Matched survival analysis in patients with locoregionally advanced resectable oropharyngeal carcinoma: platinum-based induction and concurrent chemoradiotherapy versus primary surgical resection.

PURPOSE: The outcome of a prospective case series of 47 patients with newly diagnosed resectable locoregionally advanced oropharyngeal squamous cell carcinoma treated with platinum-based induction-concurrent chemoradiotherapy (IC/CCRT) was compared with the outcome of 47 matched historical control patients treated with surgery and postoperative RT. METHODS AND MATERIALS: A total of 47 control patients with locoregionally advanced oropharyngeal squamous cell carcinoma were identified from review of a prospectively compiled comprehensive computerized head-and-neck cancer database and were matched with a prospective case series of patients undergoing IC/CCRT by disease stage, nodal status, gender, and age (± 5 years). The IC/CCRT regimen consisted of one cycle of induction chemotherapy followed by conventionally fractionated RT to a total dose of 66-70 Gy concomitantly with two cycles of chemotherapy. Each cycle of chemotherapy consisted of cisplatinum, 100 mg/m(2), and a continuous infusion of 5-fluorouracil, 1,000 mg/m(2)/d for 5 days. The survival analysis was performed using Kaplan-Meier estimates. Matched-pair survival was compared using the Cox proportional hazards model. RESULTS: No significant difference was found in the overall survival or progression-free survival rates between the two groups. The matched analysis of survival did not show a statistically significant greater hazard ratio for overall death (hazard ratio, 1.35; 95% confidence interval, 0.65-2.80; p = .415) or progression (hazard ratio, 1.44; 95% confidence interval, 0.72-2.87; p = .301) for patients undergoing IC/CCRT. CONCLUSION: Although the sample size was small and not randomized, this matched-pair comparison between a prospective case series and a historical cohort treated at the same institution showed that the efficacy of IC/CCRT with salvage surgery is as good as primary surgical resection and postoperative RT.

Early nutritional intervention improves treatment tolerance and outcomes in head and neck cancer patients undergoing concurrent chemoradiotherapy.

GOALS OF WORK: Patients with head and neck cancer (HNC) undergoing chemoradiotherapy are at high risk of malnutrition, which is related to complication rate. The aim of this study was to investigate the impact of an early intensive nutritional intervention on nutritional status and outcomes in patients undergoing chemoradiotherapy for HNC. MATERIALS AND METHODS: We analysed retrospectively the clinical documentation of 33 HNC patients who were referred for early nutritional intervention (nutrition intervention group, NG) before they were submitted to chemoradiotherapy. The outcome of these patients was compared to that of 33 patients who received chemoradiotherapy without receiving a specifically designed early nutrition support programme (control group, CG). MAIN RESULTS: NG patients lost less weight during chemoradiotherapy compared to CG patients (-4.6 +/- 4.1% vs -8.1 +/- 4.8% of pre-treatment weight, p < 0.01, at the completion of treatment). Patients in the NG experienced fewer radiotherapy breaks (>5 days) for toxicity (30.3% vs 63.6%, p < 0.01); the mean number of days of radiation delayed for toxicity was 4.4 +/- 5.2 in NG vs 7.6 +/- 6.5 in CG (p < 0.05); a linear correlation was found between percentage of weight lost from baseline to chemoradiotherapy completion and days of radiation delays (p < 0.01). There were less patients who had an unplanned hospitalisation in the NG relative to the CG (16.1% vs 41.4%, p = 0.03). In the NG, symptoms having an effect on the nutritional status developed early and were present in the nearly totality of patients at chemotherapy completion; 60.6% of NG patients needed tube feeding. CONCLUSIONS: Early nutrition intervention in patients with HNC receiving chemoradiotherapy resulted in an improved treatment tolerance and fewer admissions to hospital. This result suggests that nutritional intervention must be initiated before chemoradiotherapy, and it needs to be continued after treatment completion.

Long-term quality of life after treatment for locally advanced oropharyngeal carcinoma: surgery and postoperative radiotherapy versus concurrent chemoradiation.

The aim of this study was to evaluate the long-term quality of life (QoL) in survivors with oropharyngeal carcinoma (OC) treated with surgery and postoperative radiotherapy (PORT) versus concurrent chemoradiation (CRT) using the European Organization for Research and Treatment of Cancer QoL Questionnaires. The study group consisted of 57 patients. The scores for physical (P=0.043) and social (P=0.036) functioning were significantly more favorable in the chemoradiation group. Surgical patients showed statistically higher problems with fatigue (P=0.047), pain (P=0.027), swallowing (P=0.042), social eating (P=0.038) and social contact (P=0.002). CRT group reported significantly greater problems with teeth (P=0.049), open mouth (P=0.036), dry mouth (P=0.022) and sticky saliva (P=0.044). The global QoL score was higher in CRT group (P=0.027). These results support an organ preservation approach with CRT in patients with advanced OC. However, considering the absence of randomized trial comparing outcomes after surgical versus nonsurgical approaches, severe xerostomia following CRT, the higher postoperative morbidity in the setting of salvage surgery, future prospective clinical trials on greater samples of patients are needed to confirm our conclusions.

Multivariate analysis of risk factors for pharyngocutaneous fistula after total laryngectomy.

The objective of this study was to identify, through multivariate analyses, the configuration of factors that most closely impact the development of pharyngocutaneous fistula (PCF). Incidence and treatment of PCF was also revisited. A retrospective longitudinal study of 218 patients who have undergone total laryngectomy (TL) was conducted in a tertiary academic referral center. There were 47 patients (21.6%) developing PCF within 1 month after surgery (median 14 days, range 2-26 days). Non-surgical closure of the PCF was achieved in 36 patients (76.6%) within a median of 16.5 days (range 8-27 days). Eleven patients (23.4%) required a surgical closure of the PCF. In nine patients the surgical approach consisted in resuturing of the pharyngeal mucosa. Major surgery with the use of flaps (pectoralis major myocutaneous flap and free forearm flap) was required in two patients. Multivariate analysis revealed that diabetes mellitus (odd ratio 23.41 [95% CI 8.46-64.78]), preoperative hypoalbuminemia (odd ratio 9.42 [95% CI 3.60-24.61]), chronic pulmonary diseases (odd ratio 6.64 [95% CI 1.97-22.56]) and chronic hepatopathy (odd ratio 3.26 [95% CI 1.19-9.96]) were independent predictors for PCF formation. PCF results in prolonged hospitalization with increased medical costs, delay of adjuvant postoperative therapy and potentially life-threatening complications such as carotid rupture. In order to reduce the risk of PCF and avoid a delayed TL, optimization of comorbidities and correction of nutritional deficiencies with enteral or parenteral nutritional supplements should be achieved as early as possible.

Long-term quality of life after total laryngectomy and postoperative radiotherapy versus concurrent chemoradiotherapy for laryngeal preservation.

OBJECTIVE: To compare the quality of life (QoL) of patients who underwent total laryngectomy with voice prosthesis insertion and postoperative radiotherapy (PORT) with those receiving concurrent chemoradiation for laryngeal preservation. STUDY DESIGN: Retrospective, cross-sectional study in a tertiary academic center. METHODS: The European Organization for Research and Treatment of Cancer Quality of Life Questionnaires were used to assess long-term QoL in 67 patients treated for laryngeal cancer. RESULTS: The scores of functional scales for physical (P < .000), social (P = .001), and role functioning (P = .043) were more favorable in the chemoradiation group. The global QoL score was higher in the nonsurgical group (P = .016). Surgical patients reported on sleep disturbance (P < .000), dyspnea (P = .001), and pain (P = .003), with a higher scores and greater difficulties with the senses (P < .000), social contact (P = .002) and speech (P = .010). The chemoradiation group reported greater problems with dry mouth (P < .000) and sticky saliva (P = .005). CONCLUSION: We found better long-term QoL scores in patients undergoing concurrent chemoradiation. This appears to be mainly because of better physical functioning, social functioning, and social contact and smaller problems with pain, respiration, speech, the senses, and sleep disturbances.

The impact of radiotherapy and GERD on in situ lifetime of indwelling voice prostheses.

The aim of this study was (1) to analyze the in situ lifetime of indwelling voice prostheses (VPs) and (2) to investigate the role of some variables on device lifetime. We conducted a retrospective clinical study of patients visiting our outpatient clinic for problems related to their VP from August 1998 to March 2006. The mean in situ VP lifetime was 180.9 days (95% CI 162.6-199.2). The mean in situ VP lifetime was 163.3 and 202.9 days in patients irradiated and not irradiated, respectively (P = 0.008). The mean in situ VP lifetime was 126.5 and 215.7 days in patients with and without endoscopic evidence of erosive-ulcerative gastroesophageal reflux disease (GERD), respectively (P < 0.001). Multivariate analysis confirmed that radiotherapy and presence of GERD significantly affected the in situ VP lifetime. This study confirmed the relationship between short VP lifetime and radiation therapy. In addition, a possible association between GERD and limited device lifetime was identified.

Conservative management of deep neck abscesses in adults: the importance of CECT findings.

OBJECTIVES: To review cases of DNAs with special emphasis on contrast-enhanced computed tomography (CECT) findings and their implications for treatment planning. STUDY DESIGN AND SETTINGS: Retrospective evaluation of adult patient records with diagnosis of DNAs on CECT at Treviso Regional Hospital. RESULTS: Eighty patients were identified. In 30.0% of cases, an immediate surgical drainage was performed. In 22.5% of cases, a surgical drainage was necessary because of the lack of clinical response to medical therapy alone. Almost half of the patients were treated with antibiotics alone with complete remission. DM was predictive for lack of response to medical therapy alone (P=0.014). Intraoperative findings confirmed the CECT diagnosis in 88.1%. CONCLUSIONS: Although the mainstay of treatment for deep neck abscesses remains surgical drainage, small abscesses can respond to antibiotics alone. CECT monitoring of DNAs was the essential steps in choosing the more appropriate treatment and, probably, the basis for the good prognosis of patients.

Cervical lymph node metastases from occult squamous cell carcinoma: analysis of 82 cases.

PURPOSE: The aim of this study was to analyze the prognostic value of some clinical factors and to compare the survival of different treatment plans in patients with cervical lymph node metastases from occult squamous cell carcinoma (SCC). METHODS: A retrospective review was conducted of patients who were diagnosed as having cervical lymph node metastases from occult SCC. Overall cumulative survival was analyzed using the standard Kaplan-Meier method. Tests of significance were based on log-rank statistics. RESULTS: The 82 patients in the study consisted of 69 males (84.2%) and 13 females (15.8%). The average age at diagnosis was 64.7 years. Fifty patients (60.9%) underwent surgical treatment of cervical metastasis. Radiotherapy was performed in 79 patients. Thirty-two patients (40.5%) received primary fractioned external beam radiotherapy; 47 patients (59.5%) received postoperative fractioned external beam radiotherapy. Ipsilateral radiotherapy was performed on 37 patients (46.8%), bilateral neck plus mucosal irradiation was performed in 42 patients (53.2%). Ten patients (12.2%) developed a primary tumor during the follow-up. The actuarial survival rates of all patients 2, 5 and 10 years after diagnosis were 50.9, 25.3 and 18.5%, respectively. Patients with nodal stage N2b, N2c and N3 had a significantly poorer prognosis than those with nodal stage N1 and N2a (p = 0.0239). The survival in patients with metastatic nodes in the supraclavicular region (level IV) was significantly poorer than that of patients with involvement of the upper-middle jugular lymph nodes (p = 0.0003). We observed a statistically significant better survival in patients receiving bilateral neck plus mucosal irradiation (p = 0.0003). CONCLUSIONS: Initial N-category and metastasis localization were the most important prognostic factors and nodal relapse the major cause of treatment failure, thus optimal management of cervical nodes appears crucial for the success of treatment. Patients receiving bilateral neck plus mucosal irradiation had a higher survival rate than those who received ipsilateral irradiation.

Transglottic acinic cell carcinoma. Case report and literature review.

Acinic cell carcinoma (ACC) is a rare tumor generally involving the parotid gland and infrequently the minor salivary glands with the potential for both local recurrence and metastatic spread when tracked for decades. The biological behavior of ACC cannot be predicted on the basis of histological features, and surgical stage is still the best predictor of clinical outcome. Only 5 cases of ACC of the larynx have been reported in the English literature. The authors present a case of a rare transglottic ACC in a 74-year-old woman. At admission, a submucosal mass involving the left arytenoid and adjacent aryepiglottic fold was noted. A CT scan of the head and neck region showed a mass of the left hemilarynx involving the paraglottic space and extending from the aryepiglottic fold to the sinus piriformis. Definitive histopathological examination showed an ACC with a large amount of clear cells. The patient was treated by radiotherapy alone (66 Gy in 7 weeks) with complete remission.

Randomized phase III trial of neoadjuvant chemotherapy in head and neck cancer: 10-year follow-up.

In 1986, we initiated a multicenter, randomized trial to compare induction chemotherapy with cisplatin and 5-fluorouracil followed by locoregional treatment (surgery and radiotherapy or radiotherapy alone) with locoregional treatment alone in patients with head and neck squamous cell carcinoma. Here we report the long-term results of the trial. A total of 237 patients with nonmetastatic stage III or IV head and neck carcinoma were randomly assigned to receive four cycles of neoadjuvant chemotherapy followed by locoregional treatment (group A) or locoregional treatment alone (group B). Among all patients, overall survival at 5 and 10 years was 23% (95% confidence interval [CI] = 15.3% to 30.9%) and 19% (95% CI = 11.6% to 26.4%), respectively, for those in group A and 16% (95% CI = 9.6% to 23.4%) and 9% (95% CI = 3.5% to 14.7%), respectively, for those in group B (P = .13). Among operable patients, we observed no difference between group A and group B in overall survival at 5 and 10 years (group A, 31% [95% CI = 14.9% to 47.3%] and 22.7% [95% CI = 7.1% to 38.3%], respectively; group B, 43.3% [95% CI = 25.6% to 61.0%] and 14.2% [95% CI = 0.1% to 28.3%], respectively; P = .73). Among inoperable patients, overall survival at 5 and 10 years was 21% (95% CI = 12.3% to 30.1%) and 16% (95% CI = 7.7% to 23.9%), respectively, for group A and 8% (95% CI = 1.5% to 12.3%) and 6% (95% CI = 0.1% to 9.1%), respectively, for group B (log-rank P = .04). Four cycles of neoadjuvant chemotherapy is a promising approach for treating patients with inoperable advanced head and neck cancer but not for treating patients with operable disease.

Laryngeal tuberculosis: an often forgotten diagnosis.

OBJECTIVE: Clinical description of laryngeal tuberculosis. METHODS: Clinical case review. RESULTS: The authors report three cases of laryngeal tuberculosis with lung involvement in HIV-negative patients; symptoms were mostly laryngeal. Diagnosis was made in all cases through laryngeal biopsy and examination of the sputum. Patients fully recovered after being given standard antituberculosis therapy. CONCLUSIONS: Laryngeal tuberculosis almost disappeared after the 1950s, but, concomitant with the increase in pulmonary forms, may still be found and, being uncommon, is often misdiagnosed.