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For patients with stage III through IVB head and neck squamous cell carcinoma (HNSCC), concurrent high-dose cisplatin plus radiation therapy is a widely accepted standard of care. HNSCC tumors that express high levels of vascular endothelial growth factor have been associated with a worse prognosis, and bevacizumab may sensitize tumors to cisplatin and radiation.Planned treatment consisted of definitive intensity-modulated radiation therapy (IMRT) (total, 70 grays) with concurrent cisplatin (50 mg/m(2) on days 1, 2, 22, 23, 43, and 44) and bevacizumab (15 mg/kg on days 1, 22, and 43). The primary endpoint was 2-year progression-free survival (PFS), and overall survival (OS) was a secondary endpoint.Forty-two previously untreated patients (34 men and 8 women; median age, 55 years; range, 27-75 years) with stage III through IV HNSCC without distant metastasis (oropharyngeal carcinoma, 39 patients; laryngeal carcinoma, 3 patients) were treated. Human papillomavirus (HPV) status by was determined by in situ hybridization (HPV positive, 16 patients; HPV negative, 14 patients, unknown HPV status, 12 patients). The toxicities (determined according to version 3.0 of Common Terminology Criteria for Adverse Events Common) that were experienced by all patients (any grade) were mucositis, lymphopenia, leukopenia, throat pain, fatigue, and anemia. There were 2 treatment-related deaths, including 1 sudden death and 1 death from aspiration pneumonia. The median follow-up was approximately 31.8 months (range,3 to 51 months). The 2-year PFS rate was 75.9% (95% confidence interval, 63.9%-90.1%), and the 2-year OS rate was 88% (95% confidence interval, 78.6%-98.4%). Among 32 patients for whom post-treatment Head and Neck Performance Status Scores were obtained (median, 5.6 months after completing radiation therapy), scores of 100 for eating, speech, and diet, respectively, were recorded among 75%, 84%, and 50% of patients.The addition of bevacizumab to high-dose cisplatin plus IMRT did not appear to increase toxicity to unacceptable levels among patients with HNSCC, and the efficacy results were encouraging.

Retinoblastoma is the most common primary cancer of the eye in children. The incidence of second tumors in survivors of bilateral retinoblastoma and in survivors of unilateral retinoblastoma who presumably carry a germline RB1 mutation is documented. This article describes the previously unrecognized association of sinonasal adenocarcinoma as a second malignancy in retinoblastoma survivors. We present three cases who received radiation therapy as a part of their treatment and developed sinonasal adenocarcinoma as a second malignancy. Sinonasal adenocarcinoma should be considered as a second malignancy in retinoblastoma survivors who present with vague sinus symptoms.

BACKGROUND The objectives of the current study were to report the incidence of postoperative complications for salvage total laryngectomy (STL) compared with primary total laryngectomy (PTL) and to identify patient and tumor-related factors predictive of postoperative complications. METHODS A sample of 183 patients who had received a total laryngectomy were identified from an existing database of 662 patients treated for squamous cell carcinoma of the larynx. PTL and STL were performed in 113 and 70 patients, respectively. Initial therapy in the patients who required salvage surgery included radiotherapy (RT) in 32 (46%) and chemoradiotherapy (CTRT) in 38 (54%). Postoperative complications were recorded for each group and categorized into local, swallowing, airway, and systemic complications. Postoperative complication rates for STL after RT and CTRT were compared with those after PTL by univariate analysis. Patient and tumor-related predictors of complications were identified by univariate and multivariate analyses. RESULTS The overall mortality rate was 0.5%. Forty percent of all patients developed a postoperative complication after total laryngectomy. Local complications, which were the most frequent, occurred in 52 (28%) patients. Pharyngocutaneous fistula occurred in 31 (17%) patients. Statistical analysis showed that there was a greater number of patients with local wound (45% vs. 25%, P = 0.02) and fistula complications (32% vs. 12%, P = 0.012) in the STL-CTRT group compared with the primary laryngectomy group. Multivariate analysis showed that primary CTRT was an independent predictor of local complications and pharyngocutaneous fistula. CONCLUSIONS Salvage laryngectomy was more frequently associated with postoperative complications after CTRT compared with PTL. Problems related to local wound healing, especially the development of pharyngocutaneous fistula, constituted the most common postoperative complication in these patients. Multivariate analysis showed that primary CTRT was an independent predictor of local wound complications and pharyngocutaneous fistula. Cancer 2005. © 2005 American Cancer Society.

We report two patients with leptomeningeal metastases from squamous cell cancer of the skin. In one patient cauda equina metastases appeared 6 years after initial presentation; the tumor from radical neck dissection demonstrated perineural invasion suggesting a possible route for subarachnoid dissemination. The other patient presented 2 years after initial diagnosis with confusion and cranial nerve seven and twelve palsies. Both patients died from complications of leptomeningeal metastases.

Harvey Cushing said “I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work.” He was, of course, the greatest surgeon of his time, someone whose achievements everyone would wish to emulate. In that simple quotation he recognized a major problem that beset the surgeons of his time and those of every successive generation. In other words, how to select the most appropriate treatment for our patients. Now, almost 75 years after Harvey Cushing's death, patients demand the evidence that the treatments we recommend are effective and in their best interests. Our health care systems will not tolerate or fund therapies based on anecdote, treatments that offer little more than hope of a good outcome. For even the most common skull base tumor, vestibular schwannoma, there is no evidence from a randomized controlled trial that surgery is better than stereotactic radiotherapy, radiosurgery, or vice versa. Nevertheless, we practice perfectly ethically identifying those patients for whom treatment rather “watchful waiting” is indicated. We guide our patients in the selection of their treatment while respecting their inherent right to choose. For the majority of patients, recommendations would be based on such factors as tumor size, age, co-morbidities, hearing acuity, balance disturbance, other cranial nerve deficits, and the availability of surgical or radiation oncology expertise. Even with the most common skull base tumor, there are wide variations in clinical practice from country to country and mounting evidence, particularly with small tumors, that practices are changing. How much more difficult it is to recommend treatment for diseases that are not common. Sadly a large number of the skull base tumors fall into this category. For patients with these conditions we rely on inferior levels of evidence often acquired on the basis of data from sites other than the skull base. The time has come to make amends, to use the power of meta-analysis and well-structured systematic reviews of skull base diseases. Only in this way will progress be made, treatment prescribed on the basis of the best possible evidence, and our patients spared the morbidity of ineffective and costly therapy. In time, this might encourage the design of randomized controlled trials of new adjuvant agents that would appeal to and help recruit our patients. The Editorial Board of Skull Base has decided to take a lead on this initiative by commissioning and encouraging systematic reviews on topics that affect everyday skull base practice. These studies will be subject to very critical peer review and so help to form management guidelines for others to follow. “Adenoid cystic carcinoma of the nasal cavity and paranasal sinuses: a meta-analysis” is the first of these papers that will be published in the following months.