Thyroid dysfunction after radiation therapy in head and neck cancer patients

INTRODUCTION: The reported incidence of hypothyroidism following surgery and/or radiation therapy for head and neck cancer varies widely. Most patients undergo thyroid lobectomy during laryngectomy. Standard radiation treatment portals often include the thyroid gland. The insidious development of hypothyroidism may be misdiagnosed. This study examines the incidence of thyroid dysfunction in the setting of head and neck cancer therapy. MATERIALS AND METHODS: Thyroid function tests were performed on 100 consecutive patients treated in the head and neck tumor clinic. Statistical inferences on proportions were made using chi-square analysis. RESULTS: Therapy included surgery only (10 patients), radiation therapy only (28 patients), and combined therapy (62 patients). These patients experienced thyroid dysfunction in 0%, 29%, and 45% of individuals respectively. These differences were statistically significant (P < .05). The highest rate of dysfunction (69%) was associated with patients undergoing laryngectomy and radiation therapy. When laryngectomy was not performed, thyroid dysfunction occurred in 28%. CONCLUSION: The likelihood of thyroid dysfunction after radiation therapy is high particularly when combined with surgery in which thyroid lobectomy is performed and the contralateral lobe is potentially devascularized. These results suggest that radiation therapy is a primary factor in alteration of thyroid function. We recommend that routine thyroid function testing be part of follow-up of all head and neck cancer patients.     

Decreased hearing after combined modality therapy for head and neck cancer

PURPOSE: Combined platinum-based chemoradiation therapy is frequently being used as therapy for head and neck cancer at multiple sites. These therapies are individually ototoxic, but little has been reported on their combined toxicity. MATERIALS AND METHODS: A retrospective investigation of 37 patients known to have undergone therapy with both agents, in combination, for head and neck malignancy was performed. Sixty percent of the patients had complaints of hearing loss subjectively. Reliable pretreatment and posttreatment audiograms were obtained on 15 of these patients. Audiograms were analyzed for sensorineural changes at 0.5, 1, 2, 4, and 8 kHz. RESULTS: By paired t test analysis, there were significant changes in the patients with pretreatment and posttreatment audiograms at all frequencies. More than 50% of the patients had a change of 10 dB or greater in their pure-tone average. More than 85% of the patients experienced changes in their hearing at 4 and 8 kHz. CONCLUSIONS: We conclude that patients undergoing combined modality therapy for head and neck cancer experience hearing loss. We recommend that hearing assessment, including pretreatment and posttreatment audiometry, be performed in all patients undergoing combined platinum-based chemotherapy and radiation for the treatment of head and neck cancer.     

Electroporation therapy in head and neck cancer

OBJECTIVE: To prove the efficacy of electroporation therapy (EPT) in T1 and T2 squamous cell cancers of the oral cavity and oropharynx. MATERIAL AND METHODS: Twelve patients were treated with EPT within the framework of a European trial. Tumors were infiltrated with a bleomycin solution and subsequently treated with EPT. Four weeks after treatment the necrotic mass at the site of the former tumor was resected with save margins and accurately examined histologically. RESULTS: Whereas 10 specimens were completely free of cancer cells, 2 cases showed viable tumor cells. CONCLUSION: EPT has the potential to serve as an interesting alternative in the treatment of head and neck cancer.     

Photodynamic therapy in head and neck cancer

A group of 24 patients with recurrent and/or metastatic cancers were treated with photodynamic therapy using hematoporphyrin derivative (HpD) to study feasibility of this new technique. This experience demonstrated that photodynamic therapy is possible for head and neck cancer and that the toxic reactions and complications are minimal. The short durations of response in this group of patients most probably are a reflection of current lack of understanding about what represents maximal tolerable doses of HpD and frequencies of treatment.     

Nutritional and immunological investigations in head and neck cancer patients before and after therapy

Summary We studied the nutritional and immunological states of 20 patients with advanced head and neck carcinomas. Treatment included chemotherapy with methotrexate, cis-platinum and bleomycin prior to operation and radiotherapy. Nutritional and immunological parameters were examined before and after each therapy given. Most of these parameters decreased during chemotherapy. However, while we found that nutrition improved or normalized by the end of the primary tumor treatment, immunologie parameters failed to change significantly.     

Nutritional and immunological investigations in head and neck cancer patients before and after therapy

We studied the nutritional and immunological states of 20 patients with advanced head and neck carcinomas. Treatment included chemotherapy with methotrexate, cis-platinum and bleomycin prior to operation and radiotherapy. Nutritional and immunological parameters were examined before and after each therapy given. Most of these parameters decreased during chemotherapy. However, while we found that nutrition improved or normalized by the end of the primary tumor treatment, immunologic parameters failed to change significantly.     

Endoscopic management of hypopharyngeal stenosis after organ sparing therapy for head and neck cancer

OBJECTIVES: The objective of this study was to describe and evaluate the efficacy of an endoscopic technique for the management of postchemoradiation hypopharyngeal stenosis in head and neck cancer patients. STUDY DESIGN: Retrospective review. METHODS: Patients with postchemoradiation hypopharyngeal stenoses were identified from the Dana Farber Cancer Institute head and neck database. Patients who had undergone extirpative surgery and reconstruction were excluded. All patients underwent either anterograde dilatation (AD) by the lead author (C.A.S.) or transgastric retrograde esophagoscopy with anterograde dilatation (TREAD) (C.A.S., M.T.J.). Chemoradiation records, clinic notes, operative reports, and swallowing test data were reviewed. Removal of the gastric feeding tube was considered the endpoint of rehabilitation. RESULTS: Seventeen patients had postcricoid stenoses identified by modified barium swallow. Endoscopy confirmed 15 postcricoid stenoses and 2 proximal esophageal stenoses. Nine (53%) patients had partial stenoses, and eight (47%) had complete stenoses. Eight partial stenosis patients underwent 10 AD procedures and 3 TREAD procedures. Eight complete stenosis patients underwent 9 TREAD procedures and 26 subsequent AD procedures. Fifteen of 16 (93%) patients resumed swallowing after dilatation. Thirteen (81%) patients maintained their weight on an oral diet and had their gastric feeding tubes removed. Complications included hypopharyngeal perforation (13%), abdominal wall infection (6%), stomach wall dehiscence (6%), and chondroradionecrosis of the cricoid cartilage (6%). CONCLUSIONS: Postcricoid hypopharyngeal stenosis may be partial or complete after organ sparing chemoradiation for head and neck cancer. Using the TREAD technique, successful rehabilitation of swallowing can be achieved with a low incidence of complications.     

头颈部放射线损伤25例临床分析

目的探讨预防、诊治放射治疗所致头颈部肿瘤患者的放射线损害.方法回顾分析头颈癌25例放疗后发生并发症患者的临床资料.结果男21例,女4例,18～68岁,原发头颈肿瘤分别为鼻咽癌21例,硬腭癌1例,喉癌1例,食道癌1例,腮腺混合瘤1例;放射线损害30例次局部骨髓炎伴瘘管5例次、神经损伤2例次、上腔静脉综合征1例次、鼻咽闭锁1例次、腭瘘2例次、颌面颈淋巴回流障碍2例次、放疗诱发第二原发癌9例次、局部溃疡大出血4例次、颞颌关节强直4例次.经保守治疗、手术及综合治疗,死亡10例,其中5例死于放疗所致的并发症,5例死于第二原发癌,生存期3～43年,健在15例,存活7～37年.结论放疗对机体产生的各种损害多为不可逆,且随时间的推移逐渐累积和显现;严格掌握放疗指征,杜绝不必要的放疗;精确设计放射野和剂量,采用高能放射源及立体定向技术等能预防放射线损伤,综合治疗对放射线损伤有效.     

Two cases of pulmonary embolism after head and neck surgery

Pulmonary embolism (PE) is a prominent cause of morbidity and mortality in surgical patients. Here, we report two cases of PE following head and neck surgery: (1) in case 1, the patient underwent endoscopic sinus surgery (ESS), and (2) in case 2, the patient was suspected PE after resection of the parotid gland and radical neck dissection. Prophylactic compression devices were used during the operation in both cases. In case 1, PE was diagnosed 3 days following surgery after the patient complained of dyspnea while walking. PE was successfully treated by intravenous administration of heparin. In case 2, PE was strongly suspected 13 days following surgery after the patient experienced syncope and chest pain and exhibited abnormal findings on a cardiac echogram. This patient died 18 h after the onset of cardiac symptoms. Despite prophylactic measures taken during surgery, the prognosis was poor for this patient due to numerous high-risk factors (e.g., advanced age, obesity, prolonged immobilization). Although the incidence of postoperative PE in our department during the last 7 years is very low (0.04%), the frequency of postoperative PE in Japan has steadily increased in recent years. PE still is one of the most significant complications leading to morbidity and mortality following surgery. Given the gaining prominence of PE, we conclude that otolaryngologists including those in Japan should be reminded of high-risk factors associated with PE and be made aware of prophylactic treatments newly aimed at reducing the frequency of PE.     

Clinical review of autopsy cases that succumbed to head and neck malignancies

We investigated autopsy cases that had succumbed to head and neck malignancies in the light of the relationships between locoregional tumors and distant metastasis, between the frequency and site of distant metastasis and between the occurrence of locoregional tumors/distant metastasis and the cause of death. Of the 203 cases autopsied at the Kitasato University Hospital between 1972 and 1999, 174 had epithelial tumors and 29 had non-epithelial tumors (malignant lymphoma in 20/29). In terms of epithelial tumors, 107 patients (61%) had locoregional disease and 101 (58%) exhibited distant metastases; 39 cases (28%) had distant metastasis without locoregional tumors. Although the cause of death was mostly as the result of locoregional disease, death related to distant metastasis was also frequently observed. Of the 20 cases with malignant lymphoma, 17 had distant metastases and only 2 of them manifested tumors in the primary region. All 17 patients with distant metastases showed tumors in the distant lymph nodes, with a relatively high occurrence of metastasis to the gastrointestinal tract. Key words: cause of death, distant metastasis, locoregional tumor.     

Three cases of renal cell carcinoma metastasizing to the head and neck

Renal cell carcinoma (RCC) tends to metastasize hematogenously, although metastasis to the head and neck is rare. We report 3 cases of RCC head and neck metastasis within the last 6 years. CASE 1: A 74-yearold woman presented with cervical metastasis from RCC 4 years after right total nephrectomy, involving modified neck dissection. She later had additional surgery and radiation for further distant metastases, survived almost 5 years after the first neck metastasis. CASE 2: A 60-year-old man showed metastatic RCC in the right parotid gland 3 years after right total nephrectomy, involving superficial parotidectomy. CASE 3: A 54-year-old man presented with a metastasis lesion from RCC to the right maxillary sinus 7 years after left total nephrectomy, involving total maxillectomy. Distant metastasis reportedly often occurs long after initial primary RCC treatment. Physicians considering metastatic RCC in differential head and neck diagnosis and resection could conceivably promote better prognosis.     

New substances in the therapy of head and neck cancer

During the last 3 years the FDA approved numerous innovative drugs for cancer therapy. Drugs relevant to the otolaryngologist are presented and discussed. These new therapeutic tools may play a future part also in the therapy of head and neck cancer.     

Hypothyroidism after treatment for nonthyroid head and neck cancer

OBJECTIVES: To determine the incidence of posttreatment hypothyroidism in patients treated with surgery with or without radiotherapy for advanced-stage nonthyroid head and neck cancer and to make recommendations for its detection. DESIGN: A prospective study to assess the incidence and time frame of occurrence of hypothyroidism in patients by primary tumor site and treatment modality. Thyroid function tests were performed preoperatively, at the first postoperative visit, and then approximately every 6 months. Patients were followed up for up to 3 years. SETTING: Arthur G. James Cancer Hospital and Research Institute, Columbus, Ohio. PATIENTS: A total of 251 patients with nonthyroid head and neck cancer were originally enrolled; 198 patients with evaluable data were studied to determine the incidence of posttreatment hypothyroidism. Approximately 80% of the patients had advanced stage (III or IV) or recurrent cancer. RESULTS: The overall incidence of posttreatment hypothyroidism was 15% in 198 patients followed up for a mean of approximately 12 months. Hypothyroidism developed in 12% of patients treated with nonlaryngeal surgery and radiotherapy. The group undergoing total laryngectomy (with thyroid lobectomy) and radiotherapy had a 61% incidence of hypothyroidism. The average time to detection of hypothyroidism was 8.2 months. CONCLUSIONS: Approximately 15% of patients treated for advanced head and neck cancer with surgery and radiotherapy will develop hypothyroidism. Those treated with total laryngectomy and radiotherapy are at greatest risk.     

Planned neck dissection after concomitant radiochemotherapy for advanced head and neck cancer

OBJECTIVES/HYPOTHESIS: Since 1998, at our academic, multidisciplinary head and neck cancer treatment center, it has been our policy to treat appropriate patients with locoregionally advanced squamous cell carcinoma of the head and neck (SCCHN) with concomitant radiochemotherapy followed within 6 weeks by planned neck dissection(s). Our objective was to investigate the oncologic efficacy of planned neck dissection, to date, in this patient population with a focus on outcomes in the neck. STUDY DESIGN: Retrospective analysis of a cumulative patient database. METHODS: The medical records of all patients who underwent planned neck dissection(s) after concomitant radiochemotherapy for locoregionally advanced SCCHN at Beth Israel Medical Center and The Institute for Head and Neck Cancer in New York City were reviewed. For each patient, preradiochemotherapy primary and neck stage, postradiochemotherapy/preneck dissection clinical and radiographic neck status, type of neck dissection(s) performed, pathologic status of the neck dissection specimen(s), length of follow-up (after planned neck dissection), disease status at last follow-up, and site(s) of recurrence were recorded. Local, regional, and distant disease control rates were calculated by the Kaplan-Meier method. RESULTS: Fifty-one planned neck dissections were performed on 39 radiochemotherapy patients (12 patients had bilateral operations) between early 1998 and October, 2003. Thirty-two (82%) patients had N2 or greater neck disease, with 29 (74%) having T3/T4 disease at various upper aerodigestive tract primary sites. Patients received an average of 6,700 cGy and 6,000 cGy external beam radiation therapy to primary disease sites and involved cervical lymphatics respectively, concomitant with one of three platinum-based chemotherapy schedules. At a mean follow-up time of 24 (range 8-57) months for the entire study population, there has been only one neck recurrence (N2A neck). No patient with N2B (n = 11), N2C (n = 13, with majority of heminecks staged N2B), or N3 (n = 5) disease has recurred in the neck. No recurrences have occurred in the 41 heminecks (in 33 patients) where modified neck dissection (including 24 selective procedures) was performed despite the presence of residual carcinoma in 13 (32%) of these heminecks on pathologic review. Among all heminecks with residual carcinoma present (n = 18) in the neck dissection specimen, there has been only one neck recurrence. There have been no recurrences in the 26 heminecks (in 19 patients) with incomplete clinical response after radiochemotherapy despite the presence of residual carcinoma in 14 (54%) of these necks on pathologic review. The clinical and radiographic absence of residual disease after radiochemotherapy did not always predict a complete pathologic response. Surgical complications have been limited (1 chyle leak, 1 wound breakdown). CONCLUSIONS: The integration of planned neck dissection into the multidisciplinary management of patients with locoregionally advanced SCCHN is highly effective in controlling cervical metastatic disease. Modified and selective neck dissection procedures can be performed in the majority of patients, regardless of the response in the neck subsequent to concomitant radiochemotherapy. We recommend a planned neck dissection(s) in all patients staged (pretreatment) with N2 or greater neck disease and in select N1 cases.     

Neoadjuvant therapy for organ preservation in head and neck cancer

OBJECTIVES/HYPOTHESIS: We designed two sequential trials of induction chemotherapy followed by definitive radiation in patients with potentially resectable head and neck cancer to determine whether organ preservation is feasible without apparent compromise of survival Study Design Both trials were Phase II studies. METHODS: Two clinical trials were conducted sequentially at the University of Michigan. Fifty-two patients enrolled in the first study and were treated with a planned three cycles of carboplatin and 5-fluorouracil. Patients who achieved at least 50% reduction in the size of the primary tumor received definitive radiation therapy, to a dose of 6600 to 7380 cGy. Patients with minimal response or progression had immediate salvage surgery. Thirty-seven patients enrolled in the second trial, in which the chemotherapy consisted of carboplatin, 5-fluororuracil, and leukovorin. Responders were treated with accelerated radiation therapy, to a total dose of 7120 cGy delivered in 41 fractions over 5.5 weeks. RESULTS: Toxicity and response were similar in both trials; therefore, the results are reported first separately and then combined for all 89 patients. Tumor sites included: oropharynx, 55 patients; hypopharynx, 34 patients. Eighty-three percent of patients tolerated all three cycles of chemotherapy and toxicity was mild. Response to chemotherapy was: 48% complete response at the primary tumor site, and 34% partial response at the primary tumor site. Initial organ preservation at individual tumor sites was: oropharynx, 58%; hypopharynx, 59%. Median survival was 28 months, and survival at 3 and 5 years was 40% and 24%, respectively. CONCLUSIONS: These two regimens were well tolerated, and survival did not appear to be compromised by organ preservation treatment compared with historical controls. This approach warrants further investigation, particularly in those patients for whom surgery could be functionally debilitating.     

Recent advances in radiation therapy for head and neck cancer

The treatment of locally advanced or recurrent head and neck cancers has improved from single modality interventions of surgery and radiation therapy alone to include combined modality therapy with surgery, chemotherapy and radiation. Combined therapy has led to improved local control and disease-free survival. New developments in radiation oncology such as altered fractionation, three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, stereotactic radiosurgery, fractionated stereotactic radiotherapy, charged-particle radiotherapy, neutron-beam radiotherapy, and brachytherapy have helped to improve this outlook even further. These recent advances allow for a higher dose to be delivered to the tumor while minimizing the dose delivered to the surrounding normal tissue. This article provides an update of the new developments in radiotherapy in the management of head and neck cancers.