Search

We compared concurrent combination chemotherapy and radiotherapy with surgery and adjuvant radiotherapy in patients with stage III/IV nonmetastatic squamous cell head and neck cancer. Patients with non-nasopharyngeal and nonsalivary resectable squamous cell head and neck cancer were randomised to receive either surgery followed by adjuvant radiotherapy (60 Gy over 30 fractions) or concurrent combination chemotherapy and radiotherapy (66 Gy in 33 fractions). Combination chemotherapy comprised two cycles of i.v. cisplatin 20 mg m(-2) day(-1) and i.v. 5-fluorouracil 1000 mg m(-2) day(-1), both to run over 96 h given on days 1 and 28 of the radiotherapy. A total of 119 patients were randomised. At a median follow-up of 6 years, there was no significant difference in the 3-year disease-free survival rate between the surgery and concurrent chemoradiotherapy (50 vs 40% respectively). The overall organ preservation rate or avoidance of surgery to primary site was 45%. Those with laryngeal/hypopharyngeal disease subsite had a higher organ-preservation rate than the rest (68 vs 30%). Combination chemotherapy and concurrent irradiation with salvage surgery was not superior to conventional surgery and postoperative radiotherapy for resectable advanced squamous cell head and neck cancer. However, this form of treatment schedule with a view to organ-preservation can be attempted especially for those with laryngeal/hypopharyngeal and possibly oropharyngeal disease subsites.

Introduction: Data on combined modality treatment for locally advanced squamous cell carcinoma of the oesophagus involving Asian patients are limited., Materials and Methods: A retrospective study of 56 consecutive patients with this condition treated with concurrent chemoradiotherapy followed by surgery in a single tertiary institution in Singapore was performed., Results: The median overall survival of the entire cohort was 14.1 months [95% confidence interval (CI); range, 8.6 to 19.6 months]. In patients who underwent successful oesophagectomy after chemoradiotherapy (n = 17), the median survival was 27.8 months compared to 9.8 months for those who did not have surgery (n = 39) (P = 0.046, log-rank test). The median time to first relapse for the entire cohort was 16.1 months (95% CI, 7.7 to 24.5 months). The time to first relapse was 23.9 months in the subgroup of patients with successful surgery and 12.1 months in the group which did not (P = 0.147, log-rank test). The high proportion of patients who were medically unfit for surgery or declined surgery may have conferred a selection bias., Conclusion: Concurrent chemoradiotherapy followed by surgery is feasible in selected patients. The benefit of adding of surgery to chemoradiotherapy is still controversial and we await the results of randomised controlled trials comparing chemoradiotherapy with surgery versus chemoradiotherapy alone.

Introduction: The 5-year survival rate after resection of oesophageal cancer is still poor, reported to be between 5% to 34% in the literatures. We conducted this retrospective study to determine the prognostic factors and long-term survival rate for surgical resection of oesophageal carcinoma in Singapore., Materials and Methods: Sixty-seven consecutive patients who underwent surgical resection of oesophageal carcinoma from January 1989 to December 1996 were reviewed., Results: Majority of the patients were Chinese (94%), males (81%) with a history of dysphagia (96%), cigarette smoking (84%) and alcohol ingestion (58%). The median age at surgery was 63.6 (range 29 to 81) years. Sixty-four patients had squamous cell carcinoma of the oesophagus and 3 patients had adenocarcinoma. The lower one-third of the oesophagus was the most common site (48.6%) followed by the middle third (46%). Postoperative complications included pneumonia (43.3%), vocal cord paralysis/paresis (19.4%) and anastomotic leakage (17.9%). Thirty-day postoperative mortality was 7.5%. There was an almost equal number of patients undergoing transhiatal (34 patients) and transthoracic approach (33 patients). There was no significant difference in postoperative complications and survival outcome for both approaches. The median survival was 15.3 months after surgery. Tumour features such as depth of involvement and TNM stage were useful in predicting survival (P < 0.05, log-rank test)., Conclusions: We conclude that the poor outcome of surgical resection (5-year survival rate was 18% by Kaplan-Meier survival plots) was mainly attributed to late presentation (80% patients had T3 or T4 tumour).

The nasolabial flap was used in 11 patients for reconstruction of moderate sized intra-oral defects. There was minimal morbidity of donor and recipient sites in terms of function and cosmesis. The flap was easily harvested, with a reduction in operating time. The superb vascularity and reliability of the flap was demonstrated by the fact that it was possible to use this flap even after a radical neck dissection had been performed on the same side or after radiotherapy. This article describes the authors' experience with the use of the subcutaneously-pedicled, inferiorly-based, double-staged nasolabial flap for intra-oral reconstruction.

A consecutive series of 78 patients who underwent conservation surgery for squamous cell carcinoma of the supraglottic larynx is analyzed. The majority of the patients were middle-aged men who had early-stage disease, with only 18 patients in stage III and 6 in stage IV. The epiglottis was the most frequent site, followed by the aryepiglottic fold and other sites in the supraglottic larynx. There was no operative mortality and the complication rate was low. Univariate analysis showed no influence of tumor stage, tumor differentiation, or involved surgical margins on survival. Determinate survival rates of 85 percent at 3 years and 72 percent at 5 years were observed. Local recurrences took place in 12 patients, 4 of whom were salvaged by total laryngectomy; neck failure occurred in 13 patients, 7 of whom were salvaged after further treatment; and 1 of the 2 patients with distant metastasis was salvaged after further treatment. We believe that every patient with a favorable lesion of the supraglottic larynx should be considered for conservation surgery, specifically, supraglottic partial laryngectomy, adhering to the criteria mentioned. Initial surgical treatment offers excellent local control and 5 year survival. Adjuvant postoperative radiotherapy may be considered in those patients with bulky primary tumors, positive surgical margins, and histologically confirmed cervical lymph node metastases.

Two hundred fifty radical neck dissections, undertaken for mucosal squamous carcinomas of the head and neck, were reviewed with reference to pathological findings and their clinical implications. No major differences in descriptive surgical pathology were established between irradiated and non-irradiated resections. In general, irradiated dissections had lower total node counts and somewhat fewer nodal metastases involving a smaller number of different nodal groups. The topography of nodal deposits was similar in irradiated and non-irradiated resections. Palpable keratin granulomas (without intact tumor) were almost confined to irradiated patients. Transcapsular spread of tumor from involved lymph nodes was common: it was demonstrated in 160/188 'positive' dissections (85%) and was subclassified as 'macroscopic' in 90 and 'microscopic' in 70. The incidence and extent of transcapsular spread was similar in irradiated and nonirradiated resections. It was more frequently observed in association with large nodal masses but it was also regularly found with small nodal deposits less than 3 cm in diameter. Statistical analyses showed strong associations (p less than 0.0005) between the presence and/or extent of transcapsular spread and subsequent recurrence in the operated neck and overall survival. The predictive value of other clinical and pathological features vis-a-vis local neck recurrence such as numbers of involved nodal groups was weaker. Macroscopic transcapsulr spread emerges as the major prognostic factor for recurrent disease in the neck (p less than 0.0001). Attention is drawn to the advantages of accurate descriptive categories ('macroscopic', 'microscopic') for this critical prognostic feature.

This study retrospectively analyzed 105 patients with squamous carcinoma of the nasal cavity and paranasal sinuses. The primary tumor was located in the maxillary sinus in 65 patients (62 percent), the nasal cavity in 27 (26 percent), the ethmoid sinus in 11 (10 percent), and the sphenoid sinus in 2 (2 percent). Over half of the patients with antral cancer were treated with surgery and radiotherapy, whereas one-third of the remaining patients received combination therapy. Most procedures were radical, including sacrifice of the orbital contents in half of the surgically treated patients. The 5-year determinate cure rate was 45 percent for patients with nasal cavity tumors, 38 percent for those with maxillary sinus lesions, and 13 percent for those with ethmoid tumors. Local recurrence remains a major problem despite aggressive surgery and increased use of adjunctive radiotherapy.

The occurrence and prognostic implications of perineural spread were examined in 239 patients with mucosal squamous carcinomas of the head and neck. Perineural spread was demonstrated in resections from 64 patients (27%), the majority having primary tumors at one of three sites: buccal cavity, larynx, and pharynx. Perineural spread near nodal metastases was uncommon. There was no evidence that perineural involvement was more commonly associated with large tumors or less differentiated ones. No association was established between perineural spread and coexistent lymph node deposits in the surgical resections. Perineural spread was, however, shown to be a statistically significant prognostic factor for an increased incidence of subsequent locoregional recurrence and for decreased survival.

The radiologic and histologic features of mandibular invasion, and its clinical implications, are considered in a retrospective series of 111 patients with squamous carcinomas of the oral cavity and oropharynx treated by composite resection. Eighty percent of the entire group had either recurrent or advanced (T3, T4) local disease, and 33 patients (30%) had histologic evidence of mandibular invasion by tumor. Preoperative radiologic assessment was unreliable in cases in which infiltrating tumor was confined to the periosteum and superficial cortex-44% false negatives. The extent of bone invasion was found to correlate with the size of the tumor, but not with its histologic grade. The mandibular periosteum was not seen as a morphologically discrete "barrier" and infiltration occurred at various points along the mandibular body, mainly related to the course of the inferior dental canal. The gross and microscopic patterns of bone invasion appeared to be similar in irradiated and nonirradiated resections. The incidence and pattern of recurrent disease following composite resection was the same in the groups with and without mandibular invasion: in each group half the patients were dead from disease and one third alive and free of disease at 2 years. Mandibular invasion alone did not appear to influence prognosis in this series.

The incidence, extent, and selected clinicopathologic correlations of transcapsular spread from metastatic tumor in the cervical lymph nodes have been investigated in 210 specimens obtained by radical neck dissection from 203 patients with squamous cell carcinomas of the head and neck. Transcapsular spread was detected in 137 of 159 (86 percent) positive specimens, and classified as macroscopic in 74 (54 percent) and microscopic in 63 (46 percent). Macroscopic transcapsular spread was seen most frequently in association with large nodal masses more than 3 cm in diameter (48 of 70 specimens, 69 percent), but also occurred in some specimens with smaller lymph nodes less than 3 cm in diameter (26 of 67 specimens, 39 percent). Anatomic structures most commonly invaded in areas of neck dissection with macroscopic spread from nodal metastases were skeletal muscle (39 dissections) and the adventitial coat of the internal jugular vein (27 dissections). Macroscopic transcapsular infiltration was associated with a high incidence (44 percent) of recurrent tumor in the ipsilateral neck, particularly within 12 months of surgery. Microscopic transcapsular growth was associated with a lower incidence (25 percent) of recurrent tumor in the ipsilateral neck but the difference did not reach statistical significance. Similar recurrence figures (32 percent) were found in the minority of patients whose nodal disease was intracapsular at the time of neck dissection. More precise definition of the morphologic extent of transcapsular spread could be important in clarifying its clinicopathologic correlations.

We reviewed a 20-year experience with squamous carcinoma of the gums in 347 patients who received definitive therapy. More than three-quarters of the lesions involved the lower gum and all but 37 patients were previously untreated. The proportion of patients with localized tumors (N0) remained the same (64 percent). Surgery continued to be the treatment of choice in 97 percent of patients, but proportionately more patients had a more conservative procedure which preserved lower jaw continuity. The 5-year determinate survival rate was little changed (54 percent). Advanced clinical stage (stages III and IV), prior dental extraction, bone invasion, and involvement of surgical margins were predictive of a lower survival rate on univariate analysis. Clinical stage was the only significant predictor of survival on multivariate analysis. The impact of adjunctive radiotherapy could not be assessed.

A pilot study was carried out to assess the value of a radiolabeled antibody against epidermal growth factor receptor (EGFR1) in localizing tumors in patients with squamous carcinomas of the head and neck. Positive images of large tumours (greater than 3 cm diameter) were obtained in 8 of 11 patients after intravenous administration of 111indium-labeled EGFR1. Two patients gave equivocal results, while negative scans were obtained from the patient with the smallest tumor (1 cm diameter). There were no false-positive images. The success of this study in localizing relatively large squamous carcinomas indicates that the antibody should be evaluated in patients with smaller tumors to establish the limits of detection of the technique.

Total glossectomy is a procedure based on sound oncologic principles, and its usefulness may not be fully appreciated. Given the dimensions of the tongue and the need to obtain a wide margin of resection, this procedure may be indicated in selected T3 lesions and recurrences after irradiation. The procedure offers excellent palliation of pain, and form and function may be preserved by rim mandibulectomy when indicated. New reconstructive techniques allow for speedier recovery. Aspiration need not be a complication of total glossectomy if care is taken to preserve the superior laryngeal nerve. Speech rehabilitation plays an important role in returning these patients to their normal environment. Overall 1 and 3 year disease-free survival rates have been encouraging.