C.A. Meeuwis

Reirradiation of recurrent head and neck cancers: external and/or interstitial radiation therapy

Recurrent cancer in the head and neck is not an uncommon clinical problem. The average cure rate of these patients has been reported to vary between 30 and 40% and most failures are due to locoregional relapses. After a previous full course of radiation, surgery is the salvage modality of choice; however, if surgery was not feasible for whatever reason, reirradiation has been offered to some patients. To establish the role of reirradiation in head and neck cancer, we analyzed a 13-year experience with patients reirradiated in the DDHCC. The reirradiation was performed between 1970 and 1980 by means of external beam radiation therapy (ERT series; n = 55) and between 1985 and 1988 by external radiation combined with interstitial radiation therapy (IRT +/- ERT series; n = 18). A minimum follow-up of 3 years was allowed for. An improvement in local control was observed (50% vs. 29%) for the IRT +/- ERT series and the ERT series, respectively. The improvement in local control was not reflected in a survival benefit; i.e. an actuarial overall survival of 20% at 5 years was observed in both series. No treatment-related deaths occurred. However, for the patients that were controlled at the reirradiated site, 28% (4/16 of the ERT series and 3/9 of the IRT +/- ERT series) did experience severe side effects.

Fractionated high-dose-rate and pulsed-dose-rate brachytherapy: First clinical experience in squamous cell carcinoma of the tonsillar fossa and soft palate

PURPOSE Fractionated high-dose-rate (fr.HDR) and pulsed-dose-rate (PDR) brachytherapy (BT) regimens, which simulate classical continuous low-dose-rate (LDR) interstitial radiation therapy (IRT) schedules, have been developed for clinical use. This article reports the initial results using these novel schedules in squamous cell carcinoma (SCC) of the tonsillar fossa (TF) and/or soft palate (SP). METHODS AND MATERIALS Between 1990 and 1994, 38 patients with TF and SP tumors (5 T1, 22 T2, 10 T3, and 1 T4) were treated by fr.HDR or PDR brachytherapy, either alone or in combination with external irradiation (ERT). Half of the patients were treated with fr.HDR, which entailed twice-daily fractions of > or = 3 Gy. The other 19 patients were administered PDR, which consisted of pulses of < or = 2 Gy delivered 4-8 times/day. The median cumulative dose of IRT +/- ERT series was 66 Gy (range 55-73). The results in these patients treated by brachytherapy were compared to 72 patients with similar tumors treated in our institute with curative intent, using ERT alone. The median cumulative dose of ERT-only series was 70 Gy (range 40-77). RESULTS Excellent locoregional control was achieved with the use of IRT +/- ERT, with only 13% (5 of 38) developing local failure, and salvage surgery being possible in three of the latter (60%). Neither BT scheme (fr.HDR vs. PDR) nor tumor site (TF vs. SP) significantly influenced local control rates. The type and severity of the side effects observed are comparable to those reported in the literature for LDR-IRT. These results contrast sharply with our ERT-only series, in which 39% of patients (28 of 72) developed local failure, with surgical salvage being possible only in three patients (11%). Taking the data set of 110 patients, in a univariate analysis IRT, T stage, N stage, overall treatment time (OTT), and BEDcor10 (biological effective dose with a correction for the OTT) were significant prognostic factors for local relapse-free survival (LRFS) and overall survival (OS) at 3 years. Using Cox proportional hazard analysis, only T stage and BEDcor10 remained significant for LRFS (p < 0.001 and 0.008, respectively), as well as for OS (p < 0.001 and 0.003, respectively). With regard to the current (IRT) and historical (ERT) series, for the LRFS at 3 years, dose-response relationships were established, significant, however, only for the BEDcor10 (p = 0.03). CONCLUSION The 3-year LRFS of approximately 90% for TF and SP tumors reported here is comparable with the best results in the literature, particularly given the fact that 30% of the patients (11 of 38) presented with T3/4 tumors. When compared with our historical (ERT-only) controls, the patients treated with IRT had superior local control. A dose-response relationship was established for the BEDcor10.

The Value of Ultrasound With Ultrasound-Guided Fine-Needle Aspiration Biopsy Compared to Computed Tomography in the Detection of Regional Metastases in the Clinically Negative Neck

PURPOSE Head and neck oncologists have not reached consensus regarding the role of contemporary imaging techniques in the evaluation of the clinically negative neck in patients with head and neck squamous cell carcinoma (HNSCC). The purpose of the present study was to compare the accuracy of ultrasound with guided fine-needle aspiration biopsy (UGFNAB) and computed tomography (CT) in detecting lymph node metastasis in the clinically negative neck. METHODS AND MATERIALS Sixty-four neck sides of patients with HNSCC were examined preoperatively by ultrasound/UGFNAB and CT at one of five participating tertiary care medical centers. The findings were correlated with the results of histopathologic examination of the neck specimen. RESULTS Ultrasound with guided fine-needle aspiration biopsy was characterized by a sensitivity of 48%, specificity of 100%, and overall accuracy of 79%. Three cases had nondiagnostic aspirations using UGFNAB and were excluded. CT demonstrated a sensitivity of 54%, specificity of 92%, and overall accuracy of 77%. UGFNAB detected two additional metastases not visualized on CT, whereas CT detected no metastases not seen on UGFNAB. The results of UGFNAB were similar between the participating centers. CONCLUSIONS Approximately one half of the clinically occult nodal metastases in our patient group were identified by both CT and UGFNAB. Overall, UGFNAB and CT demonstrated comparable accuracy. The sensitivity of CT was slightly better than UGFNAB, but the latter remained characterized by a superior specificity. The results of CT and UGFNAB did not appear to be supplementary. The choice of imaging modality for staging of the clinically negative neck depends on tumor site, T-stage, and experience and preference of the head and neck oncologist. If CT is required for staging of the primary tumor, additional staging of the neck by UGFNAB does not provide significant additional value.

Patient participation in clinical decision-making for treatment of T3 laryngeal cancer: a comparison of state and process utilities.

PURPOSE To study the use of two different approaches, and feasibility of four commonly used utility assessment methods to assess preferences for treatment of T3-laryngeal cancer by surgery or radiation therapy (RT). METHODS Utility assessment methods, namely, time trade-off (TTO), standard reference gamble (SRG), rating scale (RS), and direct comparison (DC), were used to assess utilities in two groups of former cancer patients (n = 10 for both), a group of clinicians (n = 9), and a group from the general population (n = 10). For the treatment modalities, ie, surgery and RT, two types of scenarios were developed and used: the state scenario, which describes a stable health state after treatment, and the process scenario, which describes a dynamic process. First, utilities were assessed based on state scenarios. Next, respondents were thoroughly informed and educated with respect to the relevant aspects of both treatment modalities. Subsequently, utilities were again assessed, but now based on the process scenarios. The outcome of each approach was calculated and expressed in a quality-adjusted life-expectancy (QALE) score for each treatment modality, and the treatment with the highest outcome was said to be the preferred treatment modality. RESULTS In general, a higher QALE score for each treatment modality was found for clinicians and for the general population as compared with the former-cancer-patient groups. When the outcome of both approaches was compared on an individual level dependent on the utility assessment method, 32% to 43% of respondents showed an inconsistent treatment preference. CONCLUSION The approach to assess utilities and the extent to which respondents are informed about treatment modalities have a major effect on individual treatment preferences.

NUT Midline Carcinoma of the Parotid Gland With Mesenchymal Differentiation

Nuclear protein in testis midline carcinomas (NMC) are highly aggressive carcinomas typically arising in midline structures in young individuals. These carcinomas are characterized by the presence of a chromosomal rearrangement of nuclear protein in testis the (NUT) gene on chromosome 15 (15q14), resulting from a chromosomal translocation most commonly involving the BRD4 gene on chromosome 19p13. Rarely, in about 1/3 of cases, other translocation partners are involved (termed NUT-variants). Most cases have involved midline structures and with few exceptions were located in the upper aerodigestive tract and the mediastinum. Except for a single case, all reported NMC have been fatal, proving resistant to multimodality treatment. We report an exceptional case of a NMC presenting outside of midline structures in the parotid gland and showing mesenchymal chondroid differentiation in a 15-year-old male. The presence of the t(15;19) chromosomal translocation in the chondroid component was confirmed by fluorescence in situ hybridization analysis and immunohistochemical staining, indicating mesenchymal transdifferentation of the tumor. The findings demonstrate the first case of NMC arising within salivary gland, and the first example of mesenchymal differentiation in this group of tumors.

A new applicator design for endocavitary brachytherapy of cancer in the nasopharynx

INTRODUCTION In attempting to improve local tumor control by higher doses of radiation, there has been a resurgence of interest in the implementation of brachytherapy in the management of primary and recurrent cancers of the nasopharynx. Brachytherapy with its steep dose fall-off is of particular interest because of the proximity of critical dose limiting structures. Recent developments in brachytherapy, such as the introduction of pulsed-dose-rate and high-dose-rate computerized afterloaders, have encouraged further evolution of brachytherapy techniques. MATERIALS AND METHODS We have designed an inexpensive, re-usable and flexible silicone applicator, tailored to the shape of the soft tissues of the nasopharynx, which can be used with either low-dose-rate brachytherapy or high (pulsed)-dose-rate remote controlled afterloaders. RESULTS AND CONCLUSIONS This Rotterdam nasopharynx applicator proved to be easy to introduce, patient friendly and can remain in situ for the duration of the treatment (2-6 days). The design, technique of application and the first consecutive 5 years of clinical experience in using this applicator are presented.

Continuity of information in cancer care: evaluation of a logbook

A logbook, or patient-dossier, was developed, to improve continuity of information in the treatment and care of head-and-neck cancer patients. It contained information modules on different aspects of care, as well as forms to facilitate communication both between patient and care-professional and between the various care-professionals. The logbooks effectiveness was evaluated in two hospitals in Rotterdam, by comparing outcomes for trial and comparison groups of, respectively, 71 and 54 patients and 59 and 35 care-professionals. Trial patients proved to be better informed, to receive more support and to experience fewer psychosocial problems. Professionals who used the logbook were better informed about their patients, and about the care-activities of fellow-professionals than those who did not. They recognised an improvement in their contact with colleagues and in the harmonisation of their respective care-activities.

Partial laryngectomy for recurrent glottic carcinoma after radiotherapy

Early laryngeal cancer is treated with surgery or radiotherapy. A partial laryngectomy instead of a total laryngectomy can be used for treating patients with radiation failures.

Surgery for recurrent laryngeal carcinoma after radiotherapy: Partial laryngectomy or total laryngectomy for a better quality of life?

OBJECTIVE To investigate the quality of life after partial laryngectomy versus total laryngectomy for recurrent laryngeal carcinomas after radiotherapy. STUDY DESIGN AND SETTING: A retrospective study performed at least one year after treatment. This study was performed in a university hospital. RESULTS: Twenty-three patients (N = 12 partial laryngectomy, N = 11 total laryngectomy) with recurrent laryngeal cancer after radiotherapy were included in the study. Three different questionnaires, 1) EORTC Quality of Life Questionnaire (QLQ)-C30 Dutch version 3.0, 2) EORTC-H & N 35, and 3) the Voice Handicap Index, were sent to all patients. The only major difference in quality of life of patients after partial laryngectomy versus total laryngectomy was found to be smell and taste related. No other differences were found. CONCLUSION: We did not find much difference in quality of life after treatment with a partial laryngectomy or a total laryngectomy in patients with recurrent laryngeal cancer after radiotherapy.

Evaluation of treatment results of squamous cell carcinoma of the buccal mucosa

Of the 49 patients with squamous cell carcinoma of the buccal mucosa referred to the Rotterdam Radio-Therapeutic Institute (RRTI) and Universital Hospital Dijkzigt Rotterdam (AZD) during 1970-1984, 31 patients had an advanced stage of disease, 21 patients had clinical evidence of lymph node metastasis. Forty patients were treated with curative intention. Treatment modalities were: radiation therapy, preoperative radiation followed by surgery, and primary surgery. Eighteen of the 40 patients (45%) developed a local tumor recurrence; nearly all recurrences occurred within 2 years. The incidence was equal in all treatment groups. Of the 22 patients with initial clinically negative neck, regional relapse occurred in 3 of the 14 patients, of whom the neck was not treated electively by radiation therapy; all three in combination with a local recurrence. None of the 8 patients with electively irradiated necks developed a regional relapse. Eight of the 18 patients with initial clinically enlarged lymph nodes treated either by radiotherapy or surgery, developed a regional relapse, 5 in combination with a local recurrence. Treatment of the clinically positive neck by neck dissection was superior to radiotherapy. Local recurrence carried a poor prognosis. Almost 70% died of their disease. The overall and corrected 5-year survival was 38% and 52% respectively.