Outcomes of patients with n3 neck nodes treated with chemoradiation

Objective: To evaluate the outcomes of patients with locally advanced head and neck squamous cell carcinoma with N3 neck nodes treated with definitive chemoradiation. Study Design: Retrospective review. Methods: Thirty‐two patients with nonmetastatic locally advanced head and neck squamous cell carcinoma and N3 neck disease treated with concurrent chemoradiation therapy were evaluated. Overall survival, disease‐ free survival, locoregional control, and distant control were recorded. Results: Median follow‐up for surviving patients was 25 (range, 3–93) months. Seventeen of 32 (53%) patients failed, 13 in distant sites only, 2 in the neck only, 1 in the neck and a distant site, and 1 in the neck and primary site. The absolute rates of locoregional control and distant control were 88% and 56%, respectively. Actuarial overall survival and disease‐free survival at 2 years were 51% and 29%, respectively. Conclusion: Patients with N3 neck disease treated with chemoradiation experience a very high rate of distant failure. Future studies investigating the role of additional systemic therapy in these patients are warranted.     

Juvenile malignant melanoma of the head and neck

Malignant melanoma of the head and neck is a potentially lethal disease and considered rare among juveniles. Treatment patterns have historically been dictated by experience with adults, however a paucity of data is available to determine the natural history and treatment guidelines for juveniles and children with malignant melanoma. Therefore a retrospective computer-aided analysis of patients less than 20 years of age having malignant melanoma were obtained from the records of 4,843 patients with malignant melanoma recorded from 1972 through 1986. Eighty-seven patients were identified from this group with 17 patients having primary malignant melanomas confined to the head and neck. Parameters evaluated were age at diagnosis, sex, type of melanoma, Clark Level, Breslow depth of invasion, pathologic classification, site of primary, nodal status at diagnosis, surgical treatment, recurrence rate and site of recurrence, and follow-up status. Two of 17 patients had stage II disease and were treated with wide local excision and therapeutic radical neck dissection. Fifteen of 17 patients initially presented with stage I disease were treated with wide local excision. Two of these patients underwent elective radical neck dissection both of which proved to have positive occult nodal disease. Both are alive without evidence of disease 2 1/2 to 7 years later. Of the 13 patients who were initially treated with only wide local excision, nine patients developed local (3), regional (3), or systemic (3) disease within 3 months to 9 years from the date of diagnosis. Seven of the nine died of their disease 5 months to 20 years later. When juvenile patients with melanomas of the head and neck are compared to a comparable age group of patients with melanomas at other primary body sites, the head and neck group had a significantly higher frequency of death. Compared to the adult head and neck population, juvenile patients had identical actuarial survival time, but shorter disease-free intervals, even though the adult population had a higher percent of poor prognostic indices (presence of ulceration and thickness of lesions). Failure to control local and regional disease coupled with the overall poor survival rate, indicates that malignant melanoma occurs in the young as a biologically active tumor and suggests an aggressive approach for better control of local and regional disease and, hopefully, survival.     

Absence of planned neck dissection for the N2-N3 neck after chemoradiation for locally advanced squamous cell carcinoma of the head and neck

OBJECTIVE: To review our institutional experience of patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) and N2-N3 neck disease with respect to neck recurrence after chemoradiation without planned neck dissection (ND). DESIGN: Retrospective study. SETTING: Tom Baker Cancer Centre, Calgary, Alberta, Canada. PATIENTS: Fifty-four adults with locally advanced SCCHN and N2-N3 neck disease. INTERVENTIONS: Eighty consecutive patients were treated with chemoradiation, 70 Gy given as 2 Gy daily for 7 weeks, with cisplatin, 20 mg/m(2), given on the first 4 days of weeks 1 and 5. Of the 80 patients, 54 were evaluable. MAIN OUTCOME MEASURES: Primary outcomes were overall survival and absence or presence of neck disease after chemoradiation. Secondary outcomes included disease-specific survival and locoregional recurrence-free survival. RESULTS: Median follow-up of living patients was 35 months. Patients with a complete response (CR) did not have any planned ND. Factors associated with the absence of recurrent neck disease included CR (P < .001), younger age (P = .02), and better Karnofsky Performance Status (P = .049). In patients achieving CR, 2-year overall, disease-specific, and locoregional recurrence-free survival was 92%, 95%, and 95%, respectively. Three of the 43 patients (7%) with N2 lesions obtaining CR subsequently experienced a neck recurrence at a median of 15 months (range, 7-24 months). CONCLUSIONS: In these patients with locally advanced SCCHN and N2-N3 neck disease treated with chemoradiation and achieving CR, only a few patients with N2 neck disease experienced recurrence despite the absence of planned ND. Prospective trials are needed to identify patients with N2 neck disease who may still benefit from planned ND after chemoradiation. There were not enough patients with N3 neck disease to make any recommendations.     

Predefinitive and postdefinitive chemotherapy for locally advanced squamous carcinoma of the head and neck.

Advanced squamous carcinoma of the head and neck remains refractory to the best combinations of surgery and radiotherapy. Weekly methotrexate in high doses with leucovorin "rescue" is able to produce significant remissions in a majority of patients treated palliatively for recurrent disease yet is associated with little or no toxicity. We have attempted to improve the cure of patients with advanced disease by the use of high dose methotrexate (3-7.5 g/M2) and leucovorin prior to and following definitive surgery and/or radiotherapy. In a series of 24 patients we have achieved a response rate of 52%, with minimal toxicity during chemotherapy, and no apparent potentiation of toxicity with radiotherapy. Survival free of disease appears to be prolonged in patients with response to this chemotherapy. Multimodality approaches to locally advanced squamous carcinoma of the head and neck may soon yield improved cure rates.     

Computed tomography of cervical lymph nodes. Staging and management of head and neck cancer

Forty patients with head and neck cancer had a computed tomographic (CT) scan followed by lymphadenectomy and pathologic confirmation. The overall accuracy of clinical examination of the neck was 70% vs 93% by CT. The CT correctly "upstaged" the neck in nine patients. One was upstaged from NO to N1, and four each from NO to N2 and N1 to N2. It correctly "downstaged" the neck in one patient (from N2 to N1). Eight patients had extranodal disease on CT confirmed by pathology. The CT findings were correct in ten of 11 previously treated patients. Because CT is more accurate than the clinical examination, it should be included in the staging of not only the primary tumor but also nodal disease of the neck. It can have an important role in the management of head and neck cancer.     

The role of the carbon dioxide laser in treatment of carcinoma of the tongue

This paper presents 35 patients with carcinoma of the tongue who have been treated in Southampton using the Carbon Dioxide laser. The treatment programme for each individual patient was determined by radiotherapists and surgeons in a combined head and neck/oncology clinic. T1 carcinomas were treated by primary laser excision biopsy whereas larger tumours were treated first by conventional radiotherapy unless there was a significant contraindication to this treatment modality. Of 10 patients with T1 lesions nine are alive and well and disease free, but one patient died of other causes with no sign of recurrence. The minimum follow-up period has been two years. Of 25 patients with T2 and T3 lesions treated either before or after radiotherapy, nine are alive and disease-free, eleven died of disease and five patients died of other causes with no evidence of recurrence.     

Evaluation of survival of patients with locally advanced head and neck cancer treated in a single center

IntroductionEven with improved treatment outcomes with multimodality approaches, the question of what is the best initial treatment for locally advanced head and neck cancer still remains unanswered.ObjectiveTo review the overall survival of a large cohort of head and neck cancer, patients with locally advanced head and neck cancer treated in a single institution.Material and methodsWe studied a cohort of patients with locally advanced head and neck cancer treated in our institution in the last fifteen years. To gather a large sample of patients with adequate follow-up time, a cross-check between ours and Fundação Oncocentro de São Paulo databases were done. We included patients with head and neck cancer, clinical or pathological staging III or IV, treated with surgery followed by radiotherapy or surgery plus chemoradiation or radiotherapy alone or chemoradiation alone.Results796 patients with locally advanced head and neck cancer were included, 88% male, 44% age >60 years and 76% stage IV. The tumor location was the oral cavity (34%), oropharynx (27%), hypopharynx (17%) and larynx (17%). The treatment groups were chemoradiation alone (39.7%), surgery plus chemoradiation (26.3%), surgery followed by radiotherapy (18.5%) and radiotherapy alone (15.5%). Comparing the clinical variables between the treatment groups significant differences in age and clinical stage were observed. With a median follow up of 7.5 years (1–16 years), for the entire cohort, the overall survival at 5 and 10 years was 34.8% and 28%. The overall survival at 5 and 10 years was 16.7% and 12.2% for radiotherapy alone, 38.8% and 26.3% for surgery followed by radiotherapy, 28% and 16.6% for chemoradiation alone, and 37.3% and 23.2% for surgery plus chemoradiation. The staging IV (p = 0.03) and radiotherapy alone (p = 0.05), had a worst survival in multivariate analysis. Surgical groups vs. chemoradiation alone had no significant difference for overall survival.ConclusionThe present study is the largest cohort of locally advanced head and neck cancer of Brazilian patients to evaluate treatment outcomes. Although there were significant clinical differences between surgical and radiotherapy groups, surgery or chemoradiation alone as the initial treatment resulted in no significant difference in survival.     

Ewing's sarcoma of the head and neck in children.

OBJECTIVE: The purpose of this paper was to review our experience with Ewing's sarcoma of the head and neck in children. DESIGN: Retrospective chart review. SETTING: The Hospital for Sick Children, Toronto, Ont., Canada. METHODS: Between 1986 and 1996, 70 cases of Ewing's sarcoma were identified. The medical records, roentgenographic and pathology reports were reviewed retrospectively. The gender, age of presentation, location and clinical presentation of the tumor were noted in the cases involving the head and neck. The treatment and follow-up of these patients were recorded. RESULTS: Of the 70 cases of Ewing's, five involved the head and neck (7.1%). The age of presentation ranged from 7.5 to 14 years. An enlarging mass in the mandible was the mode of presentation in three of the five children. Two patients had metastases at initial presentation. All patients received combination treatment regimens with chemotherapy initially, followed by adjuvant surgery and/or radiation. Follow-up ranged from 2 to 11 years. Three of five patients died of metastatic disease. Two are alive and well with no evidence of disease. CONCLUSIONS: Ewing's sarcoma occurs infrequently in the head and neck in children. An enlarging mass in the mandible is the most frequent mode of presentation. This tumor is treated systemically with high dose chemotherapy and locally with surgical excision where possible. In lesions that are initially unresectable and/or show a poor response to chemotherapy, radiation is used for local control. A good prognosis can be expected if the disease has not metastasized.     

Follicular dendritic cell tumor: an aggressive head and neck tumor

OBJECTIVE: To characterize the clinicopathologic features of head and neck follicular dendritic cell (FDC) tumor and report the experience of this entity at our institution. Study Design: Two case presentations are compared with a retrospective analysis of all published head and neck cases. SETTING: A tertiary academic medical center. RESULTS: Thirty four cases of FDC tumor of the head and neck cases have been published. Twenty five occurred in the cervical lymph nodes, 4 in the tonsils, 2 in the palate, 1 in the pharynx, 1 in the parapharyngeal region, and 1 in the thyroid gland. Patient ages ranged from 13 to 73 years (mean, 38), and there was a roughly equal number of men and women. Patients were treated with surgery (17), surgery and chemotherapy (8), and surgery and radiation (9). After the primary treatment, 12 patients had no evidence of disease, whereas 5 were incurable. Ten tumors recurred locally and 3 distally. Of these 13 patients who suffered recurrences, 4 had no evidence of disease after secondary treatment, 6 were alive with disease, and one was lost to follow up. Two patients died after recurrence. We add 2 unique cases to the 9 previously reported extranodal cases, 1 in the tonsil and 1 in the parotid gland. CONCLUSION: FDC tumor is a rare malignant neoplasm that can present in the head and neck region in both lymph nodes and extranodal sites. Because of their rarity, these tumors are probably underrecognized by both clinicians and pathologists. Distinct light microscopic, immunohistochemical, and ultrastructural features do exist, however, and are reviewed. Surgery has been the mainstay of treatment and should include diligent control of surgical margins. The role of adjuvant therapy remains controversial. Although originally considered to be a low-grade malignancy, our review suggests both high recurrence rates and metastatic potential. We believe that FDC tumor should be viewed and treated as a moderately aggressive head and neck tumor.     

The role of postoperative adjuvant radiation therapy in the treatment of mucosal melanomas of the head and neck region

BACKGROUND: Mucosal melanoma of the head and neck is uncommon, and has a poor prognosis due to locoregional and distant failure. The optimal treatment paradigm for patients with this disease has yet to be determined. OBJECTIVE: To compare the outcomes of patients treated with various commonly used protocols for mucosal melanoma of the head and neck. DESIGN: Retrospective study. SETTING: Academic tertiary referral center. PATIENTS: The medical records of 48 consecutive patients treated at a single institution from January 1, 1985, to December 31, 1998, were reviewed. INTERVENTIONS: Patients were treated with surgery alone, surgery and adjuvant radiotherapy, or surgery and biochemotherapy, with or without adjuvant radiotherapy. MAIN OUTCOME MEASURES: The outcomes of disease recurrence and survival were correlated with the treatment received. RESULTS: Twenty patients received surgical treatment alone; in 9 patients (45%), this treatment failed locoregionally, and 10 (50%) of the patients developed distant metastases. The 5-year survival rate was 45% (9 of 20 patients). Twenty-four patients received postoperative adjuvant radiotherapy; in 4 patients (17%), this treatment failed locally, and 11 (46%) of the patients developed distant metastases. The 5-year survival rate was 29% (7 of 24 patients). CONCLUSION: The addition of radiotherapy tended to decrease the rate of local failure (P =.13), but did not significantly improve survival (P =.73), because of the high rate of distant metastatic disease.     

Phase 2 bioadjuvant study of interferon alfa-2a, isotretinoin, and vitamin E in locally advanced squamous cell carcinoma of the head and neck: long-term follow-up

OBJECTIVE: To evaluate the long-term effects of the combination of isotretinoin, interferon alfa-2a, and vitamin E in locally advanced squamous cell carcinoma of the head and neck. DESIGN: Phase 2 prospective study. SETTING: Tertiary care academic medical centers. PATIENTS: Forty-five patients entered this study. All patients had stage III or IV squamous cell carcinoma of the head and neck and had been treated with surgical resection, radiation, or both. All patients were then treated with bioadjuvant chemopreventive treatment for 12 months. We previously reported a 24-month median follow-up of this phase 2 trial of the combination of isotretinoin, interferon alfa-2a, and vitamin E as bioadjuvant therapy after definitive local therapy. In that study, all 45 patients completed treatment, but 1 patient was excluded from analysis of recurrence and development of second primary tumors.Main Outcome Measure Longer-term (49.4-month median) follow-up. RESULTS: Among the 45 patients treated under the protocol, only 7 patients (16%) had died. Nine (20%) of 45 patients experienced progressive disease. Only 1 second primary tumor (acute promyelocytic leukemia) occurred during follow-up, and no aerodigestive second primary tumors occurred among the 45 patients. The 5-year progression-free survival and overall survival percentages were 80% (95% confidence interval, 65.1%-89.1%) and 81.3% (95% confidence interval, 63.7%-90.9%), respectively. These results are significantly better than the historical 5-year overall survival for advanced squamous cell carcinoma of the head and neck (approximately 40%). CONCLUSION: The bioadjuvant combination is highly effective in preventing recurrence and second primary tumors, and its role as standard therapy in advanced squamous cell carcinoma of the head and neck is being investigated in a randomized phase 3 study.     

Osteogenic sarcoma of the head and neck. The UCLA experience

Eighteen cases of osteogenic sarcoma of the head and neck were treated at our institution between 1955 and 1987. The patients' ages ranged from 5 to 73 years, with a median age of 28 years. The sex distribution was equal. Follow-up ranged from 1 to 276 months, with a median of 79 months. The primary site of the tumor was the mandible in nine cases, maxilla and paranasal sinuses in six, skull in two, and orbit in one. Six of 18 patients were free of disease with greater than 5 years of follow-up. Four of the six received combined surgery, radiation therapy, and chemotherapy as their primary treatment. Of the five patients treated with surgery alone, four suffered recurrences, one of whom was salvaged with further surgery and chemotherapy. Five patients were treated initially without surgery. They received radiation therapy with or without chemotherapy; all five developed local recurrence. We conclude that osteogenic sarcoma of the head and neck is an aggressive tumor, prone to both local and distant failure. Based on our series and from published experience involving the extremities, osteogenic sarcoma of the head and neck should be managed with multimodality therapy.     

Limited use of complementary and alternative medicine in Israeli head and neck cancer patients

HYPOTHESIS/OBJECTIVE: The use of complementary or alternative medicine (CAM) is growing among cancer patients. A Medline search failed to reveal any dedicated report of CAM use specifically in patients with head and neck cancer (HNC). STUDY DESIGN: Use of CAM was evaluated in a cohort of treated HNC patients. METHODS: Patients treated for HNC were asked if they had used CAM since their diagnosis. Demographic data and data pertaining to mode of CAM, duration of treatment and effects were obtained. RESULTS: One hundred forty-three patients (mean age 61 years) were included. Only nine patients (6.3%) reported using disease related CAM. This included acupuncture (4), Reiki (2), naturopathy (2), hypnosis (1), shiatsu (1), chiropractic treatment (1), homeopathy (1), and selenium (1). CONCLUSION: Contrary to the reported use, few of our HNC patients used CAM. Although this could be related to good caregiver-patient relationship, further studies in comparable populations are warranted to evaluate if this is a local or a pervading finding in head and neck cancer patients.     

Significance of distant metastases and secondary cancers as a cause of death in patients with ENT cancers

Hospital charts and autopsy reports of 148 patients with head and neck carcinoma were reviewed in order to assess the mortality from distant metastases and other primaries. 49% of the patients with uncontrolled local or regional disease died with distant metastases. Only 4% of these patients had a second primary. In patients with controlled local and regional disease the opposite was found. Distant metastases were uncommon (9%). Yet, 44% of the patients died of a second primary located in the upper aerodigestive tract or lungs. If life expectancy in patients with controlled head and neck carcinoma is to be improved, early detection of second primaries is important. As only 9% of patients with locally controlled disease die from distant metastases adjuvant chemotherapy is not indicated.     

MOHS for head and neck mucosal cancer: report on 111 patients

Microscopically Oriented Histologic Surgery (MOHS) has been applied to primary epidermoid cancers of the mucosal tissues of the head and neck since 1979. In that time we have treated 170 patients and maintained excellent records, losing no patients to follow-up. One hundred three patients have been followed for 2 years. Of this group, only nine patients have developed local recurrences; three were salvaged, six were not. This presentation reviews the concept of MOHS and its application to head and neck mucosal lesions. The results are analyzed, and conclusions are drawn regarding what we have learned about the biologic behavior of head and neck tumors and the role of MOHS in treating these neoplasms.     

Radical combined treatment of locally extensive head and neck cancer in the elderly

PURPOSE: Few studies have described the effects of aggressive combined therapy for locally extensive head and neck cancer in the elderly. Our study evaluated the outcome of this particular cohort of patients after such treatments. METHODS: Survival, failure, morbidity, and complication rates were determined retrospectively in 43 elderly patients with stage III or IV head and neck cancer who underwent curative surgery and postoperative radiotherapy (n = 33) or neoadjuvant, 3-drug chemotherapy plus radiotherapy (n = 10) between the years 1977 and 1992. RESULTS: The crude survival rate at 3 years was 27% in patients managed by surgery plus radiotherapy, and 30% in individuals treated with chemoradiation; the corresponding locoregional failure rates were 23% and 30%; and the distant failure rates were 13% and 0%, respectively. The acute toxicity rate was 12% in the surgery plus radiotherapy group and 30% in the chemoradiation patients; the corresponding late complication rates were 0% and 10%. There were no toxic deaths. CONCLUSION: Radical combined treatments can be performed safely and achieve long-term, disease-free survival in selected elderly patients with locally extensive head and neck cancer.     

Follicular dendritic cell sarcoma of the head and neck: case report and literature review

Objectives/Hypothesis: This article presents a case of a patient with follicular dendritic cell sarcoma (FDS), a rare neoplasm usually of the head and neck, and reviews the literature. Study Design: Literature review. Methods: A MEDLINE literature search was performed and the literature was reviewed. Results: Our patient presented with an FDS that had been excised from the upper neck and recurred in a level V node. He was treated with neck dissection and postoperative irradiation and remains disease free 5.25 years after salvage treatment. The literature search yielded 67 case reports on FDS of the head and/or neck. Most patients were treated with surgery (94%). Twenty-eight percent of patients received adjuvant radiotherapy; 18% received adjuvant chemotherapy. Fifty percent of patients were alive with no evidence of disease at last follow-up; 9% died from disease. Conclusions: We currently treat head and neck FDS with wide resection and postoperative radiotherapy.     

A rare late complication after concomitant chemoradiation of an oropharyngeal tumor: cervical necrotizing fasciitis

Chemoradiation is increasingly being used to treat locally advanced head and neck carcinomas. Possible rare complications of this treatment modality have begun to appear, as the number of treated patients increase. In this report, we present a case who underwent chemoradiation due to T3N3M0 tonsil cancer and developed necrotizing fasciitis of the neck at seven months following treatment. The patient recovered fully after treatment with surgical debridement with pectoralis major flap reconstruction and intravenous antibiotherapy.     

Myxomas of the head and neck

PURPOSE: Myxomas are rare, locally infiltrative, benign, connective tissue tumors that are found in bone and somatic soft tissues. This article reports our experience with head and neck myxomas and provides a comprehensive literature review. MATERIALS AND METHODS: Retrospective record review of head and neck myxoma cases seen at 2 tertiary referral centers in Houston, Texas, from 1970 to 1994. Comprehensive literature review and compilation of all myxomas reported in the head and neck. RESULTS: We identified 7 cases of true head and neck myxoma treated in our centers and identified 169 cases reported in the literature. Most often, myxomas originated in bone (mandible or maxilla) and were most commonly found in adults. All tumors except 1 were treated surgically. Recurrence rates were 6% for local or wide excision and 28% for more conservative surgery such as enucleation or curretage. CONCLUSIONS: Myxomas of the head and neck should be treated with complete excision of the tumor with clear margins.     

Photodynamic therapy in the treatment of multiple primary tumours in the head and neck,located to the oral cavity and oropharynx

Objectives: Multiple primary tumours are a common problem in the head and neck cancer patients. Curative surgery or radiotherapy of these tumours can be very mutilating or even impossible. This study aims at evaluating meta‐tetrahydroxy‐phenyl chlorin‐mediated photodynamic therapy for second or multiple primary tumours in the head and neck. Design: Retrospective study of all patients with second or multiple primary tumours treated by photodynamic therapy over a 10‐year period. Setting: All patients were treated in the Netherlands Cancer Institute, a tertiary referral centre for the head and neck cancer patients. Participants: A total of 27 patients with 42 the second or the multiple primary head and neck tumours were treated by photodynamic therapy (0.15 mg/kg meta‐tetrahydroxy‐phenyl chlorin). Main outcomes measures: Cure rates. Results: Twenty‐eight of 42 tumours were cured (67%). Cure rates for stage I or in situ disease were 85%versus 38% for stage II/III. Conclusions: Cure rates for photodynamic therapy of the multiple primary head and neck tumours were lower than previously described for first primaries, but were still very encouraging for this difficult patient population. The high cure rate obtained in stage I multiple primaries emphasises the importance of a meticulous follow‐up of patients treated for the head and neck cancer to detect new tumours at a curable stage.