The National Cancer Institute states that cancers of the head and neck account for 3% to 5% of all malignancies in the United States. Although this percentage may seem small, it still means that more than 55,000 Americans will develop cancer of the head and neck this year and nearly 13,000 of them will die from it, according to the American Academy of Otolaryngology-Head and Neck Surgery.
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October 2007Two scientific sessions at the April 2007 Combined Otolaryngology Spring Meeting focused on post-chemoradiation issues related to head and neck cancer. Adam S. Jacobson, MD, from the Department of Otolaryngology-Head and Neck Surgery at the Mount Sinai School of Medicine in New York and Alexander Langerman, MD, of the University of Chicago’s Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, presented results from their studies titled, Efficacy of Selective Neck Dissection Following Adjuvant Radiation or Chemoradiation for Advanced Head and Neck Cancer and Aspiration in Chemoradiated Head and Neck Cancer Patients, respectively. Dr. Langerman’s paper has been accepted by the Archives of Otolaryngology-Head and Neck Surgery.
Selective Neck Dissection
Recent advances in medical therapy for cancers of the head and neck include combined chemoradiation and induction chemotherapy plus concomitant chemoradiation.1 Regional recurrence is common in patients with advanced nodal disease, and radical and modified radical neck dissections have long been the standard of care following primary chemoradiation.
However, there has been a gradual shift in the surgical management of advanced head and neck cancer toward selective neck dissection (SND)2,3,4 in patients with locoregionally advanced disease following definitive adjuvant therapy.5,6,7
There is an improved quality of life for patients who had SND following chemoradiation when compared to those patients who had a radical or modified radical neck dissection, said Dr. Jacobson.
Dr. Jacobson and his colleagues conducted a retrospective chart review of 58 patients with either stage III or IV squamous cell carcinoma of the upper aerodigestive tract with bulky nodal disease (N2, N3) to determine the efficacy of SND after primary radiation therapy or chemoradiation. The primary tumor sites included oropharynx (15/58), hypopharynx (12/58), pharynx (16/58), larynx (11/58), and unknown primary (4/58).
In his study, Dr. Jacobson stated that definitive treatment consisted of either concomitant chemoradiation (67.2%) or external beam radiation therapy (32.8%). In the monotherapy group, all patients received a total curative dose of 66 to 72 Gy in once-daily fractions of 180 to 200 cGy. The chemoradiation group received a similar radiation schedule and a four-day continuous infusion of cisplatin, 20 mg/m2/day and 5-fluorouracil, 1000 mg/m2/day. The infusions were given on the first and fourth weeks of radiotherapy. A planned selective neck dissection was performed on all the patients three to 12 weeks after completion of definitive medical therapy. CT scans of the neck were not routinely obtained prior to the staged neck dissection. All patients had a selective neck dissection encompassing levels II-IV. Following neck dissection, the median time of follow-up was 37 months (range 17-71 months).
Findings from the study showed that pathologically, 22.4% (13/58) of the patients had viable tumor cells identified in the neck dissection specimen. Seventy-two percent of the patients are currently alive and 28% died as a result of distant disease, local or regional recurrence, or other causes. Of those patients who died from distant disease, 13% had pathological evidence of residual tumor cells identified in the neck dissection specimen. Of the patients who died from local or regional disease, 40% had pathological evidence of residual tumor cells identified in the neck dissection specimen.
Our study demonstrated that performing SND after radiation or chemoradiation did not adversely affect the regional or distant control when compared to historical controls and resulted in similar rates, said Dr. Jacobson. Earlier studies indicate that regional and distant control after a modified radical or radical neck dissection preceded by radiation therapy or chemoradiation approximated 83%8 and 88%,9 respectively.
This study demonstrated pathological evidence of viable tumor in 22.4% (13/58) of the patients after undergoing primary radiation or chemoradiation. We believe that this percentage of persistent viable tumor following treatment supports the need to perform staged SNDs in patients after completion of their adjuvant therapy, said Dr. Jacobson.
SND represents a reasonable surgical alternative to the classic radical and modified radical neck dissections for the management of N2, and possibly N3 disease, after primary medical treatment, continued Dr. Jacobson.
In time, SND may replace the radical and modified radical neck dissection for patients with low-volume (N1, N2) disease and in some cases of higher-volume neck disease that either have a partial or complete response to the chemoradiation, as in our study, said Dr. Jacobson. However, it will not replace the radical and modified radical neck dissections for high-volume disease that has clinically invaded major structures, such as the internal jugular vein, sternocleidomastoid muscle or the accessory nerve.
Preoperative imaging is invaluable in helping to determine whether an effective SND can be performed, continued Dr. Jacobson. One must carefully evaluate the preoperative imaging to make the judgment that a selective neck dissection is the appropriate procedure for any given patient.
Aspiration
During his presentation at the American Head and Neck Society meeting, Dr. Langerman provided results from a study that was done as an adjunct to a larger, prospective, multi-institution clinical trial of induction chemotherapy followed by chemoradiation for advanced head and neck cancer for whom oropharyngeal motility (OPM) study data were available.
Our retrospective review was designed to evaluate the incidence of aspiration among chemoradiated head and neck cancer patients, said Dr. Langerman. We know that the incidence is considered high, especially in the peritreatment period, but data is still emerging about aspiration and its relationship to the primary tumor site, as well as the severity of aspiration, as it may lead to pneumonia with significant morbidity and possible mortality.
Additionally, these patients may lack sufficient laryngeal sensation to detect aspiration, continued Dr. Langerman. The incidence of subclinical or ‘silent’ aspiration may be much higher than clinical aspiration.
Right now, there are no formalized guidelines for post-chemoradiotherapy swallowing assessment, said Dr. Langerman. However, as more data on the effects of primary tumors and chemoradiation on swallowing function have become available, the need for swallowing assessment for some patients has become obvious. The appropriate timing of these assessments is still under investigation.
In this study, the presence of aspiration was quantified as a percentage of the swallowed bolus during the OPMs. An OPM study performed with videofluoroscopic observation of the swallowing reflex is a highly sensitive tool for the detection of aspiration. For the purposes of this study, aspiration (deep laryngeal or tracheal penetration) of 5% or less of the swallowed bolus was considered trace and greater than 5% was considered frank.
In the first year following treatment, 118 patients (91%) had OPMs. Eighty-one patients (69%) had at least one OPM demonstrating aspiration within the first year following chemoradiation, with 30 (25%) demonstrating frank aspiration. Of the patients who aspirated, 61 (75%) reported no symptoms of coughing or choking (80% of trace and 67% of frank aspirators). For the 62 patients with pretreatment OPM data, 33 (53%) demonstrated aspiration at baseline.
The study demonstrated a very high rate of aspiration in advanced-stage head and neck cancer patients both prior to (53%) and in the first year following chemoradiation (69%). The study also concluded that therapeutic swallowing maneuvers taught during OPMs are effective, especially for those patients with trace aspiration, and CRT may improve response to therapy.
In our series, every patient in whom aspiration was identified underwent additional swallows using therapeutic maneuvers designed specifically for their impairment, said Dr. Langerman. For instance, if a patient had poor clearing of food from the laryngeal inlet ultimately leading to aspiration, he may have been taught to swallow twice with each food bolus, helping to clear the food. If this eliminated aspiration, he could be cleared for oral intake of food, with precautions of course. Changing the consistency of the food, such as thickening liquids, can also help some patients not to aspirate.
Perhaps the most troubling finding of the study was the number of patients with aspiration on their OPMs who reported no symptoms of aspiration. This occurred both before and after chemoradiation, said Dr. Langerman. This highlights the importance of routine swallowing assessment in head and neck cancer patients, to detect subclinical aspiration and to institute therapeutic maneuvers and swallow precautions, as well as to determine the safety of oral feeding.
History alone cannot rule out aspiration in the post-chemoradiation period (or even at baseline). It may be that aspiration risk follows a predictable post-treatment time course and the need for swallowing assessment may diminish over time; however, it is known that swallowing dysfunction is still present even a year following chemoradiation.10
However, many patients do report symptoms of aspiration, such as coughing or choking, while eating or suctioning food from their tracheostoma, said Dr. Langerman. Almost always, at presentation these patients were continuing to eat despite the signs. Some continued because they were unaware of the significance of these findings and the dangers of aspiration, others because they simply wanted to continue eating food at any cost. In the former, the physician’s role is education, prior to initiation of oral feeding. The latter group of patients can be a challenge to convince to stay NPO.
Every ENT who cares for cancer patients should ask about symptoms of aspiration and educate their patients about its dangers, said Dr. Langerman. However, the absence of clinical symptoms cannot rule out aspiration in advanced head and neck cancer patients, particularly in the peri-chemoradiation period. At our institution, all patients undergo routine functional swallowing assessment at baseline and following medical or surgical treatment; those with swallowing abnormalities are taught therapeutic maneuvers during the same exam with the goal of safe oral feeding.
References
- Stenson KM, Huo D, Blair E, et al. Planned post-chemoradiation neck dissection: significance of radiation dose. Laryngoscope 2006;116(1):33-6.
- Pellitteri PK, Robbins KT, Neuman T. Expanded application of selective neck dissection with regard to nodal status. Head Neck 1997;19(4):260-5.
- Andersen PE, Warren F, Spiro J, et al. Results of selective neck dissection in management of the node-positive neck. Arch Otolaryngol Head Neck Surg 2002;128(10):1180-4.
- Chepeha DB, Hoff PT, Taylor RJ, et al. Selective neck dissection for the treatment of neck metastasis from squamous cell carcinoma of the head and neck. Laryngoscope 2002;112(3):434-8.
- Boyd TS, Harari PM, Tannehill SP, et al. Planned postradiotherapy neck dissection in patients with advanced head and neck cancer. Head Neck 1998;20(2):132-7.
- Doweck I, Robbins KT, Mendenhall WM, et al. Neck level-specific nodal metastases in oropharyngeal cancer: is there a role for selective neck dissection after definitive radiation therapy? Head Neck 2003;25(11):960-7.
- Clayman GL, Johnson CJ, 2nd, Morrison W, et al. The role of neck dissection after chemoradiotherapy for oropharyngeal cancer with advanced nodal disease. Arch Otolaryngol Head Neck Surg 2001;127(2):135-9.
- Narayan K, Crane CH, Kleid S, et al. Planned neck dissection as an adjunct to the management of patients with advanced neck disease treated with definitive radiotherapy: for some or for all? Head Neck 1999;21(7):606-13.
- Gupta T, Agarwal JP. Planned neck dissection following chemo-radiotherapy in advanced HNSCC. Int Semin Surg Oncol 2004;1(1):6.
- Pauloski BR, Rademaker AW, Logemann JA, et al. Relationship between swallow motility disorders on videofluorography and oral intake in patients treated for head and neck cancer with radiotherapy with or without chemotherapy. Head Neck 2006;28:1069-76.
©2007 The Triological Society