Sonographic examination of the neck after definitive radiotherapy for node-positive oropharyngeal cancer.

BACKGROUND AND PURPOSE: Radiographic determination of viable disease in cervical adenopathy following RT for head and neck cancer can be challenging. The purpose of this study was to evaluate the utility of US, with or without FNA, in regard to the postradiotherapy effects on documented metastatic adenopathy in patients with oropharyngeal cancer. MATERIALS AND METHODS: This study included 133 patients with node-positive oropharyngeal cancer who were irradiated from 1998 to 2004. Sonographic evaluation was performed within 6 months of completion of radiation. Posttreatment US results were compared with pretreatment CT images and were recorded as the following: progression, suspicious, indeterminate, posttreatment change, or regression (positive) versus nonsuspicious or benign (negative). FNAC was classified as nondiagnostic, negative, indeterminate, or positive. Results of US and US-guided FNAC were correlated with findings at neck dissection and disease outcome. RESULTS: Of 203 sonographic examinations, 90% were technically feasible and yielded a nonequivocal imaging diagnosis. Of 87 US-guided FNAs, 71% yielded a nonequivocal tissue diagnosis. The PPV and NPV of initial posttreatment US were 11% and 97%. Sensitivity and specificity were 92% and 28%. The PPV and NPV of US-guided FNA were 33% and 95%, and the sensitivity and specificity were 75% and 74%. On serial sonographic surveillance, of 33 patients with nonsuspicious findings, only 1 (3%) had neck recurrence. Of 22 patients with questionable findings on CT and negative findings on US, none had a neck recurrence. CONCLUSIONS: In experienced hands, serial US is an inexpensive noninvasive reassuring follow-up strategy after definitive head and neck RT, even when CT findings are equivocal.

Scaling exponents of forced polymer translocation through a nanopore.

We investigate several properties of a translocating homopolymer through a thin pore driven by an external field present inside the pore only using Langevin Dynamics (LD) simulations in three dimensions (3D). Motivated by several recent theoretical and numerical studies that are apparently at odds with each other, we estimate the exponents describing the scaling with chain length (N) of the average translocation time , the average velocity of the center of mass , and the effective radius of gyration during the translocation process defined as approximately Nalpha, approximately N(-delta), and Rg approximately Nnu respectively, and the exponent of the translocation coordinate (s-coordinate) as a function of the translocation time approximately tbeta. We find alpha = 1.36 +/- 0.01, beta = 1.60+/- 0.01 for approximately taubeta and beta = 1.44 +/- 0.02 for approximately taubeta, delta = 0.81 +/- 0.04, and nu congruent with nu = 0.59 +/- 0.01, where nu is the equilibrium Flory exponent in 3D. Therefore, we find that approximately N1.36 is consistent with the estimate of approximately /. However, as observed previously in Monte Carlo (MC) calculations by Kantor and Kardar (Y. Kantor, M. Kardar, Phys. Rev. E 69, 021806 (2004)) we also find the exponent alpha = 1.36 +/- 0.01 < 1 + nu. Further, we find that the parallel and perpendicular components of the gyration radii, where one considers the "cis" and "trans" parts of the chain separately, exhibit distinct out-of-equilibrium effects. We also discuss the dependence of the effective exponents on the pore geometry for the range of N studied here.

Utilization of custom electron bolus in head and neck radiotherapy.

Conventional methods of treating superficial head and neck tumors, such as the wedge pair technique or the use of multiple electron fields of varying energies, can result in excellent tumor control. However, in some cases, these techniques irradiate healthy tissue unnecessarily and/or create hot and cold spots in junction regions, particularly in patients with complex surface contour modification or varying planning target volume (PTV) thickness. The objective of this work is to demonstrate how bolus electron conformal therapy can be used for these patients. Two patients treated using this technique are presented. The first patient was diagnosed with malignant fibrous histiocytoma involving the right ear concha and was treated with 12-MeV electrons. The second patient was diagnosed with acinic cell carcinoma of the left parotid gland and was treated with 20-MeV electrons after having undergone a complete parotidectomy. Each patient's bolus was designed using bolus design tools implemented in an in-house treatment-planning system (TPS). The bolus was fabricated using a computer-controlled milling machine. As part of the quality assurance process to ensure proper fabrication and placement of the bolus, the patients underwent a second computed tomography (CT) scan with the bolus in place. Using that data, the final dose distribution was computed using the Philips Pinnacle(3) TPS (Philips Medical Systems, Andover, MA). Results showed that the 90% isodose surface conformed well to the PTV and that the dose to critical structures such as cord, brain, and lung was well below tolerance limits. Both patients showed no evidence of disease six months post-radiotherapy. In conclusion, electron bolus conformal therapy is a viable option for treating head and neck tumors, particularly patients having a variable thickness PTV or surface anatomy with surgical defects.

Identification of intermediate and branch metabolites resulting from biotransformation of 2-benzoxazolinone by Fusarium verticillioides.

Detoxification of the maize (Zea mays) antimicrobial compound 2-benzoxazolinone by the fungal endophyte Fusarium verticillioides involves two genetic loci, FDB1 and FDB2, and results in the formation of N-(2-hydroxyphenyl)malonamic acid. Intermediate and branch metabolites were previously suggested to be part of the biotransformation pathway. Evidence is presented here in support of 2-aminophenol as the intermediate metabolite and 2-acetamidophenol as the branch metabolite, which was previously designated as BOA-X. Overall, 2-benzoxazolinone metabolism involves hydrolysis (FDB1) to produce 2-aminophenol, which is then modified (FDB2) by addition of a malonyl group to produce N-(2-hydroxyphenyl)malonamic acid. If the modification is prevented due to genetic mutation (fbd2), then 2-acetamidophenol may accumulate as a result of addition of an acetyl group to 2-aminophenol. This study resolves the overall chemistry of the 2-benzoxazolinone detoxification pathway, and we hypothesize that biotransformation of the related antimicrobial 6-methoxy-2-benzoxazolinone to produce N-(2-hydroxy-4-methoxyphenyl)malonamic acid also occurs via the same enzymatic modifications. Detoxification of these antimicrobials by F. verticillioides apparently is not a major virulence factor but may enhance the ecological fitness of the fungus during colonization of maize stubble and field debris.

Chemical and spectroscopic analysis of lignin in isolated flax fibers.

The chemistry of pure flax fibers, free of contaminating nonfiber components, has not been determined. Fibers from the center sections of the stem of seed and fiber flax (Linum usitatissium L.), which had been retted after soaking in water and removal of the epidermis by hand, underwent chemical and spectroscopic analysis. Wet chemical analysis showed only trace indications of aromatics and no long chain fatty acids or alcohols in fibers. Pyrolysis mass spectroscopy (PyMS) and pyrolysis gas chromatography mass spectrometry (PyGCMS) showed only trace amounts of aromatic constituents that could be attributed to the presence of lignin. Mid-infrared (Mid-IR) and Raman spectroscopy of these fibers showed no aromatic compounds present. This study suggests that earlier work reporting the presence of lignin ranging from 1 to 4% may be the result of residual shive or epidermis/cuticle material remaining after the retting process which may be responsible for the favorable properties desired by the composites industry.

Analysis of fiber content in flax stems by near-infrared spectroscopy.

The conventional means of measuring the fiber content of flax is time-consuming and laborious, and the results obtained vary with the analysis technique used. The plant tissues must first be "retted", a process by which the fibers are separated from the rest of the stem, either by indigenous organisms in the soil when the stems are left in the field or by water (anerobic bacteria) or enzymatic retting. The fiber content is then determined by mechanical or manual separation. In this study, fiber content of flax stems was measured rapidly and objectively by near-infrared spectroscopy (NIRS) using whole pieces of stem in a large cell, in reflectance mode. Compared to the conventional method, the standard error of performance of the NIRS method was between 0.96 and 1.45% (dry matter basis), depending on the model and data processing used. NIRS calibrations were generated by hand separation of fiber from water-retted specimens. The water retting procedure takes several days to complete and requires considerable trained labor to complete the hand separation step. The NIRS procedure was conducted on pieces of stem to simulate measurement in the field.

Plant factors influencing enzyme retting of fiber and seed flax.

Retting, which is the microbial activity through which bast fibers are released from nonfiber tissues, is the limiting factor in flax processing. The objective of this work is to identify chemical and structural characteristics in a variety of fiber and seed flax types that influence enzyme retting in a recently developed method. Analyses of flax retted in a series of tests, including two enzyme rettings in some cases, indicated that lignin did not limit the separation of fibers from shive and showed that pectinases in enzyme-retting mixtures could ret fiber and seed flax. However, mature stems, such as that in flax produced for seed, had greater amounts of cutin and wax in the cleaned fiber product, suggesting that the cuticle could be a greater antiquality factor in seed versus fiber flax. With seed flax, the fraction of finer fibers produced during retting was significantly lower than with fiber flax. Results indicated that enzyme retting could be used to obtain flax fibers from seed flax stem residues and add value to this agricultural material.

Postoperative radiotherapy for malignant tumors of the submandibular gland.

PURPOSE: This retrospective study assessed the outcome and patterns of failure for patients with malignant submandibular tumors treated with surgery and postoperative radiation. METHODS AND MATERIALS: Between 1965 and 1995, 83 patients aged 11-83 years old received postoperative radiotherapy after resection of submandibular gland carcinomas. The most common radiation technique was an appositional field to the submandibular gland bed using electrons either alone or mixed with photons. Primary tumor bed doses ranged from 50 to 69 Gy (median, 60 Gy). Regional lymph nodes (ipsilateral Levels I-IV) were irradiated in 66 patients to a median dose of 50 Gy. Follow-up time ranged from 5 to 321 months (median, 82 months). RESULTS: Actuarial locoregional control rates were 90%, 88%, and 88% at 2, 5, and 10 years, respectively. The corresponding disease-free survival rates were 76%, 60%, and 53%, because 27 of 74 patients (36%) who attained locoregional control developed distant metastases. Adenocarcinoma, high-grade histology, and treatment during the earlier years of the study were associated with worse locoregional control and disease-free survival. The median survival times for patients with and without locoregional control were 183 months and 19 months, respectively. Actuarial 2-, 5-, and 10-year survival rates were 84%, 71%, and 55%, respectively. Late complications occurred in 8 patients (osteoradionecrosis, 5 patients). CONCLUSIONS: High-risk cancers of the submandibular gland have a historic control rate of approximately 50% when treated with surgery alone. In the current series, locoregional control rates for high-risk patients with submandibular gland cancers treated with surgery and postoperative radiotherapy were excellent, with an actuarial locoregional control rate of 88% at 10 years.

Randomized trial addressing risk features and time factors of surgery plus radiotherapy in advanced head-and-neck cancer.

PURPOSE: A multi-institutional, prospective, randomized trial was undertaken in patients with advanced head-and-neck squamous cell carcinoma to address (1) the validity of using pathologic risk features, established from a previous study, to determine the need for, and dose of, postoperative radiotherapy (PORT); (2) the impact of accelerating PORT using a concomitant boost schedule; and (3) the importance of the overall combined treatment duration on the treatment outcome. METHODS AND MATERIALS: Of 288 consecutive patients with advanced disease registered preoperatively, 213 fulfilled the trial criteria and went on to receive therapy predicated on a set of pathologic risk features: no PORT for the low-risk group (n = 31); 57.6 Gy during 6.5 weeks for the intermediate-risk group (n = 31); and, by random assignment, 63 Gy during 5 weeks (n = 76) or 7 weeks (n = 75) for the high-risk group. Patients were irradiated with standard techniques appropriate to the site of disease and likely areas of spread. The study end points were locoregional control (LRC), survival, and morbidity. RESULTS: Patients with low or intermediate risks had significantly higher LRC and survival rates than those with high-risk features (p = 0.003 and p = 0.0001, respectively), despite receiving no PORT or lower dose PORT, respectively. For high-risk patients, a trend toward higher LRC and survival rates was noted when PORT was delivered in 5 rather than 7 weeks. A prolonged interval between surgery and PORT in the 7-week schedule was associated with significantly lower LRC (p = 0.03) and survival (p = 0.01) rates. Consequently, the cumulative duration of combined therapy had a significant impact on the LRC (p = 0.005) and survival (p = 0.03) rates. A 2-week reduction in the PORT duration by using the concomitant boost technique did not increase the late treatment toxicity. CONCLUSIONS: This Phase III trial established the power of risk assessment using pathologic features in determining the need for, and dose of, PORT in patients with advanced head-and-neck squamous cell cancer in a prospective, multi-institutional setting. It also revealed the impact of the overall treatment time in the combination of surgery and PORT on the outcome in high-risk patients and showed that PORT acceleration without a reduction in dose by a concomitant boost regimen did not increase the late complication rate. These findings emphasize the importance of coordinated interdisciplinary care in the delivery of combined surgery and RT.

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.

Caffeoyl coenzyme A O-methyltransferase and lignin biosynthesis.

Lignin, a complex phenylpropanoid compound, is polymerized from the monolignols p-coumaryl alcohol, coniferyl alcohol and sinapyl alcohol. These three monolignols differ only by the 3- and 5-methoxyl groups. Therefore, enzymatic reactions controlling the methylations of the 3- and 5-hydroxyls of monolignol precursors are critical to determine the lignin composition. Recent biochemical and transgenic studies have indicated that the methylation pathways in monolignol biosynthesis are much more complicated than we have previously envisioned. It has been demonstrated that caffeoyl CoA O-methyltransferase plays an essential role in the synthesis of guaiacyl lignin units as well as in the supply of substrates for the synthesis of syringyl lignin units. Caffeic acid O-methyltransferase has been found to essentially control the biosynthesis of syringyl lignin units. These new findings have greatly enriched our knowledge on the methylation pathways in monolignol biosynthesis.

Chemical composition of components comprising bast tissue in flax.

Components from the bast region of flax (Linum usitatissium) were removed by hand from seed flax and fiber flax and analyzed by gas chromatography and mass spectrometry. Stems soaked in water were separated by hand into an outer layer, which consisted of epidermis with cuticle and parenchyma cells, and fiber bundles. Each of the two fractions were evaluated for chemical markers that could be used to predict the degree of retting and possibly fiber quality. The outer layer was subsequently treated with a mixed enzyme preparation to remove the carbohydrate portion, thus providing another fraction consisting primarily of cuticle. Four main constituent groups were investigated: dihydroxy fatty acids, long-chain fatty acids and alcohols, sterols, and aromatics. Long-chain fatty acids and alcohols located in the outer layer accounted for 80-92% of the total found in both fractions. Aromatics and sterols in the outer layer accounted for 29--72 and 27--67%, respectively, of the total and do not appear to be a reliable marker for the degree of retting. The best markers for retting were the dihydroxy fatty acids, of which 98--99% were accounted for in the outer layer. The main dihydroxy fatty acids were a mixture of 8,16- and 9,16-dihydroxyhexadecanoic acids and represented 87--89% of the total dihydroxy fatty acids measured. As a constituent of cuticle, this compound may serve as an excellent marker for indicating the degree of retting as well as a possible marker for fiber quality because this compound is almost always exclusively associated with the outer layer and not the fiber.

A katanin-like protein regulates normal cell wall biosynthesis and cell elongation.

Fibers are one of the mechanical tissues that provide structural support to the plant body. To understand how the normal mechanical strength of fibers is regulated, we isolated an Arabidopsis fragile fiber (fra2) mutant defective in the mechanical strength of interfascicular fibers in the inflorescence stems. Anatomical and chemical analyses showed that the fra2 mutation caused a reduction in fiber cell length and wall thickness, a decrease in cellulose and hemicellulose contents, and an increase in lignin condensation, indicating that the fragile fiber phenotype of fra2 is a result of alterations in fiber cell elongation and cell wall biosynthesis. In addition to the effects on fibers, the fra2 mutation resulted in a remarkable reduction in cell length and an increase in cell width in all organs, which led to a global alteration in plant morphology. The FRA2 gene was shown to encode a protein with high similarity to katanin (hence FRA2 was renamed AtKTN1), a protein shown to be involved in regulating microtubule disassembly by severing microtubules. Consistent with the putative function of AtKTN1 as a microtubule-severing protein, immunolocalization demonstrated that the fra2 mutation caused delays in the disappearance of perinuclear microtubule array and in the establishment of transverse cortical microtubule array in interphase and elongating cells. Together, these results suggest that AtKTN1, a katanin-like protein, is essential not only for normal cell wall biosynthesis and cell elongation in fiber cells but also for cell expansion in all organs.

Merkel cell carcinoma of the head and neck: effect of surgical excision and radiation on recurrence and survival.

BACKGROUND: Merkel cell carcinoma is a rare malignant neoplasm of the skin that most often arises in the head and neck region. Despite the innocuous appearance of the primary lesion, Merkel cell carcinoma often has an aggressive clinical course with frequent locoregional recurrences and distant metastases. We evaluated the association of the width of surgical margins and the use of postoperative radiation therapy with locoregional control and survival rates. METHODS: The medical records of 66 patients with head and neck Merkel cell carcinoma seen between 1945 and 1995 were retrospectively reviewed. The Fisher exact test was used to compare outcomes. Kaplan-Meier survival curves were constructed. RESULTS: Eighteen patients for whom there was adequate information were divided into the following groups according to the width of their surgical margins: smaller than 1 cm, 1 to 2 cm, and larger than 2 cm. No statistical difference in locoregional control or survival was found among these groups owing to the small patient population. In contrast, a comparison of the patients who did (n = 26) and did not (n = 34) receive postoperative radiation therapy revealed a significant difference in local (3 [12%] vs 15 [44%], respectively; P<.01) and regional (7 [27%] vs 29 [85%], respectively; P<.01) recurrence rates. There was, however, no significant difference in the disease-specific survival between these groups (P = .30). Distant disease developed in 36% of all patients regardless of therapy. CONCLUSIONS: Any effect of the width of surgical margins on outcome was not detectable in the small number of patients analyzed. The use of postoperative radiation therapy was associated with a significant improvement in locoregional control. There was no detectable influence of the type of initial therapy on the rates of distant metastases or on survival. Future therapeutic innovations should be directed toward controlling the development of distant metastases in patients with Merkel cell carcinoma.

Essential role of caffeoyl coenzyme A O-methyltransferase in lignin biosynthesis in woody poplar plants.

Caffeoyl coenzyme A O-methyltransferase (CCoAOMT) has recently been shown to participate in lignin biosynthesis in herbacious tobacco plants. Here, we demonstrate that CCoAOMT is essential in lignin biosynthesis in woody poplar (Populus tremula x Populus alba) plants. In poplar stems, CCoAOMT was found to be expressed in all lignifying cells including vessel elements and fibers as well as in xylem ray parenchyma cells. Repression of CCoAOMT expression by the antisense approach in transgenic poplar plants caused a significant decrease in total lignin content as detected by both Klason lignin assay and Fourier-transform infrared spectroscopy. The reduction in lignin content was the result of a decrease in both guaiacyl and syringyl lignins as determined by in-source pyrolysis mass spectrometry. Fourier-transform infrared spectroscopy indicated that the reduction in lignin content resulted in a less condensed and less cross-linked lignin structure in wood. Repression of CCoAOMT expression also led to coloration of wood and an elevation of wall-bound p-hydroxybenzoic acid. Taken together, these results indicate that CCoAOMT plays a dominant role in the methylation of the 3-hydroxyl group of caffeoyl CoA, and the CCoAOMT-mediated methylation reaction is essential to channel substrates for 5-methoxylation of hydroxycinnamates. They also suggest that antisense repression of CCoAOMT is an efficient means for genetic engineering of trees with low lignin content.

Neurocognitive effects of therapeutic irradiation for base of skull tumors.

PURPOSE: To determine whether radiation therapy delivered to the paranasal sinuses causes any long-term impairment in neurocognitive function as a result of incidental brain irradiation. METHODS AND MATERIALS: Nineteen patients who received paranasal sinus irradiation at least 20 months and up to 20 years before assessment were given a battery of neuropsychologic tests of cognitive function. Radiation was delivered by a three-field (one anteroposterior and two lateral) technique. The median radiation dose was 60 Gy (range 50-68 Gy) in fractions of 1.8 to 2 Gy. The volume of irradiated brain was calculated from planning computed tomography slices or simulation films. The results of the neuropsychologic tests were compared to normative control values. RESULTS: Memory impairment was found in 80% of the patients, and one-third manifested difficulty with visual-motor speed, frontal lobe executive functions, and fine motor coordination. Two of the patients had frank brain necrosis with resultant dementia and blindness, and three had evidence of brain atrophy. Three of the fourteen patients without documented cerebral atrophy or necrosis were disabled from their normal activities. Three patients also developed pituitary dysfunction. Neurocognitive symptoms were related to the total dose of radiation delivered but not to the volume of brain irradiated, side of radiation boost, or chemotherapy treatment. The pattern of test findings was consistent with radiation injury to subcortical white matter. CONCLUSIONS: Radiation therapy for paranasal sinus cancer may cause delayed neurocognitive side effects. Currently, however, the development of severe adverse effects appears to be decreasing because of improvements in the techniques used to deliver radiation. Lowering the total dose and improving dose distributions should further decrease the incidence of delayed brain injury due to radiation.

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.

What are IDSs doing about poorly performing physician networks?

A national survey of 105 healthcare organizations conducted by Longshore & Simmons found that most IDSs' networks of acquired physician practices are losing money. The survey examined a variety of issues related to management and structure of IDS physician networks and physician compensation. In addition to finding that most networks were unprofitable, the survey found that for 75 percent of respondents, capitation revenue represented 25 percent or less of total revenue. The survey also disclosed there was no single, preferred method for allocating capitation revenue among physicians; 43 percent of physician networks were organized as hospital departments, cost centers, or divisions; and only 21 percent of respondents were using relative value units as a means to measure physician productivity, despite the proven effectiveness of this approach.

Postoperative radiation for squamous cell carcinoma metastatic to cervical lymph nodes from an unknown primary site: outcomes and patterns of failure.

BACKGROUND: This retrospective study assesses the outcomes and patterns of failure in patients with squamous cell carcinoma metastatic to cervical lymph nodes from an unknown primary site treated with combined surgery and postoperative radiotherapy. METHODS: One hundred thirty-six patients with squamous cell carcinoma metastatic to cervical lymph nodes from an unknown primary source were treated postoperatively with radiotherapy at the University of Texas M. D. Anderson Cancer Center between the years 1968 and 1992. Stage distribution was: N1, 31 patients; N2a, 49; N2b, 25; N2c, 3; N3, 18; and Nx, 10. Thirty-nine patients had excisional biopsies only, 64 patients underwent modified neck dissections, and 33 had radical neck dissections. Extracapsular extension was present in 87 cases. Fifty-nine patients had multiple nodes involved. The median duration of follow-up for surviving patients was 8.7 years. RESULTS: Twelve patients, all with extracapsular nodal disease, developed regional relapse. The 5-year actuarial rates of regional relapse in patients with and without extracapsular nodal disease were 16% and 0%, respectively (p = .004). Nine patients (22%) with extracapsular disease and multiple nodes relapsed compared with three patients (7%) with extracapsular disease and a solitary node (p = .02). None of the patients treated with excisional biopsy and radiotherapy relapsed regionally. No statistically significant relationship between dose, treatment duration, time interval between surgery, and the start of radiotherapy and relapse was detected. The 2-, 5-, and 10-year actuarial disease-specific survival rates were 82%, 74%, and 68%, respectively. Fourteen patients developed cancers in head and neck mucosal sites; six of these cancers were located in unirradiated tissues. CONCLUSIONS: Relapse occurred infrequently in patients treated with excisional biopsies and postoperative radiotherapy. Extracapsular extension and multiple nodes were associated with worse regional control and disease-specific survival. These results appear consistent with those expected for patients with advanced neck disease and a known primary site, and the absence of a primary site should not exclude patients from studies aiming to improve outcomes in patients with extensive neck disease from a head and neck squamous cell cancer. We continue to recommend radiation to the necks and pharyngeal axis for patients suspected of having residual microscopic disease following surgery for squamous cell carcinoma metastatic to the neck from an unknown primary site.