RESUMEN
BACKGROUND: Concurrent chemoradiation (CCRT) and upfront surgery followed by adjuvant therapy both are recommended treatment options for patients with advanced stage squamous cell carcinoma (SCC) of the tonsil. To the authors' knowledge, the question of whether surgical-based treatments can achieve better survival compared with CCRT has never been compared in a clinical trial. The authors analyzed the National Cancer Data Base to measure the impact of different treatment modalities on overall survival (OS). METHODS: All patients aged ≤70 years diagnosed with clinical stage III to IVB (excluding T4B) SCC of the tonsil from 1998 through 2011 were selected. Analysis was limited to patients receiving CCRT, surgery plus CCRT, or surgery followed by adjuvant radiotherapy (RT). OS was compared using the Kaplan-Meier method and log-rank test. Univariable and multivariable hazards analyses were performed to identify factors significant for survival. Propensity score matching was performed. RESULTS: There were 16,891 patients who met the inclusion criteria. The most common treatment was CCRT (8123 patients; 48.1%), followed by surgery plus CCRT (5249; 31.1%) and surgery plus RT (3519 patients; 20.8%). Patients treated with surgery plus CCRT were found to have the highest 3-year OS rate (88.5%) followed by those treated with surgery plus RT (84%) and CCRT (74.2%) (P<.0001). In a propensity score-matched subpopulation of 4962 patients, the 3-year OS rate was 90.2% for those treated with surgery plus CCRT, 84.9% for those treated with surgery plus RT, and 82.1% for those treated with definitive CCRT (P<.0001). CONCLUSIONS: Patients with advanced stage SCC of the tonsil who underwent surgery followed by CCRT had the greatest OS. Patients undergoing upfront surgery may avoid chemotherapy without jeopardizing survival. Triple-modality therapy may provide a survival benefit for a subset of patients with advanced stage tonsil cancer. Cancer 2017;123:3269-76. © 2017 American Cancer Society.
Asunto(s)
Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/terapia , Quimioradioterapia/métodos , Glosectomía/métodos , Neoplasias de la Lengua/patología , Neoplasias de la Lengua/terapia , Anciano , Carcinoma de Células Escamosas/mortalidad , Distribución de Chi-Cuadrado , Estudios de Cohortes , Terapia Combinada , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Ganglios Linfáticos/patología , Ganglios Linfáticos/cirugía , Masculino , Análisis Multivariante , Invasividad Neoplásica/patología , Estadificación de Neoplasias , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Análisis de Supervivencia , Neoplasias de la Lengua/mortalidad , Resultado del Tratamiento , Estados UnidosRESUMEN
PURPOSE: Assessment of donor site morbidity and recipient site complications following free radial forearm osteocutaneous flap (FRFOCF) harvest and evaluation of patient perceived upper limb disability for free radial forearm osteocutaneous versus fasciocutaneous flaps (FRFF). METHODS: First a case series was undertaken of 218 patients who underwent an FRFOCF at two tertiary referral centers between February 1998 and November 2010. Outcomes included forearm donor site morbidity and recipient site complications. Second, the disability of the arm, shoulder, and hand (DASH) questionnaire assessing patient perceived arm disability was administered by phone to 60 consecutive patients who underwent an FRFOCF or FRFF. RESULTS: Mean patient age was 63 years with male predominance (62.8%). Median bone length harvested was 8 cm (range, 3-12 cm) with prophylactic plating of the radius following harvest. Donor site morbidity included fracture (1 patient, 0.5%) and sensory neuropathy (5 patients, 2.3%). Mean DASH scores were comparative between groups and to established normative values. Mandibular malunion rate was 3.2% and hardware extrusion at the recipient site occurred in 15.6%. CONCLUSION: Reluctance to perform FRFOCF by surgeons usually centers on concerns regarding potential donor site morbidity and adequacy of available bone stock; however, we identified minimal objective or patient perceived donor site morbidity or recipient site complications following harvest of FRFOCFs. Mild wrist weakness and stiffness are common but do not impede ability to perform activities of daily living. Data from this and other reports suggest this flap is particularly useful for midfacial and short segment mandibular reconstruction.
Asunto(s)
Antebrazo/cirugía , Colgajos Tisulares Libres , Complicaciones Posoperatorias/etiología , Sitio Donante de Trasplante , Trasplante Óseo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Trasplante de Piel , Encuestas y CuestionariosRESUMEN
Oral cavity squamous cell carcinoma (OCSCC) is the most common nonmelanoma head and neck cancer in the world, with an estimated 405 000 new cases expected each year. Subsites of the oral cavity include the alveolar ridge, buccal mucosa, anterior tongue, tonsillar pillar, retromolar trigone, hard palate, gingiva, and floor of the mouth. In this issue of the AHNS "Do you know your guidelines?" series, we review the evidence-based approach to the management of oral cavity carcinomas based on the framework provided by the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology.
Asunto(s)
Carcinoma de Células Escamosas/terapia , Medicina Basada en la Evidencia , Neoplasias de la Boca/terapia , Guías de Práctica Clínica como Asunto , Carcinoma de Células Escamosas/diagnóstico por imagen , Procedimientos Quirúrgicos Electivos , Humanos , Metástasis Linfática , Neoplasias de la Boca/diagnóstico por imagen , Disección del Cuello , Invasividad Neoplásica , Biopsia del Ganglio Linfático CentinelaRESUMEN
In this first article of the "Do You Know Your Guidelines" series, we review National Comprehensive Cancer Network (NCCN) recommendations and underlying evidence for the follow-up and surveillance of head and neck cancer survivors. The goals of follow-up and surveillance care are (1) to maximize long-term oncologic outcomes of therapy with appropriate evaluation for recurrence, (2) to maximize functional and quality of life outcomes, and (3) minimizing unnecessary and harmful low-value care. Finding the right balance of testing and surveillance is a challenge for providers and patients. Herein, we review all NCCN recommendations for head and neck cancer survivors. We pay particular attention to an area of controversy: the use of ongoing surveillance imaging, in particular, PET/CT scans.
Asunto(s)
Neoplasias de Cabeza y Cuello , Vigilancia de la Población/métodos , Sobrevivientes , ADN Viral/aislamiento & purificación , Atención Odontológica , Depresión/diagnóstico , Diagnóstico por Imagen , Práctica Clínica Basada en la Evidencia , Pruebas Auditivas , Herpesvirus Humano 4 , Humanos , Evaluación Nutricional , Examen Físico , Cese del Hábito de Fumar , Sociedades Médicas , Medición de la Producción del Habla , Tirotropina/sangreRESUMEN
IMPORTANCE: Limited data exist on performing major oral cavity resections and reconstructions without elective tracheotomy. OBJECTIVES: To describe a group of patients who successfully underwent major microvascular mandibular reconstruction without an elective tracheotomy and to perform a literature review to identify commonalities between our group and the available literature to identify potential common factors that might contribute to the success of this approach. DESIGN, SETTING, AND PARTICIPANTS: Case series with retrospective medical chart review of 15 patients who underwent fibula microvascular free flap reconstruction of mandibular defects without tracheotomy between 2000 and 2014 (the most common indication was osteoradionecrosis) conducted at a tertiary referral hospital center. EXPOSURES: Mandibular reconstruction with fibula free flap without elective tracheotomy. MAIN OUTCOMES AND MEASURES: Perioperative morbidity and mortality with a focus on airway management and perioperative complications. RESULTS: The median age of 15 patients (11 males and 4 females) at the time of reconstruction was 42 years (range, 10-64 years). The indication for surgery was nonmalignant pathologic abnormalities in 8 patients (53%), osteosarcoma in 4 patients (27%), and oral cavity squamous cell carcinoma in 3 patients (20%). All patients were intubated endonasally and, excepting 1 pediatric case, were extubated the day following surgery. The fibula spanned the parasymphysis and/or symphysis in 2 patients, and was limited to the mandibular body in others (mean length, 7.6 cm [range, 4.0-15.0 cm]). The flap design was osteocutaneous in 3 patients and osseous in the rest. No patient required reintubation or tracheotomy. No complications due to endonasal intubation occurred. The average hospital length of stay was 11 days. CONCLUSIONS AND RELEVANCE: Major oral cavity resection and reconstruction with microvascular free flaps can be performed safely without elective tracheotomy in a select group of patients. Limited data exist on patient selection criteria. Further studies are needed to identify favorable factors and develop protocols for safe patient selection.
Asunto(s)
Colgajos Tisulares Libres/irrigación sanguínea , Enfermedades Mandibulares/cirugía , Reconstrucción Mandibular , Procedimientos de Cirugía Plástica , Traqueotomía , Adolescente , Adulto , Niño , Femenino , Peroné , Humanos , Masculino , Enfermedades Mandibulares/patología , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Whether elective lymph neck dissection (ELND) is associated with improved survival in oral squamous cell carcinomas (SCC) of the maxillary alveolus/hard palate is not known. METHODS: One hundred ninety-nine patients presenting de novo and receiving treatment for clinically node negative SCC of the maxillary alveolus/hard palate at 2 cancer centers between 1985 and 2011 were analyzed. RESULTS: Forty-two patients (21%) received ELND. Occult nodal metastases were present in 29% of the dissected necks. The ELND group had more T3 to T4 status tumors (62% vs 34%; p < .001) and positive-margin resections (59% vs 38%; p = .019). Patients undergoing ELND experienced lower rates of neck recurrence (6% vs 21%; p = .031), superior 5-year recurrence-free survival (68% vs 45%; p = .026), and overall survival (86% vs 62%; p = .043). ELND was associated with a 2-fold decrease in risk of recurrence in multivariable analysis. CONCLUSION: ELND was associated with lower rates of recurrence and improved survival in SCC of the maxillary alveolus/hard palate. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1688-E1694, 2016.
Asunto(s)
Carcinoma de Células Escamosas/cirugía , Neoplasias Maxilares/cirugía , Disección del Cuello , Neoplasias Palatinas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/patología , Femenino , Humanos , Metástasis Linfática , Masculino , Neoplasias Maxilares/patología , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Estadificación de Neoplasias , Neoplasias Palatinas/patología , Paladar Duro/patología , Estudios RetrospectivosRESUMEN
OBJECTIVES/HYPOTHESIS: Hard palate and maxillary alveolus are two commonly grouped oral cavity subsites due to their anatomic contiguity and oncologic disease behavior. Few studies have been conducted investigating clinical presentation, staging, prevalence of cervical metastases, and outcomes in this population. The primary objective of this study was to analyze predictors of disease-free survival (DFS) in surgically treated patients, particularly as it relates to the role of neck dissection. STUDY DESIGN: Cohort study with planned data collection. METHODS: This cohort study used planned data collection over 15 years (1994-2008) at a large tertiary care cancer center to study all patients presenting with squamous cell carcinoma of the maxillary alveolus and hard palate treated surgically. Univariate and multivariate Cox regression analyses were used to identify predictors of DFS. RESULTS: Ninety-seven patients met the inclusion criteria (54 male, 56%). The majority of patients (54, 56%) presented with locally advanced disease (cT3, cT4). Occult nodal metastases were noted in 26% (17 of 65) of patients clinically staged as N0. The 3-year DFS was 70% (95% confidence interval = 59%-78%) with a median time to failure of 1.1 years (range = 0.3-9.7 years). Cox regression multivariate model demonstrated that advanced pathologic T stage, hard palate tumor site, and poorly differentiated tumor grade were each independent predictors of DFS. CONCLUSIONS: A significant portion of the patients with hard palate and maxillary alveolus tumors harbor occult cervical metastases. Elective neck dissection in the high-risk patients may potentially be beneficial in providing more accurate staging and improving DFS. LEVEL OF EVIDENCE: 2b.