John W. Werning

Radiotherapy alone or combined with surgery for adenoid cystic carcinoma of the head and neck

The purpose of this study was to analyze the results of radiotherapy (RT) alone or combined with surgery for adenoid cystic 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.

Diagnostic evaluation of squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site

To discuss our experience with the diagnostic evaluation in patients with squamous cell carcinomas (SCCAs) of the head and neck metastatic to the cervical lymph nodes from an unknown primary site.

POSTOPERATIVE IRRADIATION FOR SQUAMOUS CELL CARCINOMA OF THE ORAL CAVITY: 35-YEAR EXPERIENCE

The purpose of this study was to analyze factors influencing outcome in patients who received postoperative irradiation for advanced squamous cell carcinoma of the oral cavity.

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.

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.

ADULT HEAD AND NECK SOFT TISSUE SARCOMAS

The purpose was to determine the optimal treatment for adult patients with head and neck soft tissue sarcomas.

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.

Salivary Gland Pleomorphic Adenoma

We discuss the optimal treatment and outcomes for pleomorphic adenoma of the salivary glands by reviewing the pertinent literature. Pleomorphic adenoma is the most common benign salivary gland neoplasm. It is found mostly in the parotid gland in middle-aged women. It progresses slowly and, left untreated, can produce significant morbidity and, rarely, death. The optimal treatment is superficial or total parotidectomy with facial nerve preservation, which results in local control rates of 95% or higher. Radiotherapy (RT) is useful to obtain local control in patients with positive margins, unresectable tumors, and multifocal recurrences after prior resection. Local control rates after RT for microscopic and gross residual tumor are approximately 80% to 85% and 40% to 60%, respectively. The main complication is surgically induced 7th nerve injury. Surgery is the mainstay of treatment and results in a very high cure rate. RT increases the likelihood of local control in the small subset of patients with incompletely resectable tumors and/or multifocal recurrences.

Cutaneous squamous cell carcinoma metastatic to parotid-area lymph nodes.

Introduction: Metastatic spread to parotid‐area lymph nodes (PALN) occurs in 1% to 3% of patients with cutaneous squamous cell carcinoma of the head and neck. Presented herein is the University of Florida experience using radiation therapy (RT) to treat patients with PALN metastases from a skin primary.