The treatment of recurrence following fast neutron therapy for head and neck malignancy

Twenty-eight patients received fast neutron therapy for head and neck malignancy. Of these, seven had no recurrence, 13 had a recurrence at the primary site, five had a recurrence in the neck and three had a recurrence in the neck and at the primary site. Treatment of a primary site recurrence was difficult with seven of the eight patients submitted for major surgical resection developing serious complications. Of the six patients developing a fistula four required flap repair. The tumour specific 5-year survival for the whole group of 28 patients was 29%. The surgical treatment of locoregional recurrence following fast neutron therapy is fraught with problems and some type of flap repair is usually necessary.     

Treatment of neck nodes after induction chemotherapy in patients with primary advanced tumours

Responsiveness of neck nodes to induction chemotherapy often differs from that of the primary tumour. We have conducted a retrospective study to evaluate the results of treating the neck in a cohort of 350 patients with locally advanced (T3–4) head and neck carcinomas treated with radiation therapy at the primary location of the tumour after induction chemotherapy. One hundred and thirty-nine patients (40%) did not have neck nodes on diagnosis (N0). The treatment of the neck included surgery in 65 patients. Neck dissections were carried out before radiotherapy in 37 patients and after radiotherapy in 28 patients. The frequency of neck treatment failure was 24%. There was a tendency to better neck control when treatment included neck dissection, independently of the neck stage or response to chemotherapy. This tendency was statistically significant in patients with an advanced regional tumour (N2–3) who did not achieve a complete regional response after chemotherapy. In a multivariate analysis the variables that were related to the regional failure were the relapse of the tumour at the primary site, the neck stage (N), the type of treatment used in the neck, and the grade of regional response after induction chemotherapy. Our results lead us to suggest that after induction chemotherapy neck surgery is advisable in all cases with advanced regional disease (N2–3), independently of the grade of response achieved after induction chemotherapy, and is also advisable in N1 patients in whom induction chemotherapy does not achieve a complete response. Received: 27 December 1999 / Accepted: 6 June 2000     

Second radical neck dissection

We report a series of 96 patients (62 men and 34 women) undergoing a second radical neck dissection for enlarged contralateral cervical nodes after primary treatment of a squamous cell carcinoma of the head and neck, including an ipsilateral radical neck dissection. The proportion of patients requiring a second later neck dissection varied from 0% for tumours of the nasopharynx, nasal cavity and paranasal sinuses, to 5% for tumours of the hypopharynx. The incidence of second neck dissection was not determined by the original T stage of the primary tumour, but patients with enlarged nodes at presentation were 5 times more likely to need a second neck dissection than those with no palpable nodes at presentation. Also, patients with a poorly differentiated tumour were twice as likely to need a second neck dissection as those with a well differentiated tumour. The overall 5-year survival after second neck dissection was 35% and the perioperative mortality 1.92%. Significant factors predicting survival after a second neck dissection were the time to recurrence, the clinical neck node status at recurrence, the number of histologically invaded nodes in the neck and the presence of extra-nodal disease.     

Anaplastic carcinoma presenting with cervical lymphadenopathy

We describe 50 patients with anaplastic carcinoma presenting with a mass in the neck. The diagnosis of anaplastic carcinoma was confirmed by immunocytochemistry to exclude very poorly differentiated squamous carcinomas, amelanotic melanoma, and non-Hodgkin's lymphoma. The primary site was established immediately in 26 patients (25 in the head and neck; 1 in the lung); a further 4 had radiological evidence of a primary tumour in the lung. The primary site was established later in 1 patient, in the ethmoid sinuses. In 20 patients the primary site was never established. The commonest primary site was the nasopharynx. The basic treatment policy was radiotherapy, although 20% of patients with a known primary tumour, and 50% of those without, were untreated. The 2-year survival was about 30% in both groups, and did not differ significantly. Prognostic factors for survival were age, performance status, and T status of the primary tumour. Sex, node status, node level, and laterality of nodes, were not.     

Survival in second primary malignancies of patients with head and neck cancer

Second primary tumours occur frequently in patients with a history of head and neck malignancies. Delays in making an early and correct diagnosis can seriously affect the therapy management and survival. This was a retrospective study of 120 patients with a history of head and neck cancer, presenting with a second primary tumour. Current follow-up strategies and the use of routine sonographic imaging of the head and neck regions were evaluated, and the impact that tumour chronology, the tumour site and the various treatment modalities have on the survival were assessed. Forty-two per cent of patients developed a metachronous second malignancy more than five years after diagnosis of the index tumour. The accuracy of colour-duplex sonography in detection of second primaries in the head and neck was 82.3 per cent. First and second primary tumours located in the larynx were observed to have the highest five-year survival rate. Patients who developed metachronous tumours had a five-year survival rate of 68.9 per cent for the index tumours, and a 26 per cent five-year survival rate with the occurrence of a second neoplasm. With synchronous tumours a mean survival time of 18 months and a five-year survival rate of 11.9 per cent was found (p < 0.0001). Where clinically appropriate an aggressive treatment strategy was employed and yielded the most favourable results with a five-year survival rate of 66.8 per cent and 35.9 per cent for index tumours and second primary malignancies, respectively. Since more than 40 per cent of the metachronous second primaries in patients with a history of head and neck malignancy occur beyond the five-year follow-up period, an extended protocol with individually adjusted close monitoring of high-risk patients seems appropriate. Colour-duplex sonography is a valuable screening investigation for the early detection of second primary tumours. The treatment of a second primary is often less successful than for the same malignancy occurring primarily. The prognosis of synchronous tumours is significantly lower when compared to malignancies of a metachronous nature, despite some encouraging individual results. Only the early implementation of aggressive treatment methods for second primaries is successful in terms of survival.     

Surgical treatment of squamous cell carcinoma of the hypopharynx: analysis of treatment results, failure patterns, and prognostic factors

Patients with squamous cell carcinoma of the hypopharynx (HPSCC) are often seen in advanced stages and have a poor prognosis. The authors analysed 104 patients who had HPSCC and underwent surgery as the primary treatment between 1986 and 1995 in their institute. Of the 104 patients, 83 patients (80 per cent) had advanced T(3) or T(4) staged and 64 patients (62 per cent) had cervical metastasis. Thirteen patients (13 per cent) had conservation surgery with laryngeal preservation and 69 patients (66 per cent) received post-operative radiotherapy. The five-year overall and disease-specific survival was 47 per cent and 62 per cent, respectively. Recurrence occurred in 38 patients (37 per cent), including 12 (12 per cent) with local, 22 (21 per cent) with regional, and 12 (12 per cent) with distant recurrence. Sixteen patients (15 per cent) had recurrence at multiple sites. The site and size of the primary tumour, neck biopsy before surgery, early post-operative complications, and pathological nodal stage were significant prognostic factors of disease-specific survival (DSS) in univariate analysis. Neck biopsy before surgery and site of primary tumour were significant factors in multivariate analysis. In conclusion, surgical treatment for the HPSCC patients has achieved good local-regional control and survival. Bilateral neck dissection for the tumour across the midline and avoiding neck biopsy before surgery may reduce regional recurrence.     

Technetium-99m(v) dimercaptosuccinic acid planar scintigraphy in head and neck cancer: clinical, scintigraphic and radiological study

Technetium-99m (Tc99m)(v) Dimercaptosuccinic Acid (DMSA) is an imaging agent which has been proposed as a scintigraphic marker for head and neck squamous cell carcinoma. Fifty-four patients were studied of whom 51 had a head and neck tumour. All patients were examined and then imaged using Tc99m(v) DMSA scintigraphy and computerized tomography. Scintigraphy was less sensitive than clinical examination in the detection of patients with cancer, patients with primary tumours and patients with metastatic neck disease. CT was as sensitive and as accurate as clinical examination but more sensitive than Tc99m(v) DMSA in detecting patients with cancer and with primary tumours. CT was more sensitive and more accurate than both clinical examination and Tc99m(v) DMSA scintigraphy in predicting which patients had metastatic neck disease. Although Tc99m(v) DMSA is accumulated by squamous cell carcinoma, its inability to detect low volume disease and apparent low specificity means it has no role to play in the management of patients with head and neck squamous cell carcinoma.     

Interstitial irradiation for squamous carcinoma of the oral cavity

Interstitial radiation delivered by iridium 192 implants was used to treat 38 patients with squamous carcinoma of the oral cavity. Thirty-six patients had either T1 or T2 tumours and no patient had palpable nodes at the time of implantation. Control of the primary tumour was achieved in all but 2 patients; these 2 were successfully treated by surgery. Fifteen patients (39%) went on to develop metastatic neck nodes. Nine were cured by radical neck dissection but the remaining 6 died of their disease. This gives a 5-year actuarial survival of 81%. Since all deaths occurred after the development of metastatic disease in the neck with control of the primary lesion, the evidence for and against prophylactic treatment of the neck lymphatics in clinically negative necks was reviewed. Prophylactic irradiation of the neck is probably preferable to any form of neck dissection but clear evidence that this improves long-term survival compared with careful follow-up and radical neck dissection for palpable nodes is still lacking.     

Non-squamous malignancy in lymph nodes: the occult primary

The present study presents 105 patients seen at a head and neck specialist clinic with a neck gland which subsequently proved to be a non-squamous malignancy. Of the 105 patients, 50 patients were eventually found to have a tumour in the head and neck region, 30 to have a distant primary and in 25 no primary site was ever found. The majority of patients were diagnosed in the clinic after careful examination and most of the remainder were diagnosed during endoscopy/biopsy. Chest radiography was the most useful investigation for diagnosing primary tumours of the lung. The 5-year-survival for the whole group of 105 patients was 28% (95% CI 17–39). The 5-year-survival for the head and neck primary tumour group was 44% (95% CI 25–60). The median survival of patients with a distant primary tumour was only a 6 months, there was one 5-year-survivor. The median survival for those in whom the primary was never discovered was 18 months. However, a reasonable proportion of these patients survived, five being alive at 5 years. The difference between survival for the three groups was statistically significant (P < 0.001). The most common histological type was undifferentiated/anaplastic tumours (37 out of 105) and this was followed by adenocarcinoma (33 out of 105). There was a significant difference in the survival between these two groups (χ²= 2.02, d.f. = 1, P= NS). Multi-variate analysis suggested that survival was better in the older age group and was affected by histology (P= 0.0093, P= 0.0332 respectively). The present study suggests that the treatment of patients in whom the primary site is eventually found to be in the head and neck region is rewarding with the same survival as a similar group of patients with squamous cell carcinoma. Sixty of the group of 105 patients had excision biopsies of the neck node and this did not affect survival.     

Squamous cell carcinoma in the area of the parotid gland. Metastasis or primary tumor?

A total of 61 patients with a histological diagnosis of squamous cell carcinoma of the parotid gland were studied. The patients were classified into three categories. There were 34 patients with a metastasis to the parotid gland from a squamous cell carcinoma elsewhere within the head and neck who presented on average 2.1 years (range 3 months to 7 years) after diagnosis of the primary tumour; in one case a salivary gland tumor presented 32 years after irradiation of a squamous cell carcinoma of the temple. Six patients had histological evidence of a metastasis within the parotid gland, but no evidence of a primary tumour. Twenty-one patients presented with a primary epidermoid carcinoma of the parotid gland. Two patients showed a primary squamous cell carcinoma of the parotid arising in myoepithelial sialadenitis.     

Sentinel lymph node biopsy in squamous cell carcinoma of the head and neck: 10 years of experience

Sentinel node (SN) biopsy of head and neck cancer is still considered investigational, and agreement on the width of the surgical sampling has not yet been reached. From May 1999 to Dec 2009, 209 consecutive patients entered a prospective study: 61.7% had primary tumour of the oral cavity and 23.9% of the oropharynx. SN was not found in 26 patients. Based on these data and definitive histopathological analysis, we proposed six hypothetic scenarios to understand the percentage of neck recurrences following different treatments Among patients with identified SN, 54 cases were pN+: 47 in SN and 7 in a different node. Considering the six hypothetic scenarios: "only SN removal", "SN level dissection", "neck dissection from the tumour site to SN level", "selective neck dissection of three levels (SND)", "dissection from level I to IV" and "comprehensive I-V dissection", neck recurrences could be expected in 6.5%, 3.8%, 2.18%, 2.73%, 1.09% and 1.09% of cases, respectively. SN biopsy can be considered a useful tool to personalize the surgical approach to a N0 carcinoma. The minimum treatment of the neck is probably dissection of the levels between the primary tumour and the level containing the SN(s). Outside the framework of a clinical study, the best treatment can still be considered SND.     

Clinical outcome following radiotherapy and planned neck dissection in N+ head and neck cancer patients

Conclusions. This study confirms earlier findings that patients with viable tumour cells in the neck after external beam radiotherapy (EBRT) have a poor prognosis. The study also indicates that neck dissection (ND) does not change the prognosis for patients with a complete clinical response in the neck. At the moment our guidelines concerning this matter are being reviewed. Objectives. The protocol at our institution stipulates a planned ND in patients with metastasis in the neck after EBRT regardless of the response in the neck. As the necessity for a planned ND has not been clarified we wanted to evaluate our results. Patients and methods. Patients diagnosed from 1998 to 2002 with metastasis in the neck who received EBRT were evaluated for histopathological findings and clinical outcome. Results. A total of 156 patients were included. Overall survival was 62% and disease-specific survival was 76%. There was a complete response (CR) in the neck in 63 patients (40%); among these 15 had viable tumour cells in the neck. In patients not achieving CR, 40% (37/93) had viable tumour cells left in the neck. Patients with viable tumour cells in the neck after EBRT had disease-specific survival of 48% compared with 90% among patients without viable tumour cells.     

Radiofrequency induced thermotherapy: an alternative palliative treatment modality in head and neck cancer

Bipolar radiofrequency induced thermotherapy (RFITT) is a minimally invasive electrosurgical technique characterized by a precise controllable effect in the tissue. It has demonstrable efficacy, safety and reproducibility in the management of solid malignancies. Our aim was to assess the morbidity and efficacy of RFITT as a palliative treatment of head and neck cancer. Prospective, non-randomized case series and analysis. After evaluation by the multidisciplinary Head and Neck Tumour Board at Helsinki University Central Hospital, Finland, 12 consecutive patients with a head and neck cancer without curative treatment possibilities were enrolled into the study. Five patients had pharyngeal carcinomas, one had an unknown primary tumour growing through the skin on the neck, two had a recurrent malignant melanoma originating from the maxillary sinuses, one had a carcinoma of the tongue, two had laryngeal carcinomas, and one had a recurrent adenoid cystic carcinoma of the parotid gland. RFITT was performed with a CelonLabPrecision® generator using appropriate electrodes. The treatment was administered under local or general anaesthesia. The subjective morbidity of the treatment was evaluated. The response to the treatment was assessed clinically and with radiological imaging when feasible. All but two of the patients received palliation to their disease. RFITT induced clinically a partial response in ten patients, and there were radiological detectable changes. There were no treatment related complications, and the patients tolerated the treatment well. RFITT in head and neck cancer patients is easy to perform, well tolerated, and induces reduction in the tumour mass. Continuous evaluation of RFITT treatment modality is warranted in selected palliative care patients.     

Is laterality important in neck node metastases in head and neck cancer?

We present a series of 2219 previously untreated squamous carcinomas of the head and neck, 141 (6.5%) of whom had bilateral nodes at presentation. Bilateral nodes became progressively less common with increasing age but were not related to other host factors. They were also strongly related to the site of the primary tumour, its T-stage and its histological grade, being more common in tumours of the oro or naso-pharynx, in poorly or moderately differentiated tumours, and in tumour stages T3 or T4 at presentation. There were also interactions between these tumour factors, and patients with all three factors had a 25% incidence of bilateral nodes. 126 of these patients could be matched for the main prognostic factors with 126 patients with unilateral neck node disease. The survival rate of the latter group was 9% better than that of the unilateral group. Further breakdown showed that the survival of patients with nodes smaller than 6 cm is not affected by laterality, whereas it is for patients with massive nodes.     

Características diferenciales de los pacientes con carcinomas escamosos de cabeza y cuello en función del género

ObjectiveTo analyse the trend in the percentage of patients with squamous cell carcinoma of the head and neck of female gender over the last decades, and differences in survival according to gender.Material and methodsRetrospective study of 5,828 squamous cell carcinoma of the head and neck diagnosed during the period 1985-2019. In the survival analysis we only included only patients with more than two years of follow-up.ResultsThe proportion of tumours in female patients increased significantly over the study period. There was greater increase of tumours located in the oral cavity, oropharynx and larynx in the percentage of female patients. When considering the total number of patients, there were no significant differences in disease-specific survival according to gender. We observed a variable behaviour of disease-specific survival according to gender depending on the primary location of the tumour. For tumours of the larynx and oropharynx the female patients had a disease-specific survival significantly higher than that of men, while for tumours of the oral cavity, the female patients had a significant reduction of disease-specific survival.ConclusionsIn our setting, the percentage of female patients with squamous cell carcinoma of the head and neck has been increasing steadily over recent decades. There were differences in disease-specific survival according to gender depending on the location of the primary tumour.     

Elective radiotherapy of the neck in patients with squamous cell carcinoma of the head and neck.

A prospectively recorded 5-year series of 254 patients receiving elective neck irradiation is evaluated. All had clinically negative necks and initial control at the primary site. Forty-seven percent of the patients had T3-4 tumours. Radiotherapy was delivered from a megavolt source at 2 Gy/day 5 days a week to a total dose of 46-50 Gy. All but 3 patients completed the treatment as planned. Neither tumour stage nor site of the primary tumour was related to the incidence of regional recurrences. Of 30 patients receiving 46-49 Gy, 5 died from neck node recurrences. Of 221 patients treated to 50 Gy or more, 16 (7.2%) developed regional recurrences. Two of these recurrences were avoided, giving a regional failure rate of 6.3%. As a whole, 7.8% died from regional, 11.4% from local, and 3.1% from distant recurrences.     

Carcinoma occurring in branchial cleft cysts.

In order to find histological data in the differentiation between branchial cleft carcinomas and metastatic carcinomas, the specimens from 154 patients with branchial cleft cysts and 7 patients with an isolated tumour in the neck with unknown primary tumour were reviewed and compared with 10 normal lymph nodes. Absence of lymph node structures as peripheral lobulation, internodular trabeculae and perinodular sinuses in branchial cleft cystc, are found valuable for distinguishing primary carcinoma of branchial cleft cysts from metastases. A correct diagnosis of this rare tumour is important in order to avoid overtreatment of these patients, who have a good prognosis if treated with surgical excision only.     

CEA studies in squamous cell carcinomas of the head and neck

The serum CEA levels of 134 patients with squamous cell carcinoma of the head and neck were studied at the time of diagnosis, at the end of primary therapy and every three months during the follow-up period. Since such patients are mostly nicotine and alcohol addicts, only CEA concentrations above 5 ng/ml were regarded as abnormal. At the time of diagnosis 30% of the patients had clearly abnormal CEA values, more commonly in oropharyngeal and hypopharyngeal tumours than for oral and laryngeal carcinomas. The incidence of pathological CEA concentrations also increased with increasing tumour extension, to a greater extent in well-differentiated than in undifferentiated squamous cell carcinomas. After termination of the primary therapy we found no correlation between success of treatment and serum CEA concentration. Studies of the course of CEA values in tumour-free patients revealed both rising and falling serum values during the period of observation. It was not possible to diagnose tumour recurrence early with the aid of increasing CEA concentrations. CEA exhibits only moderate sensitivity towards squamous cell carcinomas of the head and neck. As correlations between the course of the disease and CEA concentrations in serum could only rarely be observed, the usefulness of this tumour marker for following the course of head and neck squamous cell carcinoma must be regarded as rather low.     

Diagnostic work-up and outcome of cervical metastases from an unknown primary

CONCLUSIONS: An intensive diagnostic work-up including (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) detects many unknown primary tumours, leads to a low emergence rate of primary tumours, and selects carcinoma of unknown primary with much more favourable results after neck dissection and postoperative radiotherapy. OBJECTIVE: To investigate the optimal diagnostic approach and best treatment modality for rare head and neck cancer of unknown primary. PATIENTS AND METHODS: In a retrospective study, 69 patients admitted from 1987 to 2002 with cervical lymph node metastases without apparent primary were reviewed. Test characteristics of all diagnostic procedures were calculated. Disease-free and overall survival rates were calculated. Major prognostic factors were analysed uni-variously. RESULTS: At the primary site FDG-PET showed the best sensitivity with 69% and the highest negative predictive value with 87%. Computed tomography and magnetic resonance imaging had a better specificity with 87% and 95%, respectively. The primary tumour was detected in 23 cases (33%). Frequent primary tumour origin was the palatine tonsil (n=8, 35%), base of the tongue (n=6, 26%) and lung (n=4, 17%). All patients with unknown primary were treated by neck dissection. Adjuvant radiotherapy was performed in 26 patients (57%), concurrent radiochemotherapy was performed in 12 patients (26%). The primary emergence rate was 7%. The 5-year overall survival rate was inferior in patients with detected primary in comparison with patients with unknown primary (22% versus 52%). Significant prognostic factors in case of unknown primary were M stage, smoking, alcohol consumption and tonsillectomy. Radiotherapy but not chemotherapy with carboplatin influenced the overall survival.     

Evaluation of the impact of addition of PET to CT and MR scanning in the staging of patients with head and neck carcinomas

The addition of whole body positron emission tomography (PET) to the investigation of patients with newly diagnosed head and neck squamous cell carcinoma (HNSCC) was assessed over a 6-month period. Staging investigations included laryngoscopy, oesophagoscopy, CXR, CT and MRI. In addition, all patients had an extended-field (whole body) FDG-PET scan and were restaged. Standardised Uptake Values (SUV) were used to measure FDG uptake. SUV levels above 5 were considered indicative of the presence of tumour, values below 3 indicative of benign aetiology and values equal to and between 3 and 5 were considered equivocal. Forty-eight consecutive patients with biopsy proven HNSCC were included for study. Three patients presenting with neck disease had unknown primary tumours. Of the remaining 45 patients, CT scan correctly identified 40 of the primary tumours (89%). MRI and PET both identified 41 primary tumours (91%). Thirty-two patients underwent neck dissection. Of these patients 12 had pathologically N0 necks and 20 had positive nodal disease. CT scan and MRI each correctly staged pN0 necks in 10 of 12 patients (83%) whereas PET alone had a lower true negative rate of 8 out of 12 patients (67%). PET correctly staged the N+ necks in 14/20 patients (70%) versus 12/20 (60%) for MRI, and 8/20 (40%) for CT alone. All four patients who were judged to have distant metastases by PET had these metastases deemed negative by other investigation. None of the three imaging modalities was able to identify the tumour site in the three patients with unknown primaries. In conclusion, although PET has got a higher sensitivity in detecting nodal disease, it has only slightly improved the classification of N+ necks. The findings of this study cast doubt on the merit of routine addition of PET to the current investigative protocols for HNSCC patients.Presented at the Irish Otolaryngology Society annual meeting, Oct 2003