Transcript Document

Surgery
Surgery in Multimodal Treatment
January 28, 2006
STATEMENTS ON
Head and
Neck Cancer
Frankfurt am Main, Germany
Jatin P. Shah, MD, FACS
Hon. FRCS (Edin), Hon. FRACS,
Hon. FDSRCS (Lond.)
Professor of Surgery
Elliot W. Strong Chair in Head and Neck Oncology
Chief, Head and Neck Service
Memorial Sloan-Kettering Cancer Center
New York, New York
Development of Multimodal Therapy
for Head & Neck Cancer
Gene
Therapy
Targeted
Therapy
Chemotherapy
Radiotherapy
Surgery
1900
1950 1960 1970 1980 1990 2000 2005
Challenge of Squamous
Carcinoma of the Head & Neck
 2/3 will present with Stage III or IV disease at
primary site and/or neck
 50-60% will develop local recurrence
 30%+ will develop distant metastases
 10-40% will develop second primary tumors
Survival - if resectable 40%
if not resectable, but irradiated, 20%
Dimery & Hong. J Natl Cancer Inst 85:95-111, 1993.
Choice of Surgery vs. Radiotherapy
Survival with single
modality treatment
Choice of Treatment
depends upon:
Site
Location
Stage
Histology
Node Status
and also
Competence
Convenience
Cost
Compliance
Complications
Head and Neck Cancer
Presentation
5 Yr Survival
Stage 1
15%
90%
Stage II
20%
70%
Stage III
25%
55%
Stage IV
25%
40%
Inoperable
15%
5-10%
Multimodal Treatment
Combinations
• RT
Surg
• Surg
RT
• RT
Surg
RT
• Surg
RT
Chemo
• Chemo
Surg
RT (+ Chemo)
• Chemo
RT (+ Chemo)
• Concurrent Chemo & RT
• Intraarterial Chemo
• Brachytherapy
Development of
Multimodal Therapy for Head and
Neck Cancer
20th
century
1960’s
Single modality treatments
Surgery – RT – Chemo Rx
Pre-operative radiotherapy
1970’s
1980’s
1990’s
2002
Post-operative radiotherapy
Induction chemotherapy with
surgery + RT
Neoadjuvant chemo Rx
Organ preservation strategies
Concurrent chemo Rx & RT
Levels of Evidence
1.
2.
3.
4.
Randomized controlled trial or
Meta-analysis
Nonrandomized controlled clinical trial,
subset analysis of RCT
Case series, population based,
consecutive or not
Opinions of respected authorities based
upon clinical experience or reports of
expert committees
MEDLINE
• Over 9 million articles, dating to 1966
• 31,000 added each month
– 754,383 (8.4%) - human cancer
– 131,760 (1.5%) - clinical trials
– 68,301 (0.75%) - prospective randomized
• 5,811 (0.06%) human cancer prospective
randomized clinical trials
Neurology Homunculus
The Onculus
U.S. Cancer Incidence
U.S. Cancer
Incidence
U.S. Cancer
Mortality
U.S. Cancer
Incidence
U.S. Cancer
Mortality
Cancer
Level I
Evidence
Surgery in Multimodal Treatment of
Head & Neck Cancer
History
Timeline
Multimodal Treatment
1960 - 1966
Preop RT  Surgery
1974 - 1978
Surgery  Postop RT
1978 - 1982
– Induction Chemo  Surgery  RT or RT 
Surgery
– Planned Surgery or Salvage Surgery
1985 - 1991
1992 - 2000
– Organ Preservation with Chemo  RT 
Salvage Surgery
– Chemo  Surgery  RT
– Concurrent Chemo/RT vs Induction
– Chemo and RT vs RT alone
Surgery in Multimodal Treatment of
Head & Neck Cancer
History
Timeline
Multimodal Treatment
1994 - 2000
Surgery  Adjuvant Chemo/RT
Organ/Function
Preservation
Surgical?
Non-Surgical?
Salvage?
Role of Conservation
Surgery in
Multimodal Treatment
And Salvage Surgery
e.g. Selective Neck Dissection
Partial Laryngectomy
Preoperative Radiation and
Radical Neck Dissection
1960 – 1966
348 Patients
Strong EW.
Surg Clin North Am. Apr 1969; 49(2):271-276.
Elective Postoperative
Radiation Therapy in Stages III and IV
Epidermoid Carcinoma of the
Head and Neck
1974 – 1978
104 Patients
Vikram B, Strong EW, Shah J, Spiro RH.
Am J Surg. Oct 1980; 140(4):580-584.
Adjuvant Chemotherapy for
Advanced Head and Neck
Squamous Carcinoma
1978 – 1982
462 Patients
Final Report of the Head and Neck Contracts Program.
Cancer. Aug 1 1987; 60(3):301-311.
Induction Chemotherapy Plus
Radiation Compared with
Surgery Plus Radiation in Patients with
Advanced Laryngeal Cancer
1985 – 1991
332 Patients
The Department of Veterans Affairs Laryngeal
Cancer Study Group
N Engl J Med. Jun 13 1991; 324(24):1685-1690.
Concurrent Chemotherapy and
Radiotherapy for Organ Preservation in
Advanced Laryngeal Cancer
1992 – 2000
547 Patients
Forastiere AA, Goepfert H, Maor M, et al.
N Engl J Med. Nov 27 2003; 349(22):2091-2098.
Postoperative Irradiation with or without
Concomitant Chemotherapy for
Locally Advanced Head and Neck Cancer
1994 – 2000
334 Patients
Bernier J, Domenge C, Ozsahin M, et al.
N Engl J Med. May 6 2004; 350(19):1945-1952.
Postoperative Concurrent
Radiotherapy and Chemotherapy for
High-Risk Squamous-Cell Carcinoma
of the Head and Neck
1995 – 2000
459 Patients
Cooper JS. Pajak TF, Forastiere AA, et al.
N Engl J Med. May 6 2004; 350(19):1937-1944.
Limitations to Organ
Preservation Approach
• Previous radiotherapy
• Cartilage invasion
• T4 primary
• Non laryngeal sites (BOT, hypopharynx)
• < C.R.
• Medical contraindications (renal,
pulmonary, otologic)
Surgery Remains Initial Definitive Treatment
for Most Sites in Head & Neck
1. SCC of Oral Cavity
2. SCC of Nasal Cavity and Paranasal Sinuses
3. Advanced Carcinomas (T4) of the
Larynx and Hypopharynx
4. Salivary Tumors
5. Thyroid Cancer
6. Sarcomas
7. Skin Cancer and Melanoma
Surgery Employed as
Planned Intervention in
Multimodal Treatment Programs
N2 – N3 Disease
Post Chemo/RT
?
Predictors of Long Term Regional Control
in Pts treated with Chemo/RT
58 pts
5 yr NRFS Survival
N0 – 87%
N1 – 93%
N2 – 69%
(p<0.008)
5 yr NRFS Survival
C.R. – 92%
P.R. – 65%
(p<0.0001)
MSKCC – unpublished data.
Management of the Neck
After Chemo/Radiotherapy
•
•
•
•
•
Planned Comprehensive Neck Dissection
Planned Selective Neck Dissection
Nidusectomy
Observation
Imaging – PET/CT/MRI
Surgery Employed as
Salvage Treatment for
Chemo/RT Failure/Recurrence
1. Ca of Oropharynx
2. Ca of Larynx/Hypopharynx
3. Ca of Nasopharynx (?)
4. Metastatic Ca to Neck Nodes
Salvage of Recurrent Neck Disease
in Radiated Neck
• Mendenhall W.M., et al (1984)
• 139 pts – treated with RT
• 35 recurred in neck
• Salvage attempted in 9, but successful in 2
• Peters L.J., et al (1996)
• 75 pts with OPH treated with RT
• 62 had a CR
• 8 recurred in neck
• Salvage attempted in 7, but successful in 1
Jerry Goodwin
Surgery for
Complications and Sequelae of
Radiotherapy / Chemotherapy
1. Oro-nasopharyngeal stenosis
2. Laryngeal edema/obstruction
3. Radionecrosis of larynx
4. Pharyngoesophageal stricture
5. Osteoradionecrosis of mandible
Surgery Employed for Palliation
1. Pain
2. Bleeding
3. Airway Obstruction
4. Esophageal Obstruction
5. Fungating Tumor
6. Distant Metastases
Life History of a Patient
with Head and Neck Cancer
Diagnosis
Evaluation
S
Management of
complications
Surveillance
S
S
Prevention
S
S
C
C
R
New primary
S
Definitive
therapy
S
R
C
Salvage
treatment
S
Rehabilitation
S
Palliation
S
C
R
Disease-specific survival (DSS) for T1 to T2 glottic laryngeal tumors that required salvage
partial laryngectomy (SPL) or salvage total laryngectomy (STL) following failed radiation
Ganly, I. et al. Arch Otolaryngol Head Neck Surg 2006;132:59-66.
Copyright restrictions may apply.
Effect of T stage at recurrence on disease-specific survival (DSS) for patients with T1 to T2
glottic laryngeal tumors that required salvage laryngectomy following failed radiation
Ganly, I. et al. Arch Otolaryngol Head Neck Surg 2006;132:59-66.
Copyright restrictions may apply.