Andrew Sizeland

Radiation with concurrent late chemotherapy intensification ('chemoboost') for locally advanced head and neck cancer.

The aim of this study was to review our experience with a treatment regimen that combined conventionally fractionated radiation therapy (70 Gy over 7 weeks) with chemotherapy (cisplatin and fluorouracil), given concurrently in the last 2 weeks of radiation therapy in patients with previously untreated advanced squamous cell cancer of the head and neck region.Twenty-eight patients, all but two having UICC stage IV disease, were treated at the Peter MacCallum Cancer Institute between November 1995 and April 1998. Planned chemotherapy consisted initially of continuous infusion at 10 mg/m(2) per day of cisplatin and 400 mg/m(2) per day of fluorouracil on days 1-5 of weeks 6 and 7 of a conventionally fractionated course of radiotherapy. After the first 14 patients, the dose of fluorouracil was reduced to 360 mg/m(2) per day because of acute toxicity.36.8 months), with an estimated 50% surviving at 2 years (CI, 29-71%). Sixteen patients (57%) developed confluent mucositis and 11 (39%) developed patchy mucositis. The median duration of mucositis for these 27 patients was 1.5 months. Seventeen patients (61%) required nutritional support for a median duration of 1.4 months. Fourteen patients (50%) had grade three skin reactions, and 12 (43%) had one or more other significant (Grade 3) toxicities, predominantly infective. Grade 3 late toxicity has been observed in three patients to date (three xerostomia, including one with severe depression), and one patient had chronic ulceration of the oral tongue (grade 4). This chemoradiation regimen achieved an excellent complete response rate and good locoregional control at 2 years in patients with a poor initial prognosis. Acute toxicity was significant but manageable. The regimen offers an alternative to surgery and postoperative radiation therapy in locally advanced head and neck cancer.

Review: mucosal melanoma of the head and neck.

Head and neck mucosal melanoma (MM) is a rare and aggressive neoplasm, with high rates of local, regional, and distant failure. Owing to the small size of most reported series and their retrospective nature, and the lack of uniform comprehensive staging system, the effect of various treatment strategies on disease control and survival has been difficult to assess. The optimal management of head and neck MM is not well defined. Surgical treatment has being advocated as the primary treatment modality, with growing consideration for postoperative radiotherapy, as wide surgical resection in the head and neck region is often difficult. Radiotherapy is recently reported as a beneficial management modality, regardless of the fact that MM has been considered to be radioresistant. As significant morbidity is expected in high doses of radiotherapy to the head and neck region, new radiographic modalities with better precision are required. Furthermore, high-energy radiotherapy was suggested as a better therapy to mucosal MM due to the suggested biology of the tumor. The high rates of locoregional recurrence and distant metastasis also suggest that a systemic treatment is needed. Currently, there is no role for adjuvant systemic therapy for patients who have been successfully resected, but recent developments in the understanding of the biology of melanoma and, in particular, specific growth pathways holds promise for the future. We strongly recommend further evaluation of the role of chemotherapy and immunotherapy to decrease the rates of distant metastasis and improve survival.

Safety of thromboprophylaxis after oncologic head and neck surgery. Study of 1018 patients.

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are significantly reduced with appropriate use of thromboprophylaxis and scarcely evaluated in patients undergoing oncologic head and neck surgery (OHNS).

Keystone island flap : An alternative reconstructive option to free flaps in irradiated tissue

Background:  The Keystone Flap is an island flap that is very useful for repairing skin defects of the integument. Described as a keystone, this arc‐shaped flap in fact consists of a schematically designed, perforator‐based reconstructive unit which serendipitously resembles two conjoined VY flaps. This facilitates closure because of the multiple VY points at the extremes, where the surrounding tissue is advanced to close the defect while the flap size remains basically static.

Aggressive behavior of cutaneous squamous cell carcinoma in patients with chronic lymphocytic leukemia.

Immunosuppression in organ transplant recipients increases the incidence and aggressiveness of cutaneous squamous cell carcinoma. However, there are little clinical data on cutaneous squamous cell carcinoma in patients with immunosuppression due to chronic lymphocytic leukemia. In this study we evaluated the clinical features, patterns of recurrence, and outcomes of cutaneous squamous cell carcinoma in patients with chronic lymphocytic leukemia.

Treatment outcome of n3 nodal head and neck squamous cell carcinoma

OBJECTIVE The aim of this study was to investigate the treatment outcome of N3 nodal disease. Study design A single institution retrospective nonrandomized study was conducted. A total of 53 patients with primary presentation of squamous cell carcinomas from various head and neck sites from 1980 to 1994 were recruited for this study. Eight patients with nasopharyngeal cancers who underwent treatment with palliative intent were excluded from the study. Treatment options were broadly divided into 4 treatment categories; postoperative radiotherapy; preoperative radiotherapy; surgery alone; and chemotherapy pre- or postoperatively with or without radiotherapy. RESULTS Mean age of the participants was 63 years (SD = 8.2); 93% were men. Median follow-up period was 12 months (range, 5 to 184 months). Of the 45 N3 patients, 21 patients had a recurrence in the neck after treatment, with 1 in the contralateral neck. The overall rates of control in the neck at 1, 3, and 5 years were 73.1%, 34.6%, and 26.9%, respectively. The 1, 3, and 5-year neck control rates for each main group were 92.3%, 46.1%, and 46.1% with postoperative radiotherapy; 66.7%, 33.3%, and 11.1% with preoperative radiotherapy and 33.3%, 0%, and 0% with surgery alone. Overall survival rates at 1, 3, and 5-years were 52.8%, 25%, and 22.2%. Survival rates in those who received radiotherapy were better than those who only had surgery. The 5-year survival rate was significantly higher for those who had postoperative radiotherapy (38.9%) compared with patients who had preoperative radiotherapy (9.1%) and surgery alone (0%). CONCLUSION Our treatment outcomes, particularly those in the group receiving postoperative radiotherapy, were similar to other studies. The prognosis of N3 neck disease was poor but improved with radiotherapy, particularly postoperative radiotherapy. The role of definitive chemotherapy and/or radiotherapy and salvage surgery is difficult to evaluate as the results are inconsistent and the available data are limited. Future studies in particular with quality of life assessment are needed to evaluate the management of N3 head and neck cancer.

Laryngo-pharyngeal carcinoma in childhood

Laryngo-pharyngeal carcinoma is rare in children. We present two cases of squamous cell carcinoma of the laryngopharynx in children less than 15 years of age. Both patients presented with a prolonged history of symptoms and extensive disease at diagnosis. Early visualisation the vocal cords with flexible larygnoscopy is important in children presenting with symptoms suggestive of laryngeal pathology. Long-term complications of definitive local therapy for laryngopharyngeal carcinoma are important in young children. Evidence from studies in adult patients suggests that adjuvant chemotherapy may play a role in laryngeal preservation in a select group of patients.

Bidirectional esophageal dilatation in pharyngoesophageal stenosis postradiotherapy

Severely stenosed radiation‐induced benign strictures around the level of cricopharyngeus post–radical chemoradiation for head and neck or upper esophageal cancers pose significant management problems. We report our technique of bidirectional assessment and dilatation of pharyngoesophageal strictures in patients with an in situ percutaneous endoscopic gastrostomy (PEG) tube. The upper gastrointestinal surgeon approached the area of stenosis in a retrograde manner through the PEG tube to guide the otolaryngeal surgeon who performed anterograde dilatation via a rigid laryngoscope. Between 2005 and 2009, bidirectional esophageal dilatation was performed on 5 patients at our institution. Video fluoroscopy confirmed improved patency of stenosed esophagus in all cases and good improvement in swallowing ability in 4 patients. The ability to accurately assess pharyngoesophageal strictures using bidirectional visualization and transillumination is the key modification of our technique. We suggest using bidirectional esophageal dilatation on difficult cases with severe pharyngoesophageal stenoses although extreme care is required.

Managing regional metastasis in patients with cutaneous head and neck melanoma – is selective neck dissection appropriate?

BACKGROUND Neck dissection is recommended for patients with head and neck cutaneous melanoma and nodal metastasis. However, there appears to be no clear evidence to guide the extent of nodal resection. METHODS Loco-regional recurrence (LR), overall survival (OS) and progression free survival (PFS) was retrospectively compared between patients who had Comprehensive neck dissection (CND) and Selective neck dissection (SND). RESULTS There was no difference in LR, OS and PFS between CND (n=18) and SND groups (n=79). Extra capsular extension (ECE), frontal disease and increasing number of involved nodes resulted in worse OS and PFS but had no impact on LR. CONCLUSION Patients with disease limited to one node without ECE can be effectively treated by SND alone. In patients who have these unfavourable pathological features more extensive nodal resection does not improve outcome if they receive radiotherapy. Extent of neck dissection or adjuvant radiotherapy has no impact on overall survival.

The interpretation of vascular changes observed in keystone island flaps: a hypothesis.

The pathogenesis of augmented vascular perfusion observed in keystone island flaps remain unexplained. In this setting, we refer to excerpts from Baker’s textbook Local Flaps in Facial Reconstruction regarding routine skin flap physiology: ‘Both cutaneous and sympathetic nerves are severed in the process of flap elevation. When a sympathetic nerve is divided, catecholamines are released from the nerve terminal and the mechanism of catecholamine reuptake is eliminated. A local ‘hyperadrenergic state’ exists, which produces vasoconstriction mediated by a-adrenergic receptors in the cutaneous vasculature. The vasoconstricting effect of sympathectomy further reduces the total flap blood flow,