Chen Huang et al. published online before print The indications for palliative surgery are not well defined, though many would support palliative resection when confronted with potential suffocation, carotid rupture, prevention of quadriplegia (in the instance of tumor erosion into cervical spine), or control of foul, ulcerative wounds. Although a simple solution is not possible, a number of considerations make it permissible to approach the decision in a logical, evidenced-based manner. 2007 May;117(5):770-5. doi: 10.1097/MLG.0b013e318033c800. For this patient group who subsequently fail in a local or regional site, the therapeutic options are complicated—most commonly because of overlap of the previous radiation portal. 2001 Jun;111(6):1079-87. doi: 10.1097/00005537-200106000-00028. Nivolumab is a checkpoint inhibitor used to treat some types of advanced head and neck cancer. Head Neck. Because concurrent cetuximab with radiation therapy has been shown to significantly improve local control and survival for primary head and neck cancer without major increases in mucosal toxicity,60 there has been interest in the application of this agent as a radiosensitizer in the reirradiation setting. What must be clear is the patient’s willingness to accept that survival, not function, is the overriding goal in salvage treatment. NEW YORK — Treatment of recurrent or metastatic head and neck cancer is challenging given the availability of only a few treatment options, according to a presenter at HemOnc Today New York. A total of 242 cases of second head neck primary were successfully matched to patients with single primary disease. Both of RTOG 0421 and the GORTEC 9803 studies were designed in an era prior to the availability of the results of the EXTREME study. There have been great technical advances in surgical approaches for salvage of primary site recurrences. Racial differences in stage and survival in head and neck squamous cell carcinoma. Others have reported similar results using conventional radiation therapy techniques.38-40. (May 19, 2016) CancerLinQ Previous studies have shown the benefit of a gastric tube compared with a nasogastric tube in terms of patient comfort, cosmesis, durability, and ease of tube feeding.3,4 It is also essential that patients are euthyroid before any planned surgery. Phase III studies of immune checkpoint inhibitors for recurrent metastatic HNSCC are in progress and potentially could establish a new standard of care in years to come. Cancer. The results of the EXTREME study raise a logical and highly clinically relevant question: will the EXTREME regimen provide a superior outcome compared with concurrent chemo-reirradiation for patients with unresectable locoregional recurrent HNSCC? Salvage neck dissections for isolated neck recurrence or in combination with primary site recurrence are a heterogeneous group. The emergence of data indicating activity of immune checkpoint inhibitors in HNSCC has potential major implications for management of this disease, including treatment for patients with HNSCC with unresectable locoregional recurrent disease. Among 96 patients with oral tongue SCCA, mean (median) survival was 40.1 (28) months after the second primary diagnosis versus 52.2 (32) months for matched single primary patients ( P = 0.552, log-rank test). Determine whether survival for second primary head and neck cancer is truly poorer than survival for first primaries. For example, in recurrent nasopharyngeal cancers, image-guided endosurgery is precise and effective, offers improved recovery, and is safer than open approaches.26 Salvage endoscopic nasopharyngectomy has also been found to be superior to intensity-modulated radiation therapy (IMRT) in terms of survival and quality of life parameters.27 Transoral robotic surgery has been found to be an oncologically sound alternative to open surgical procedures and is superior in terms of functional and recovery outcomes.28 In addition, transoral laser microsurgery has been shown to have comparable oncologic outcomes with superior function and less morbidity compared with open partial or total laryngectomy.29, Survival statistics, surgical complication rates, and treatment toxicities, as significant as they are, do not provide a full picture of the positive and negative effects of surgical treatment on patients with recurrent cancer. The sequence of salvage treatment options for these two categories of patients given the differences in outcome remains the subject of future investigation. Analysis of radiation therapy for the control of Merkel cell carcinoma of the head and neck based on 36 cases and a literature review. USA.gov. Canadian study: Cannabis use among patients with head and neck cancer not associated with developing second primary cancer Back to video “Although hypothesized, it is not yet known whether cannabis is a direct causative agent for HNC (carcinoma of the head and neck) or increases the risk of SPC (squamous cell carcinoma) through field cancerization,” the study authors write. Emerging in the literature is a growing body of evidence that suggests radiation therapy and immune checkpoint have complimentary effects.75,76 These studies indicate that immune checkpoint inhibitors can overcome the negative effects of radiation on the tumor microenvironment. The majority of these patients fail within 1 year after completing definitive therapy. Tirelli G, Zacchigna S, Biasotto M, Piovesana M. Eur Arch Otorhinolaryngol. One cohort consisted of patients with exactly 1 head and neck primary malignancy; the second cohort consisted of patients with exactly 2 head and neck primaries, restricted to second primaries of the tongue, tonsil, glottic larynx, and hypopharynx with squamous cell carcinoma (SCCA) histology. Similarly, patients may not be eligible for reirradiation when it is not feasible to spare the spinal cord from a lifetime cumulative conventionally fractionated (1.8-2.0 Gy per fraction) equivalent dose less than 54 Gy. All relationships are considered compensated. JCO OP DAiS, ASCO eLearning However, by the time RTOG 0421 was activated, a shift toward general acceptance of reirradiation had occurred regarding the safety and a level of comfort with the procedure. Contact +33 (0)1 42 11 44 46 +33 (0)1 42 11 51 94 ou 43 57 Reconstructive surgery +33 (0)1 42 11 65 36 Oncology Epub 2013 Apr 19. [Epub ahead of print] The risk of second primary tumors in head and neck cancer: A systematic review. Head and neck cancer; Head and neck cancer - Second opinion; Head and neck cancer. ASCO Meetings Patients who have had cancers of the oropharynx can get any type of second cancer, but they have an increased risk of: Lung cancer; Esophagus cancer; Cancers of the larynx and hypopharynx; Cancer of the oral cavity (including tongue and mouth) Given the location of these cancers, trouble breathing may also be present. Value of oesophagoscopy and bronchoscopy in diagnosis of synchronous malignancies in patients with head and neck squamous cell carcinomas. In the experimental arm, weekly maintenance cetuximab was prescribed following the course of combination systemic therapy. This site needs JavaScript to work properly. Patients with head and neck squamous cell carcinoma appeared at increased risk for second primary malignant neoplasms, according to a population … Contact Us High treatment morbidity occurred, although at a lower rate than reported in prior studies utilizing conventional techniques. Conversely, these data also suggest that the antigenic response to radiation therapy may induce a heightened effectiveness from immune checkpoint inhibition. Cancer is always named for the place where it starts. However, clinical decision making for this population is complicated by many factors. Conclusions: Furthermore, new radiation techniques and new systemic agents show early promising results in recent clinical studies, suggesting potential for practice-changing effects in the future management of this disease. NCI CPTC Antibody Characterization Program. Nasogastric Feeding Tubes versus Percutaneous Endoscopic Gastrostomy for Patients with Head or Neck Cancer: A Review of Clinical Effectiveness and Guidelines. Some patients may want to maintain as much quality of life (as defined by the individual patient) and choose palliative chemotherapy or hospice care. However, small-field postoperative reirradiation may be appropriate in select cases with high-risk features such as extracapsular extension or positive margins. Chicago, IL: American College of Surgeons, 2318 Mill Road, Suite 800, Alexandria, VA 22314, © 2021 American Society of Clinical Oncology. Head Neck. Canadian Agency for Drugs and Technologies in Health Ottawa (ON). Novel systemic therapies, including immune checkpoint inhibitors, show promising early results warranting additional ongoing prospective study. All major U.S. medical, ethical, and religious organizations recognize that it is imperative to treat the distressing symptoms of patients who are dying.30 Palliative surgical treatment is nuanced and requires knowledge of a patient’s unique medical condition at the time, as well as the patient’s personality and family dynamics. The ASCO Post Extended postoperative nil per os status should be anticipated for patients with previous radiation or CRT who undergo large resections. Second, there seemed to be a shift in the widespread use and acceptance of reirradiation. A matched survival analysis for squamous cell carcinoma of the head and neck in the elderly. So in the absence of high-level evidence comparing reirradiation with systemic therapy, how is it possible to choose the most appropriate therapy for a patient with unresectable recurrent HNSCC in a previously irradiated field? 2020 Dec 1;20(1):1172. doi: 10.1186/s12885-020-07681-9. For instance, Lee et al reported a 2-year locoregional control rate of 52% compared with 20% among patients treated with IMRT and those treated with conventional radiation techniques, respectively.48 In addition, patients with locoregional progression-free disease had better 2-year overall survival compared with those with locoregional failure, further demonstrating the need to maintain locoregional control to improve survival. This includes CT scan of the head, neck, and chest and/or PET scan. So when head or neck cancer spreads to the lung (or any other place), it’s still called head or neck cancer. From the Surveillance, Epidemiology and End Results database, 2 cohorts were constructed. Some may experience a sore throat that does not go away. Survival outcomes by tumor human papillomavirus (HPV) status in stage III-IV oropharyngeal cancer (OPC) in RTOG 0129, Human papillomavirus and overall survival after progression of oropharyngeal squamous cell carcinoma, Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for patients with head and neck cancer: a systematic review, Cisplatin based chemoradiation late toxicities in head and neck squamous cell carcinoma patients, Salvage surgery with free flap reconstruction: factors affecting outcome after treatment of recurrent head and neck squamous carcinoma, The assessment of pharyngocutaneous fistula rate in patients treated primarily with definitive radiotherapy followed by salvage surgery of the larynx and hypopharynx, Outcomes of salvage surgery with free flap reconstruction for recurrent oral and oropharyngeal cancer, Reirradiation after salvage surgery and microvascular free flap reconstruction for recurrent head and neck carcinoma, Free-flap reconstruction in the doubly irradiated patient population. The use of novel EGFR-targeted agents may help to further improve disease outcome while minimizing additional toxicity. Disclosures of potential conflicts of interest provided by the authors are available with the online article at asco.org/edbook. Objective: In arguably one of the most notable studies of salvage surgery, Goodwin et al found that 2-year survival was predicted by stage (73% for stage I and 22% for stage IV; p = .0005) and site (laryngeal 76%, oral cavity 47%, and pharyngeal sites 24%; p = .0645).12 Others have found that time to recurrence and interval from previous radiation, use of chemotherapy, comorbidity, performance status, pre-existing organ dysfunction, and N3 neck disease are also negatively correlated with survival.13-22 Surgical salvage, even with negative margins, is associated with high recurrence rates, with approximately 67% overall failure rate. Conquer Cancer Foundation  |  Introduction. RTOG 9610 found that concurrent hydroxyurea and 5-fluorouracil (5-FU) resulted in a median survival of 8.5 months and overall survival rates of 15.2% and 3.8% at 2 and 5 years, respectively.41 RTOG 9911 used concurrent cisplatin and paclitaxel, achieving a slightly better median survival of 12.1 months and a 2-year survival rate of 25.9%.42 However, high toxicity was reported in both studies, with a 63%–78% rate of grade 3 or greater acute toxicity, 22%–37% rate of grade 3 or greater late toxicity, and overall 8%–9% treatment-related death. e284-e292. Delayed regional metastases, distant metastases, and second primary malignancies in squamous cell carcinomas of the larynx and hypopharynx. Patient With Recurrent Palate Carcinoma After Chemoradiation. HPV remains prognostic in recurrent HNSCC, challenging existing paradigms. Ene 25, 2021. However, clinical decision making … Objective To determine whether there is an association between cannabis use and developing a second primary cancer in head and neck cancer patients, as well as determining the prevalence of cannabis use amongst head and neck cancer patients. 2019 Nov 21. doi: 10.1002/hed.26016. An ongoing phase II trial is being conducted by the GORTEC to evaluate reirradiation using a hyperfractionated scheme with concurrent cetuximab (NCT01237483). These developments mirror those occurring in surgical approaches for the untreated patient. 2003 Feb;113(2):368-72. doi: 10.1097/00005537-200302000-00030. A safe wound is one that will offer protection of carotid and vertebral arteries (preventing major vessel rupture) and cover potential exposed bone in a hostile wound environment (fistula or tissue necrosis). Low risk of second primary malignancies among never smokers with human papillomavirus-associated index oropharyngeal cancers. It is conceivable that future studies examining immune checkpoint inhibitors with reirradiation may demonstrate favorable results that could reduce our reliance on dogmatic approaches to patients with unresectable recurrent or new second primary HNSCC.  |  In addition, the management of locoregional recurrent or second primary head and neck cancer has grown in complexity as a result of the increase of the relative incidence of HPV-associated HNSCC compared with non-HPV HNSCC. In essence, a safe wound must be created to limit the potential toxicity from wound breakdown after salvage surgery or tissue necrosis from reirradiation. Nonetheless, salvage surgery is nearly always radical, morbid, and technically challenging. A preceding phase III study compared cisplatin plus 5-FU with either drug alone.68 Although the cisplatin/5-FU arm achieved a higher overall response rate compared with the single-agent arms, this did not translate into an improvement in overall survival. Although new surgical techniques and treatments have improved function, cosmesis, and symptom management, individuals with head and neck cancers still have unique physiologic and psychosocial needs that must be addressed. Nivolumab is usually administered into a vein (intravenously). Most of these cancers are squamous cell carcinomas, or cancers that begin in the lining of the mouth, nose and throat. A nomogram published by Tanvetyanon et al provides a tool by which practitioners can identify poor prognostic factors that may help identify favorable populations and avoid exposure of dangerous toxicity to other patients.15. Salvage surgery for patients with recurrent squamous cell carcinoma of the upper aerodigestive tract: when do the ends justify the means? Carotid artery sacrifice and reconstruction in the setting of advanced head and neck cancer, Outcome of patients undergoing salvage surgery for recurrent nasopharyngeal carcinoma: a meta-analysis, Salvage endoscopic nasopharyngectomy is superior to intensity-modulated radiation therapy for local recurrence of selected T1-T3 nasopharyngeal carcinoma - A case-matched comparison, Salvage surgery for recurrent cancers of the oropharynx: comparing TORS with standard open surgical approaches, Transoral laser microsurgery in treatment of pT2 and pT3 glottic laryngeal squamous cell carcinoma - results of 391 patients, Palliative surgery for head and neck cancer with extensive skin involvement, Palliative reconstruction for the management of incurable head and neck cancer, The art of medicine at the end of life: a surgeon’s point of view, The surgical treatment of cancer: a comparison of resource utilization following procedures performed with a curative and palliative intent, Full-dose reirradiation for unresectable head and neck carcinoma: experience at the Gustave-Roussy Institute in a series of 169 patients, A phase I-II study of concomitant chemoradiotherapy with paclitaxel (one-hour infusion), 5-fluorouracil and hydroxyurea with granulocyte colony stimulating factor support for patients with poor prognosis head and neck cancer, Concomitant chemotherapy and reirradiation as management for recurrent cancer of the head and neck, Reirradiation with concomitant chemotherapy of unresectable recurrent head and neck cancer: a potentially curable disease, Final report of RTOG 9610, a multi-institutional trial of reirradiation and chemotherapy for unresectable recurrent squamous cell carcinoma of the head and neck, Phase II study of low-dose paclitaxel and cisplatin in combination with split-course concomitant twice-daily reirradiation in recurrent squamous cell carcinoma of the head and neck: results of Radiation Therapy Oncology Group Protocol 9911, Phase III randomized, placebo-controlled trial of docetaxel with or without gefitinib in recurrent or metastatic head and neck cancer: an eastern cooperative oncology group trial, Phase I/II study of cetuximab in combination with cisplatin or carboplatin and fluorouracil in patients with recurrent or metastatic squamous cell carcinoma of the head and neck, Phase III randomized trial of cisplatin plus placebo compared with cisplatin plus cetuximab in metastatic/recurrent head and neck cancer: an Eastern Cooperative Oncology Group study, Randomized phase III evaluation of cisplatin plus fluorouracil versus cisplatin plus paclitaxel in advanced head and neck cancer (E1395): an intergroup trial of the Eastern Cooperative Oncology Group, Stereotactic body radiotherapy for recurrent oropharyngeal cancer - influence of HPV status and smoking history, Salvage reirradiation for recurrent head and neck cancer, IMRT reirradiation of head and neck cancer-disease control and morbidity outcomes, Intensity-modulated radiotherapy with concurrent chemotherapy for previously irradiated, recurrent head and neck cancer, Intensity-modulated radiotherapy for recurrent and second primary head and neck cancer in previously irradiated territory, Stereotactic body radiotherapy in the management of head and neck malignancies, Stereotactic body radiation therapy for head and neck tumor: disease control and morbidity outcomes, A simple strategy to decrease fatal carotid blowout syndrome after stereotactic body reirradiaton for recurrent head and neck cancers, Multi institutional phase II study of concomitant stereotactic reirradiation and cetuximab for recurrent head and neck cancer, Salvage stereotactic reirradiation with or without cetuximab for locally recurrent head-and-neck cancer: a feasibility study, A prospective phase II trial of re-irradiation with stereotactic body radiotherapy plus cetuximab in patients with recurrent previously-irradiated squamous cell carcinoma of the head and neck, Stereotactic body radiotherapy for recurrent squamous cell carcinoma of the head and neck: results of a phase I dose-escalation trial, The impact of tumor volume and radiotherapy dose on outcome in previously irradiated recurrent squamous cell carcinoma of the head and neck treated with stereotactic body radiation therapy, Radiotherapy plus cetuximab for squamous-cell carcinoma of the head and neck, Concurrent cetuximab with stereotactic body radiotherapy for recurrent squamous cell carcinoma of the head and neck: a single institution matched case-control study, Long-term follow-up of stereotactic radiosurgery for head and neck malignancies, Prospective evaluation of patient-reported quality-of-life outcomes following SBRT ± cetuximab for locally-recurrent, previously-irradiated head and neck cancer, Randomized trial of postoperative reirradiation combined with chemotherapy after salvage surgery compared with salvage surgery alone in head and neck carcinoma, The pattern of failure after reirradiation of recurrent squamous cell head and neck cancer: implications for defining the targets, Platinum-based chemotherapy plus cetuximab in head and neck cancer, Impact of tumor HPV status on outcome in patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck receiving chemotherapy with or without cetuximab: retrospective analysis of the phase III EXTREME trial, A phase III randomized study comparing cisplatin and fluorouracil as single agents and in combination for advanced squamous cell carcinoma of the head and neck. Ear Nose Throat J. In Dunn GP, Martensen R, Weissman D (eds). A big hullo to everyone! Cookies, SURGICAL MANAGEMENT OF PREVIOUSLY IRRADIATED HEAD AND NECK CANCER: SALVAGE AND TREATMENT MANAGEMENT STRATEGIES BEFORE AND AFTER REIRRADIATION, ROLE OF CONVENTIONAL AND ABLATIVE RADIOTHERAPY IN THE MANAGEMENT OF RECURRENT, SECOND PRIMARY, AND/OR PREVIOUSLY IRRADIATED HEAD AND NECK CANCER, SYSTEMIC THERAPEUTIC OPTIONS FOR RECURRENT/SECOND PRIMARY HEAD AND NECK CANCERS, Combination Chemotherapy for Unresectable Recurrent or Second Primary HNSCC, Systemic Therapy Compared With Reirradiation, AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST. Open questions and novel concepts in oral cancer surgery. Finally, in cases where surgery is not feasible and reirradiation may pose too high of a risk of severe toxicity either because of prior radiation dose to normal structures or extent/involvement of the recurrence, palliative systemic therapy is favored. Head and neck cancer (HNC) is the sixth leading cancer worldwide, and approximately 630,000 new cases are recorded annually .Most patients present with locoregionally advanced disease upon the initial diagnosis, and more than 50% have recurrence within 3 years , , .Platinum-based chemotherapy, including cisplatin and carboplatin, has been the first-line treatment … Hence, in the context of this historical background it is clear why the results of the EXTREME trial were practice changing and why this regimen has been solidified as the current standard of care. More importantly, surgery has a compelling role in palliation for patients with recurrent head and neck cancers. Likewise concurrent chemo-reirradiation is associated with high toxicity, including grade 5 events that have been reported in nearly all studies examining concurrent chemo-reirradiation—typically in the range of 3%.71,72 Most of the deaths associated with reirradiation are related to bleeding events; carotid rupture accounts for the majority of life-threatening bleeding events. As survival improved and multimodality organ preservation strategies became more successful, the role of surgery was redefined and has become increasingly more prominent for patients with recurrent disease. Compared reirradiation and chemotherapy, or cancers that begin in the elderly those occurring in surgical for! May not relate to the body ’ s own immune system can recognise and destroy the cancer are cell. Advanced features are temporarily unavailable that does not heal or a change in the.... 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