Racial differences in stage and survival in head and neck squamous cell carcinoma

OBJECTIVES: The goal of this study was to characterize differences in survival between black patients and white patients with squamous cell carcinoma of the head and neck (HNSCCA). DESIGN: Cases of oral tongue and glottic SCCA in black patients or white patients were extracted from the Surveillance, Epidemiology, and End Results (SEER) database (years 1988-2002). For each primary site, TNM staging was imputed, and staging distributions were compared between races. For each black patient, a randomly selected white control was matched for age at diagnosis, sex, stage, surgical treatment, and radiation. Kaplan-Meier survival comparisons for both overall and disease-specific survival were then conducted for the matched pairs. RESULTS: From 1,919 cases of carcinoma of the oral tongue, those of 151 black and 1,768 white patients were extracted. Black patients had a significantly elevated T stage (P = .001) and N stage (P = .002) at primary presentation. Of glottic carcinoma, 4,578 cases (625 black and 3,953 white patients) were extracted. Black patients again presented with significantly elevated T stage (P < .001) and N stage (P < .001) compared with white patients. For 43 matched pairs with tongue carcinoma, mean overall survival for black patients was 66.1 months versus 74.8 months for matched white controls (P = .502, log-rank test). Disease-specific survival was 91.1 months for black patients versus 109.6 months for white patients (P = .168). For 401 matched pairs with glottic carcinoma, mean overall survival for black patients was 96.6 months versus 114.5 months for white controls (P < .001). Similarly, the mean disease-specific survival was 149.4 months for black patients versus 167.1 months for white patients (P < .001) CONCLUSION: Controlling for stage and treatment, black patients demonstrate poorer overall and disease-specific survival with SCCA, implying other intrinsic or extrinsic factors influencing survival.     

Extrathyroidal extension in well-differentiated thyroid cancer: macroscopic vs microscopic as a predictor of outcome

OBJECTIVE: To examine the prognostic difference in well-differentiated thyroid cancer between macroscopic extrathyroidal extension (ETE), which is appreciated in the operating room, vs microscopic ETE, which is only appreciated under the microscope by the pathologist. DESIGN: Retrospective medical record review. SETTING: Tertiary care academic hospital. PATIENTS: Among 582 patients, those who were surgically treated for stage III well-differentiated thyroid cancer with a minimum 5-year follow-up were included. Fifty-five patients (10%) (17 males and 38 females [mean age, 53.1 years]) met the selection criteria. MAIN OUTCOME MEASURES: Disease-specific survival and overall survival. RESULTS: Thirty-two patients (58%) had macroscopic ETE, while 23 patients (42%) had microscopic ETE. Twenty-year disease-specific survival in the macroscopic group was 47% (8 of 17) and 45% (5 of 11) in the microscopic group (P=.45). Twenty-year overall survival in the macroscopic group was 27% (3 of 11) and 24% (4 of 17) in the microscopic group (P=.59). The only confounding factor was external beam radiation therapy (EBRT). More patients with macroscopic ETE were treated with EBRT (P=.007). When survival was stratified according to EBRT, patients with macroscopic ETE who did not receive EBRT had diminished disease-specific survival (P=.07) and overall survival (P=.12). On multivariate analysis, EBRT was the only predictor of improved disease-specific survival (P=.02) and overall survival (P=.06). CONCLUSIONS: In selected patients with macroscopic ETE, we recommend postoperative EBRT. Further investigation is required to determine whether macroscopic ETE vs microscopic ETE is an independent predictor of outcome.     

Survival and staging characteristics for non-squamous cell malignancies of the maxillary sinus

OBJECTIVE: To characterize the clinical behavior of non-squamous cell cancer of the maxillary sinus. METHODS: Cases of non-squamous cell maxillary sinus malignancy during 1988 through 1998 were extracted from the Surveillance, Epidemiology, and End Results database. Data for histologic type of tumor, tumor stage, and survival were analyzed using the Kaplan-Meier method to determine mean, median, and 5-year survival statistics for the overall cohort and for individual histologic types of tumor. The effect of tumor stage on overall survival was assessed. To determine relative survival, the non-squamous cell group was compared with a second group of patients with squamous cell carcinoma, matched according to age at diagnosis, year of diagnosis, and T stage. RESULTS: One hundred eighty-eight cases of non-squamous cell malignancy were identified. The mean patient age was 57.8 years, and 143 patients (76%) presented with T3 or T4 tumors. There were 31 adenocarcinomas, 64 adenoid cystic carcinomas, 15 mucoepidermoid carcinomas, 22 melanomas, 45 sarcomas, and 11 undifferentiated carcinomas. The overall mean survival was 63.4 months, and 5-year survival was 45.6%. Adenoid cystic carcinoma exhibited the best mean survival (79 months), whereas melanoma and undifferentiated carcinoma exhibited poor mean survivals (30.3 and 12.8 months, respectively). T stage did not statistically affect overall survival (P =.86). Survival for patients with non-squamous cell cancer was substantially better than survival for the matched group with squamous cell carcinomas (mean survival, 41.5 months; 5-year survival, 27.4%). CONCLUSIONS: Patients with non-squamous cell carcinoma of the maxillary sinus typically present with advanced T stage but have significantly better survival than patients with similar-stage squamous cell carcinoma of the maxillary sinus. T stage has less effect than histologic type of tumor on prognosis in non-squamous cell carcinoma of the maxillary sinus.     

Matched analysis of survival in patients with squamous cell carcinoma of the head and neck diagnosed before and after 40 years of age

OBJECTIVES: To compare the survival rates of patients 40 years or younger and diagnosed with squamous cell carcinoma of the head and neck (SCCHN) with those of patients older than 40 years who underwent the same treatment. In 2 previous matched-pair analyses, the patients had been matched for tumor stage, site, sex, and date of presentation but not type of treatment. METHODS: Between 1995 and 2001, 46 patients 40 years or younger participated in a prospective epidemiologic study that included more than 500 patients newly diagnosed with SCCHN. We matched each of these patients by sex, race, tumor site, overall stage, and treatment modality with 2 patients older than 40 years. Ultimately, 31 of the younger patients were matched with 62 of the older patients. Survival analysis was performed using Cox proportional hazard models and accounting for the matched trios. RESULTS: There was no difference in overall, disease-specific, or recurrence-free survival rates between the patients who were 40 years or younger and those older than 40 years. Furthermore, matched survival analysis did not demonstrate a difference in overall survival rate (risk ratio [RR], 0.71; 95% confidence interval [CI], 0.22-2.29; P =.56), disease-free survival rate (RR, 0.83; 95% CI, 0.20-3.33; P =.79), or time to recurrence (RR, 1.46; 95% CI, 0.50-4.23; P =.49), and was not affected by adjustment for medical comorbidities or the severity of cancer-associated symptoms. CONCLUSIONS: We found no evidence of a difference in the survival rates of patients with SCCHN who were 40 years or younger or older than 40 years and underwent similar treatment at our institution.     

A matched survival analysis for squamous cell carcinoma of the head and neck in the elderly

OBJECTIVE: To determine whether elderly patients manifest poorer survivals for head and neck squamous cell carcinoma. METHODS: Cases of squamous cell carcinoma of the glottic larynx, oral tongue, and tonsil were extracted from the Surveillance, Epidemiology and End Results database for 1988 to 1998. For each primary site, patients were segregated into two age groups: 50 to 69 years of age and 70 years of age and older. For each case in the latter, elderly group, a reference group case was randomly matched for gender, year of diagnosis, cancer stage, extent of surgery, and radiation therapy. Overall survival and disease-specific survival were compared between the two groups with stage stratification with the Kaplan-Meier method. RESULTS: Cases of glottic carcinoma (1882), tongue carcinoma (426), and tonsillar carcinoma (200) in elderly patients were matched to the reference group. Overall mean survival differences were significant for glottic carcinoma (73.9 vs. 96.7 mo, elderly and younger groups, respectively) (P <.001) and tongue carcinoma (59.5 vs. 73.1 mo) ( P=.002) but not for tonsillar carcinoma (46.0 vs. 54.4 mo) ( P=.220). Disease-specific survival differences were significant but small in magnitude for glottic carcinoma (105.9 vs. 114.1 mo, respectively (P <.001) and tongue carcinoma (81.6 vs. 93.6 mo) (P =.009) but not for tonsillar carcinoma (71.5 vs. 70.7 mo) (P =.422). However, after stage stratification, elderly patients often did not exhibit statistically or practically significant poorer overall or disease-specific survivals. CONCLUSIONS: Elderly patients do not necessarily exhibit clinically significant poorer survivals for head and neck squamous cell carcinoma. Age alone should not be used to determine treatment options for elderly patients with squamous cell carcinoma.     

Racial disparities in patients with head and neck squamous cell carcinoma

OBJECTIVES/HYPOTHESIS: Black patients are reported to have a higher incidence of advanced disease and increased mortality from head and neck squamous cell carcinoma (HNSCC) but constitute the minority of patients in large-scale studies investigating the effect of race on outcome. This study sought to determine if racial disparities exist between black and white patients with HNSCC treated at a single large institution in the South with a high proportion of black patients. STUDY DESIGN: The authors conducted a nonrandomized retrospective cohort analysis. METHODS: The tumor registry was used to identify patients diagnosed with HNSCC from 1985 to 2002. The medical records of non-Hispanic white and black adult patients were retrospectively reviewed. Median household income, percentage of population below poverty level, and education level based on census tract and block information were obtained from U.S. Census 2000 data. Standard statistical analysis, including Kaplan-Meier survival curve analysis and Cox proportional hazards models, was used to analyze the effects of covariables on survival. RESULTS: A total of 1,128 patients met study criteria (478 black, 650 white). Compared with white patients, black patients were significantly younger (mean age, 53.9 vs. 56.4 years, P<.0001), male (81.2% vs. 72.3%, P=.0005), more commonly abused alcohol (88.0% vs. 74.3%, P<.0001), and were significantly less likely to have insurance (8.6% vs. 21.7%, P<.0001). There was no difference in the incidence of tobacco use (91.7%), advanced comorbidity (35.9%), or primary tumor site. Black patients had a significantly greater incidence of stage IV disease (65.7% vs. 46.6%, P<.0001) and nonoperative treatment (48.7% vs. 30.8%, P<.0001), which was performed for inoperable disease in 57.1% of black compared with 31.0% of white patients (P<.0001). Black patients resided in census block groups with significantly lower mean education level, median income, and a higher percentage of population below poverty compared with white patients. The 5-year disease-specific survival differed significantly between black (29.3%) and white (54.7%) patients (P<.0001). Cox proportional hazards models revealed that alcohol abuse, advanced TNM stage, high tumor grade, nodal disease, extracapsular spread, advanced comorbidity, and regional or distant metastatic disease were associated with poorer survival for all patients. An interaction with race was found for insurance status, nonoperative treatment, and extracapsular spread. Stepwise variable selection adjusting for patient, tumor, and treatment characteristics showed a significant effect only for race by payor status on disease-specific survival (P=.0228). CONCLUSIONS: Insurance status, treatment, and extracapsular spread differentially affected the survival of black patients compared with white patients. Only insurance status had a significant effect on survival in black patients after controlling for other variables. These data suggest that racial differences in HNSCC outcomes are primarily related to differences in access to health care.     

Prognostic factors and outcome for nasopharyngeal carcinoma

BACKGROUND: Nasopharyngeal cancer (NPC) is a distinct form of cancer of the upper respiratory or digestive tract in which the epidemiologic features, origin, histopathologic types, treatment, and prognosis are different from those associated with other malignant neoplasms of this anatomical area. Recent publications have demonstrated the advantage of aggressive multimodality treatment for advanced NPC. OBJECTIVES: To evaluate the results of standardized treatment of NPC during 11 years and to identify pertinent factors for clinical outcome. METHODS: Between January 1, 1989, and December 31, 2000, 173 patients with newly diagnosed NPC were treated at Instituto Nacional de Cancer. Clinical records and radiographic studies of the patients were retrospectively reviewed. Documented data of the initial presenting symptoms, head and neck examination, radiotherapy protocols, chemotherapy regimens, and surgical technique were analyzed. To determine important prognostic factors, we correlated survival rates with age, clinical stage, tumor extent, histopathological type, and therapeutic approach. The major end point used for assessment was relapse-free survival. Survival curves were estimated by the Kaplan-Meier product-limit method. Multivariate analysis was performed using the Wilcoxon signed rank and Cox proportional hazards regression tests. RESULTS: Most patients (88.5%) had locoregional advanced disease, mostly (53.4%) of the nonkeratinizing subtype. Forty-seven percent of patients had clinical cervical nodal metastases at first consultation. Gross extension of the primary tumor involving the facial bones and skull base was observed in 39.3% and 20.8%, respectively. Just under 75% of patients were treated with radiotherapy (median dose, 6600 cGy), and 25.4% underwent concomitant chemoradiotherapy with adjuvant chemotherapy (cisplatin plus 5-fluorouracil) (median dose, 6800 cGy). The 5-year disease-specific survival for the 173 patients was 32.3%. The disease-specific survival for the radiotherapy group was 22.5%, compared with 61.4% for the chemoradiotherapy plus adjuvant chemotherapy group (P =.004). Factors associated with adverse outcomes were age older than 40 years at treatment (P =.001), advanced TNM stage (P =.002), skull base invasion (P =.004), and facial bone invasion (P<.001). CONCLUSIONS: Compared with radiotherapy alone, concomitant chemoradiotherapy with adjuvant chemotherapy improved the treatment outcome of patients with NPC treated in our institution. Advanced age, local extension, and stage of the disease adversely affected the prognosis in our patients. Compared with reirradiation, salvage brachytherapy and radical neck dissection for local and regional residual or recurrent NPC were associated with increased rates of locoregional control and survival.     

Esthesioneuroblastoma: a population-based analysis of survival and prognostic factors

OBJECTIVES: To investigate the characteristics associated with survival in esthesioneuroblastoma and to determine whether the modified Kadish staging system can predict outcome. DESIGN: Retrospective population-based cohort study. SUBJECTS: All patients in the Surveillance, Epidemiology, and End Results tumor registry diagnosed as having esthesioneuroblastoma (1973-2002). MAIN OUTCOME MEASURES: The modified Kadish stage and the overall and disease-specific survival rates were determined. RESULTS: The cohort included 311 patients with a mean age of 53 years and a unimodal age distribution. The overall 5- and 10-year survival rates were 62.1% and 45.6%, respectively. The modified Kadish staging system was applied to 261 patients. Kaplan-Meier analysis showed the overall and disease-specific survival rates at 10 years to be 83.4% and 90%, respectively, for patients with stage A disease; 49% and 68.3% for patients with stage B disease; 38.6% and 66.7% for patients with stage C disease; and 13.3% and 35.6% for patients with stage D disease. Log-rank test comparisons found Kadish stage (P<.01), treatment modality (P<.002), lymph node status (P<.01), and age at diagnosis (P<.001) to be significant predictors of survival. Cox regression analysis confirmed that Kadish stage remained a significant predictor of disease-specific survival. CONCLUSION: The modified Kadish staging system, lymph node status, treatment modality, and age are useful predictors of survival in patients who present with esthesioneuroblastoma.     

Management of stage IV glottic carcinoma: therapeutic outcomes

OBJECTIVES/HYPOTHESIS: The best therapeutic approach for the treatment of stage IV glottic carcinoma is controversial. STUDY DESIGN: A retrospective study. METHODS: A retrospective study of Tumor Research Project data was performed using patients with stage IV glottic squamous cell carcinoma treated with curative intent by five different treatment modalities from 1955 to 1998 at Washington University School of Medicine and Barnes-Jewish Hospital (St. Louis, MO). RESULTS: Ninety-six patients with stage IV glottic carcinoma were treated by five modalities: total laryngectomy (TL) (n = 13), total laryngectomy with neck dissection (TL/ND) (n = 18), radiation therapy alone (RT) (n = 7) (median dose, 69.5 Gy), total laryngectomy combined with radiation therapy (TL/RT) (n = 10), and total laryngectomy and neck dissection combined with radiation therapy (TL/ND/RT) (n = 48). The overall 5-year observed survival (OS) rate was 39%, and the 5-year disease-specific survival (DSS) rate was 45%. The 5-year DSS rates for the individual treatment modalities included the following: TL, 58.3%; TL/ND, 42.9%; RT, 50.0%; TL/RT, 30.0%; and TL/ND/RT, 43.9%. There was no significant difference in DSS for any individual treatment modality (P =.759). The overall locoregional control rate was 69% (66 of 96). The overall recurrence rate was 39% with recurrence at the primary site and in the neck at 19% and 17%, respectively. Recurrence was not related to treatment modality. The 5-year DSS after treatment of locally recurrent cancer (salvage rate) was 30% (3 of 10) and for recurrent neck disease (28 of 67) was 42%. The incidence of delayed regional metastases was 28%; of distant metastasis, 12%; and of second primary cancers, 9%. There was no statistically significant difference in survival between node-negative (N0) necks initially treated (5-y DSS, 31%) versus N0 necks observed and later treated if necessary (5-y DSS, 44%) (P =.685). CONCLUSION: The five treatment modalities had statistically similar survival, recurrence, and complication rates. The overall 5-year DSS for patients with stage IV glottic carcinoma was 45%, and the OS was 39%. The cumulative disease-specific survival (CDSS) was 0.4770 with a mean survival of 10.1 years and a median survival of 3.9 years. Patients younger than age 55 years had better survival (DSS) than patients 56 years of age or older (P =.0002). Patients with early T stage had better survival than patients with more advanced T stage (P =.04). Tumor recurrence at the primary site (P =.0001) and in the neck (P =.014) and distant metastasis (P =.0001) had a deleterious effect on survival. Tumor recurrence was not related to treatment modality. Patients with clear margins of resection had a statistically significant improved survival (DSS and CDSS) compared with patients with close or involved margins (P =.0001). Post-treatment quality of life was not significantly related to treatment modality. Patients whose N0 neck was treated with observation and appropriate treatment for subsequent neck disease had statistically similar survival compared with patients whose N0 neck was treated prophylactically at the time of treatment of the primary. A minimum of 7 years of follow-up is recommended for early identification of recurrent disease, second primary tumors, and distant metastasis. None of the standard treatment modalities currently employed has a statistical advantage regarding survival, recurrence, complications, or quality of life.     

Squamous cell carcinoma of the ear arising in patients after radiotherapy for nasopharyngeal carcinoma

Radiation-induced malignancies are a rare but serious complication arising in patients receiving radiotherapy for nasopharyngeal carcinoma (NPC). To characterize patients who develop post-irradiation squamous cell carcinoma (PISCC) of the ear after radiotherapy for NPC and to compare their outcomes with patients who have de novo squamous cell carcinoma (SCC) of the ear. Clinical and pathological characteristics and their outcomes were analysed and compared between post-irradiation and de novo SCC cases. From 2002 to 2011, 25 patients were treated at our institution for SCC of the ear, of which 8 (32 %) occurred after prior irradiation. There were no significant differences between the two groups with regards to age, gender, race, smoking status, tumour size, grade, stage and differentiation. Patients in the PISCC group appeared to have inferior overall survival (median survival 71.2 vs. 85.6 months; p = 0.292) and disease-specific survival (mean 59.6 vs. 71.5 months; p = 0.441). PISSC of the ear in long-standing survivors of NPC has a poor prognosis despite advances in medical care. Surgical resection with clear margins seems to offer the best outcomes.     

Cancer of the nasal cavity: survival and factors influencing prognosis

OBJECTIVE: To determine overall survival and prognostic factors for cancer of the nasal cavity. DESIGN: Cross-sectional analysis of a national cancer database. METHODS: All cases of nasal cavity cancer were extracted from the Surveillance, Epidemiology and End Results database for 1988 through 1998. Cases with distant metastatic disease were excluded. Tumor histologic types, TNM staging, and pathological features were computed. Kaplan-Meier and Cox proportional hazards analyses were conducted to determine factors influencing overall survival. RESULTS: A total of 981 cases were identified, with 3.5% presenting with distant metastatic disease. After exclusion of missing variables, 783 cases were analyzed, with a mean patient age of 63.8 years. Squamous cell carcinoma was the most common tumor histologic type (49.3%), followed by esthesioneuroblastoma (13.2%). More than half of the cases presented with early (T1) primary site disease, and only 5% had positive nodal disease at presentation. Overall mean (median) survival was 76 (81) months, with an overall 5-year survival rate of 56.7%. On multivariate analysis, male sex, increasing age, T stage, N stage, and poorer tumor grade independently adversely affected survival (P<.05). Radiotherapy was administered in 50.5% of patients and also independently predicted poorer survival (P =.03). The mean (median) survival for squamous cell carcinoma was 79 (84) months; only melanoma showed a statistically significantly poorer mean survival of 40 (30) months when compared with other tumors (P<.001). CONCLUSIONS: Age, sex, and staging variables have a significant prognostic impact in nasal cavity cancer. Melanomas of the nasal cavity manifest very poor survival.     

Craniofacial resection for nonmelanoma skin cancer of the head and neck

OBJECTIVES/HYPOTHESIS: We reviewed our experience with craniofacial resection for advanced, nonmelanoma skin cancer of the head and neck to determine prognostic factors, local control rate, disease free survival, morbidity, and mortality. STUDY DESIGN: Retrospective review of consecutive patients treated at a tertiary referral center from 1982 to 1993. METHODS: Charts of patients having craniofacial resection for aggressive nonmelanoma cutaneous malignancies were reviewed and living patients followed for 10 additional years. Demographics, histology, previous interventions, treatment, surgical pathology, reconstructions, and complications were examined. The product-limit method was used to calculate survival functions, and the log-rank test was used to compare survival distributions. RESULTS: Thirty-five patients, mean age 66.7 years, received treatment at our facility. Follow-up ranged from 2 to 191 (mean 47.4) months. Histology included 20 squamous cell carcinomas (SCC) and 15 basal cell carcinomas (BCC). Sixty percent had craniofacial resection alone, and 28.6% also had postoperative radiotherapy. There were two perioperative deaths, and 37.1% suffered early and 14.3% late surgical complications. Two- and five- year survival was significantly better (P=.02) with BCC (92% and 76%) than with SCC (54% and 24%). Long-term disease-specific survival was 20%, and 11.4% of our subjects were living with disease. Intracranial extension (P=.02), perineural invasion (P=.049), and prior radiotherapy significantly decreased 5-year survival. CONCLUSIONS: Acceptable mortality and morbidity is possible using craniofacial resection to treat advanced nonmelanoma skin cancer. Although disease-specific survival remains poor, positive trends were noted in local control beginning at 2 years of follow-up. Because patients often have few remaining options for cure, craniofacial resection is justified when technically feasible.     

Primary tumor volume calculation as a predictive factor of prognosis in nasopharyngeal carcinoma

CONCLUSIONS: Primary tumor volume (PTV) has a close relationship with survival rates of patients with nasopharyngeal carcinoma (NPC) who were treated with concurrent chemoradiotherapy (CCRT) or radiotherapy. Besides the current AJCC staging system, measurement of PTV may be needed to predict prognosis of NPC and adjust treatment strategy. OBJECTIVES: We conducted a retrospective study to elucidate the effect of PTV on treatment outcomes in patients with NPC who were treated with CCRT or radiotherapy. PATIENTS AND METHODS: A total of 66 patients with newly diagnosed NPC were enrolled in this study. Computed tomography (CT)-derived or magnetic resonance imaging (MRI)-derived PTV was calculated. The correlation between AJCC disease stage, PTV, and disease-specific survival was analyzed. Correlations between different prognostic factors were assessed using a Cox regression model. RESULTS: The median PTV for the whole series was 12.01 ml (range 1.25-166.58 ml). The median PTV was 3.45 ml in T1 disease, 7.96 ml in T2 disease, 17.95 ml in T3 disease, and 64.73 ml in T4 disease. Disease stage and T stage carried no prognostic significance (p=0.25 and p =0.30, respectively). Four categories of PTV (<12.5 ml, 12.5-25 ml, 25-50 ml and >50 ml) had prognostic significance (p=0.02). Survival analysis demonstrated a significant difference in overall survival with larger tumor volume (risk ratio 5.447; p=0.044).     

Postirradiation sinus mucosa disease in nasopharyngeal carcinoma patients

OBJECTIVES/HYPOTHESIS: We sought to determine the incidence, progression, and risk factors for postirradiation sinus mucosa diseases (SMD) incidentally found on follow-up magnetic resonance images MRIs) in nasopharyngeal carcinoma (NPC) patients.STUDY DESIGN: RETROSPECTIVE. METHODS: The medical records, pre- and postradiotherapy (RT) MRIs were reviewed in NPC patients. Lund-Mackay system for staging of rhinosinusitis (Lund score) was used as a tool for investigation. RESULTS: One hundred twelve NPC patients (77 males and 35 females) were recruited in this study. The distribution of tumor staging in these patients were 39 (34.8%) patients in T1,23(20.5%) in T2, 31(27.7%) in T3, and 19 (17.0%) in T4 by MRI staging before RT. In these 62 patients with normal sinus ventilation before RT, 42 (67.7%) patients returned to having SMDs 3 months after RT. The maxillary,anterior ethmoid, and posterior ethmoid sinuses were most readily affected. In patients with SMDs at 3 months postRT, advanced tumor stage (P = .013) and smoking habit (P =.047) were the two factors that significantly influence Lund score. When comparing Lund score with different times after radiation therapy, a trend of decrease in Lund score could be noted from 3 months to 3 years after irradiation.CONCLUSIONS: The incidence and severity of SMD was found to be highest at 3 months postRT and decreased gradually with time. Conservative management with clinical symptom correlation should be attempted first in these patients. In these NPC patients,advanced tumor stage and smoking habit would predispose them to SMD development.     

Patterns of failure and outcome in esthesioneuroblastoma

OBJECTIVES: To evaluate the results of standardized treatment of esthesioneuroblastoma (ENB) during a 17-year period and to identify pertinent factors for clinical outcome. DESIGN: Review of clinical and radiographic data and retrospectively staging ENB according to 3 staging systems: Kadish, Biller, and Dulguerov and Calcaterra. SETTING: Hospital do Cancer I-Instituto Nacional de Cancer, Rio de Janeiro, Brazil. PATIENTS: Thirty-six patients with histologically confirmed ENB treated between January 1, 1983, and December 31, 2000; 35 fulfilled study inclusion criteria. INTERVENTIONS: Treatment included gross tumor resection through a transfacial approach with postoperative radiotherapy (RT) in 11 patients, craniofacial resection (CFR) and postoperative RT in 7, exclusive RT in 14, CFR alone in 1, and a combination of chemotherapy and RT in 2. Histopathological slides were reviewed and graded using the Hyams staging system. Analysis of prognostic factors was performed. MAIN OUTCOME MEASURES: Evaluation of survival rates using the Kaplan-Meier method. Analysis of prognostic factors carried out with the Fisher exact test and the log-rank test. RESULTS: Analysis of survival showed that the Kadish classification best predicted disease-free survival (P =.046). The presence of regional and distant metastases adversely affected prognosis (P<.001 and P =.01, respectively). Craniofacial resection plus postoperative RT provided a better 5-year disease-free survival rate (86%) compared with the other therapeutic options used (P =.05). The 5-year disease-specific survival rate was 64% and 43% for the low- and high-grade tumors, respectively (P =.20). Disease-free survival for this cohort of 35 patient was 46% and 24% at 5 and 10 years, respectively. Overall survival was 55% and 46% at 5 and 10 years of follow-up, respectively. CONCLUSIONS: The development of cervical nodal metastases and distant metastases had a significant adverse impact on prognosis. The value of the Kadish staging system was confirmed in our study, significantly correlating with prognosis. Tumor grade according to the Hyams staging system also seems to be an important factor in determining prognosis for tumor recurrence and survival. Aggressive multimodality therapeutic strategies, particularly CFR and adjuvant RT, yielded the best treatment outcome.     

Squamous cell carcinoma of the oral tongue in young patients: a matched-pair analysis

CONCLUSIONS: Young patients with squamous cell carcinoma (SCC) of the oral tongue developed fewer locoregional recurrences. The overall survival and disease-specific survival rates were better in the young patient population. OBJECTIVES: To compare the survival rates of patients under 45 years of age and diagnosed with SCC of the oral tongue with those of patients older than 45 years. PATIENTS AND METHODS: A retrospective review of 20 patients under 45 years of age with SCC of the oral tongue was performed. These patients were matched to an older population by sex and clinical stage. Overall survival, disease-free survival, disease-specific survival, and rates of local, regional and distant metastases were determined for both populations. RESULTS: Stage and treatment modality were similar in the two age groups. There were significant differences in overall survival (p=0.013) and disease-specific survival (p=0.046) favoring young patients. Rates of locoregional recurrence and distant metastasis were higher in the older patients.     

Survival rates of sinonasal squamous cell carcinoma with the new AJCC staging system

OBJECTIVE: To investigate the validity of the sixth edition of the American Joint Committee on Cancer (AJCC) staging system for sinonasal squamous cell carcinoma. DESIGN: A 15-year retrospective case series review. SETTING: Multicenter study from tertiary care facilities. PATIENTS: Data from 113 patients diagnosed as having and treated for sinonasal squamous cell carcinoma from September 1988 through August 2003 were retrieved. Ninety patients followed up for at least 12 months were included in the study. MAIN OUTCOME MEASURES: The TNM staging system and survival rates were analyzed using the Kaplan-Meier method to determine the mean, disease-free, and 5-year survival statistics. The effect of tumor stage on overall survival was assessed with stages defined by the fifth and sixth editions of the AJCC staging systems. RESULTS: The overall 5-year survival rate was 59.5%. According to the sixth edition, the survival rates of patients with stages III, IVA, and IVB tumors showed a significant difference (P = .002). In 32 cases, the stages were changed in accordance with the criteria in the sixth edition. The group in which the stage changed from III (fifth edition) to IVA (sixth edition) showed a worse survival rate than the group in which the stage did not change, although the difference was statistically insignificant. The 5-year disease-free survival rates of the group in which the stage did not change and of the group in which the stage changed from III (fifth edition) to IVA (sixth edition) were 64% and 34%, respectively (P = .08). Local recurrence was more frequently observed in the group in which the stage changed from III (fifth edition) to IVA (sixth edition). CONCLUSION: The new AJCC staging system seems to be more accurate in predicting the survival rates for patients with advanced but surgically resectable sinonasal squamous cell carcinoma (stage IVA).     

Glutathione S-transferase pi expression in nasopharyngeal cancer

BACKGROUND: Glutathione S-transferase pi (GST-pi) is an enzyme that catalyzes the conjugation of electrophilic substrates and prevents oxidative damage. Although GST-pi expression has been analyzed in many cancers, the significance of GST-pi expression in nasopharyngeal cancer (NPC), a tumor with a high treatment failure rate, is still unclear. OBJECTIVE: To elucidate the significance of GST-pi expression in NPC. DESIGN: Evaluation of GST-pi expression in NPC tissue specimens and determination of its relationship with tissue iron (a pro-oxidant) and clinicopathological factors in NPC. MATERIALS AND METHODS: Immunohistochemical expression of GST-pi was carried out in 55 NPC and 4 normal nasopharyngeal tissue sections. Eleven nasopharyngeal biopsy specimens (4 normal and 7 NPC) were analyzed for tissue iron levels. The expression of GST-pi in NPC was correlated with corresponding tissue iron levels. The relationships between GST-pi expression with sex, race, tumor stage, cervical nodal status, and clinical staging were also analyzed. RESULTS: Glutathione S-transferase pi immunoreactivity was observed in all NPC sections, with the percentage of immunopositive cells ranging from 1.0% to 72.0%. Tissue iron levels were significantly higher in the NPC tissues compared with normal tissues (P =.001). A direct correlation was observed between GST-pi expression and total and nuclear iron levels in NPC (P =.01 and P =.047, respectively). A significant association was also observed between GST-pi expression and cervical nodal disease (P =.007). CONCLUSIONS: Nasopharyngeal tumor cells may respond to pro-oxidant conditions by modulating intracellular antioxidant defense. Glutathione S-transferase pi expression appears to be associated with lymphogenous metastasis in NPC.     

Nasopharyngeal carcinoma in a non-endemic country—Validation of the new NPC staging system

BackgroundNasopharyngeal carcinoma (NPC) staging has recently been updated, with the eighth edition of the AJCC/UICC. In the last ten years, Intensity Modulated Radiotherapy (IMRT) has become a standard treatment for NPC. The authors aim to assess the benefits of the new AJCC staging system in predicting prognosis, as well as the improvement in survival outcomes in the IMRT era, in non-edemic population.MethodsRetrospective study selecting patients treated for NPC between January 2009 and December 2019 in a cancer treatment center in Portugal. Initial TNM staging (according to the seventh edition of the AJCC/UICC) was collected and each patient was restaged according to the new TNM staging system. Overall survival (OS) and Distant Metastasis Free Survival (DMFS) stratified by T and N classification and stage (according to the both TNM staging systems) were analyzed. Univariate and multivariate analysis was performed to evaluate which factors influence OS and DMFS. Data in this series was compared with a previous report from the same institution, before IMRT standard use.Results113 patients were included, averaging 53.74 (±1.4) years old. With the new TNM staging, 5 patients were downstaged and 3 patients were upstaged. Over a median follow-up time of 41 months, the 5-year OS and DMFS were 77% and 79.8%, respectively. Neither the seventh nor the eighth editions of the AJCC/UICC staging system had good overall discrimination between each T classification OS and DMFS curves. Both the seventh and the eighth editions of the AJCC/UICC staging system had statistically significant overall discrimination between each N group and each stage group classification OS curves. Only N classification predicted OS in multivariate analysis. When comparing to a previous report from the same institution, OS has not improved majorly, especially in locoregionally advanced disease.ConclusionsTNM staging still presents limitations in adequately predicting OS and DMFS.     

Prognostic factors in well-differentiated thyroid carcinoma

OBJECTIVES: To test the prognostic significance of standard clinicopathologic factors in patients with well-differentiated thyroid carcinoma (WDTC). STUDY DESIGN: A retrospective chart review of the thyroid cancer database at Mount Sinai Hospital (Toronto, Canada 1963-2000) was carried out. METHODS: All patients consecutively treated for WDTC with a follow-up period of at least 5 years were eligible for inclusion. Relevant patient, tumor, treatment, and outcome data were collected. The main outcome measures were recurrence rate, actuarial overall, and disease-specific survival at 20 years. RESULTS: Three hundred and thirty-three patients (F 275, M 58) with a median age of 39.7 (range 9-82.9) years were eligible for inclusion in this study (median follow-up 10.4 years, range 5-34.4 years, minimum 5 years). The recurrence rate was 15.6% (52 /333). The overall and disease-specific survival at 10 years was 97.5% and 98.5%, respectively. Likewise, the overall and disease-specific survival at 20 years was 88.4% and 93.3%, respectively. Clinicopathologic factors significant on multivariate regression for the development of disease recurrence included family history of WDTC, advanced stage, and total thyroidectomy (all P < .05). Similarly, advanced stage on presentation was associated with a worse disease-specific survival on multivariate regression (all P < .05). There was a trend for age 60 or greater to predict disease-specific survival (P = .09). CONCLUSIONS: WDTC is associated with a significant recurrence rate but good disease-specific survival. The most important prognostic factors are family history of WDTC, extent of surgical treatment (i.e., total thyroidectomy), and advanced initial stage of disease, with a trend for age 60 years and older.