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More selective neck node dissection approaches (including SNB)
512Symposia/Proffered
Papers
Symposia + Proffered Papers Optimizing Treatment for Pharyngo-LaryngealSCC: TowardslessMorbidity 39 speaker IMRT AND FOCUSED RADIOTHERAPY W. De Neve UNIVERSITYHOSPITALGENT,Department of Radiotherapy, Gent, Belgium IMRT reports on head and neck cancer show that Ioco-regional failure mostly occurs in the gross tumor volume (GTV). Substantial dose escalation beyond the presently prescribed dose levels requires focusing radiation to small targets, iMRT dose painting using dose escalation focused to radiation-resistant GTV-regions combined with conventional dose prescription levels to the remaining volume of the GTV represents a popular but investigational approach aiming at increased local control. Many aspects of this approach remain unknown including the relation between signal-value in biological images and radioresistance; the techniques to adapt dose painting to changing anatomy and biology in fractionated schedules; the optimal fractionation schedules; the maximum fraction size and total dose as function of focal target volume. Conceptually, the difficulties of the focused dose escalation are reduced by single fraction dose painting upfront, eventually followed by fractionated radiation therapy using a less structured dose distribution, insights regarding the participation of non-malignant tissue in tumor response support the single fraction approach. Some questions are best addressed by biology or physics research, others require clinical studies. Phase i trials studying the dose/volume/toxicity relationship of focused dose escalation in a variety of tumor sites are needed. Phase il trials with local control and topography of recurrence as primary endpoints might test the validity of the approach. The rationale of IMRT focused dose escalation is clear. Pre-clinical, translational and clinical research can be conducted simultaneously as many research-type specific questions need to be addressed. 40 speaker MORE SELECTIVE NECK NODE DISSECTION APPROACHES (INCLUDING SNB) J. Werner, A.A. DOnne UNIVERSITYOF MARRURG,Department of Otolaryngology, Head and Neck
Surgery, Marburg, Germany As the prognosis of patients suffering from a carcinoma of the upper aerodigestive tract is related to the extent of lymphogenic metastatic spread improvement of the therapy of the lymph nodes draining the head and neck area is requested. According to the main lymphatic drainage of the upper aerodigestive tract, lymphatic metastatic spread into several lymph groups is depending on the location of the primary, which directly influences surgical treatment concepts. The dominating metastatic region of pharyngeal and laryngeal carcinomas is mainly level II and less commonly, level ill. Carcinomas of the anterior oral cavity drain mostly into level I and less commonly into level II. Accordingly, selective neck dissection of these lymph node levels can be expected to include the majority of clinically occult metastases. With this background, it must still be clarified whether the intraoperative identification of the radiolabeled sentinel lymph node is appropriate to reduce the extent of selective neck dissection in the suspected NO neck, or whether neck dissection can be completely avoided in the case of histologically proven tumor-free sentinel lymph node. Also in this context the sensibility increased that lymph node metastases treated with primary radiochemotherapy may persist and be
Saturday, February 24, 2007 the starting point for recurrences of the regional lymphatic drainage region as well as further distant metastasis. Even if a series of scientific studies deal with the value of neck dissection after radiochemotherapy there are still many unanswered questions. This fact may be explained by a high heterogeneity of the data with different radiochemotherapy protocols, different extents of neck dissection as well as a missing standard of histological assessment. It is obvious that the conclusions drawn from those evaluations may not confirm general validity. 41 speaker QUALITY OF LIFE FOLLOWING PHARYNGO-LARYNGEAL CANCER S. Rogers UNIVERSITYHOSPITALAINTREE,Merseyside Head and Neck Cancer Centre,
Regional Maxillofacial Unit, Liverpool, UK This presentation will attempt to briefly summarise the literature on quality of life (QOL) outcomes following the management of pharyngoqaryngeai cancer. There is a body of evidence to support the use of organ preservation protocols in terms of Ioco-regional control and survival but the data on QOL is yet to be adequately determined. Some of the reasons are; i. Non surgical management can be associated with severe treatment-reiated toxic effects. Usually toxicity is not included as part of QOL but consideration should be given to an assessment of life-utility (QALY) as it may be helpful in determining 'meaningful' survival, particularly in the first year. ii. Preserving organ function does not necessarily mean the organ functions adequately from the patients perception. Although longterm data is emerging it might be weakened by the use of general cancer and generic head and neck cancer questionnaires. Newer function specific questionnaires should be more sensitive and examples include; MD Anderson Dysphagia Inventory, Swallowing Quality of Life measure, Voice-Related QOL Measure, Voice Handicap Index, Xerostomia related quality of life scale. iii. In the evaluation of functional outcomes it is useful to combine subjective (patient-derived) and objective (physical tests) but thus far studies have tended to rely on one or the other. However, some objective test can make good surrogate markers of QOL outcome in certain circumstances, such as PEG tube. iv. The relationship between function and QOL is not straight forward and although differences might be detected in functional subscales these might not translate to overall QOL scores. This however does not mean that functional deficits are any less important. v. Data from other units needs to be interpreted within local healthcare systems and as QOL reflects patients expectations cross-cultural differences should be accounted for. vi. Individual patients response to treatment is variable and in pooled data this can be masked. vii. It must be recognised that QOL outcomes are liable to various confounding variables for example; patient selection for primary treatment, coping strategies, drop out, response shift, and adaptation. vi. There is a distinct paucity of randomised trials to compare treatments where one of the primary outcomes is QOL. in the future, more data will emerge on QOL outcomes following pharyngo-laryngeal cancer and treatment selection wiii become more refined. However further research is necessary to explore trade off (choice) for patients and their families based on QOL outcomes and survival benefit. Also how this data is best presented needs careful evaluation, it should be possible to better predict patients who are likely to have poorer QOL outcomes and also target interventions with the intention of improving post-treatment QOL.
Papers
Symposia + Proffered Papers Optimizing Treatment for Pharyngo-LaryngealSCC: TowardslessMorbidity 39 speaker IMRT AND FOCUSED RADIOTHERAPY W. De Neve UNIVERSITYHOSPITALGENT,Department of Radiotherapy, Gent, Belgium IMRT reports on head and neck cancer show that Ioco-regional failure mostly occurs in the gross tumor volume (GTV). Substantial dose escalation beyond the presently prescribed dose levels requires focusing radiation to small targets, iMRT dose painting using dose escalation focused to radiation-resistant GTV-regions combined with conventional dose prescription levels to the remaining volume of the GTV represents a popular but investigational approach aiming at increased local control. Many aspects of this approach remain unknown including the relation between signal-value in biological images and radioresistance; the techniques to adapt dose painting to changing anatomy and biology in fractionated schedules; the optimal fractionation schedules; the maximum fraction size and total dose as function of focal target volume. Conceptually, the difficulties of the focused dose escalation are reduced by single fraction dose painting upfront, eventually followed by fractionated radiation therapy using a less structured dose distribution, insights regarding the participation of non-malignant tissue in tumor response support the single fraction approach. Some questions are best addressed by biology or physics research, others require clinical studies. Phase i trials studying the dose/volume/toxicity relationship of focused dose escalation in a variety of tumor sites are needed. Phase il trials with local control and topography of recurrence as primary endpoints might test the validity of the approach. The rationale of IMRT focused dose escalation is clear. Pre-clinical, translational and clinical research can be conducted simultaneously as many research-type specific questions need to be addressed. 40 speaker MORE SELECTIVE NECK NODE DISSECTION APPROACHES (INCLUDING SNB) J. Werner, A.A. DOnne UNIVERSITYOF MARRURG,Department of Otolaryngology, Head and Neck
Surgery, Marburg, Germany As the prognosis of patients suffering from a carcinoma of the upper aerodigestive tract is related to the extent of lymphogenic metastatic spread improvement of the therapy of the lymph nodes draining the head and neck area is requested. According to the main lymphatic drainage of the upper aerodigestive tract, lymphatic metastatic spread into several lymph groups is depending on the location of the primary, which directly influences surgical treatment concepts. The dominating metastatic region of pharyngeal and laryngeal carcinomas is mainly level II and less commonly, level ill. Carcinomas of the anterior oral cavity drain mostly into level I and less commonly into level II. Accordingly, selective neck dissection of these lymph node levels can be expected to include the majority of clinically occult metastases. With this background, it must still be clarified whether the intraoperative identification of the radiolabeled sentinel lymph node is appropriate to reduce the extent of selective neck dissection in the suspected NO neck, or whether neck dissection can be completely avoided in the case of histologically proven tumor-free sentinel lymph node. Also in this context the sensibility increased that lymph node metastases treated with primary radiochemotherapy may persist and be
Saturday, February 24, 2007 the starting point for recurrences of the regional lymphatic drainage region as well as further distant metastasis. Even if a series of scientific studies deal with the value of neck dissection after radiochemotherapy there are still many unanswered questions. This fact may be explained by a high heterogeneity of the data with different radiochemotherapy protocols, different extents of neck dissection as well as a missing standard of histological assessment. It is obvious that the conclusions drawn from those evaluations may not confirm general validity. 41 speaker QUALITY OF LIFE FOLLOWING PHARYNGO-LARYNGEAL CANCER S. Rogers UNIVERSITYHOSPITALAINTREE,Merseyside Head and Neck Cancer Centre,
Regional Maxillofacial Unit, Liverpool, UK This presentation will attempt to briefly summarise the literature on quality of life (QOL) outcomes following the management of pharyngoqaryngeai cancer. There is a body of evidence to support the use of organ preservation protocols in terms of Ioco-regional control and survival but the data on QOL is yet to be adequately determined. Some of the reasons are; i. Non surgical management can be associated with severe treatment-reiated toxic effects. Usually toxicity is not included as part of QOL but consideration should be given to an assessment of life-utility (QALY) as it may be helpful in determining 'meaningful' survival, particularly in the first year. ii. Preserving organ function does not necessarily mean the organ functions adequately from the patients perception. Although longterm data is emerging it might be weakened by the use of general cancer and generic head and neck cancer questionnaires. Newer function specific questionnaires should be more sensitive and examples include; MD Anderson Dysphagia Inventory, Swallowing Quality of Life measure, Voice-Related QOL Measure, Voice Handicap Index, Xerostomia related quality of life scale. iii. In the evaluation of functional outcomes it is useful to combine subjective (patient-derived) and objective (physical tests) but thus far studies have tended to rely on one or the other. However, some objective test can make good surrogate markers of QOL outcome in certain circumstances, such as PEG tube. iv. The relationship between function and QOL is not straight forward and although differences might be detected in functional subscales these might not translate to overall QOL scores. This however does not mean that functional deficits are any less important. v. Data from other units needs to be interpreted within local healthcare systems and as QOL reflects patients expectations cross-cultural differences should be accounted for. vi. Individual patients response to treatment is variable and in pooled data this can be masked. vii. It must be recognised that QOL outcomes are liable to various confounding variables for example; patient selection for primary treatment, coping strategies, drop out, response shift, and adaptation. vi. There is a distinct paucity of randomised trials to compare treatments where one of the primary outcomes is QOL. in the future, more data will emerge on QOL outcomes following pharyngo-laryngeal cancer and treatment selection wiii become more refined. However further research is necessary to explore trade off (choice) for patients and their families based on QOL outcomes and survival benefit. Also how this data is best presented needs careful evaluation, it should be possible to better predict patients who are likely to have poorer QOL outcomes and also target interventions with the intention of improving post-treatment QOL.