and distant recurrence. On univariate analysis, a more favourable prognosis in terms of both OS and PFS was evident for supratentorial tumours compared to infratentorial tumours (OS p=0.007, PFS p=0.045), stereotactic radiosurgery/ fractionated stereotactic radiotherapy compared to craniospinal irradiation or local posterior fossa/local brain±boost radiotherapy modalities (OS p=0.047, PFS p=0.031), total radiotherapy dose >50 Gy compared to ≤50 Gy (OS p=0.008, PFS p=0.005), and in patients with no tumour recurrence compared to those with recurrence (OS p=0.03, PFS p<0.001). Although not statistically significant, a more favourable multivariate outcome was evident in patients who underwent complete surgical resection. Chemotherapy treatment and histopathological grade, however, were not relevant to prognosis. This study supports the need to pursue more aggressive treatment for infratentorial and/or recurrent tumours. Ideal treatment involves maximal surgical resection, followed by adjuvant radiotherapy (>50 Gy).

Leptomeningeal carcinomatosis from perineural invasion of a lip squamous cell carcinoma

Perineural invasion resulting in leptomeningeal carcinomatosis is a rare, but well-recognized phenomenon in head and neck carcinomas. We report the rare case of a patient with a squamous cell carcinoma of the lip resulting in leptomeningeal carcinomatosis and review the relevant published work. A 51-year-old man presented with progressive facial paraesthesia after treatment for a recurrent squamous cell carcinoma of the lower lip. Cavernous sinus involvement was confirmed on MRI and he received stereotactic radiotherapy. He subsequently developed progressive lower limb neurological signs. An MRI showed multiple enhancing leptomeningeal nodules in the cervical and lumbar spine consistent with leptomeningeal carcinomatosis. Whole spine radiotherapy and dexamethasone resulted in short-term stabilization of symptoms only and he rapidly succumbed to progressive neurological disease. To our knowledge, this is the first published report of a squamous cell carcinoma of the lip resulting in leptomeningeal disease of the cauda equina. It illustrates the potential aggressive natural history of squamous cell carcinomas with perineural invasion.

Hyperbaric oxygenation for tumour sensitisation to radiotherapy

BACKGROUND

Cancer is common and radiotherapy is one well-established treatment for some solid tumours. HBO may improve the ability of radiotherapy to kill hypoxic cancer cells, so the administration of radiotherapy while breathing HBO may result in a reduction in mortality and tumour recurrence.

OBJECTIVES

To assess the benefits and harms of radiotherapy while breathing HBO.

SEARCH STRATEGY

In November 2004 we searched The Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library Issue 3), MEDLINE, EMBASE , CINAHL, DORCTHIM and reference lists of articles. Relevant journals were handsearched.

SELECTION CRITERIA

Randomised and quasi-randomised studies comparing the outcome of malignant tumours following radiation therapy while breathing HBO versus air (with or without sham therapy).

DATA COLLECTION AND ANALYSIS

Three reviewers independently evaluated the quality of the relevant trials using the method of Schulz (Schulz 1995) and extracted the data from the included trials.

MAIN RESULTS

Nineteen trials contributed to this review (2286 patients: 1103 allocated to HBO and 1153 control). With HBO, there was a reduction in mortality for head and neck cancers at both one year and five years after therapy (Relative risk (RR) 0.83, P = 0.03, number needed to treat (NNT) = 11 and RR 0.82, P = 0.03, NNT = 5 respectively), as well as improved local tumour control at three months (RR with HBOT 0.58, P = 0.006, NNT = 7). The effect of HBO varied with different fractionation schemes. Local tumour recurrence was less likely with HBO at one year (head and neck, RR 0.66, P < 0.0001, NNT = 5), two years (uterine cervix RR 0.60, P = 0.04, NNT = 5) and five years (head and neck (RR 0.77, P = 0.01). Any advantage is achieved at the cost of some adverse effects. There was a significant increase in the rate of both severe radiation tissue injury (RR 2.35, P < 0.0001, (number needed to harm (NNH) = 8) and the chance of seizures during therapy (RR 6.76, P = 0.03, NNH 22) with HBO.

AUTHORS' CONCLUSIONS

There is some evidence that HBO improves local tumour control and mortality for cancers of the head and neck, and local tumour recurrence in cancers of the head and neck, and uterine cervix. These benefits may only occur with unusual fractionation schemes. HBO is associated with significant adverse effects including oxygen toxic seizures and severe tissue radiation injury. The methodological and reporting inadequacies of the primary studies included in this review demand a cautious interpretation. More research is needed for head and neck cancer, but is probably not justified for bladder cancer. There is little evidence available concerning malignancies at other anatomical sites on which to base a recommendation.

Hyperbaric oxygen therapy for late radiation tissue injury

BACKGROUND

Cancer is a significant global health problem. Radiotherapy is a treatment for many cancers and about 50% of patients having radiotherapy with be long-term survivors. Some will experience LRTI developing months or years later. HBOT has been suggested for LRTI based upon the ability to improve the blood supply to these tissues. It is postulated that HBOT may result in both healing of tissues and the prevention of problems following surgery.

OBJECTIVES

To assess the benefits and harms of HBOT for treating or preventing LRTI.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2004, MEDLINE, EMBASE, CINAHL and DORCTHIM (hyperbaric RCT register) in September 2004.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the effect of HBOT versus no HBOT on LRTI prevention or healing.

DATA COLLECTION AND ANALYSIS

Three reviewers independently evaluated the quality of the relevant trials using the guidelines of the Cochrane Handbook Clarke 2003) and extracted the data from the included trials.

MAIN RESULTS

Six trials contributed to this review (447 participants). For pooled analyses, investigation of heterogeneity suggested important variability between trials. From single studies there was a significantly improved chance of healing following HBOT for radiation proctitis (relative risk (RR) 2.7, 95% confidence Interval (CI) 1.2 to 6.0, P = 0.02, numbers needed to treat (NNT) = 3), and following both surgical flaps (RR 8.7, 95% CI 2.7 to 27.5, P = 0.0002, NNT = 4) and hemimandibulectomy (RR 1.4, 95% CI 1.1 to 1.8, P = 0.001, NNT = 5). There was also a significantly improved probability of healing irradiated tooth sockets following dental extraction (RR 1.4, 95% CI 1.1 to 1.7, P = 0.009, NNT = 4). There was no evidence of benefit in clinical outcomes with established radiation injury to neural tissue, and no data reported on the use of HBOT to treat other manifestations of LRTI. These trials did not report adverse effects.

AUTHORS' CONCLUSIONS

These small trials suggest that for people with LRTI affecting tissues of the head, neck, anus and rectum, HBOT is associated with improved outcome. HBOT also appears to reduce the chance of osteoradionecrosis following tooth extraction in an irradiated field. There was no such evidence of any important clinical effect on neurological tissues. The application of HBOT to selected patients and tissues may be justified. Further research is required to establish the optimum patient selection and timing of any therapy. An economic evaluation should be also be undertaken. There is no useful information from this review regarding the efficacy or effectiveness of HBOT for other tissues.

Malignancies of the external auditory canal and temporal bone: a review

BACKGROUND

Malignancies of the external auditory canal and temporal bone are uncommon. A retrospective review was conducted of a large series treated at the Prince of Wales hospital between 1974 and 1995.

METHODS

Retrospective review of 59 cases of ear canal and temporal bone malignancies. These were analysed according to histopathology, disease extent, surgery, margin status and survival. A TNM-type staging system was applied to 51 cases and Kaplan-Meier survival analysis applied to this group.

RESULTS

The 5-year cancer-specific survival (CSS) for the series was 54%. For stages 1, 2, 3 and 4 disease, the CSS were 90, 45, 40 and 19%, respectively. Survival was significantly higher where clear surgical margins were achieved (80 vs 35%).

CONCLUSIONS

Carcinoma of the external ear canal is rare and, in Australia, is often related to recurrence of periauricular cutaneous malignancy. Surgical extirpation with clear margins provides the best survival.

Early glottic carcinoma: results of treatment by radiotherapy

The purpose of the present paper was to review the results of treating early (stages T1-2N0) glottic, squamous cell carcinoma by radiotherapy in the Department of Radiation Oncology, Prince of Wales Hospital, Sydney. A retrospective review was carried out of all patients seen in the department from 1967 to 1994, inclusive. To be eligible, patients had to have newly diagnosed cancer and to have been treated with curative intent by radiotherapy alone. Three hundred and sixty-nine patients satisfied the eligibility requirements. The mean follow-up time was 12.2 years (maximum: 28 years). At 5 years the actuarial local control rate was 80% (84% for stage T1 and 72% for T2). The ultimate local control rate was 96%. The overall survival rates at 5 and 10 years were 73% and 52%, respectively. The risk of nodal recurrence was much higher after persisting disease or local recurrence. Our results confirm the high cure rates achieved with this modality of treatment and are comparable with those reported in the literature.

Does waiting time affect the outcome of larynx cancer treated by radiotherapy?

AIM

To determine the impact of waiting for radiotherapy on local control in early larynx cancer treated by radiotherapy alone.

METHODS

Records of patients with T1 and T2, N0-2 larynx cancer were examined at three radiotherapy centres. Waiting time was defined in three ways, (1) time from biopsy to radiotherapy, (2) time from presentation to radiation department to start of radiotherapy and (3) the minimum of (1) and (2). Time to relapse was the major end point.

RESULTS

There were 581 patients with a median follow-up of 6.8 years. Stage distribution was as follows: T1, 370; T2a, 106; T2b, 94; T2 unspecified, 11; N0, 563; N+, 18. Median times from biopsy, presentation and minimum time to treatment were 24, 16 and 15 days, respectively. Ninety percent of minimum waiting times were < or = 31 days. The median dose was 61 Gy in a median of 30 fractions over a median 46 days. Local recurrence occurred in 126 patients. The actuarial recurrence free rate at 5 years was 77% (SE 2%). In a multivariate analysis the significant predictors of relapse were higher T stage, longer treatment duration and increasing field area. Waiting time was not significantly associated with local relapse.

CONCLUSION

This study did not show longer waiting time to be a significant predictor of relapse in early larynx cancer. Other end-points which are relevant, such as quality of life, have not been examined. Longer treatment times were significantly associated with relapse.

Paranasal sinus cancer

This is a review of 65 patients with paranasal sinus malignancies who were treated by radical surgery. Most patients received either pre- or postoperative radiotherapy. Twenty-nine tumours arose in the maxillary antrum, seventeen in the ethmoid labyrinth and the remainder from the vestibule, nasal septum, lateral nasal wall and vault. There were 58 epithelial cancers. The 5-year survival rate for patients with adenocarcinoma was 78%, and 70% for antral squamous cell cancer and esthesioneuroblastoma. None of the melanoma patients survived free of disease for 5 years. The 5-year survival rate for the 21 patients undergoing orbital exenteration was 50%, compared with 70% when the eye was spared. Twelve free flap revascularized tissue transfer flaps were used to reconstruct large cranial and sino-orbital defects.