Muhammad Shahid Iqbal

Small Cell Neuroendocrine Carcinoma of the Oropharynx Harbouring Oncogenic HPV-Infection

Small cell carcinoma/neuroendocrine carcinoma (SCNEC) of the oropharynx is uncommon. Recently, an association has been reported between oropharyngeal SCNEC and high-risk human papillomavirus (HPV) infection. While HPV infection confers a better prognosis for oropharyngeal squamous cell carcinoma, HPV infection does not appear to influence the biological behaviour of SCNECs, which are generally associated with poor clinical outcomes. We document two cases of SCNEC arising in the oropharynx with evidence of high-risk HPV infection. The cases highlight the expanding range of malignant oropharyngeal neoplasms that harbour oncogenic HPV infection and support the concept that, irrespective of HPV infection, neuroendocrine differentiation portends a poor prognosis.

Spindle cell carcinoma of the head and neck region: treatment and outcomes of 15 patients

Introduction Spindle cell carcinoma of the head and neck is a rare entity and the evidence of optimal management is lacking. The objective of our study was to report the treatment and outcomes of 15 patients treated in a single institution over a seven year period. Materials and Methods A total of 15 patients (12 males and 3 females) with spindle cell carcinoma of the head and neck were treated between July 2007 to June 2014. In six patients the disease developed after previous radiotherapy. Of the 15 patients, five patients had their primary in the tongue, four in the paranasal sinuses, two in the hypopharynx, two in the vocal cords, and one each in the soft palate and the floor of mouth. Eleven patients were treated with radical intent (seven patients required surgery only and four were treated with combined modality). The remaining four patients were treated with palliative intent. Results Among 11 patients treated with radical intent eight are alive or died of non-oncological causes. The disease recurred locally in three patients and they died of the disease (two patients with locally advanced disease in the tongue and one patient with T1N0 tumour in the hypopharynx). Median overall survival (OS) was 18 months. Conclusion Surgery or surgery combined with radiotherapy has a real impact on the natural cause of spindle cell carcinoma of the head and neck region. Even locally advanced tumours can be controlled with aggressive treatment. The worst outcome is seen with the tongue as the primary site because of a high local recurrence rate.

Maintenance Therapy with Trastuzumab in Her2 Positive Metastatic Parotid Ductal Adenocarcinoma

Salivary ductal carcinomas (SDCs) are extremely rare and aggressive malignancies, accounting for approximately 6% of all salivary gland malignancies. One distinct feature is their resemblance to ductal carcinomas of breast. A significant percentage of SDCs overexpress Her2 and the use of targeted therapy with trastuzumab can be considered in these patients. We report a rare case of long term disease control with trastuzumab in Her2 positive metastatic parotid ductal carcinoma. Our case also highlights that isolated brain metastasis should be managed aggressively to allow optimal local control when systemic disease is under remission with trastuzumab. We have also reviewed the published literature on the use of trastuzumab in SDCs.

Palliative radiotherapy for locally advanced non-metastatic head and neck cancer: A systematic review

OBJECTIVES The objective of this systematic review was to identify and appraise the existing evidence of role of palliative radiotherapy for locally advanced non-metastatic head and neck cancer. METHODS A systematic search of the literature was conducted using Medline, Embase and Cochrane databases and relevant references were included. RESULTS Literature search revealed a wide variation in dose fractionation regimens. Reported outcomes showed high efficacy and low rate of significant side effects, except in studies utilising higher doses of radiotherapy where higher grade toxicities were seen. Reported median overall survival was in the range of 3.3-17 months, but most studies reported median survival of around 6 months. CONCLUSIONS The choice of palliative radiotherapy varies significantly. This is in contrast to regimens of curative radiotherapy for locally advanced head and neck cancer, which are well standardised. Given the reported relatively short overall survival of this patient group, an ideal treatment should be of the shortest possible duration whilst ensuring effective palliation and minimal side effects. Future well designed trials are needed to evaluate quality of life and duration of side effects in addition to survival and severity of toxicities in this group of patients.

Palliative radiotherapy for locally advanced non-metastatic head and neck cancer: A survey of UK national practice

Glossary: TD = total dose [Gy]; d = dose per fraction [Gy]; a/b = alpha beta r fractions [Gy]. As highlighted in our systematic review on palliative radiotherapy for locally advanced head and neck cancer [1], there is a wide variation of dose fractionation regimes. We conducted an email based survey looking at the choice of dose fractionation of palliative radiotherapy in non-metastatic head and neck cancers across the UK. The primary objective was to describe the range of palliative radiotherapy dose fractionation regimens in use for head and neck cancer management across the United Kingdom. Lead clinicians at all 48 UK radiotherapy centres that treat head and neck cancers were approached via email asking their ‘choice of dose/ fractionation for high-dose palliative radiotherapy in non-metastatic head and neck cancers’. Non-responders were sent a reminder. Thirty-four centres (71%) responded. The survey showed a range of dose fractionations (some centres used more than one schedule) varying from 20 Gy in 5 daily fractions to 68 Gy in 34 fractions. The most commonly used regimen

Managing older patients with head and neck cancer: The non-surgical curative approach

Managing older patients with head and neck cancers poses a challenge due to the often reduced levels of physiological reserve, the frequent comorbidities and treatment related toxicity. These factors have implications on speech, breathing and swallowing functions. Treatment management plans in these patients may result in de-intensification strategies and as a result of this, use of non-standard treatments is increasing. There have been published reports that indicate the addition of concurrent systemic therapy to radiation in selected older patients is feasible, and produces outcomes comparable with younger patients. However, some other studies including meta-analyses suggest a lack of real survival benefit with the addition of chemotherapy. So, the key point appears to be the optimal patient selection. Appropriate geriatric and frailty assessments are required to help determine the optimal treatment for older patients with head and neck cancer. Treatment for this population still needs to be well defined and optimized in both modality and intensity. Qualitative studies are also required to address short and long-term post-treatment quality-of-life and survivorship issues in this specific patient population. This review summarizes the evidence available regarding the non-surgical management of older patients with head and neck cancers.

Primary Concurrent Chemoradiation in Head and Neck Cancers with Weekly Cisplatin Chemotherapy: Analysis of Compliance, Toxicity and Survival

Introduction Concurrent chemoradiation is the standard of care in inoperable locally advanced squamous cell head and neck cancers. The most widely accepted schedule of concomitant cisplatin is 100mg/m2 given on a 3 weekly basis but the optimal regime is unknown. Objective The objective of this study is to assess the tolerability, compliance, and clinical outcomes of weekly cisplatin (40mg/m2). Methods During the period of January 2007–December 2009, we analyzed retrospectively 122 patients with histologically proven squamous cell carcinoma of head and neck (nasopharynx, oropharynx, larynx, hypopharynx, and oral cavity) treated with definitive chemoradiation. All patients received 63 Gy in 30 daily fractions with concomitant weekly cisplatin 40mg/m2. We assessed treatment toxicities and patient compliance. We estimated overall survival using the Kaplan-Meier method. Results Sixty-eight percent of patients managed to complete all six cycles of chemotherapy while 87% of patients completed at least 5 cycles of weekly cisplatin. Incidence of grade 3/4 toxicity was as follows: mucositis 33%, dermatitis 41%, dysphagia 15%, mouth/neck pain 17%, neutropenia 2%, and renal impairment 3%. 53% patients required at least one hospital admission for symptom control. The 5-year overall survival rate was 60%. Conclusion Concurrent chemoradiotherapy using weekly cisplatin at 40mg/m2 per week is an effective, well tolerated regimen allowing most patients to receive at least 5 cycles of chemotherapy. However, a phase III randomized control trial comparing the standard dose of 100mg/m2 cisplatin tri-weekly with a weekly regimen is needed to establish the long term clinical outcome.