Management of cervical lymph node metastases in squamous cell carcinoma of the tonsillar fossa, base of tongue, supraglottic larynx, and hypopharynx

doi:10.1016/0002-9610(72)90067-0

The American Journal of Surgery

Volume 124, Issue 4, October 1972, Pages 462-467

https://doi.org/10.1016/0002-9610(72)90067-0 Get rights and content

Abstract

1.
1. The records of 596 patients with previously untreated squamous cell carcinoma of the tonsillar fossa, base of the tongue, supraglottic larynx, and hypopharynx were reviewed to evaluate the efficacy of three modalities of initial treatment of cervical lymph nodes.
2.
2. Elective irradiation of the neck is indicated in patients with tumors of the tonsillar fossa and base of the tongue. For patients with lesions of the supraglottic larynx and hypopharynx and a clinically negative neck, elective irradiation of only the subdigastric and midjugular node areas is adequate if the primary lesion is treated with irradiation.
3.
3. In patients with clinically positive nodes, combined treatment is clearly superior to either radiation or surgery alone in preventing cervical recurrence in the initially involved side of the neck. Pre- and postoperative irradiation is equally effective.
4.
4. As the treatment policies have evolved, combined therapy has been used with increasing frequency, the order dictated by the treatment of the primary lesion.

References (2)

DS Berger et al.
Elective irradiation of the neck lymphatics for squamous cell carcinomas of the nasopharynx and oropharynx
Amer J Roentgen
(1971)
GH Fletcher
Elective irradiation of subclinical disease in cancers of the head and neck
Cancer
(1972)

Cited by (179)

Positron Emission Tomography-Computed Tomography Surveillance after (Chemo)Radiotherapy in Advanced Head and Neck Squamous Cell Cancer: Beyond the PET-NECK Protocol
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To evaluate the implementation of 18-fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) surveillance after (chemo)radiotherapy, to compare outcomes for those who achieved a complete (CR), equivocal (EQR) and incomplete (ICR) nodal response on 12-week PET-CT according to their human papillomavirus (HPV) status, and to assess the safety of ongoing surveillance beyond 12 weeks in the HPV-positive EQR group.
All patients with node-positive head and neck squamous cell carcinoma (HNSCC) treated with (chemo)radiotherapy between January 2013 and September 2017 were identified. PET-CT responses were classified as CR, ICR or EQR. Patient outcomes were obtained from electronic records.
In total, 236 patients with a minimum of 2 years of follow-up were identified. The mean age was 59 years; 79.3% had N2 disease; 77.1% of patients had oropharyngeal cancer and 10.1% had squamous cell carcinoma of unknown primary, of whom 82.0% (169) were HPV positive; 78.0% received chemoradiotherapy. The median time from the end of radiotherapy to PET-CT was 91 days. Of the HPV-related HNSCC, 60.4% achieved CR, 29.0% EQR and 10.6% ICR. With a median follow-up of 41.7 months, there was no difference in survival between patients with HPV-related HNSCC achieving CR and EQR (median overall survival not reached for both, P = 0.67) despite the omission of immediate neck dissection in 98.0% of the EQR group.
Patients with HPV-positive HNSCC who have achieved EQR have comparable survival outcomes to those who achieved a CR despite the omission of immediate neck dissections; this shows the safety of ongoing surveillance beyond 12 weeks in this group of patients.
Randomized clinical trial on reduction of radiotherapy dose to the elective neck in head and neck squamous cell carcinoma; update of the long-term tumor outcome
2020, Radiotherapy and Oncology
A multicenter prospective randomized controlled trial was performed to investigate whether dose reduction to the elective nodal volume (PTVelect) in head and neck carcinoma reduces radiation-induced dysphagia, primary endpoint, without compromising tumor control, secondary endpoint. Here, we report on the long-term follow-up of the secondary endpoint (NCT01812486).
Two hundred patients treated with primary (chemo)radiotherapy (RT) were randomized (1:1) between the standard arm, irradiation to PTVelect up to an equivalent dose (EQD2) of 50 Gy and the experimental arm, irradiation to PTVelect up to EQD2 of 40 Gy. The primary tumor and involved nodes were treated according to the standard of care, EQD2 70 Gy (PTVhigh). Regional recurrences (RR) were projected on the initial RT planning-CT to identify the recurrence localization.
The 5-year (5Y) RR was 14.0% (CI95% 7.9; 21.8) in the 40 Gy arm versus 7.5% (CI95% 3.3; 14.0) in the 50 Gy arm (p = 0.10). Majority of RR in the 40 Gy arm (9/13) were projected in PTVhigh and 2 RR were seen outside the treated RT volume. Only 2 RR occurred in PTVelect irradiated up to 40 Gy which was the same number as RR occurring in the 50 Gy PTVelect.
The 5Y-overall survival (OS) was 56.5% (CI95% 45.7; 65.9) in the 40 Gy arm versus 49.6% (CI95% 39.0; 59.2) in the 50 Gy arm (p = 0.56).
At 5-years, no statistically significant differences regarding OS, local recurrence, RR nor distant metastases were observed between both treatment arms. This study is underpowered to undoubtedly demonstrate non-inferiority. However, since in both arms only two RR in the PTVelect were observed, reducing the dose to PTVelect appears safe and should be further investigated.
The Evolving Role of Radiotherapy for Head and Neck Cancer
2020, Hematology/Oncology Clinics of North America
Head and neck cancer management and cancer stem cells implication
2019, Saudi Dental Journal
Head and neck squamous cell carcinomas (HNSCCs) arise in the mucosal linings of the upper aerodigestive tract and are heterogeneous in nature. Risk factors for HNSCCs are smoking, excessive alcohol consumption, and the human papilloma virus. Conventional treatments are surgery, radiotherapy, chemotherapy, or a combined modality; however, no international standard mode of therapy exists. In contrast to the conventional model of clonal evolution in tumor development, there is a newly proposed theory based on the activity of cancer stem cells (CSCs) as the model for carcinogenesis. This “CSC hypothesis” may explain the high mortality rate, low response to treatments, and tendency to develop multiple tumors for HNSCC patients. We review current knowledge on HNSCC etiology and treatment, with a focus on CSCs, including their origins, identifications, and effects on therapeutic options.
Postoperative Radiation Therapy for Metastatic Cervical Adenopathy
2019, Seminars in Radiation Oncology
Citation Excerpt :
In addition to recurrences in the ipsilateral neck their data added 2 points of information: (1) frequency of recurrences in the nonoperated contralateral neck, and (2) a more robust analysis of recurrence by stage. Data from Barkley et al. revealed that in patients treated with surgery alone there was a recurrence rate of 21%, and a 28% rate of recurrence in the nonoperated clinically negative neck.23 The work of Barkley et al.23 also described a staging system for nodal disease that had been used since the 1950s, and ultimately was very similar to that incorporated into the first iteration of the American Joint Commission on Cancer staging system.
The management of cancers of the head and neck focuses on primary site and regional (neck) disease control. Many patients are treated with surgery as the principal mode of treatment, and surgery often includes an elective or therapeutic neck dissection. Risk factors assessed for recurrence subsequent to neck dissection include nodal size, number, levels, and the presence of extranodal spread. Adjuvant radiation therapy (with or without chemotherapy) is offered to patients deemed at sufficient risk of recurrence based on assessment of these factors. However, randomized trials have not been performed to test the need and/or benefit of adjuvant postoperative radiation. The necessity of adjuvant radiation has been based on decades of clinical observations, retrospective studies, and indirect randomized trials. The case for postoperative radiation for patients with adverse features in the neck, and recommendations are made in the accompanying article.
Final Report of a Prospective Randomized Trial to Evaluate the Dose-Response Relationship for Postoperative Radiation Therapy and Pathologic Risk Groups in Patients With Head and Neck Cancer
2017, International Journal of Radiation Oncology Biology Physics
To present the long-term and final report of a phase 3 trial designed to assess dose-response relationship for postoperative radiation therapy (PORT) and pathologic risk groups in head and neck cancer.
Patients who underwent primary surgery for American Joint Committee on Cancer stage III or IV squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx and who required PORT were eligible. Patients' primary sites and involved necks were independently assigned to higher- or lower-risk categories based on a cumulative point score representing increasing risk of recurrence. The sites in the lower-risk group were randomized to receive 57.6 or 63 Gy and those in the higher-risk group were randomized to receive 63 or 68.4 Gy, all at 1.8 Gy per fraction.
A total of 264 patients were included. The actuarial 5-year locoregional control rate was 67%. A second primary cancer was documented in 27% of patients. The 5- and 10-year freedom–from–distant metastasis rates were 64% and 60%, respectively, whereas the 5- and 10-year overall survival rates were 32% and 20%, respectively. There was no statistically significant difference in tumor control between different dose levels in both the lower- and higher-risk groups. On multivariate analysis, nonwhite race (P=.0003), positive surgical margins (P=.009), extracapsular extension (ECE, P=.01), and treatment package time (TPT) ≥85 days (P=.002) were independent correlates of worse locoregional control, whereas age ≥57 years (P<.0001), positive surgical margins (P=.01), ECE (P=.026), and TPT ≥85 days (P=.003) were independently associated with worse overall survival.
This long-term report of PORT delivered at 1.8 Gy/d to total doses of 57.6 to 68.4 Gy without chemotherapy for head and neck squamous cell carcinoma demonstrated that increasing dose did not significantly improve tumor control. On multivariate analysis, the only significant treatment variable was TPT. The results confirm that positive surgical margins and/or nodal ECE remains the most significant predictive pathologic factors.

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^☆: This investigation was supported by USPHS Grants CA-06294, CA-05654, and CA-05099 from the National Cancer Institute.

^☆☆: Presented at the First Joint Meeting of the American Radium Society, James Ewing Society, and the Society of Head and Neck Surgeons on the occasion of the Eighteenth Annual Meeting of the Society of Head and Neck Surgeons, Boca Raton, Florida, May 14–19, 1972.

¹: From the Departments of Radiotherapy and Surgery, The University of Texas at Houston, M. D. Anderson Hospital and Tumor Institute, Houston, Texas.

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Scientific paperManagement of cervical lymph node metastases in squamous cell carcinoma of the tonsillar fossa, base of tongue, supraglottic larynx, and hypopharynx☆,☆☆

Abstract

Elective irradiation of the neck lymphatics for squamous cell carcinomas of the nasopharynx and oropharynx

Amer J Roentgen

Elective irradiation of subclinical disease in cancers of the head and neck

Cancer

Scientific paper
Management of cervical lymph node metastases in squamous cell carcinoma of the tonsillar fossa, base of tongue, supraglottic larynx, and hypopharynx☆,☆☆