While chemoradiation is becoming more common for managing head and neck cancers, some patients should have surgery as an initial treatment
Explore This IssueApril 2006
TORONTO—There has been a paradigm shift in the management of oropharyngeal and laryngopharyngeal cancer, and top surgeons now opt more frequently for chemoradiation treatment than surgery. At the same time, otolaryngologists–head and neck surgeons need to do their best to determine which patients are not good chemoradiation candidates and should undergo surgery as a first modality.
These were among the key messages presented by a panel of five experts who discussed head and neck cancers at the recent meeting of the Eastern Section of the Triological Society here. The panel, moderated by Ashok Shaha, MD, Professor of Surgery at Memorial Sloan-Kettering Cancer Center in New York City, covered treatment options in response to a series of questions and sample cases presented.
Radiation Therapy: Good for Many Patients
Radiation therapy came out as top choice for the management of early vocal cord cancer, though panelists provided different reasons. It isn’t for all levels of cancer, and it doesn’t discount the value of other specific treatments.
Jeremy L. Freeman, MD, Professor of Otolaryngology at the University of Toronto in Ontario, explained that radiation is the treatment of choice at his center, in part, because there isn’t enough manpower for doing laser ablation. “We’d need one person dedicated to do this job two or three times a week, and we just don’t have this resource. We do have a radiation resource and that’s what we do.” He added that laser ablation is cost-effective, and that radiation can be used later on if there is a recurrence.
Gady Har-El, MD, Professor of Otolaryngology and Neurosurgery at SUNY Health Science Center in Brooklyn, NY, said it depends on the whether the cancer is T1 or T2 since they need different levels of aggression in treatment.
And, while radiation is often effective, it doesn’t work for everyone, a point made by Jonas Johnson, MD, Chair of Otolaryngology at the University of Pittsburgh School of Medicine (Pa.).
“The best data suggest 70% of patients with T2 laryngeal cancer are cured with radiation, which means a 30% failure rate. If those [failed] patients are carefully followed, they can often be treated with partial laryngeal surgery.” However, if patients are not followed carefully, 30% of the failed patients lose their larynx, which is “an abomination,” Dr. Johnson said.
In locally aggressive thyroid cancer, panelists agreed that evaluating vocal cord function was a high priority. “You have to understand the function of the cords before you go into any thyroidectomy,” said Dr. Freeman.
Managing Tongue and Tonsil Cancer
Another issue addressed was management of a Stage IV carcinoma of the base of the tongue. Panelists concurred that the use of chemoradiation alone was appropriate for many cases, but some patients would need neck dissection as well. When it came to the treatment of patients with T2N2 tonsil cancer, chemoradiation therapy was the preferred choice and represents a shift in practice.
“During my training the standard was to do a tonsillectomy and neck resection, and if the nodes were positive then post-operative radiation therapy. Now, about 90% of our patients will get chemoradiation therapy,” Dr. Shaha said.
Generally, most patients can be cured without surgery. But if there is residual disease after chemoradiation “then they’ll need a salvage neck dissection,” said Dr. Johnson.
On the other hand, some centers are seeing a small return of surgery as robotic surgery and other new technologies arrive, said Bert O’Malley Jr., MD, Professor and Chair of Otorhinolaryngology at the University of Pennsylvania in Philadelphia. There is the question of how much radiation is needed on the primary site if it is given before or after surgery on the neck.
But if the mass is large and firm, there is often a problem with persistent fibrosis, said Dr. Har-El. “We end up doing neck dissection on radiated necks. In those cases, I’d like to do a neck dissection first—then submit the patient to chemo and radiation therapy.”
However, if the oropharyngeal cancer involves the tonsil, this particular location is more radio sensitive than other sites, said Dr. Shaha.
Still, about 15% to 20% of these patients will develop pharyngeal stricture and will require a permanent gastrostomy. Panelists agreed this high rate of stricture leads to a poor quality of life for these patients. “We need something better than just chemoradiation,” said Dr. O’Malley. At the same time, there is still some question about which doses of radiation are most effective, he said.
Treatment Approaches Differ
There was a split in opinion when asked how a 28-year-old female patient with T2 tongue cancer should be treated after partial glossectomy and selective neck dissection with one positive node—observation or radiation therapy. A problem here is that there is a lack of good evidence in terms of what to do, said Dr. Freeman.
“On the one hand you don’t want to give radiation to a young woman, on the other you’ve got an indication for post-operative adjuvant radiotherapy, that is, a positive node. If you think selective neck dissection is therapeutic then you don’t have to do anything. But there’s no compelling evidence in the literature that that’s correct,” he said.
The panelists agreed that in this sort of patient, more needs to be known about the node and whether there has been extranodal spread. Dr. Shaha advised going back to pathology and getting more details about the tumor and whether there was spread.
If the patient had three positive nodes, then this is a high-risk case. In this variation of the case, panelists agreed on the use of chemoradiation, even with its risks and side effects. “The patient will get an incremental benefit of about 8% if they get chemo with the radiation. I think they should get chemoradiation,” said Dr. Johnson. Treatment of high-risk cases is also supported by two papers from the May 2005 edition of the New England Journal of Medicine.
A Branchial Cyst and Tumor
Dr. Shaha then presented more cases for discussion. One was of a 56-year-old male who presented with a right neck mass and was initially referred as having a branchial cyst. However, closer examination of CT scans revealed that below the cyst was a 4 cm by 4 cm tumor at the base of the tongue. A substantial portion consisted of cyst material.
Again, panelists agreed that chemoradiation is an effective way to treat cases like this. As Dr. Johnson noted, “Chemoradiation is needed under any circumstances. I’m reasonably confident that chemoradiation without surgery will cure this patient. I don’t know why we bother them with surgery,” he said.
During my training the standard was to do a tonsillectomy and neck resection, and if the nodes were positive then post-operative radiation therapy. Now, about 90% of our patients will get chemoradiation therapy.” – —Ashok Shaha, MD
This approach is a major paradigm shift, and is something that likely still confuses most clinicians, said Dr. Shaha.
Interestingly, there are centers in Europe and the US in which tongue base tumors are treated endoscopically with laser excision, Dr. Johnson said. “Most of the patients I see require chemoradiation, primarily to control cervical adenopathy. It is unclear if the surgery enhances local control or if equal results could be achieved with chemoradiation alone.”
Chemoradiation tends to be effective in these patients, and if the patient has no disease afterward (as shown by radiological findings and PET scan), neck dissection won’t be needed.
When neck dissections are performed, there is often a small amount of thickening remaining that is fibrosis. Dr. Shaha suggested that ultrasound-guided biopsy could be a useful tool to check on this vague fullness. But if there is cancer there, it needs to be removed quickly.
Malignant Hypopharynx Tumor and Thyroid Cancer
The case of a 78-year-old female patient presenting with shortness of breath, a hoarse voice, and considerable dysphagia, was discussed. A large malignant hypopharynx tumor was found, with extensive disease involving the entire right side of the pyriform sinus, and extending into the postcricoid area. Here, panelists agreed that the patient needed laryngectomy and adjuvant therapy—unless there are other comorbidities altering this course of action.
Some in the medical field argue that total laryngectomy is disfiguring. However, “it’s the disease that is mutilating and the total laryngectomy is the right operation,” and improves quality of life, Dr. Shaha said. An important point is to consider exactly which patients will benefit most from total laryngectomy along with chemoradiation.
The final case discussed was of a 43-year old male presenting with elevated carcinoembryonic antigen (CEA). A chest CT scan revealed a large 4 cm by 3 cm mass involving the right thyroid, and serum calcitonin was at 9,000. Fine needle biopsy was positive for medullary thyroid cancer.
Here, panelists agreed the patient needed a total thyroidectomy and modified neck dissection with follow-up studies to check for recurrence or metastatic spread. Follow-up should include imaging of the neck, brain, and abdomen.
Watch Calcitonin Levels
However, even if imaging reveals no disease spread, the patient isn’t necessarily cured. Indeed, Dr. Shaha described such a patient who had no evidence of spread detected, yet returned with calcitonin levels of 12,000. The patient had multiple metastases on the liver, “a common problem in patients who present with medullary carcinoma and high calcitonin,” Dr. Shaha said.
About the only thing that can be done for these patients is to refer them for experimental treatment. Dr. Shaha suggested that otolaryngologists should check the National Institutes of Health Web site to find lists of study groups and protocols.
Many of the conditions described at the session are now treated with chemoradiation as the primary modality, though patients still need to be appropriately chosen. “We still have a responsibility to find out who is not going to do well with this treatment, and treat those cases with surgery initially,” Dr. Shaha said.
©2006 The Triological Society