Can positron emission tomography improve the quality of care for head-and-neck cancer patients?

PURPOSE: Fluoro-2-deoxy-d-glucose-positron emission tomography (FDG-PET) is a functional imaging modality that measures the relative uptake of 18FDG with PET. The purpose of this review is to assess the potential contribution of FDG-PET scans to the treatment of head-and-neck cancer patients. METHODS AND MATERIALS: Data were assessed from the literature with attention to what additional information may be gained from the use of FDG-PET in four clinical settings: (1) detection of occult metastatic disease in the neck, (2) detection of occult primaries in patients with neck metastases, (3) detection of synchronous primaries or metastatic disease in the chest, and (4) detection of residual/recurrent locoregional disease. RESULTS: Although the data are somewhat conflicting, FDG-PET appears to add little additional value to the physical examination and conventional imaging studies (supplemented by biopsy when appropriate) for the detection of subclinical nodal metastases, unknown primaries, or disease in the chest. However, FDG-PET scans are quite useful in differentiating residual/recurrent disease from treatment-induced normal tissue changes. A positive FDG-PET scan at 1 month after radiotherapy is highly indicative of the presence of residual disease, and a negative scan at 4 months after treatment is highly predictive of tumor eradication. CONCLUSIONS: Large-scale studies using newer generation equipment and more defined methods are needed to more rigorously assess the potential of FDG-PET in the detection of subclinical primary or simultaneous secondary tumors and of nodal or systemic spread. Currently, however, FDG-PET can contribute to the detection of residual/early recurrent tumors, leading to the timely institution of salvage therapy or the prevention of unnecessary biopsies of irradiated tissues, which may aggravate injury.

Preoperative assessment for and outcomes of mandibular conservation surgery.

INTRODUCTION: The role of marginal mandibulectomy and other conservative resective procedures for patients with early cortical mandibular invasion from squamous carcinoma of the oral cavity remains poorly defined. The purpose of this retrospective study was to evaluate the efficacy of preoperative assessment for bone invasion and the outcomes of different mandibular resective procedures that preserve mandibular continuity. METHODS: The charts of 222 patients treated at the University of Texas M. D. Anderson Cancer Center between 1960 and 1990 were reviewed. All patients had a biopsy-confirmed diagnosis of squamous carcinoma involving either the lower gingiva, floor of mouth, oral tongue, or retromolar trigone. All patients had a surgical resection that involved removing less than a segment of the mandible. Patient data were analyzed to determine the usefulness of preoperative assessment and outcomes of therapy. RESULTS: Clinical evaluation of mandibular bone invasion was more sensitive than radiologic evaluation, whereas radiologic assessment was more specific and had a higher reliability index. The overall local and regional recurrence and distant metastasis rates for all T stages were 14.4%, 18.0%, and 2.7%, respectively. Sixty-nine point eight percent of all patients were without evidence of disease 2 years after treatment. CONCLUSIONS: Mandibular conservation surgery is oncologically safe for patients with early mandibular invasion. Accurate preoperative assessment that combines clinical examination and radiographic evaluation is better than either modality alone, but clinical judgment is still necessary for proper patient selection.

Squamous cell carcinoma of the tongue in young adults: increasing incidence and factors that predict treatment outcomes.

OBJECTIVE: This study was designed to determine whether the incidence of squamous cell carcinoma of the oral tongue (SCCOT) in young adults has changed during the past 25 years and to determine prognostic factors for young adult patients (aged < 40 years) with SCCOT. METHODS AND PATIENTS: A retrospective review of young adults with SCCOT who sought treatment at the M. D. Anderson Cancer Center between 1973 and 1995 was undertaken. RESULTS: The percentage of young adult SCCOT patients at M. D. Anderson increased from 4% in 1971 to 18% in 1993. T stage, N stage, perineural invasion, and lymphatic invasion were all associated with decreased survival. Patients who received a neck dissection as part of their primary treatment had a better chance of survival than patients who did not. CONCLUSIONS: The incidence of SCCOT in the young adult population is increasing in the United States. Appropriate surgical management for young adults with SCCOT includes resection of the primary tumor along with a selective node dissection.

Phase I/II trial of radiation with chemotherapy "boost" for advanced squamous cell carcinomas of the head and neck: toxicities and responses.

PURPOSE: Extrapolating from our experience delivering a "boost" field of radiation concurrently with fields treating both gross and subclinical disease at the end of a course of radiation therapy, we developed a regimen to deliver concurrent chemotherapy during the last 2 weeks of a conventionally fractionated course of radiation. PATIENTS AND METHODS: Patients had stage III or IV biopsy-proven squamous cell carcinoma originating from a head and neck mucosal site. The regimen was 70 Gy delivered over 7 weeks with concurrent fluorouracil (5-FU) and cisplatin given daily with each radiation dose during the last 2 weeks. A phase I study was performed to determine the maximum-tolerated dose (MTD) before a phase II study was conducted. RESULTS: The MTD was 400 mg/m(2) per day for 5-FU and 10 mg/m(2) per day for cisplatin. Mucositis persisting more than 6 weeks after therapy was the dose-limiting toxicity. A total of 60 patients were treated on the two phases of the study. Eighteen patients (35%) treated at the MTD developed prolonged mucositis. There were two cases of neutropenic sepsis, including one fatality. The actuarial 2-year rates for overall survival, freedom from relapse, and local control were 62%, 59%, and 80%, respectively. CONCLUSION: Preliminary locoregional control rates seem to be higher than those reported for treatment with radiation alone. Toxicity was also greater than that seen with radiation alone, but the regimen was designed to deliver an intense treatment schedule, which could be completed without significant interruptions, and to obtain high control rates above the clavicles. These end points were achieved.

Selective neck dissections for squamous carcinoma of the upper aerodigestive tract: patterns of regional failure.

BACKGROUND: Surgeons have been using selective neck dissections in the treatment of squamous carcinoma of the upper aerodigestive tract for over 20 years. To date, no data is available that can answer the question "What are the patterns of failure in the neck following a selective neck dissection and is a selective neck dissection a reliable procedure for metastatic disease?" METHODS: To answer this question, the medical records of all patients with squamous carcinoma of the oral cavity, oropharynx, larynx, and hypopharynx treated at The University of Texas M. D. Anderson Cancer Center from January 1, 1985-December 31, 1990, with a selective neck dissection were reviewed. Five hundred seventeen neck dissections were analyzed: suprahyoid (41), supraomohyoid (284), and anterolateral (192). The end point of the study was regional failure and survival. RESULTS: Regional recurrence in patients treated with a suprahyoid dissection was 43% with pathologically positive nodes. The regional recurrence in the patients treated with a supraomohyoid neck dissection was 1.9% with pathologically negative nodes, 35.7% with path N1 without postoperative radiation therapy, and 5.6% with postoperative radiation therapy. The neck staged pathologically N2B failed with and without postoperative radiation, 8.3% and 14%, respectively. Thirteen percent of the anterior/lateral neck dissections failed regionally. If multiple pathologically positive nodes (N2B) were present, the regional failure with postoperative radiation was 30% and 33.3% without postoperative radiation. CONCLUSION: The results of this retrospective study suggest that a selective neck dissection is a satisfactory staging procedure and is a definitive operation if all the nodes are pathologically negative. However, if a node is found to be invaded with cancer, the use of postoperative radiation is advisable.

Treatment of the neck in melanoma.

The treatment of the neck/parotid in melanoma of the head and neck has changed in recent years. With the use of ultrasound, fine-needle aspiration, lymphoscintigraphy, modified/selective dissection, adjuvant radiation therapy, and systemic interferon, patients with suspected metastatic melanoma in the neck have a better opportunity to have early diagnosis, preservation of function, and improved regional control and survival.

Nonnasopharyngeal lymphoepithelioma of the head and neck.

BACKGROUND: Lymphoepithelioma (squamous cell carcinoma with associated lymphoid stroma) commonly occurs in the nasopharynx, rarely at other sites. As a result, the clinical course and optimal treatment of nonnasopharyngeal lymphoepithelioma of the head and neck have not been well described. This retrospective study was undertaken to analyze the clinical course of the disease in patients treated at a single institution and to formulate recommendations for treatment based on that experience as well as results reported in the literature. METHODS: Between 1950 and 1994, 34 patients with nonnasopharyngeal lymphoepithelioma of the head and neck were treated at the University of Texas M. D. Anderson Cancer Center. The patients' medical records were reviewed and their pathologic specimens evaluated. The primary tumor sites were: oropharynx (24 patients), salivary gland (4), laryngohypopharynx (4), and the maxillary sinus/nasal cavity (2). Assessed in accordance with the 1992 American Joint Committee Against Cancer TNM staging system, T classifications were TX-2, T1-7, T2-8, T3-10, and T4-7, and N classifications were N0-8, N1-5, N2-15, and N3-6. Treatment consisted of radiotherapy for 24 patients, excisional biopsy of the primary tumor followed by radiotherapy for 7 patients, and surgery for 3 patients. Of the patients treated with radiotherapy, neck dissections were performed on only two, both of whom had persistent lymph node masses after completing radiotherapy. The median dose delivered to the primary tumor was 65 gray (Gy) (range, 46-78 Gy). The median fraction size was 2.1 Gy (range, 1.6-3.2 Gy). RESULTS: The 5-year actuarial disease specific survival and overall survival rates were 59% and 39%, respectively. The 5-year actuarial local control rate for all patients was 94%. For the irradiated patients, the 5-year regional control rates were 77% overall and 83% within the radiation field. The 5-year actuarial rate of distant metastasis for all patients was 30%. For patients who presented with and without regional adenopathy, the 5-year rates of distant metastasis were 36% and 12%, respectively (P = 0.27). CONCLUSIONS: Nonnasopharygeal lymphoepithelioma is a radiosensitive disease. High rates of locoregional tumor control were achieved with radiotherapy at all head and neck sites. The main cause of treatment failure was distant metastasis, which occurred more frequently in patients with lymph node involvement. Radiotherapy is appropriate initial locoregional therapy for patients with this disease. Surgery should be reserved for patients who have persistent disease after completing radiotherapy. Systemic therapy is a reasonable approach for patients who present with regional adenopathy because they have a relatively high rate of distant metastasis.

Can we detect or predict the presence of occult nodal metastases in patients with squamous carcinoma of the oral tongue?

BACKGROUND: When to do a neck dissection as part of the surgical treatment for a patient with squamous carcinoma of the oral tongue is controversial, particularly when the primary can be resected without entering the neck. If the patient who is at high risk for having occult nodal disease in the neck can be identified, node dissection with the glossectomy could be justified. To better identify patients for this procedure, we correlated various tumor and patient factors along with preoperative diagnostic studies with the presence or absence of pathologically positive nodes in a group of patients who underwent node dissection. METHODS: Ninety-one previously untreated patients with biopsy-proved squamous carcinoma of the oral tongue were prospectively studied. All patients had a glossectomy and neck dissection as their initial treatment. The pathology findings (ie, lymph nodes with squamous cancer) were correlated with many preoperative and intraoperative factors, and a statistical analysis was made. RESULTS: The use of computed tomography and ultrasound was not better than the clinical examination in determining the presence or absence of nodal metastases. The best predictors were depth of muscle invasion, double DNA aneuploidy, and histologic differentiation of the tumor. CONCLUSIONS: All patients with stage T2-T4 squamous cancers of the oral tongue should have an elective dissection of the neck. Patients with T1N0 cancer who have a double DNA-aneuploid tumor, depth of muscle invasion > 4 mm, or have a poorly differentiated cancer should definitely undergo elective neck dissection. Ultrasound and computed tomography are of little value in predicting which patients have positive nodes.

Frequency and therapeutic implications of "skip metastases" in the neck from squamous carcinoma of the oral tongue.

BACKGROUND: Supraomohyoid neck dissection is an adequate operation for the elective treatment of the neck for patients with oral cavity cancer. Squamous cell carcinoma of the oral tongue, however, metastasize to clinically negative nodes in 20% to 30% of patients. These nodes usually are located in levels I-III. METHODS: The medical records of 277 previously untreated patients with squamous cell carcinoma of the oral tongue were reviewed between the years 1970 and 1990. All patients had a glossectomy and neck dissection as part of their initial treatment. Patients were evaluated as to the findings in their neck. The following group of patients were included: (1) patients who had level III nodes positive, without disease in levels I and II; (2) patients with disease in level IV; (3) patients with disease in level IIB or IIIB, and; (4) patients who were electively dissected and whose neck did not demonstrate any pathologically involved nodes, but level IV was not included in the dissection and the patient subsequently developed pathologically positive nodes in level IV. RESULTS: Of all patients, 15.8% had either level IV metastasis as the only manifestation of disease in the neck or the level III node was the only node present without disease in level I-II. CONCLUSION: The usual supraomohyoid neck dissection is inadequate for a complete pathologic evaluation of all the nodes at risk for patients with squamous carcinoma of the oral tongue. This may create a dilemma in determining whether postoperative radiotherapy is necessary. Consequently, all patients with squamous cell carcinoma of the oral tongue should have levels I-IV nodes removed if an elective neck dissection is part of their initial therapy.

Neck surgery in patients with primary oropharyngeal cancer treated by radiotherapy.

BACKGROUND: The role of neck surgery in node-positive patients whose primary tumors are treated by definitive radiotherapy is controversial. This analysis was undertaken to assess the risk of withholding planned neck dissection in patients who obtain a complete nodal response to irradiation. METHODS: We reviewed the records of 100 patients who presented between 1984 and 1993 with oropharyngeal cancers metastatic to the neck and whose primary tumors were treated by radiotherapy using the concomitant boost regimen. Seventy-five patients had their nodal disease treated definitively by radiotherapy; those who had complete clinical resolution of all nodal disease (62) had no planned surgery, while 13 underwent neck dissection for presumed residual disease. The remaining 25 patients had either node excision (8) or neck dissection (17) prior to radiotherapy. RESULTS: There were 8 cases of isolated neck failure of which 3 occurred in the 62 patients who had no planned neck surgery, 0 in the 13 patients who had surgery for presumed residual (pathologically negative in 7). and 5 in the 25 patients who had initial neck surgery. In those who obtained a complete response to definitive radiotherapy, the risk of neck relapse was unrelated to pretreatment nodal size. CONCLUSIONS: The policy of observation of the neck after complete nodal response to full-dose irradiation is both safe and cost effective. Imaging to confirm the resolution of nodal disease is recommended.

Lower gingival carcinoma. Clinical and pathologic determinants of regional metastases.

OBJECTIVE: To determine which clinical and pathologic features are associated with regional metastases in patients with lower gingival squamous cell carcinoma. PATIENTS AND METHODS: The medical charts of 155 previously untreated patients seen between 1970 and 1990 were retrospectively analyzed. All patients underwent surgical resection of the primary tumor. In addition, 66 patients underwent elective neck dissection, while a therapeutic neck dissection was performed in 28. Sixty-one patients who had clinically N0 neck disease did not undergo treatment of the cervical lymphatics. RESULTS: T stage (P = .01), radiologic (P = .03) or histologic (P = .01) evidence of mandibular invasion, and decreased tumor differentiation (P = .004) significantly correlated with the presence or evolution of regional metastases. In addition, tumors involving the symphyseal region were associated with an increased incidence of nodal metastases, although the relationship did not achieve statistical significance (P = .08). Occult regional disease was found in 18% of patients who underwent elective neck dissection, and the presence of metastases was pathologically confirmed in 68% who underwent a therapeutic dissection. Six patients with clinically N0 neck disease did not undergo elective dissection and later developed regional metastases. In all patients, survival was adversely impacted by the presence or later development of regional metastases (P < .001). Two- and 5-year survival rates for patients with no cervical metastases were 0.91 and 0.85, respectively, while for those with cervical metastases, the survival at 2 and 5 years declined to 0.72 and 0.59. More importantly, the 2- and 5-year survivals of patients with clinically N0 necks who were found to have lymph node metastases histologically after neck dissection were 1.00 and 0.78. This contrasts with the 0.50 survival rate at 2 and 5 years for those who did not undergo elective dissection and later developed cervical metastases (P = .36). CONCLUSIONS: Patients with adverse clinical and pathologic features, even in the absence of demonstrable neck disease, are at risk for harboring regional metastases. Elective treatment of the cervical lymphatics should be considered for patients with primary tumors that overlie the mandibular symphysis, moderately or poorly differentiated tumors, or radiographic or histologic evidence of mandibular invasion.

Influence of biopsy on the prognosis of cutaneous melanoma of the head and neck.

BACKGROUND: This study was performed to determine the effect of biopsy type on survival rates and on local, regional, and distant metastasis in patients with head and neck cutaneous melanoma. METHODS: A case series of 159 patients with melanoma of the head and neck referred to a tertiary-care center between 1983 and 1991, with a median follow-up of 38 months, was reviewed. Information analyzed included patient's age, sex, type of treatment, mode of biopsy, presence of residual melanoma in reexcision, location of lesion, presence of ulceration, Clark's level, Breslow thickness, and histologic type of the melanoma. RESULTS: Excisional biopsy was performed in 79 patients, incisional biopsy in 48, and other procedures (shave, needle biopsy, cauterization, or cryotherapy) in 32. There were no significant pretreatment differences among the three groups in sex, thickness, histologic type, presence of nodal disease, or type of treatment. Pretreatment location of lesion was significantly different (p = .03) between the excisional and other biopsy types. Association between type of biopsy and survival rate was significant (p<.001):31.3% of patients in the incisional biopsy group died of disease, as did 25% of the other biopsy group, versus 8.9% of the excisional biopsy group; 31.3% of patients in the incisional biopsy group developed distant metastases, as did 28.1% of the other biopsy type, versus 10.1% of those in the excisional biopsy group (p = .01). There was no significant difference in local p = .37) or regional (p = 1.00) recurrence among the three biopsy groups. Multivariate analysis showed presence of tumor in the re-excision specimen, biopsy type, and nodal disease to be independent prognostic factors. CONCLUSIONS: Our study suggests that the type of biopsy of cutaneous melanoma of the head and neck may influence the clinical outcome.

Juvenile nasopharyngeal angiofibroma: an update of therapeutic management.

BACKGROUND: Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor of the nasopharynx composed of fibrous connective tissue and an abundance of endothelium-lined vascular spaces. The name of the disease is derived from the fact that it occurs during adolescence, almost exclusively in boys. METHODS: This study examines the natural characteristics of JNA, the imaging techniques used to diagnose and stage the neoplasm, and the treatment approaches used to manage the disease. RESULTS: Forty-three cases of JNA diagnosed and treated at the University of Texas M. D. Anderson Cancer Center over a 38-year period were reviewed for the study. The cases were divided into two groups, those occurring between 1955 and 1974 and those occurring between 1975 and 1991, to accurately represent the developments in diagnostic and treatment methodology during those time periods. CONCLUSION: The results of our study show that: (1) the imaging techniques used after 1965 (angiography, computed tomography, and magnetic resonance imaging) greatly improve the staging of JNA; (2) morbidity, recurrence, and intraoperative complications decrease when preoperative embolization and skull-based surgical approaches are used; and (3) surgical resection is the most common primary treatment, with chemotherapy and radiotherapy recommended as possible other options.

Functional parathyroid cyst and hypocalciuric hypercalcemia.

Parathyroid cysts are uncommon. They can be divided into functional and nonfunctional cysts depending on whether or not they are associated with hypercalcemia. Functioning cysts are very rare, with fewer than twenty reported cases. We report a case of functioning parathyroid cyst associated with hypocalciuric hypercalcemia. We have been unable to find a similar case previously reported in the literature.

Cutaneous angiosarcoma of the head and neck. A therapeutic dilemma.

BACKGROUND: Because of a tendency for diffuse, clinically undetectable local spread, cutaneous angiosarcoma is difficult to treat with surgery alone. Radiation is a rational treatment modality for this disease, because a wide region of dermis can be treated, whereas the underlying normal tissues are spared. METHODS: The authors retrospectively studied 14 patients with dermal angiosarcoma of the head and neck who were treated with electron-beam radiation from 1970 to 1989. Primary tumors were located in the scalp and forehead (11 patients) and in the upper face (3 patients). Eleven patients presented with multiple foci of disease. Three patients were treated with radiotherapy alone; the other 11 were treated with chemotherapy (10 patients) and/or surgery (7 patients). Surgical excisions were limited procedures for patients whose disease readily could be encompassed; total scalp resections were not performed. Patients were irradiated with a multiple-field electron-beam technique. Six patients presented postoperatively for radiotherapy with no macroscopic disease in the treatment field and were given a median dose of 60 Gy (range, 50-66 Gy) over a median of 40 days (range, 37-43 days). Eight patients were irradiated with clinically evident disease; doses ranged from 55 to 75 Gy over a median of 44 days (range, 33-66 days). RESULTS: Five of the six patients irradiated without clinically detectable disease were controlled in the treatment field, but only two are currently disease free. Of the eight patients irradiated with macroscopic tumor, initial disease recurrence occurred in the radiation field in two patients and at the radiation field margin in three patients. The actuarial 5-year control rates above the clavicles for patients irradiated with and without clinical disease were 24% and 40%, respectively (P = 0.03). The 5-year actuarial incidence of distant metastases for all patients was 63%. The 5-year actuarial survival rate for patients irradiated with and without clinical disease was 13% and 50%, respectively (P = .04). CONCLUSIONS: Radiation is an effective modality for treating local disease, especially when used after surgical resection of macroscopic tumor. Our current strategy is to resect clinically evident tumor in patients presenting with focal, limited disease, and to follow this resection with moderate dose, very wide-field radiation. The survival outcome for patients presenting with diffuse multifocal disease is bleak, but some patients can be controlled infield with radiation. There must be continued efforts to develop effective systemic therapy.