How intensive should radiotherapy for head and neck cancer with synchronous distant metastases be? Review of cases.

PURPOSE: Given the differences in treatment objectives among oncologists and complexities of standards of therapy for advanced head and neck cancer (HNC), we sought to determine whether HNC patients with simultaneous distant metastases (M1) benefit from aggressive therapeutic intervention. MATERIALS AND METHODS: Among the 1,988 patients diagnosed with HNC during a 22-year period, 7 patients with synchronous M1 tumors were identified. Of these individuals, 4 were treated with a prolonged course of radiotherapy for HNC (group A) and 3 were not (group B). RESULTS: The median survival and 60-day mortality rate in group A were 14 months and 0%, respectively, whereas the corresponding observations for group B were 5.5 months and 50%. No difference in HNC stage or M1 extent was present between the 2 groups. The patients composing group A were older than those in group B. CONCLUSION: These data suggest that some benefit may be obtained by the application of a full course of irradiation for HNC with synchronous M1 disease. The practice of intensive radiotherapy for this particular complicated neoplastic condition needs to be reviewed, considering the health care reform and emphasis on cost-effectiveness in the near future.

Paraplegia of spinal epidural compression by metastatic breast cancer and urgent radiotherapy-timeliness for naught?

Four patients who became paraplegic because of spinal epidural compression by metastatic breast cancer were treated for palliation by external beam radiation. None of the four regained ambulation after therapy. Our findings place in question the urgent need for radiotherapy in these paralytic people with the disorder, especially when they are pain-free.

Does the negative node count affect disease-free survival in early-stage oral cavity cancer?

PURPOSE: We performed a retrospective study to determine whether there is a relationship between disease-free survival and negative lymph node count in patients with resected early-stage oral cavity cancers. MATERIALS AND METHODS: Of the 526 individuals diagnosed with carcinoma of the oral cavity between 1998 and 2005, 52 had undergone primary tumor resection and lymph node dissection of the neck for stage I or II disease. With a mean count of 27 examined negative nodes, these 52 patients were separated into groups with fewer than 27 or > or = 27 uninvolved lymph nodes and compared for disease-free survival. RESULTS: The tumor recurred or progressed in 10 patients (19%) during a median follow-up of 27 months. The 2-year disease-free survival rates were 75% and 78% in individuals with fewer than 27 and > or = 27 uninvolved node counts, respectively (P > .78). CONCLUSION: The removal of a greater number of regional, uninvolved cervical lymph nodes does not correlate with disease-free survival in this particular cohort of patients.

Successful tri-modality treatment of atypical carcinoma ex-pleomorphic adenoma with more than 50 nodal metastases.

Carcinoma ex-pleomorphic adenoma (CEPA), an extremely aggressive malignant tumor, bears a significant potential for locoregional recurrence and distant metastases. Management of the disease usually involves definitive surgery with postoperative radiotherapy administered for identified nodal metastases. Two cases of CEPA with many (>50) cervical lymph node metastases and other histopathological features were managed by tri-modality treatment scheme. No evidence of disease occurred during follow-up of at least 2 years. These cases may eventually establish the value of surgery with adjuvant radiochemotherapy in patients with CEPA and supernumerary nodal metastases.

Longevity after radiotherapy of stage III lung cancer: superior vena cava obstruction is associated with early mortality.

BACKGROUND: People with locally advanced lung cancer have a poor prognosis. Physicians are unable to accurately predict life expectancy of patients. The aims of this retrospective study were to identify the life spans of individuals after radiotherapy of stage III carcinoma of the lung and to determine whether potential prognostic factors could identify people with distinct life spans. METHODS: Between September 1981 and August 2010, 133 consecutive individuals underwent definitive or palliative radiotherapy (with or without chemotherapy) for stage IIIA/IIIB disease. Analysis of the survival data revealed that 14 patients experienced long-term survival, exceeding 36 months; 94 patients had a short-term life span (STLS), extending between 4 and 36 months, and 25 patients were in the end-of-life (EOL) period, referring to the last 3 months of life. Recognized pre-treatment clinicopathological features were tested for their impact on prognosis. RESULTS: The largest proportion of patients presenting with superior vena cava obstruction (SVCO) (P<0.001) and receiving palliative radiotherapy (P=0.009) were from the EOL group. Most of the individuals with inadequate or no health insurance belonged to the STLS and EOL cohorts (P=0.001). Multivariate analysis revealed that the presence of SVCO was an independent factor predictive of shortened survival/EOL status (P=0.001). CONCLUSIONS: Our study showed that a particular disease characteristic, health insurance status and provision of contemporary therapy can influence individual longevity. Selection and prioritization of health care resources remain important; therefore, identification of influential prognostic factors in lung cancer patients deserves further scrutiny.

Total laryngectomy and T3-T4 laryngeal cancer without other adverse histopathology.

OBJECTIVE: We sought to determine the postoperative management, incidence of tumor recurrence in the neck, and outcome in laryngeal cancer patients whose risk for tumor relapse is not clear. STUDY DESIGN AND SETTING: Thirty patients (27 of whom had transglottic tumors) met the study criteria (resected T3-T4 laryngeal cancer, histologically negative cervical nodes, and no other adverse histopathology). A group of 12 patients who underwent surgery alone was compared with a second group of 18 patients with similar characteristics but who received postoperative radiotherapy. RESULTS: Overall survival at five years was 50% in the surgery alone group and 61% in the combined therapy group (P=0.63). Among the 28 evaluable patients with a median follow-up of 44 months, the relapse rate in the neck was 25% in the surgery alone group and was 0% in the postoperatively irradiated group (P=0.07). Recurrences in the neck remained uncontrolled in two of the three patients at the time of death. CONCLUSION AND SIGNIFICANCE: Postoperative radiotherapy deserves consideration in selected cases of T3-T4 laryngeal cancer without adverse histopathology.

Calvarial and scalp metastases: an unusual presentation of non-small-cell lung cancer.

We report the case of a 64-year-old woman who presented with scalp and skull masses. Histological examination confirmed the diagnosis of metastatic tumor from non-small-cell lung cancer. To our knowledge, this is the sixth case reported in the English literature. Although the occurrence of the distant neoplastic spread was a preterminal event, local electron beam irradiation effected significant resolution of the metastatic tumors.

Cavernous sinus involvement by extramedullary plasmacytoma of the sphenoid sinus. An argument for the use of adjuvant chemotherapy.

A 63-year-old man with cavernous sinus involvement from extramedullary plasmacytoma (EMP) of the sphenoid sinus is described. Transient resolution of retro-orbital headache and continued progression of the locally extensive tumor were noted after chemotherapy was given following a poor response to 5400 cGy of local irradiation. To determine whether adjunctive chemotherapy will improve the outcome of these particular patients, we propose that a randomized trial comparing radiotherapy to chemoradiation be conducted.

Salvage treatment of recurrent skin cancer of the midface.

Nine patients with recurrent cutaneous cancers of the midface were treated by definitive surgery (with adjuvant radiotherapy in five individuals). The clinical courses were marked by local and regional relapses in six cases. Although the prognosis may be generally poor, aggressive therapy, as feasible, seems warranted in these patients because death was not typically rapid after reappearance of disease in several patients.

Palliation and survival in metastatic tumors compressing the cauda equina: a 19-year radiotherapeutic experience.

UNLABELLED: PURPOSE; Radiotherapy (RT) offers a means of promoting an acceptable quality of life in people with incurable cancer. We reviewed our radiotherapeutic experience of metastatic tumors compressing the cauda equina (MTCCE) because large case series and achieved palliation in these patients are infrequently documented in the literature. METHODS: Seventy-six individuals undergoing RT for MTCCE were identified from a 19-year period (1981-1999). Treatment responses and survival were assessed. RESULTS: Pain relief was complete in 94%, partial in 3%, and not achieved in 3% of the 32 evaluated patients. Complete resolution of impaired sensation in the lower limbs occurred in three cases, and of anal or bladder sphincter dysfunction in three persons also. Among the 28 evaluable individuals with lower extremity motion impairment, 11 (39%) were nonambulatory and 17 (61%) were ambulatory following treatment. The overall median survival was 3 months; the survival rate at 1 year was 18% and at 3 years 8%. CONCLUSION: Although long-term survival is not to be expected, the usefulness of RT for palliation of MTCCE may be trusted.

Induction chemotherapy followed by concomitant chemoradiation-induced regression of advanced cervical lymphadenopathy in head and neck cancer as a predictor of outcome.

OBJECTIVE: We sought to determine whether induction chemotherapy followed by concomitant chemoradiation (ICCR)-induced advanced neck disease regression could predict outcome, especially the need for complete neck dissection in patients with N2-3 stage IV head and neck cancer (HNC). METHODS: A retrospective study of 339 patients evaluated for treatment of stage IV HNC during the years 1988 to 1997 revealed 36 individuals with N2-3 cervical lymphadenopathy who were treated with ICCR. Responses to treatment, patterns of failure, and survival rates were analyzed. RESULTS: Primary and regional tumor regressions were complete in 21 patients (58%), partial in 9 (25%), and absent in 6 (17%); the corresponding local failure rates were 5%, 44%, and 33% (P < 0.02). The regional failure rates were 24%, 89%, and 83%, respectively (P < 0.001); distant failure rates were 10%, 0%, and 0% (P > 0.99). The estimated 2-year survival rates for complete and partial/nonresponders were 57% and 20%, respectively (P < 0.02). CONCLUSION: Patients with advanced regional metastases of HNC who respond completely to ICCR have an excellent chance for survival. However, such ICCR-induced complete regression of regional tumor cannot reliably predict ultimate neck disease control.

Management of epidural cauda equina disease of prostate cancer by radiotherapy.

OBJECTIVE: Secondary prostate cancer affection of the cauda equina (SPCCE) can be an ultimate cause of morbidity and mortality. Since the results of management of this particular disease condition remain largely unknown, a retrospective case review was undertaken to determine the effects of treatment by radiation in SPCCE patients. METHODS: The records of 12 patients with SPCCE treated at the Division of Therapeutic Radiology during the period 1984 to 1998 were reviewed. The administered total radiation dosage ranged from 6 Gy to 32 Gy (average, 26.6 +/- 2.0 Gy). Two individuals underwent decompressive laminectomy and bilateral orchiectomy at the time of SPCCE and prostate cancer diagnoses. Ten patients had prior hormonal manipulative treatment (orchiectomy, estrogen, or Flutamide therapy). RESULTS: Pain was relieved in three of four symptomatic patients (75%). Five of nine patients unable to walk before therapy could walk after treatment. One of two individuals with anal or bladder sphincter dysfunction improved following irradiation. The overall mean duration of survival was five months. With treatment, survival was approximately three times as long for ambulatory versus non-ambulatory patients. CONCLUSION: We conclude that radiation treatment is efficacious in promoting palliation of SPCCE, although it may not prolong life.

Is chemoradiation as effective as surgery with postoperative radiotherapy for locally advanced (operable) head and neck cancer? A retrospective observational study.

OBJECTIVE: To determine whether chemoradiation (CX) is as effective as surgery with postoperative radiotherapy (SX) for operable, locally advanced head and neck cancer (LAHNC). METHODS: A retrospective review of 78 patients with operable stage III or IV cancer of the upper aerodigestive tract who were treated by CX (n = 25) or SX (n = 53) during a 20-year period was undertaken. RESULTS: Fewer patients relapsed regionally when treated by SX than by CX (p = 0.006). On the other hand, there was no significant difference in local recurrence, distant metastasis, 2-year survival rate, or 5-year survival rate between the two patient groups. CONCLUSION: Our results suggesting that CX is not as effective as SX for patients with operable LAHNC calls for a randomized trial comparing CX to SX in such cases.

Head and neck cancer with simultaneous lung cancer.

The simultaneous occurrence of a primary malignant tumor of the lung or pulmonary metastasis in patients with head and neck cancer is uncommon. In response to the question, "Are efforts toward management of cancer in the head and neck region in a person with simultaneous malignant tumor of the lung an exercise in futility?" we present six cases evaluated at the Louisiana State University Health Sciences Center in Shreveport during a 19-year period. Men with squamous cell cancers at both locations and locally advanced malignant tumors of the lung were predominant in this series of patients. Chemoradiation was applied because of extensive disease at one or both neoplastic sites. Long-term survival was not observed in most patients (including the aggressively treated individuals) whose malignant neoplasms were concurrently managed by non-operative means.

CD23 negative chronic lymphocytic leukemia of the tonsil: report of a case.

We present the case of atypical chronic lymphocytic leukemia presenting as a tonsillar mass in an elderly man. Histological examination of the tumor revealed diffuse submucosal infiltration by small lymphocytes. On flow cytometry, a monoclonal B lymphocytic population expressing CD5, CD19, lambda light chain, but not expressing CD10, CD23, or FMC7 activities, was observed. A diagnostic conundrum occurred with the demonstration on molecular cytogenetic analysis of the chromosomal translocation abnormality, t(11;14)(q13;q32). The diagnosis of CD23 negative chronic lymphocytic leukemia was made after further molecular studies failed to detect the bcl-1 gene rearrangement.

Patient-provider delays in superior vena caval obstruction of lung cancer and outcomes.

This retrospective study investigates the types of delay in the initiation of palliative thoracic radiotherapy for superior vena caval obstruction (SVCO) of lung cancer (LCa) and the effect of treatment delay on patient outcomes. Treatment delays were categorized as patient delay (duration of symptoms), in-hospital delay, and professional delay and were determined in 42 people treated by radiation for palliation of the complicated neoplastic condition between 1981 and 2009. The median period of patient delay was 26.2 days, in-hospital delay was 3.5 days, and professional delay was 1.5 days. The majority (80%) of these individuals were uninsured or underinsured, and 69% presented with locally advanced LCa. The overall response rate was 84%, and the 1-year survival rate was 24%. Despite the longest patient-related delay, symptomatic individuals overall derived palliation from conventional treatment. Improved efforts toward early diagnosis and treatment of patients with SVCO-LCa need to be continued.