Radiation Therapy Oncology Group 8502 "QUAD shot" regimen using volumetric modulated arc therapy for incurable head and neck cancer.

OBJECTIVES: We aimed to evaluate the outcomes of the Radiation Therapy Oncology Group 8502 "QUAD shot" regimen using volumetric modulated arc therapy (VMAT) for incurable head and neck cancer (HNC). MATERIALS AND METHODS: We included 105 patients with HNC in the study, undergoing at least one QUAD shot regimen cycle. We planned the radiotherapy using VMAT with 6 MV photons. One QUAD shot cycle included 14.8 Gy in 4 fractions with at least 6-hour intervals over 2 consecutive days, repeated every 3-6 weeks up to 3 cycles. RESULTS: We completed 1, 2, and 3 cycles in 11 (10 %), 17 (16 %), and 77 (73 %) patients, respectively. We concurrently performed systemic therapy in 13 (12 %) patients. Tumor response was observed in 92 (88 %) patients and at least one symptom relief in 51 (71 %) of 72 patients. We observed an overall response (tumor response or symptom relief) in 98 (93 %) patients with all patients who completed 3 cycles achieving it. The median overall survival (OS) was 6.8 months. Our multivariate analysis revealed that non-squamous cell carcinoma (p < 0.001), T category of 0-2 (p = 0.021), and 3 QUAD shot cycles (p < 0.001) were independent prognostic factors of better OS. We observed Grade 3 toxicity in 2 (2 %) patients while no ≥ Grade 4 acute or ≥ Grade 3 late toxicity. CONCLUSIONS: The QUAD shot regimen using VMAT exerts appropriate palliative effect in patients with incurable HNC. Treatment with higher QUAD shot cycle number would be recommended for better treatment outcomes.

Significance of Continuous Low-Dose Lenvatinib for the Treating of the Patients with Unresectable Thyroid Carcinoma.

The tyrosine kinase inhibitor lenvatinib has been confirmed as an effective treatment option for patients with unresectable thyroid carcinoma. We conducted a retrospective analysis of the significance of the effect of continued lenvatinib treatment for the longest duration possible at a reasonable daily dose and with a minimum discontinuation period in 42 patients with unresectable thyroid carcinoma treated with lenvatinib between 2015 and 2020. A Cox proportional hazard model-based analysis revealed that the overall survival of the patients treated with a <8 mg/day mean dose of lenvatinib was significantly better than that of the patients treated with 8-24 mg/day (hazard ratio [HR] 0.38 for 1.14-4.54 mg/day, and HR 0.01 for 4.56-7.97 mg/day) adjusted for various factors (e.g., sex, age, drug interruption period). The cumulative dose of lenvatinib administered tended to be higher in the patients treated with low doses (< 8 mg/day) than in the patients treated with relatively high doses (8-24 mg/day). Considering its adverse events, the continuation of lenvatinib treatment with an adequate daily dose and drug interruption may help prolong the survival of patients with unresectable thyroid carcinoma.

Prevalence and risk factors for retropharyngeal and retro-styloid lymph node metastasis in hypopharyngeal carcinoma.

BACKGROUND: We evaluated the prevalence and identified the risk factors for retropharyngeal and retro-styloid lymph node metastasis (LNM) in patients with hypopharyngeal carcinoma (HPC). This was achieved using a combination of magnetic resonance (MR) and [18 F]-fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET)/computed tomography (CT) images. METHODS: Two board-certified radiation oncologists retrospectively reviewed pretreatment FDG-PET/CT images and contrast-enhanced thin-slice CT and MR images of 155 patients with HPC who underwent radiotherapy. Fisher's exact tests and logistic regression analyses were performed to assess the risk factors for LNM. RESULTS: Retropharyngeal LNM (RPLNM) was confirmed in 20 (13%) patients. Posterior wall (PW) tumors (odds ratio [OR]: 4.128, 95% confidence interval [CI]: 1.339-12.727; p = 0.014) and bilateral or contralateral cervical LNM (OR: 11.577, 95% CI: 2.135-62.789; p = 0.005) were significantly correlated with RPLNM. The RPLNM was found in 9 (32%) of the 28 patients with PW tumors. Of these 9 patients, 2 (7%) had ipsilateral RPLNM, 3 (11%) had contralateral RPLNM, and 4 (14%) had bilateral RPLNM. The PW tumors were significantly associated with contralateral RPLNM (p < 0.001). Retro-styloid LNM (RSLNM) was confirmed in two (1%) patients, both of whom had ipsilateral RSLNM with lymph nodes (LNs) of ≥ 15 mm in the upper limit of ipsilateral level II. A significant association was found between LNs of ≥ 15 mm in the upper limit of ipsilateral level II and ipsilateral RSLNM (p = 0.001). CONCLUSIONS: The RPLNM was identified in 13% of patients with HPC. The PW tumors and bilateral or contralateral cervical LNM were risk factors for RPLNM; particularly, PW tumors were a specific risk factor for contralateral RPLNM. Although the RSLNM was rare, LNs of ≥ 15 mm in the upper limit of ipsilateral level II were a risk factor for ipsilateral RSLNM.

The timing and methods for detection of recurrence in patients with head and neck cancer.

BACKGROUND: Early detection of head and neck cancer recurrence after curative treatment is crucial for effective salvage treatment. OBJECTIVE: We aimed to examine the timing and method that allowed early detection of recurrence in each primary and recurrence site. MATERIALS AND METHODS: We enrolled 440 patients with head and neck squamous cell carcinoma (HNSCC) in the oral cavity, oropharynx, hypopharynx, or larynx who underwent curative treatment focusing on surgery at our hospital between 2009 and 2018. We examined the timing and diagnostic method (clinical examination, patient symptoms, or imaging examination) for HNSCC recurrence according to the primary and recurrence sites. RESULTS: Recurrence was observed in 133 patients. In all primary sites, regional recurrence occurred significantly earlier than local and distant recurrences. Local recurrence occurred later in the larynx than in other primary sites. Furthermore, the clinical examination had a higher ratio of detection of local recurrence in the larynx than in the other primary site. Regardless of the primary site, more than half of the regional recurrences and most of the distant recurrences were detected by imaging examination. CONCLUSIONS AND SIGNIFICANCE: Imaging examination is preferable for achieving early detection of regional and distant recurrences.

Primary tracheobronchial necrosis after esophagectomy: A nationwide multicenter retrospective study in Japan.

Background: The clinical features of postoperative primary tracheobronchial necrosis (P-TBN; the necrosis without anastomotic leakage or other cervical and mediastinal abscess) remains unclear. This nationwide multicenter retrospective study first investigated the clinical features of P-TBN after esophagectomy for upper aerodigestive tract cancer with a large cohort. Methods: As a study of the Japan Broncho-Esophagological Society, a nationwide questionnaire survey was conducted in 67 institutions. The clinical data of 6370 patients who underwent esophagectomy for laryngeal, pharyngeal, and esophageal cancer between 2010 and 2019 were collected. Grades of P-TBN were defined as follows: Grade 1, mucosal necrosis; Grade 2, transmural bronchial wall necrosis without fistula or perforation; Grade 3, transmural bronchial wall necrosis with fistula or perforation. Results: P-TBN was observed in 48 (0.75%) of 6370 patients. The incidences of P-TBN for pharyngo-laryngo-cervical esophagectomy (PLCE; n = 1650), total pharyngo-laryngo-esophagectomy (TPLE; n = 205), and subtotal esophagectomy (SE; n = 4515) were 2.0%, 5.4%, and 0.1%, respectively. The upper mediastinal LN dissection (P = 0.016) and the higher level of the tracheal resection (P = 0.039) were significantly associated with a higher grade of necrosis in PLCE and TPLE. Overall survival rates were significantly lower in patients with Grade 2 (P = 0.009) and Grade 3 (P = 0.004) than in those with Grade 1. Conclusion: The incidence of TBN restricted to P-TBN was lower than previously reported. Maintaining the tracheal blood flow is essential to prevent worsening P-TBN, especially in PLCE and TPLE. Our new P-TBN severity grade may predict the outcome of patients with P-TBN.

Efficacy of a new traction method using ring-shaped thread for endoscopic submucosal dissection in the pharynx.

BACKGROUND: Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for pharyngeal cancers. However, pharyngeal ESD is sometimes technically challenging because of the narrow and complex space in which to work. Traction is important to complete the procedure efficiently. Here, we report the technical details and efficacy of a new traction method for pharyngeal ESD using ring-shaped thread and grasping forceps. METHODS: We analyzed pharyngeal ESD performed between January 2016 and March 2021 at our Institute. We designated cases resected using ring-shaped threads "Group R" and those resected without ring-shaped threads as conventional "Group C", and compared the technical outcomes between them. Multivariate analysis and the inverse probability treatment weighting (IPTW) method using propensity scores were adjusted by confounding variables. RESULTS: We analyzed 89 lesions from 68 patients, of which 46 were in Group R and 43 in Group C. Median procedure time and median dissection speed were significantly shorter in Group R than C (37 min vs. 55 min, and 16.0 mm2/min vs. 7.0 mm2/min, respectively, both P < 0.05). These results were confirmed by both multivariate analysis and after IPTW adjustment. All lesions were resected en bloc, and the complete resection rate was not significantly different between Group R and C (91.3% vs. 79.1%, P = 0.14). There were no treatment-related adverse events in either group. CONCLUSIONS: The traction method using ring-shaped thread increases the efficiency of pharyngeal ESD. This simple new traction method should be a useful option for pharyngeal ESD.

Therapeutic outcomes of laryngeal closure and laryngostomy in children with recurrent pneumonia.

PURPOSE: Children with medical complexity frequently experience difficulty breathing and swallowing and occasionally develop aspiration pneumonia. Long-term intubation may cause fatal trachea-innominate artery fistula (TIF). In the present study, we retrospectively evaluated the efficacy of laryngeal closure and laryngostomy in children with medical complexity. MATERIALS AND METHODS: Laryngeal closure and laryngostomy were performed in eight children with severe neuromuscular disorders who were incapable of oral ingestion and verbal communication. The laryngostoma was placed at a higher position compared to that in conventional tracheostomies for easier management of the airway and to prevent TIF. RESULTS: Aspiration was successfully prevented postoperatively in all cases. Laryngocutaneous fistula formation was not observed. Two patients successfully achieved oral ingestion capability and tracheal cannulas were removed in two patients. Among the six patients who needed a mechanical ventilator before surgery, two patients were weaned from mechanical ventilation. Five patients were successfully discharged from the hospital. Although two patients died because of their primary condition, pneumonia exacerbation was not observed in any of the patients. CONCLUSION: Compared to the conventional tracheostomy, our procedure improved airway management and function in children with medical complexity and reduced the risk of TIF.

Prevalence and risk factors of retro-styloid lymph node metastasis in oropharyngeal carcinoma.

BACKGROUND: Supporting data defining the selection criteria of level VIIb for inclusion in the target volume in radiotherapy (RT) planning are insufficient. We evaluated the prevalence of level VIIb retro-styloid lymph node metastasis (RSLNM) and associated risk factors in patients with oropharyngeal carcinoma (OPC). MATERIALS AND METHODS: We retrospectively reviewed pre-treatment [18F]-fluoro-2-deoxy-d-glucose-positron emission tomography/computed tomography (CT) along with contrast-enhanced thin slice CT and magnetic resonance (MR) images of 137 patients pathologically confirmed as having OPC who underwent RT. The location of lymph nodes (LNs) was confirmed on the planning CT images. Fisher's exact test and logistic regression analyses were made to determine the risk factors of RSLNM. RESULTS: RSLNM was confirmed in 18 (13%) patients. All RSLNMs were located within level VIIb on the planning CT images. No patients exhibited LNM in contralateral level VIIb. Furthermore, no patients with negative or single ipsilateral cervical LNM had RSLNM. Fisher's exact test revealed that smoking status (p=.027), multiple ipsilateral cervical LNM (p=.045) and LN ≥15 mm in the upper limit of ipsilateral level II (p<.001) were significantly associated with RSLNM. Logistic regression analyses revealed that the presence of LNs ≥15 mm in upper limit of ipsilateral level II was significantly associated with RSLNM (odds ratio: 977.297; 95% confidence interval: 57.629-16573.308; p<.001). CONCLUSIONS: RSLNM is relatively common in patients with OPC with a prevalence rate of approximately 10%. The prevalence of RSLNM in patients with negative or single ipsilateral cervical LNM and contralateral RSLNM is extremely low; therefore, level VIIb can be excluded from the target volume in such patients. LN ≥15 mm in the upper limit of ipsilateral level II is a risk factor for RSLNM. Ipsilateral level VIIb should be included in the target volume for patients with this risk factor.KEY MESSAGERetro-styloid lymph node metastasis (RSLNM) prevalence is ∼10% in oropharyngeal carcinoma.Lymph node ≥15 mm in ipsilateral level II upper limit is a risk factor for RSLNM.

Concurrent Chemoradiotherapy With Docetaxel, Cisplatin, and 5-Fluorouracil for T3 N0 Glottic Carcinoma Without Vocal Cord Fixation.

BACKGROUND/AIM: We retrospectively evaluated the efficacy and toxicity of concurrent chemoradiotherapy (CCRT) with docetaxel, cisplatin, and 5-fluorouracil (TPF) for T3 N0 glottic carcinoma without vocal cord fixation. PATIENTS AND METHODS: Twenty-five patients underwent TPF-CCRT without elective nodal irradiaion (ENI). After the RT of 40 Gy, five patients (20%) without tumor regression underwent surgery. Others underwent RT with a median total dose of 66 Gy. RESULTS: Of the five patients who underwent surgery after the RT of 40 Gy, two showed residual carcinoma pathologically and the other three were confirmed to have complete pathological response to the treatment. The 5-year local control rate was 87%. No patients exhibited regional failure. No acute toxicities of grade 5 or late toxicities ≥grade 3 were observed. CONCLUSION: TPF-CCRT provides excellent tumor control with acceptable toxicities. CCRT while omitting ENI is a reasonable approach for T3 N0 glottic carcinoma without vocal cord fixation.

Clinical impact of gastrointestinal endoscopy on the early detection of pharyngeal squamous cell carcinoma: A retrospective cohort study.

BACKGROUND: In recent years, with the growing availability of image-enhanced gastrointestinal endoscopy, gastroenterologists have contributed to the early detection of pharyngeal squamous cell carcinomas (SCC). AIM: To clarify the clinical characteristics of pharyngeal SCCs detected by gastrointestinal endoscopy. METHODS: This is a retrospective cohort study conducted in a single-center, a university hospital in Japan. We retrospectively assessed the clinical records of 522 consecutive patients with oropharyngeal or hypopharyngeal SCC who were examined in our hospital between 2011 and 2018. The lesions were classified into two groups: Group GE (detected by gastrointestinal endoscopy) and Group non-GE (detected by means other than gastrointestinal endoscopy). The clinical characteristics were compared between the two groups. Continuous data were compared using the Mann-Whitney U test. Pearson's χ 2 test or Fisher's exact test was used to analyze the categorical data and compare proportions. The Kaplan-Meier method was used to estimate the cumulative patient survival rates. RESULTS: In our study group, the median age was 65 years and 474 patients (90.8%) were male. One hundred and ninety-six cases (37.5%) involved the oropharynx and 326 cases (62.5%) involved the hypopharynx. Three hundred and ninety-five cases (75.7%) had some symptoms at the time of diagnosis. One hundred and forty-five (27.8%) cases had concurrent ESCC or a history of ESCC. One hundred and sixty-four (31.4%) cases were detected by gastrointestinal endoscopy and classified as Group GE. The proportions of asymptomatic cases, cTis-1 cases and cases with no lymph node metastasis were significantly higher in Group GE than Group non-GE (61.6% vs 7.3%, P < 0.001, 32.9% vs 12.0%, P < 0.001 and 69.5% vs 19.0%, P < 0.001). Endoscopic laryngo-pharyngeal surgery or endoscopic submucosal dissection were performed in only 0.6% of the lesions in Group non-GE but in 21.3% of the lesions in Group GE (P < 0.001). Overall survival was significantly longer in Group GE than in Group non-GE (P = 0.018). The 2-year and 4-year survival rates were 82.5% and 70.7% in Group GE, and 71.5% and 59.0% in Group non-GE, respectively. CONCLUSION: Gastrointestinal endoscopy plays an important role in the early detection and improving the prognosis of pharyngeal SCCs.

Optimal Management of the Unilateral Recurrent Laryngeal Nerve Involvement in Patients with Thyroid Cancer.

We aimed to determine the optimal management of recurrent laryngeal nerve (RLN) involvement in thyroid cancer. We enrolled 80 patients with unilateral RLN involvement in thyroid cancer between 2000 and 2016. Eleven patients with preoperatively functional vocal folds (VFs) underwent sharp tumor resection to preserve the RLN (shaving group). Thirty-three patients underwent RLN reconstruction with RLN resection (reconstruction group). We divided the reconstruction group into two subgroups based on preoperative VF mobility (normal-reconstruction and paralyzed-reconstruction subgroups). In the cases where RLN reconstruction was difficult, phonosurgeries including arytenoid adduction (AA), with or without thyroplasty type I, or nerve muscle pedicle implantation with AA were performed later (phonosurgery group). We evaluated and compared vocal function among the evaluated periods and different groups. Postoperative vocal function in the shaving and normal-reconstruction subgroups was favorable. There were no significant differences between the two groups. In the paralyzed-reconstruction and phonosurgery groups, postoperative vocal function was significantly improved, and vocal function in the paralyzed-reconstruction subgroup was significantly better than that in the phonosurgery group. For optimal management of unilateral RLN involvement in thyroid cancer, first, sharp dissection should be performed, and if this is impossible, a simultaneous RLN reconstruction procedure should be adopted whenever possible.

Treatment Outcomes of Pulmonary Metastases from Head and Neck Squamous Cell Carcinoma.

Although the lung is the most common site of distant metastases from head and neck squamous cell carcinoma (HNSCC), the number of reports about the effects of pulmonary metastasectomy for the treatment of lung metastasis from HNSCC is limited. Metachronous pulmonary metastases were detected in 45 HNSCC patients at Kumamoto University Hospital from 1998 to 2018. Twenty-two patients underwent an operative resection (Ope group) and 23 underwent chemotherapy (Chemo group). The 3-year overall survival (OS) rate and median OS were evaluated. The effects of adjuvant chemotherapy after pulmonary metastasectomy and of new drugs (cetuximab and nivolumab), in the chemo group were also assessed. The 3-year OS rates and median OS were: Ope, 66.1% and 31.5 months; Chemo, 39.7% and 18 months, respectively. In the Ope group, addi-tional recurrences were significantly fewer in the patients who underwent adjuvant chemotherapy post-surgery versus the patients who underwent surgery alone (p = 0.013). In the Chemo group, the 3-year OS rate of the patients who received new drugs was significantly better than that of the patients who did not (p = 0.021). Adjuvant chemotherapy after pulmonary metastasectomy may be a preferable treatment option for preventing recurrences. Cetuximab and nivolumab have a potential to improve OS.

QUAD shot: an effective cyclical hypofractionated palliative radiotherapy for salivary gland carcinoma.

Surgery with or without post-operative radiotherapy is the mainstay treatment for salivary gland carcinoma (SGC); however, palliative radiotherapy or supportive observation is considered for elderly patients. An 87-year-old female who was diagnosed with SGC in the left parotid gland, with a clinical stage T4aN2bM0 Stage IVA, underwent the Radiation Therapy Oncology Group 8502 "QUAD shot" regimen (14.8 Gy/4 fractions, twice-daily treatment with a 6 h interval, on 2 consecutive days), which were repeated every 4 weeks 3 times using volumetric modulated arc therapy. During and after the treatment, she experienced no acute toxicity but had Grade 1 xerostomia. At 4 months after completion of the treatment, [18F]-fluoro-2-deoxy-D-glucose positron emission tomography/CT revealed a complete metabolic response to the treatment. She is still alive without any evidence of recurrence 9 months after completion of the treatment. The Radiation Therapy Oncology Group 8502 "QUAD shot" regimen using VMAT may be an effective palliative treatment for SGC with minimal toxicity.

Swallowing dysfunction following surgery for well-differentiated thyroid cancer with extrathyroid invasion.

BACKGROUND: Differentiated thyroid carcinoma (DTC) can invade the surrounding aerodigestive tract. Radical surgery for locally advanced DTC will require resection of the trachea, recurrent laryngeal nerve (RLN), inferior pharyngeal constrictor muscles (IPCMs), or a part of the esophagus. The purpose of this study was to demonstrate the effect of resection of these surrounding tissues combined with total thyroidectomy and neck dissection on swallowing function following surgery. METHODS: We performed total thyroidectomy combined with neck dissection and resection of the RLN in 24 patients with DTC with extrathyroidal invasion (19 unilateral, 1 bilateral), IPCMs (n = 5), or muscle layers of esophagus (n = 9). Nine patients received a tracheostomy placement due to a window resection of the trachea for tumor invasion (n = 6) and necessary upper airway management (n = 3). We used the duration of nasogastric tube feeding to evaluate swallowing function following surgery. RESULTS: Patients who underwent tracheostomy or IPCM resection showed significantly longer periods of tube feeding (p = 0.0057 and 0.0017, respectively). In contrast, resection of the unilateral RLN or esophageal muscle layer showed no difference in tube feeding duration. Multiple regression analysis indicated that tracheostomy and IPCM resection were significant independent predictors of longer periods of tube feeding (p = 0.04583 and 0.00087, respectively). CONCLUSION: These results indicate that tracheostomy placement and resection of the IPCMs, together with total thyroidectomy, extends the tube feeding duration in the postoperative period.

Hypofractionated palliative volumetric modulated arc radiotherapy with the Radiation Oncology Study Group 8502 "QUAD shot" regimen for incurable head and neck cancer.

BACKGROUND: To review a single institutional experience of the Radiation Therapy Oncology Group (RTOG) 8502 "QUAD shot" regimen using volumetric modulated arc radiotherapy (VMAT) for incurable head and neck cancer (HNC). METHODS: Thirty-four consecutive patients with HNC were treated with at least one cycle of the RTOG 8502 regimen. Treatment plans included the use of VMAT with 6 MV photons generated by a linear accelerator. Two daily fractions of 3.7 Gy were delivered with an interval of at least 6 h for 2 consecutive days, totaling 14.8 Gy over 4 fractions. This was repeated every 3-4 weeks for a total of three cycles. No concurrent systemic therapy was performed. RESULTS: The number of completed cycles was 1 in 6 (18%) patients, 2 in 5 (15%), and 3 in 23 (68%). Tumor response was achieved in 29 (85%) patients and symptom relief in 20 (77%) of 26 patients. Overall response (tumor response or symptom relief) was achieved in 32 (94%) patients. All patients who received 2 or more treatment cycles achieved overall response. Median overall survival (OS) was 5.7 months. Multivariate analysis revealed that completion of all three treatment cycles was significantly associated with better OS (P = 0.002). Grade 2 toxicity was observed in four (12%) patients, but no acute Grade ≥ 3 or late toxicity was observed. CONCLUSIONS: The RTOG 8502 "QUAD shot" regimen using VMAT is effective for incurable HNC with highly reduced toxicity. Treatment with multiple cycles is recommended for better treatment response and/or survival.

Diagnostic Value of FDG-PET/CT for the Identification of Extranodal Extension in Patients With Head and Neck Squamous Cell Carcinoma.

BACKGROUND/AIM: We evaluated the diagnostic value of functional imaging with [18F]-fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography/computed tomography (PET/CT) for the identification of extranodal extension (ENE) in patients with head and neck squamous cell carcinoma (HNSCC). PATIENTS AND METHODS: In this study, 94 patients with HNSCC who underwent FDG-PET/CT were enrolled. We recorded the maximum standardized uptake value (SUVmax), compared the results with pathologic findings, and evaluated the diagnostic performance of using a SUVmax cut-off value for ENE. RESULTS: Of the 566 dissected levels examined, 53 (9.4%) exhibited ENE. The mean SUVmax of LN with and without ENE were 6.67 and 1.64, respectively (p<0.001). A receiver operating characteristics (ROC) curve analysis for SUVmax showed an area under the ROC curve of 0.913. A SUVmax cut-off of 3.0 achieved diagnostic performance for identifying ENE with sensitivity, specificity, and accuracy of 81.1%, 94.3% and 93.1%, respectively. CONCLUSION: FDG-PET/CT findings using a SUVmax cut-off of 3.0 provides appropriate diagnostic value in identifying ENE.

Detection of hypopharyngeal cancer (Tis, T1 and T2) by ENT physicians vs gastrointestinal endoscopists.

OBJECTIVES: Hypopharyngeal cancer is typically detected at a late stage by ear, nose, and throat (ENT) physicians, when the prognosis is poor. We evaluated how hypopharyngeal cancer (Tis, T1 and T2) were detected by ENT physicians and gastrointestinal endoscopists (GEs) according to the detection reasons. MATERIALS AND METHODS: A total of 109 consecutive patients with hypopharyngeal cancer (Tis, T1 and T2) who received treatment in our institution from January 2014 to February 2018 was enrolled. The detection detail of hypopharyngeal cancer lesions by ENT physicians and GEs, tumor size and location, and the characteristics of the lesions missed by ENT physicians and GEs were reviewed retrospectively. RESULTS: Twenty seven and 82 of 109 (24.8% and 75.2%) patients were detected by ENT physicians and GEs, respectively. The most frequent original reasons for ENT physicians and GEs were both pharyngeal discomfort screening and examination of swollen neck lymph nodes (12 of 27, 44.4% for each) and pre-treatment or follow-up screening for esophageal cancer (25 of 82, 30.5%), respectively. Among the 13 cases of upper gastrointestinal tract screening of the head-and-neck cancer other than pharyngeal cancer detected by GEs, 11 (84.6%) were missed by ENT physicians. In contrast, among the 25 cases of pre-treatment screening of the esophageal cancer detected by GEs, 12 (48%) were missed by other GEs just before the consultation from other institutions. CONCLUSIONS: The percentage of detection of hypopharyngeal cancer (especially, Tis and T1) by ENT physicians is low. A careful examination of the pharynx should be conducted by GEs.

Phonatory function in patients with well-differentiated thyroid carcinoma following meticulous resection of tumors adhering to the recurrent laryngeal nerve.

BACKGROUND: Well-differentiated thyroid carcinomas (WDTCs) sometimes adhere firmly to the recurrent laryngeal nerve (RLN), while allowing normal mobility of the vocal fold (VF). Meticulous dissection of the adhered tumor from the RLN is known to be effective, preserving VF mobility and oncological safety. However, phonatory function following this preservation procedure has yet to be evaluated sufficiently. The objective of this study was to examine phonatory function following the preservation procedure. METHODS: Ten patients with WDTCs, demonstrating normal preoperative VF mobility with tumors adhering to the RLN, underwent the preservation procedure between 2000 and 2013 (preservation group). During the same period, nine patients with WDTCs demonstrating normal VF mobility underwent resection and reconstruction of the tumor-invaded RLNs (reconstruction group). Phonatory function, including maximum phonation time (MPT), mean flow rate (MFR), jitter, shimmer, harmonics-to-noise ratio, and GRBAS scale score, was evaluated and compared statistically between the two groups. RESULTS: The mean values of MPT and MFR in the preservation group were at normal levels. Both G and B scores of GRBAS scale were at near-normal levels. Additionally, the mean B score of the GRBAS scale was significantly better in the preservation group than in the reconstruction group. CONCLUSIONS: When normal VF mobility is observed preoperatively, meticulous resection for preserving RLN would contribute to maintain not only normal level of MPT and MFR, but also to provide better B score of GRBAS scale than RLN resection followed by immediate reconstruction.

Radiotherapy for T3N0 glottic carcinoma without cord fixation: elective nodal irradiation or not?

BACKGROUND: Although the T3 category has been changed in the sixth edition of the TNM staging system proposed by the Union for International Cancer Control (UICC), the appropriate clinical target volume (CTV) of elective nodal irradiation (ENI) for T3N0 glottic carcinoma without cord fixation, which was formerly treated as a T1-2N0 disease, is not fully discussed. MATERIALS AND METHODS: We retrospectively analyzed 64 patients staged or restaged as T3N0 disease without cord fixation. All patients received irradiation to the primary lesion alone using opposed lateral fields. Surgery was performed in 10 patients without tumor regression after the delivery of 40 Gy. The other 54 patients received a median total dose of 66 Gy. Concurrent chemoradiotherapy (CRT) with low-dose cisplatin and UFT (low-dose CRT) and docetaxel, cisplatin, and 5-fluorouracil (TPF-CRT) were performed in 23 and 19 patients, respectively. RESULTS: Eighteen (28.1%) patients suffered treatment failure; all were recorded as local failure alone. The 5-year local control rates for RT alone, low-dose CRT, and TPF-CRT groups were 51.7%, 61.6%, and 93.8%, respectively (p = 0.027). The 5-year laryngeal preservation rates for RT alone, low-dose CRT, and TPF-CRT groups were 57.4%, 81.6%, and 89.5%, respectively (p = 0.048). CONCLUSIONS: The rate of regional failure was zero when irradiating the primary lesion alone using opposed lateral fields. This treatment technique covers the most level III regions; hence, CTV for ENI should include level III alone.

Radiation therapy for nasopharyngeal carcinoma: the predictive value of interim survival assessment.

Pretreatment characteristics are suggested as predictive and/or prognostic factors for nasopharyngeal carcinoma (NPC); however, individual tumor radiosensitivities have previously not been considered. As boost planning is recommended for NPC, we performed interim assessments of magnetic resonance (MR) images for boost planning and retrospectively evaluated their predictive value for the survival of NPC patients. Radiation therapy via elective nodal irradiation (median dose: 39.6 Gy) with/without chemotherapy was used to treat 63 NPC patients. Boost irradiation (median total dose: 70 Gy) was performed based on the interim assessment. The largest lymph node (LN) was measured on MR images acquired at the time of interim assessment. The site of first failure was local in 8 (12.7%), regional in 7 (11.1%), and distant in 12 patients (19.0%). All 7 patients with regional failure harbored LNs ≥15 mm at interim assessment. We divided the 63 patients into two groups based on LN size [large (≥15 mm), n = 10 and small (<15 mm), n = 53]. Univariate analysis showed that 5-year overall survival (OS) and cause-specific survival (CSS) rates for large LNs were significantly lower than for small LNs (OS: 12.5% vs 70.5%, P < 0.001 and CSS: 25.0% vs 80.0%, P < 0.001). Multivariate analysis showed that large LNs were a significantly unfavorable factor for both OS (hazard ratio = 4.543, P = 0.002) and CSS (hazard ratio = 6.020, P = 0.001). The results suggest that LN size at interim assessment could predict survival in NPC patients.