Follicular dendritic cell sarcoma of the head and neck: case report and literature review.

OBJECTIVES/HYPOTHESIS: This article presents a case of a patient with follicular dendritic cell sarcoma (FDS), a rare neoplasm usually of the head and neck, and reviews the literature. STUDY DESIGN: Literature review. METHODS: A MEDLINE literature search was performed and the literature was reviewed. RESULTS: Our patient presented with an FDS that had been excised from the upper neck and recurred in a level V node. He was treated with neck dissection and postoperative irradiation and remains disease free 5.25 years after salvage treatment. The literature search yielded 67 case reports on FDS of the head and/or neck. Most patients were treated with surgery (94%). Twenty-eight percent of patients received adjuvant radiotherapy; 18% received adjuvant chemotherapy. Fifty percent of patients were alive with no evidence of disease at last follow-up; 9% died from disease. CONCLUSIONS: We currently treat head and neck FDS with wide resection and postoperative radiotherapy.

Clear cell odontogenic carcinoma of the maxilla: a case report and literature review.

BACKGROUND: Clear cell odontogenic carcinoma (CCOC) is a rare tumor of odontogenic origin. It was first described as a clinicopathological entity in 1985, and since then, several case reports have been published. METHODS: We present a patient with CCOC treated at the University of Florida and review the pertinent literature. RESULTS: We treated a 52-year-old woman with CCOC of the maxilla. She received a maxillectomy and postoperative radiotherapy (RT). She developed pulmonary metastases 2 years after treatment. She remains alive and asymptomatic 7 years after completing treatment and has not required additional therapy. The literature search yielded 48 other case reports. The median age at presentation was 53 years (mean, 55 years), the female-to-male ratio was 2:1, and the most common site of presentation was the mandible. Three patients presented with submandibular lymphadenopathy. Most patients had a surgical resection (35 patients, 71%); the remainder underwent curettage. Six (12%) patients received postoperative RT. Eighty percent of patients who were initially treated with curettage developed a local recurrence. Local and/or regional recurrences occurred in 34% of patients who underwent surgical resection. Six patients developed distant metastatic disease; the most common site of the metastases was the lung. Seven patients died from or with the disease, and 3 are alive with the disease. CONCLUSIONS: Clear cell odontogenic carcinoma is a rare tumor of the mandible and maxilla that has the propensity for local destruction and the potential for lymphatic and hematogenous metastases. We recommend radical excision as the primary treatment and that adjuvant RT be added for those who have close or positive margins as well as those with lymph node metastases.

Definitive radiation therapy for squamous cell carcinoma of the soft palate.

BACKGROUND: We report the University of Florida experience with soft-palate carcinoma treated with radiotherapy alone or combined with adjuvant chemotherapy and/or neck dissection for residual disease in the neck. METHODS: A total of 145 patients treated with curative intent from 1963 to 2004 were included. Potential follow-up was > or =2 years. RESULTS: Local control rates at 5 years were: T1, 90%; T2, 91%; T3, 67%; T4, 57%. Nodal control rates at 5 years were: N0, 90%; N1, 82%; N2, 68%; N3, 71%. Ultimate local-regional control rates at 5 years were: stage I, 89%; stage II, 88%; stage III, 96%; stage IVA, 63%; stage IVB, 43%. In multivariate analysis, overall treatment time significantly affected local and ultimate local-regional control, and nodal stage significantly affected overall survival. Overall survival rate at 5 years was 44%. Cause-specific survival rate at 5 years was 73%. CONCLUSIONS: The likelihood of cure after definitive radiotherapy is relatively high and is impacted by disease extent and overall treatment time.

Lymph node-positive head and neck cancer treated with definitive radiotherapy: can treatment response determine the extent of neck dissection?

BACKGROUND: The purpose was to determine if postradiotherapy (RT) neck dissection can be limited to the neck levels of residual adenopathy on post-RT computed tomography (CT). METHODS: In all, 274 patients with lymph node-positive head and neck squamous cell carcinoma were treated with definitive RT. All patients had a contrast-enhanced CT performed 4 weeks after completing RT to evaluate tumor response. Two hundred eleven heminecks were dissected, either planned pre-RT or because of residual adenopathy on post-RT CT. CT images were reviewed to determine the presence and location of residual adenopathy. Radiographic complete response (rCR) was defined as lymph node size < or =1.5 cm and normal radiographic morphology (no filling defects or calcifications). For each neck level the CT findings were correlated with neck dissection pathology. RESULTS: Correlation of CT nodal response with neck dissection pathology revealed the following negative predictive values of rCR: level I, 100%; level II, 95%; level III, 98%; level IV, 96%; and level V, 96%. A subset analysis was performed on 61 neck levels with initially positive lymph nodes that completely responded to RT that were in a hemineck with residual lymphadenopathy elsewhere in the neck. Correlation of nodal response on CT to pathology indicated a negative predictive value of an rCR of 95% for this high-risk scenario. In 71 heminecks that underwent a selective neck dissection (defined as dissection of less than levels I-V) the 5-year neck control rate was 100%. CONCLUSIONS: rCR on post-RT CT has a negative predictive value of > or =95% for each neck level. This suggests that limiting neck dissection based on post-RT CT is safe.

Inverted papilloma of the nasal cavity and paranasal sinuses.

PURPOSE: To discuss the treatment and outcomes of inverted papilloma of the nasal cavity and paranasal sinuses. METHODS: Review of the pertinent literature. RESULTS: Inverted papilloma is a benign, locally aggressive neoplasm that arises in the nasal cavity and is associated with squamous cell carcinoma in approximately 5% of patients. Squamous cell carcinoma may be present with inverted papilloma at the initial diagnosis or it may occur metachronously after prior treatment. Surgery is the primary treatment of inverted papilloma. The likelihood of local recurrence varies from less than 5% to over 50%, depending on the extent of resection. There is likely no significant difference in the risk of local recurrence after open compared with endoscopic resection. The probability of local recurrence and/or death from tumor is increased if inverted papilloma is associated with squamous cell carcinoma. The likelihood of cure is approximately 50% when malignancy is present and postoperative radiotherapy should be considered for the majority of patients. A small subset of patients with inverted papilloma present with incompletely resectable disease. Definitive radiotherapy using doses between 65 and 70 Gy will locally control gross disease in the majority of patients. CONCLUSION: The preferred treatment of inverted papilloma is surgery; postoperative radiotherapy is added if it is associated with squamous cell carcinoma. The likelihood of local recurrence after surgery for inverted papilloma may be substantial and varies with the extent of resection. Definitive radiotherapy may be used to successfully treat patients with incompletely resectable inverted papilloma.

Multidisciplinary management of laryngeal carcinoma.

The management of head and neck cancer has evolved into a multidisciplinary approach in which patients are evaluated before treatment and decisions depend on prospective multi-institutional trials, as well as retrospective outcome studies. The choice of one or more modalities to use in a given case varies with the tumor site and extent, as exemplified in the treatment of laryngeal squamous cell carcinomas. The goals of treatment include cure, laryngeal voice preservation, voice quality, optimal swallowing, and minimal xerostomia. Treatment options include transoral laser excision, radiotherapy (both definitive and postoperative), open partial laryngectomy, total laryngectomy, and neck dissection. The likelihood of local control and preservation of laryngeal function is related to tumor volume. Patients who have a relatively high risk of local recurrence undergo follow-up computed tomography scans every 3-4 months for the first 2 years after radiotherapy. Patients with suspicious findings on computed tomography might benefit from fluorodeoxyglucose positron emission tomography to differentiate post-radiotherapy changes from tumor.

T3 and T4 true vocal cord squamous carcinomas treated with external beam irradiation: a single institution's 35-year experience.

PURPOSE: The purpose of this study was to report the outcomes after external-beam radiotherapy (RT) for selected T3 and T4 vocal cord squamous cell carcinomas. METHODS AND MATERIALS: One hundred nine patients with previously untreated T3 and T4 squamous cell carcinomas of the glottic larynx were treated with curative intent in this Institutional Review Board-approved outcome study using continuous-course RT alone (106 patients) or followed by a planned neck dissection (3 patients) between September 1966 and June 2002. Patients selected for such treatment had relatively low-volume, unilateral disease. Patients were staged according to the recommendations of the American Joint Committee on Cancer (AJCC) as follows: T3N0, 68 patients (62%); T3N1, 14 patients (13%); T3N2B, 5 patients (5%); T4N0, 17 patients (16%); T4N1, 4 patients (4%); and T4N2B, 1 patient. RESULTS: The 5-year outcomes after treatment were: local control for stage T3 and T4, 78% and 81%; locoregional control for AJCC stage III and IVa, 62% and 78%; distant metastasis-free survival for AJCC stage III and IVa, 97% and 100%; cause-specific survival for AJCC stage III and IVa, 84% and 87%; and overall survival for AJCC stage III and IVa, 52% and 67%, respectively. Severe complications occurred in 13 patients (12%). CONCLUSIONS: The results of this retrospective study compare favorably with those published elsewhere in the literature for T3 and T4 vocal cord carcinomas. Local control and ultimate cure probabilities will hopefully improve further with the addition of concomitant chemotherapy to RT for larger tumors.

Skin cancer of the head and neck with perineural invasion.

Perineural invasion occurs in 2% to 6% of cutaneous basal and squamous cell carcinomas of the head and neck and is associated with midface location, recurrent tumors, high histologic grade, and increasing tumor size. Patients may be asymptomatic with perineural invasion appreciated on pathologic examination of the surgical specimen (incidental) or may present with cranial nerve deficits (clinical). The cranial nerves most commonly involved are the 5th and 7th nerves. Magnetic resonance imaging is obtained to detect and define the extent of perineural invasion; computed tomography is used to detect regional lymph node metastases. Patients with apparently resectable cancers undergo surgery usually followed by postoperative radiotherapy. Patients with incompletely resectable cancers are treated with definitive radiotherapy. The 5-year local control, cause-specific survival, and overall survival rates are approximately 87%, 65%, and 50%, respectively, for patients with incidental perineural invasion compared with 55%, 59%, and 55%, respectively, for those with clinical perineural invasion.

Isolated neck recurrence after definitive radiotherapy for node-positive head and neck cancer: salvage in the dissected or undissected neck.

BACKGROUND: The role of salvage neck dissection for isolated regional recurrences after definitive radiotherapy (RT) is ill-defined. METHODS: Five-hundred fifty patients were treated with RT for lymph node-positive head and neck cancer. RT consisted of a median dose of 74.4 Gy. Chemotherapy was administered in 133 patients (24%). Patients were followed for neck failure after planned neck dissection (n = 341) or observation (n = 209). Salvage therapy was offered to those with isolated neck recurrences. RESULTS: There were 54 (10%) failures in the neck at a median 3.7 months after RT (range, 0 to 17 months). Thirteen patients had isolated recurrences after receiving definitive RT with (n = 11) or without (n = 2) neck dissection. Nine patients underwent attempted surgical salvage with or without re-irradiation and 4 were successfully salvaged without major complications. CONCLUSIONS: Patients with neck failure after definitive therapy usually have poor outcomes, but salvage attempts may be successful in selected patients with an isolated neck recurrence.

Surgery and postoperative radiotherapy for squamous cell carcinoma of the larynx and pharynx.

OBJECTIVE: To determine the rates of local-regional control, survival, and complications for patients treated with postoperative radiation for squamous carcinomas of the larynx, hypopharynx, and oropharynx. METHODS: There were 295 patients with previously untreated squamous cell carcinomas of the larynx (n = 199), hypopharynx (n = 80), and oropharynx (n = 16) treated postoperatively with radiotherapy (RT). RESULTS: Five-year local-regional control rates according to site and pathologic American Joint Committee on Cancer (AJCC) stage were: stage III larynx, 89% versus stage IVA larynx, 85% (P = 0.33); stage III oropharynx/hypopharynx, 76% versus stage IVA oropharynx/hypopharynx, 79% (P = 0.72). Local-regional control rates steadily declined as the number of indications for administering postoperative RT increased. Five-year absolute survival rates versus pathologic AJCC stage for the entire group were: stage III 59% and stage IVA 40% (P = 0.40). CONCLUSION: Rates of local-regional control, survival, and complications support the use of postoperative radiation in selected patients. Tumor control and survival will hopefully improve further with the addition of chemotherapy to postoperative radiation.

Postoperative radiotherapy for squamous cell carcinoma of the head and neck.

This review discusses the role of postoperative radiotherapy (RT) for patients with squamous cell carcinoma of the head and neck. Patients with unfavorable pathologic features have a high-risk of local-regional recurrence and a decreased likelihood of survival after surgery alone. Postoperative RT reduces the risk of local-regional failure and probably improves survival. Patients who are at high risk for recurrence may benefit from more aggressive altered fractionation schedules to decrease the overall time from surgery to the completion of RT. Adjuvant cisplatin-based chemotherapy also appears to improve the probability of cure in high-risk patients.

Definitive radiotherapy for tonsillar squamous cell carcinoma.

PURPOSE: The purpose of this study is to update our experience with definitive radiotherapy (RT) for carcinoma of the tonsillar area. PATIENTS AND METHODS: There were 503 patients treated between October 1964 and May 2003 (potential follow-up for at least 2 years). Of these, 198 patients underwent a planned neck dissection and 57 patients received induction (18 patients) or concomitant (39 patients) chemotherapy. RESULTS: The 5-year local control rates were as follows: T1, 88%; T2, 84%; T3, 78%; and T4, 61%. Multivariate analysis revealed that local control was significantly influenced by T stage, primary site, and fractionation. Local control after RT for early stage cancers was higher for tonsillar fossa/posterior pillar tumors than for those arising from the anterior tonsillar pillar. The 5-year cause-specific survival rates were as follows: I, 100%; II, 86%; III, 84%; IVA, 73%; and IVB, 46%. Multivariate analysis revealed that cause-specific survival was significantly influenced by T stage, overall stage, neck dissection, race, and gender. The incidence of severe late complications was 9%. CONCLUSION: Based on our data and a review of the literature, definitive RT provides cure rates that are as good as those after surgery, and is associated with a lower rate of severe complications. Patients with lateralized tumors may be safely treated with ipsilateral field arrangements. Our limited experience with intensity modulated radiotherapy suggests that it is as efficacious as conventional RT.

Postradiotherapy neck dissection for lymph node-positive head and neck cancer: the use of computed tomography to manage the neck.

PURPOSE: To determine how to use node response on computed tomography (CT) to indicate the need for neck dissection. PATIENTS AND METHODS: Five hundred fifty patients with lymph node-positive head and neck cancer were treated between 1990 and 2002 with radiotherapy (RT) at a median dose of 74.4 Gy; 24% of these patients (n = 133) were treated with chemotherapy. Three hundred forty-one patients (62%) underwent planned post-RT neck dissection. Physical examination and contrast-enhanced CT were performed 30 days after completion of RT. CT images were reviewed in 211 patients for lymph node size (largest axial dimension) and presence of a focal abnormality (lucency, enhancement, or calcification). By correlating post-RT CT to neck dissection pathology, criteria associated with a low likelihood of residual disease were identified. A subset of patients who fit these criteria of radiographic response who did not undergo post-RT neck dissection was observed for recurrence. RESULTS: Radiographic complete response (rCR) was defined as the absence of any large (> 1.5 cm) or focally abnormal lymph node. Correlation of response with neck dissection pathology indicated a negative predictive value of 77% for complete clinical response and 94% for rCR. In 32 patients (median follow-up time, 3.2 years) with rCR who did not undergo post-RT neck dissection, the 5-year ultimate neck control rate (100%) and cause-specific survival rate (72%) were not significantly different from the rates of patients with a negative post-RT neck dissection. CONCLUSION: Patients with rCR 4 weeks after RT can be spared from a post-RT neck dissection regardless of initial node stage.

Sinonasal undifferentiated carcinoma.

PURPOSE: The purpose of this paper is to discuss the treatment and outcomes for patients with sinonasal undifferentiated carcinoma. METHODS: Review of the pertinent literature. RESULTS: Most series contain a limited number of patients treated with various combinations of surgery, radiotherapy (RT), and chemotherapy. Follow-up periods for disease-free patients are sometimes relatively short. The majority of patients present with locally advanced tumors; 10% to 30% have clinically positive regional nodes. The risk of local-regional recurrence after treatment is probably 20% to 30% or higher, depending on the extent of disease. The likelihood of distant dissemination is approximately 25% to 30% and the cure rate varies from roughly 20% to 50%. Better outcomes are observed in patients treated with craniofacial resection combined with pre- or postoperative RT alone or with adjuvant chemotherapy. This is probably due, in part, to selection bias. Patients with incompletely resectable tumors are best treated with definitive RT and adjuvant chemotherapy. CONCLUSION: The optimal treatment is craniofacial resection combined with adjuvant RT alone or with chemotherapy. The risk of relapse is relatively high and the probability of cure is modest. Patients with incompletely resectable tumors may sometimes be cured with definitive chemoradiation.

Definitive radiotherapy for squamous cell carcinoma of the base of tongue.

OBJECTIVE: To evaluate definitive radiotherapy (RT) for treatment of base of tongue cancer. METHODS: There were 333 patients with squamous cell carcinoma of the base of tongue treated with definitive RT and had follow-up from 0.2 to 26.2 years. Follow-up on living patients ranged from 1.2 to 26.2 years (median, 6.6 years). RESULTS: Local control rates at 5 years were: T1, 98%; T2, 92%; T3, 82%; and T4, 53%. The 5-year rates of local-regional control rates were: I-II, 100%; III, 82%; IVA, 87%; and IVB, 58%. The rates of absolute and cause-specific survival at 5 years were as follows: I-II, 67% and 91%; III, 66% and 77%; IVA, 67% and 84%; and IVB, 33% and 45%. Severe complications developed in 52 patients (16%). CONCLUSION: Our data and review of the pertinent literature reveal that the local-regional control rates and survival rates after RT were comparable to those after surgery, and the morbidity associated with RT was less.

External beam radiotherapy for differentiated thyroid cancer.

PURPOSE: To evaluate the efficacy of external beam radiation therapy (EBRT) for differentiated thyroid carcinomas. METHODS: Forty-two patients with a locally advanced or recurrent differentiated thyroid carcinoma received high-dose EBRT. Thirty-three patients had local-regional disease and 9 patients also had asymptomatic disease metastases. Twenty patients (48%) had macroscopic local-regional disease before EBRT. RESULTS: The 5-year outcomes for the overall population and for the subset of those without distant metastases before EBRT were local-regional control (88% and 89%, respectively), cause-specific survival (80% and 86%, respectively), and overall survival (54% and 60%, respectively). Local-regional control was improved for patients with microscopic residual disease compared with macroscopic disease, those with previously untreated tumors, and for those who received more than 64 Gy. CONCLUSION: EBRT increases the likelihood of local-regional control for patients with locally advanced differentiated thyroid carcinoma.

Head and neck mucosal melanoma.

PURPOSE: The purpose of this article is to discuss the optimal treatment and outcomes for head and neck mucosal melanoma. METHODS: Review the pertinent literature. RESULTS: Head and neck mucosal melanoma is a rare entity comprising less than 1% for all Western melanomas. It usually arises in the nasal cavity, paranasal sinuses, and oral cavity. The optimal treatment is surgery. The likelihood of local recurrence after resection is approximately 50%. Radiotherapy (RT) reduces the likelihood of local failure but probably does not enhance survival, which is primarily impacted by advanced T stage and the presence of regional metastases. The 5-year survival rates vary from approximately 20 to 50%. Although the median time to relapse is roughly 1 year or less, late failures are common and cause-specific survival continues to decline after 5 years. CONCLUSION: The optimal treatment is surgery. Postoperative RT improves local-regional control but may not impact survival. Definitive RT may occasionally cure patients with unresectable local-regional disease or at least provide long-term palliation.

Adult head and neck soft tissue sarcomas.

PURPOSE: To analyze the outcomes of adult patients with head and neck soft tissue sarcomas. METHODS: Review of 39 patients treated with radiotherapy (RT) alone (6 patients) or combined with surgery (33 patients) with curative intent between December 1966 and February 2003. Follow-up for living patients ranged from 1 to 21 years (median, 8.7 years). RESULTS: Five-year outcomes were as follows: local control, 78%; distant metastasis-free survival, 85%; cause-specific survival, 69%, and overall survival, 63%. Three of 6 patients (50%) treated with definitive RT were locally controlled compared with 27 of 33 patients (82%) treated with surgery and RT. CONCLUSIONS: Approximately two thirds of patients with head and neck soft tissue sarcomas are cured with RT alone or combined with surgery. Local recurrence is a significant mode of treatment failure. Outcome is influenced by tumor extent, histologic grade, and resectability.

Radiotherapy alone or combined with surgery for salivary gland carcinoma.

BACKGROUND: The authors analyzed the outcomes of patients treated with radiotherapy (RT) alone or combined with surgery for carcinoma of the salivary glands. METHODS: Between October 1964 and June 2003, 224 previously untreated patients were treated with curative intent with RT alone (n = 64) or combined with surgery (n = 160) at the University of Florida College of Medicine (Gainesville, FL). The median follow-up period was 5.0 years (range, 0.4-31.6 years). RESULTS: The 10-year local control rate was 75%. Multivariate analysis of local control revealed that T classification (P < 0.0001) and treatment group (P < 0.0001) impacted this end point. Patients treated with surgery and adjuvant RT had improved local control compared with patients treated with RT alone. The 10-year locoregional control rate was 68%. Multivariate analysis of locoregional control revealed that overall stage (P < 0.0001) and treatment group (P = 0.0002) significantly influenced this end point. The 10-year distant metastasis-free survival rate was 68%. Multivariate analysis of distant metastasis-free survival revealed that overall stage (P < 0.0001) significantly influenced this end point. The 10-year cause-specific and overall survival rates were 57% and 44%, respectively. Multivariate analysis of cause-specific survival revealed that overall stage (P < 0.0001) significantly impacted this end point. Twenty-three patients (10%) experienced severe complications. CONCLUSIONS: A substantial proportion of patients with salivary gland carcinoma were cured with surgery combined with adjuvant RT. RT alone was used for patients with unresectable tumors and cured approximately 20% of those with advanced-stage disease. The probability of cure was influenced by the extent of disease and treatment group.

Retromolar trigone squamous cell carcinoma treated with radiotherapy alone or combined with surgery.

BACKGROUND: Treatment outcomes were analyzed for retromolar trigone squamous cell carcinoma. METHODS: Between June 1966 and August 2003, 99 patients were treated with radiotherapy alone (35 patients) or radiotherapy combined with surgery (64 patients). Followup ranged from 0.2 to 23.8 years (median, 3.3 yrs). All living patients had followup for at least 1 year. RESULTS: The 5-year local-regional control rates after definitive radiotherapy versus surgery and radiotherapy were as follows: Stages I-III, 51% and 87%; Stage IV, 42% and 62%; and overall, 48% and 71%, respectively. The 5-year cause-specific survival rates after definitive radiotherapy compared with surgery and radiotherapy were as follows: Stages I-III, 56% and 83%; Stage IV, 50% and 61%; and overall, 52% and 69%, respectively. Multivariate analyses revealed that the likelihood of cure was better with surgery and radiotherapy compared with definitive radiotherapy. CONCLUSIONS: The likelihood of cure after treatment for retromolar trigone squamous cell carcinoma was influenced by the extent of disease and treatment. Patients treated with surgery and radiotherapy had a better outcome than those treated with radiotherapy alone.