MIAMI BEACH—Managing head and neck cancer involves high-stakes decisions that are full of nuance, with a need to weigh factors that range from a patient’s history to co-morbidities to tumor grade and location. Through the presentation of two clinical scenarios, a panel of experts dug into the details of case management of head and neck carcinoma during the Triological Society Combined Sections Meeting, held January 22–24 in Miami Beach, Fla.
Case 1: Left Parotid Tail Mass
A 38-year-old white female with a new-onset, 2-cm, left parotid tail mass has a history of Hodgkin’s lymphoma, for which she has undergone five courses of R-CHOP chemotherapy.
Francisco Civantos, MD, co-director of the division of head and neck surgery/otolaryngology at the University of Miami’s Sylvester Comprehensive Cancer Center in Florida, asked whether there was anything remarkable in her clinical exam. Panel moderator and case presenter Dennis Kraus, MD, director of the Center for Head and Neck Oncology at the New York Head and Neck Institute, said the patient reported that she generally felt pretty well.
Richard Smith, MD, professor and vice chair of otorhinolaryngology-head and neck surgery and professor of pathology at Albert Einstein College of Medicine in New York City, said that recurrent lymphoma was possible. But Dr. Kraus said there were no obvious signs of that; on MRI, for instance, the mass appeared to be isolated, without infiltrating surrounding tissue. The mass was removed, Dr. Kraus said, and pathology found that the mass was a low-grade acinic cell carcinoma.
Maie St. John, MD, PhD, chair of head and neck surgery at the University of California, Los Angeles, and co-director of the UCLA Head and Neck Cancer, said the best course would probably be no further treatment. “At this point, if it’s well-encapsulated and low-grade, I would not offer neck dissection, but I would offer close surveillance,” she said. If there were no aggressive features, she would not offer postoperative radiation, she added.
Jonas Johnson, MD, professor and chair of the department of otolaryngology at the University of Pittsburgh School of Medicine, noted the importance of considering how close the mass is to the facial nerve, but Dr. Kraus said that was not a concern, given what was seen during surgery.
Ultimately, the tumor board opted for no more treatment. But high-grade acinic cell carcinomas might need a different response, Dr. Kraus said. “If you look at the literature for acinic cell, there is some controversy about our ability to grade them, although there’s clearly a distinction between low- and high-grade tumors,” he added. “There are reported cases, particularly in the higher grades, that some of these patients can develop metastatic disease.”
Case 2: Neck Node
A 68-year-old Hispanic male who, three years prior, received chemoradiation therapy for a T3N0 thoracic esophageal squamous cell carcinoma, now presents with a 3.5-cm left level 2 neck node. A needle biopsy, the pathologist determines, is HPV-negative metastatic squamous cell carcinoma that is negative for the p16(INK4a) tumor suppressor protein.
Panelists weren’t so quick to accept that the mass was a metastasis, though.
“P16-negative still could be an unknown primary of the head and neck, as opposed to metastatic disease from the esophagus and I think that’s really the critical determinant,” Dr. Smith said. “It’s a totally different treatment paradigm.” He added, “You can’t assume it’s just esophageal metastases. I would feel you have to proceed with an unknown primary workup.”
Dr. Civantos also said he would treat it as a potential second primary tumor. The most likely site for a cryptic primary is still going to be lymph node tissue in the tongue base and the tonsil, he said, so he would do extensive biopsy of the lingual tonsils, or remove them, and biopsy any lymphoid tissue of the nasopharynx and hypopharynx as well.
He said he would perform a modified radical neck dissection and mucosectomy. Additionally, he said, he would try to clarify how much adjuvant therapy could get to the neck, considering the patient’s prior treatment of the neck, because that could affect surgical decisions. “If you presume this patient’s ability to receive standard post-op radiation is somewhat compromised, then I think you could err in the direction of being more radical (with surgery).”
Dr. Kraus said that he did, in fact, consult with the radiologist and was assured that radiation was a viable option. He then asked the panel whether the tonsillectomy, neck dissection, and transoral robotic mucosectomy should all be done at once.
Dr. Johnson said no. “Our experience is that bilateral transoral tonsillectomies, invasive tongue resections with a robot, are associated with unacceptable morbidity,” because scarring contracture can cause dysphagia, he said. “I think it’s a mistake to do it all at once.”
Dr. Kraus said that a bilateral tonsillectomy was done, and they were negative. He also performed an extended radical neck dissection, finding muscle, nerve, and jugular vein involvement. After looking at the original esophageal lesion and the neck lesion, the pathologist again concluded that this was an isolated metastasis from his esophagus, even though he was three years out.
Dr. Johnson doubted the pathologist’s assessment. But he said that if muscle, nerve, and vein were involved, “then this is bad, and I would offer him CRT [conformal radiation therapy].”
Dr. St. John said that “you’re only as good as your team” and that the pathologist’s assessment would “make a difference to me.” She added that the decision on chemoradiation therapy should not be automatic. “If this is a metastatic esophageal [squamous cell carcincoma] with these types of features, then his prognosis is guarded, so one has to really think about side effects” weighed against the survival benefits of the therapy.
In the end, Dr. Kraus said, only the ipsilateral neck was irradiated, not both sides. “I think that the one thing that really offers you a ray of hope in this guy is the fact that you have a significant disease-free interval.”
Thomas R. Collins is a freelance medical writer based in Florida.Multi-Page