Neck CancerHead and

STATEMENTS ON

January 28, 2006

Frankfurt am Main, Germany

SurgerySurgery in Multimodal Treatment

Jatin P. Shah, MD, FACSHon. 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 Therapyfor Head & Neck Cancer

Development of Multimodal Therapyfor Head & Neck Cancer

19001900 19501950 19601960 19801980 20002000

Surgery

Radiotherapy

Chemotherapy

1990199019701970

Targeted Therapy

20052005

GeneTherapy

Challenge of Squamous Carcinoma of the Head & Neck2/3 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)

Dimery & Hong. J Natl Cancer Inst 85:95-111, 1993.

Survival - if resectable 40%

if not resectable, but irradiated, 20%

Choice of Surgery vs. RadiotherapyChoice of Surgery vs. Radiotherapy

SiteLocationStageHistologyNode Status

and also

CompetenceConvenienceCostComplianceComplications

SiteLocationStageHistologyNode Status

and also

CompetenceConvenienceCostComplianceComplications

Survival with single modality treatmentSurvival with single modality treatment

Choice of Treatment depends upon:

Choice of Treatment depends upon:

Head and Neck CancerHead and Neck Cancer

Stage 1 15% 90%

Stage II 20% 70%

Stage III 25% 55%

Stage IV 25% 40%

Inoperable 15% 5-10%

Stage 1 15% 90%

Stage II 20% 70%

Stage III 25% 55%

Stage IV 25% 40%

Inoperable 15% 5-10%

PresentationPresentation 5 Yr Survival5 Yr Survival

Multimodal TreatmentCombinations

• RT Surg

• Surg RT

• RT Surg RT

• Surg RT Chemo

• Chemo Surg RT (+ Chemo)

• Chemo RT (+ Chemo)

• Concurrent Chemo & RT

• Intraarterial Chemo

• Brachytherapy

Development ofMultimodal Therapy for Head and

Neck Cancer20th century

1960’s

1970’s

1980’s

2002

Single modality treatmentsSurgery – RT – Chemo Rx

Pre-operative radiotherapy

Post-operative radiotherapy

Induction chemotherapy with surgery + RTNeoadjuvant chemo RxOrgan preservation strategiesConcurrent chemo Rx & RT

1990’s

Levels of Evidence

1. Randomized controlled trial or

Meta-analysis

2. Nonrandomized controlled clinical trial, subset analysis of RCT

3. Case series, population based, consecutive or not

4. 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

U.S. Cancer Incidence

The Onculus

U.S. CancerIncidence

U.S. CancerMortality

Cancer Level I Evidence

U.S. CancerIncidence

U.S. CancerMortality

Surgery in Multimodal Treatment of Head & Neck Cancer

Timeline

1960 - 1966 Preop RT Surgery

Surgery Postop RT

– Induction Chemo Surgery RT or RT Surgery– Planned Surgery or Salvage Surgery

History

Multimodal Treatment

1974 - 1978

1978 - 1982

1985 - 1991 – Organ Preservation with Chemo RT Salvage Surgery– Chemo Surgery RT

1992 - 2000 – Concurrent Chemo/RT vs Induction– Chemo and RT vs RT alone

Surgery in Multimodal Treatment of Head & Neck Cancer

Timeline

History

Multimodal Treatment

1994 - 2000 Surgery Adjuvant Chemo/RT

Organ/FunctionPreservation

Role of ConservationSurgery in Multimodal TreatmentAnd Salvage Surgery

Surgical?Non-Surgical?Salvage?

e.g. Selective Neck Dissection Partial Laryngectomy

Preoperative Radiation and Radical Neck Dissection

1960 – 1966348 Patients

Surg Clin North Am. Apr 1969; 49(2):271-276.

Strong EW.

Elective Postoperative Radiation Therapy in Stages III and IV

Epidermoid Carcinoma of the Head and Neck

Vikram B, Strong EW, Shah J, Spiro RH.

Am J Surg. Oct 1980; 140(4):580-584.

1974 – 1978104 Patients

Adjuvant Chemotherapy for Advanced Head and Neck

Squamous Carcinoma

Final Report of the Head and Neck Contracts Program.

Cancer. Aug 1 1987; 60(3):301-311.

1978 – 1982462 Patients

Induction Chemotherapy Plus Radiation Compared with

Surgery Plus Radiation in Patients with Advanced Laryngeal Cancer

The Department of Veterans Affairs Laryngeal Cancer Study Group

N Engl J Med. Jun 13 1991; 324(24):1685-1690.

1985 – 1991332 Patients

Concurrent Chemotherapy and Radiotherapy for Organ Preservation in

Advanced Laryngeal Cancer

Forastiere AA, Goepfert H, Maor M, et al.N Engl J Med. Nov 27 2003; 349(22):2091-2098.

1992 – 2000547 Patients

Postoperative Irradiation with or without Concomitant Chemotherapy for

Locally Advanced Head and Neck Cancer

Bernier J, Domenge C, Ozsahin M, et al.N Engl J Med. May 6 2004; 350(19):1945-1952.

1994 – 2000334 Patients

Postoperative Concurrent Radiotherapy and Chemotherapy for High-Risk Squamous-Cell Carcinoma

of the Head and Neck

Cooper JS. Pajak TF, Forastiere AA, et al.N Engl J Med. May 6 2004; 350(19):1937-1944.

1995 – 2000459 Patients

Limitations to OrganPreservation Approach

• Previous radiotherapy

• Cartilage invasion

• T4 primary

• Non laryngeal sites (BOT, hypopharynx)

• < C.R.

• Medical contraindications (renal, pulmonary, otologic)

2. SCC of Nasal Cavity and Paranasal Sinuses

Surgery Remains Initial Definitive Treatment for Most Sites in Head & Neck

3. Advanced Carcinomas (T4) of the Larynx and Hypopharynx

1. SCC of Oral Cavity

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 Controlin Pts treated with Chemo/RT

5 yr NRFS Survival 5 yr NRFS Survival

N0 – 87% C.R. – 92%N1 – 93% P.R. – 65%N2 – 69%(p<0.008) (p<0.0001)

MSKCC – unpublished data.

58 pts

• Planned Comprehensive Neck Dissection• Planned Selective Neck Dissection• Nidusectomy• Observation• Imaging – PET/CT/MRI

Management of the NeckAfter Chemo/Radiotherapy

Surgery Employed asSalvage 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

• 139 pts – treated with RT

• 35 recurred in neck

Salvage of Recurrent Neck Diseasein Radiated Neck

• Salvage attempted in 9, but successful in 2

• 75 pts with OPH treated with RT

• Mendenhall W.M., et al (1984)

• Peters L.J., et al (1996)

• 62 had a CR

• 8 recurred in neck

• Salvage attempted in 7, but successful in 1

Jerry Goodwin

2. Laryngeal edema/obstruction

Surgery for Complications and Sequelae of Radiotherapy / Chemotherapy

3. Radionecrosis of larynx

1. Oro-nasopharyngeal stenosis

4. Pharyngoesophageal stricture

5. Osteoradionecrosis of mandible

2. Bleeding

Surgery Employed for Palliation

3. Airway Obstruction

1. Pain

4. Esophageal Obstruction

5. Fungating Tumor

6. Distant Metastases

Life History of a Patientwith Head and Neck Cancer

Life History of a Patientwith Head and Neck Cancer

DiagnosisDiagnosis EvaluationEvaluation Definitivetherapy

Definitivetherapy

RehabilitationRehabilitation

Management ofcomplications

Management ofcomplications

SurveillanceSurveillance SalvagetreatmentSalvage

treatmentPalliationPalliation

PreventionPrevention New primaryNew primary

S S S S

S S S S

S S

R

R R

C

C C

C

Copyright restrictions may apply.

Ganly, I. et al. Arch Otolaryngol Head Neck Surg 2006;132:59-66.

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

Copyright restrictions may apply.

Ganly, I. et al. Arch Otolaryngol Head Neck Surg 2006;132:59-66.

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