Drs. Quon and Harrison have written an excellent review on the role of brachytherapy in the management of head and neck cancer. Brachytherapy is a time-honored technique, and the authors have carefully reviewed the pertinent literature extolling its virtues. However, there are many papers that fail to document efficacy of brachytherapy over conventional techniques, demonstrating that, similar to surgery, the technique is both patientand operator-dependent.

High-risk patients with a growing mass require proper assessment, including a thorough history, physical examination, and fine-needle aspiration for diagnosis.

Background: It is important to determine the outcomes of retreatment in patients with locally recurrent nasopharyngeal carcinoma. Methods: We reviewed the records of patients treated for local recurrence at Stanford and Shantou Universities. The end points were local relapse-free survival (LRFS) and overall survival after retreatment. Results: Fifty-six patients from Stanford and 98 from Shantou qualified. For the Stanford patients, 33 had surgery alone (S group), 12 had surgery plus radiotherapy±chemotherapy (CMT group), and 22 had radiotherapy±chemotherapy (RT Stanford group). All Shantou patients received radiotherapy±chemotherapy (RT Shantou group). The 5-year LRFS rates were: 57% for S group, 25% for CMT group, 53% for RT Stanford group, and 41% for RT Shantou group (P>0.05) for rT1-2 tumors; they were 29% for S group, 25% for CMT group, 39% for RT Stanford group, and 9% for RT Shantou group for rT3-4 tumors (P>0.05). For RT patients, 5-year overall survival rates were 49% for Stanford and 25% for Shantou patients (P=0.026). Conclusions: Similar and durable LRFS rates were attained for both S and RT groups when stratified by rT-stage.

BACKGROUND: In head and neck cancer (HNC), 3-month post-treatment positron emission tomography (PET)/computed tomography (CT) reliably identifies persistent/recurrent disease. However, further PET/CT surveillance has unclear benefit. The impact of post-treatment PET/CT surveillance on outcomes is assessed at 12 and 24 months. METHODS: A 10-year retrospective analysis of HNC patients was carried out with long-term serial imaging. Imaging at 3 months included either PET/CT or magnetic resonance imaging, with all subsequent imaging comprised of PET/CT. PET/CT scans at 12 and 24 months were evaluated only if preceding interval scans were negative. Of 1114 identified patients, 284 had 3-month scans, 175 had 3- and 12-month scans, and 77 had 3-, 12-, and 24-month scans. RESULTS: PET/CT detection rates in clinically occult patients were 9% (15 of 175) at 12 months, and 4% (3 of 77) at 24 months. No difference in outcomes was identified between PET/CT-detected and clinically detected recurrences, with similar 3-year disease-free survival (41% vs 46%, P = .91) and 3-year overall survival (60% vs 54%, P = .70) rates. Compared with 3-month PET/CT, 12-month PET/CT demonstrated fewer equivocal reads (26% vs 10%, P < .001). Of scans deemed equivocal, 6% (5 of 89) were ultimately found to be positive. CONCLUSIONS: HNC patients with negative 3-month imaging appear to derive limited benefit from subsequent PET/CT surveillance. No survival differences were observed between PET/CT-detected and clinically detected recurrences, although larger prospective studies are needed for further investigation. Cancer 2013. (c) 2012 American Cancer Society.

Local control of nasopharyngeal carcinoma has substantially improved with advancing radiotherapy technology and appropriate combination with chemotherapy. However, when local recurrence occurs, this is one of the most difficult challenges. Aggressive treatment is indicated because long term salvage is achievable particularly for early recurrence, but high risk of complications is a serious concern. Treatment options include different methods of surgery and/or re-irradiation with/without chemotherapy. Available information in the literature is grossly inadequate; most reports compose of small series of highly selected patients with heterogeneous characteristics and treatment. No randomized trials have been performed to evaluate the therapeutic ratio of different treatment methods. This article reviews available treatment options, their therapeutic benefits and risks of complications; the objective is to provide information for developing treatment recommendations and suggestions for future improvement.

To assess the role of a planned neck dissection (PND) after sequential chemoradiotherapy for patients with head-and-neck cancer with N2-N3 nodal disease.We reviewed 90 patients with N2-N3 head-and-neck squamous cell carcinoma treated between 1991 and 2001 on two sequential chemoradiotherapy protocols. All patients received induction and concurrent chemotherapy with cisplatin and 5-fluorocuracil, with or without tirapazamine. Patients with less than a clinical complete response (cCR) in the neck proceeded to a PND after chemoradiation. The primary endpoint was nodal response. Clinical outcomes and patterns of failure were analyzed.The median follow-up durations for living and all patients were 8.3 years (range, 1.5-16.3 year) and 5.4 years (range, 0.6-16.3 years), respectively. Of the 48 patients with nodal cCR whose necks were observed, 5 patients had neck failures as a component of their recurrence [neck and primary (n = 2); neck, primary, and distant (n = 1); neck only (n = 1); neck and distant (n = 1)]. Therefore, PND may have benefited only 2 patients (4%) [neck only failure (n = 1); neck and distant failure (n = 1)]. The pathologic complete response (pCR) rate for those with a clinical partial response (cPR) undergoing PND (n = 30) was 53%. The 5-year neck control rates after cCR, cPR→pCR, and cPR→pPR were 90%, 93%, and 78%, respectively (p = 0.36). The 5-year disease-free survival rates for the cCR, cPR→pCR, and cPR→pPR groups were 53%, 75%, and 42%, respectively (p = 0.04).In our series, patients with N2-N3 neck disease achieving a cCR in the neck, PND would have benefited only 4% and, therefore, is not recommended. Patients with a cPR should be treated with PND. Residual tumor in the PND specimens was associated with poor outcomes; therefore, aggressive therapy is recommended. Studies using novel imaging modalities are needed to better assess treatment response.

Background. Cellular immune suppression is observed in head and neck squamous cell cancer (HNSCC) and contributes to poor prognosis. Restoration of immune homeostasis may require primary cell-derived cytokines at physiologic doses. An immunotherapy regimen containing a biologic, with multiple-active cytokine components, and administered with cytoxan, zinc, and indomethacin was developed to modulate cellular immunity.Methods. Study methods were designed to determine the safety and efficacy of a 21-day neoadjuvant immunotherapy regimen in a phase 2 trial that enrolled 27 therapy-naive patients with stage II to IVa HNSCC. Methods included safety, clinical and radiologic tumor response, disease-free survival (DFS), overall survival (OS), and tumor lymphocytic infiltrate (LI) data collection.Results. Acute toxicity was minimal. Patients completed neoadjuvant treatment without surgical delay. By independent radiographic review, 83% had stable disease during treatment. OS was 92%, 73%, and 69% at 12, 24, and 36 months, respectively. Histologic analysis suggested correlation between survival and tumor LI.Conclusion. Immunotherapy regimen was tolerated. Survival results are encouraging. (C) 2011 Wiley Periodicals, Inc. Head Neck 33: 1666-1674, 2011

BACKGROUND:Despite modern radiotherapy and open surgical techniques, treatment of recurrent nasopharyngeal carcinoma (NPC) remains challenging, with substantial morbidity involved. Targeted endoscopic nasopharyngectomy was evaluated as a viable oncologic alternative to open nasopharyngectomy or radiation for recurrent NPC. METHODS:Thirteen patients who underwent endoscopic nasopharyngectomy for recurrent NPC between August 2005 and August 2010 were retrospectively reviewed. Average age at surgery was 55.7 years, with mean follow-up period 24.2 months. Two-year disease-free survival, 2-year overall survival, margin status, and complication rate were measured. RESULTS:Including resections for subsequent recurrences, 19 endoscopic procedures were performed with curative intent. Mean operating room (OR) time was 278 minutes, mean estimated blood loss was 197 mL, and mean length of hospitalization was 1.0 days. Negative margins were obtained in 78.9% of procedures: positive margins involved the parapharyngeal space, oropharynx, fossa of Rosenmuller, and infratemporal fossa. Stereotactic radiation was given postoperatively for localized positive margins. Four patients required repeat endoscopic nasopharyngectomy for re-recurrence, despite having their margins cleared or controlled with adjuvant treatment. Two-year local disease-free and overall survival rates were 69.2% and 100.0%, respectively. The overall minor complication rate was 52.6%, with no major complications. CONCLUSION:Targeted endoscopic nasopharyngectomy is beneficial in locally recurrent NPC, with favorable morbidity and complication rates. Endoscopic surveillance and serial imaging together facilitate the early identification of re-recurrences, which often may be treated with additional directed resection. Postoperative stereotactic radiation may serve as an appropriate adjunct modality for disease control at positive margins.

ObjectiveEvaluate targeted endoscopic nasopharyngectomy as a viable oncologic alternative to open nasopharyngectomy or radiation for recurrent nasopharyngeal carcinoma (NPC).MethodA retrospective analysis at an academic medical center was performed for 13 patients who underwent endoscopic nasopharyngectomy for recurrent NPC (August 2005 to August 2010). Three patients had neck metastases for which a neck dissection was concurrently planned. Outcomes measured included 2‐year disease‐free survival, 2‐year overall survival, and complication rates.ResultsIncluding resections for subsequent recurrences, 19 endoscopic procedures were performed. Average age was 55.7 years, with mean follow‐up period 24.2 months. Mean OR time was 278 minutes, mean estimated blood loss was 197 ml, and mean hospitalization was 1.0 day. Negative margins were obtained in 78.9%: positive margins involved the parapharyngeal space, oropharynx, fossa of Rosenmuller, and infratemporal fossa. Four patients required repeat endoscopic nasopharyngectomy for re‐recurrence, despite having margins cleared or controlled with adjuvant treatment. Two‐year local disease‐free and overall survival rates were 69.2% and 100.0%, respectively. The complication rate was 52.6%, with no major complications.ConclusionTargeted endoscopic nasopharyngectomy is beneficial in recurrent NPC, with favorable morbidity and complication rates. Endoscopic surveillance facilitates identification of re‐recurrences, which often may be treated with additional directed resection. Stereotactic radiation may serve as an appropriate adjunct modality for disease control at positive margins.

Purpose: To determine long-term outcomes in patients receiving stereotactic radiotherapy (SRT) as a boost after external beam radiotherapy (EBRT) for locally advanced nasopharyngeal carcinoma (NPC).Methods and Materials: Eight-two patients received an SRT boost after EBRT between September 1992 and July 2006. Nine patients had T1, 30 had T2,12 had T3, and 31 had T4 tumors. Sixteen patients had Stage 11, 19 had Stage 111, and 47 had Stage IV disease. Patients received 66 Gy of EBRT followed by a single-fraction SRT boost of 7-15 Gy, delivered 2-6 weeks after EBRT. Seventy patients also received cisplatin-based chemotherapy delivered concurrently with and adjuvant to radiotherapy.Results: At a median follow-up of 40.7 months (range, 6.5-144.2 months) for living patients, there was only 1 local failure in a patient with a T4 tumor. At 5 years, the freedom from local relapse rate was 98%, freedom from nodal relapse 83%, freedom from distant metastasis 68%, freedom from any relapse 67%, and overall survival 69%. Late toxicity included radiation-related retinopathy in 3, carotid aneurysm in 1, and radiographic temporal lobe necrosis in 10 patients, of whom 2 patients were symptomatic with seizures. Of 10 patients with temporal lobe necrosis, 9 had T4 tumors.Conclusion: Stereotactic radiotherapy boost after EBRT provides excellent local control for patients with NPC. Improved target delineation and dose homogeneity of radiation delivery for both EBRT and SRT is important to avoid long-term complications. Better systemic therapies for distant control are needed. (c) 2008 Elsevier Inc.

5536 Background: Conventional RT (CRT) for head and neck squamous cell carcinoma (HNSCC) is associated with severe late side effects which can worsen quality of life of surviving patients. Intensity-modulated radiotherapy (IMRT) allows the delivery of tumoricidal doses to the target volume while maintaining tolerable doses to critical organs. Several previous studies have demonstrated promising results for tumor control and disease free survival for HNSCC treated with IMRT. In this study, we correlated patterns of failure with target volume delineations in HNSCC treated with IMRT at our instittuion and evaluated subjective xerostomia outcomes after IMRT as compared to CRT. Material and Methods: Between 1/00 and 4/05, 69 patients with newly diagnosed non-metastatic HNSCC underwent curative parotid sparing IMRT at Stanford University. Sites included were oropharynx (39), oral cavity (8), larynx (8), hypopharynx (8) and unknown primary (6). Forty-six patients received definitive IMRT (66 Gy, 2.2 Gy/fraction), and 23 patients received post-operative IMRT (60.2 Gy, 2.15 Gy/fraction). Fifty-one patients also received concomitant chemotherapy. Post-treatment salivary gland function was evaluated by a validated xerostomia questionnaire (XQ) in 29 IMRT and 75 matched non-IMRT patients > 6 months after completing RT. Results: At a median follow-up of 17 months for living patients (range 6.5–60), 7 locoregional failures were observed, 5 in the gross target volume (GTV), 1 in the clinical target volume (CTV), and 1 at the junction of the IMRT and supraclavicular fields. The 2-year Kaplan Meier estimates of locoregional control and overall survival were 92% and 80% for definitive IMRT and 85% and 85% for post-op IMRT patients, respectively. The mean total XQ score was significantly better for IMRT than for non-IMRT patients (p = 0.006). Conclusions: The predominant pattern of failure in IMRT treated patients is in the GTV. Parotid sparing with IMRT resulted in decreased subjective xerostomia and may improve quality of life in irradiated HNSCC patients. No significant financial relationships to disclose.

Our aim was to review our experience in the management of advanced tonsillar squamous cell carcinoma (SCC) and to compare treatment outcomes between patients treated with and without surgery to the primary site.

Thyroidectomy under local anesthesia has a long history. Although the author performs only about one third of operations under local anesthesia, the technique is a time honored and valuable one and is similar to performing other procedures under local anesthesia. The technique is described in detail; conversion to a general anesthetic is required in less than 2% of patients and usually reflects poor patient selection. The procedure can be safely performed on an outpatient basis if only a hemithyroidectomy is performed, no active drain is necessary, and the patient has a responsible adult at home, leading to cost-efficient medical care.

BACKGROUND:Seven patients received stereotaxic radiosurgery for 10 lesions at the base of the skull (BOS) from recurrent head and neck malignant neoplasms.METHODS:A radiation dose of 17.5-35.0 Gy was delivered as a single fraction. Follow-up ranged from 1 to 14 months.RESULTS:Nine lesions were symptomatic, and the symptoms improved in five and stabilized in four lesions. In addition, a significant radiographic response was observed in 4 of 10 recurrences. Cranial nerve signs developed in two patients, and an area of asymptomatic necrosis developed in one patient in the temporal lobe tip.CONCLUSIONS:From their brief experience, the authors conclude that stereotaxic radiosurgery may be a promising treatment in locally controlling recurrent head and neck cancers that involve the BOS.

Surgical resection of the nasopharynx has evolved over the years. Because of its central location, anatomic complexity, and proximity to vital structures of the head and neck, radical surgery in this region of the head and neck was once considered imprudent and fraught with major complications, including death to the patient. Because of significant advancements in the areas of skull-base surgery, lighting, and instrumentation, surgical resection of the nasopharynx is no longer considered as daunting a task for those surgeons with the prerequisite training and experience. In this presentation, the current literature is reviewed with respect to surgical resection of the nasopharynx, and the various techniques are elucidated for outcomes. There are several approaches to surgically resecting the nasopharynx. This article emphasizes the transpalatal/transmaxillary/transcervical approach, which has demonstrated reasonable outcomes with acceptable complication rates.

Twenty-nine patients with large masses attached to the carotid artery underwent surgical resection with preservation of the artery, and intraoperative 125Iodine implantation via an absorbable suture. Eighteen were treated for recurrent neoplasms, having failed prior surgery and/or irradiation therapy. Eleven were treated primarily. With the minimum follow-up of one year, 76% were disease free in the implant volume and 62% were disease free in the entire neck. Distant metastasis occurred in 45%. Mean survival was 15 months in the primary group (range, 2-50 months) and 12 months in the recurrent group (range, 4-26 months). This technique shows promise in providing local control without necessity for sacrifice of the carotid artery.

lateral or involved neck and 5000 rads to the uninvolved contralateral neck.HU 15 mg/kg was given Monday, Wednesday, and Friday starting one week prior to initiation of radiotherapy and continued through delivery of 6000 rads TD, except for periods of treatment delay.Blm 5u I.M. was given Monday and Thursday from the start of therapy through delivery of 1800 rads.Thereafter, Blm 2u was given Monday and Thursday through 6000 rads.Thirteen of 15 patients completed the proposed course of treatment.Complete tumor regression was observed in 12 of the 13 (92%).One patient had a residual 0.5 cm submandibular node following treatment, but had complete regression of the T4 retromolar trigone primary.Of the patients not completing therapy one died of aspiration pneumonia after having received 4500 rads.There was 70% regression of a T4 soft palate primary prior to death.The second patient had an acute MI at 4500 rads; there was 100% regression of a T4 tonsillar pillar primary but minimal decrease in size of a 9 cm neck mass at the time of death.Confluent mucositis was seen in all patients, but frequently responded to minor midifications in administered chemotherapy dosage without interrupting radiotherapy delivery.Nine patients were given a radiotherapy break, none lasting more than two weeks.Modest leukopenia was seen in three patients but did not require interruption of chemotherapy.Two patients who received 7500 rads TD developed extensive neck fibrosis.Mean followup time to date is 52 weeks (median 40).Recurrent disease has been noted only in the patient with the nasopharyngeal cancer.