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The Journal of Laryngology and Otology May 2016This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. There has been significant debate...
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. There has been significant debate in the management of oropharyngeal cancer in the last decade, especially in light of the increased incidence, clarity on the role of the human papilloma virus in this disease and the treatment responsiveness of the human papilloma virus positive cancers. This paper discusses the evidence base pertaining to the management of oropharyngeal cancer and provides recommendations on management for this group of patients receiving cancer care. Recommendations • Cross-sectional imaging is required in all cases to complete assessment and staging. (R) • Magnetic resonance imaging is recommended for primary site and computed tomography scan for neck and chest. (R) • Positron emission tomography combined with computed tomography scanning is recommended for the assessment of response after chemoradiotherapy, and has a role in assessing recurrence. (R) • Examination under anaesthetic is strongly recommended, but not mandatory. (R) • Histological diagnosis is mandatory in most cases, especially for patients receiving treatment with curative intent. (R) • Oropharyngeal carcinoma histopathology reports should be prepared according to The Royal College of Pathologists Guidelines. (G) • Human papilloma virus (HPV) testing should be carried out for all oropharyngeal squamous cell carcinomas as recommended in The Royal College of Pathologists Guidelines. (R) • Human papilloma virus testing for oropharyngeal cancer should be performed within a diagnostic service where the laboratory procedures and reporting standards are quality assured. (G) • Treatment options for T1-T2 N0 oropharyngeal squamous cell carcinoma include radical radiotherapy or transoral surgery and neck dissection (with post-operative (chemo)radiotherapy if there are adverse pathological features on histological examination). (R) • Transoral surgery is preferable to open techniques and is associated with good functional outcomes in retrospective series. (R) • If treated surgically, neck dissection should include levels II-IV and possibly level I. Level IIb can be omitted if there is no disease in level IIa. (R) • If treated with radiotherapy, levels II-IV should be included, and possibly level Ib in selected cases. (R) • Altering the modalities of treatment according to HPV status is currently controversial and should be undertaken only in clinical trials. (R) • Where possible, patients should be offered the opportunity to enrol in clinical trials in the field. (G).
Topics: Chemoradiotherapy; Combined Modality Therapy; Humans; Interdisciplinary Communication; Magnetic Resonance Imaging; Neoplasm Staging; Oropharyngeal Neoplasms; Papillomavirus Infections; Prognosis; Tomography, X-Ray Computed; United Kingdom
PubMed: 27841123
DOI: 10.1017/S0022215116000505 -
American Society of Clinical Oncology... Jan 2019HPV-positive (HPV+) oropharyngeal carcinoma (OPC) continues to increase in incidence across the globe. Multimodality treatment offers a high likelihood of cure in HPV+... (Review)
Review
HPV-positive (HPV+) oropharyngeal carcinoma (OPC) continues to increase in incidence across the globe. Multimodality treatment offers a high likelihood of cure in HPV+ OPC but comes at a high cost of treatment-related morbidity. As a result, de-escalation of treatment to limit toxicity without compromising high cure rates has emerged as a major trend in head and neck cancer clinical research. Primary surgery with minimally invasive resection of the primary disease may allow for the elimination of chemotherapy and decrease radiation dose intensity. Primary dose-reduced radiation, with or without systemic therapy, is also under study, as is replacing concurrent cisplatin with newer systemic agents. Numerous institutional series and phase II trials have been presented, and the first generation of de-escalation randomized phase III trials have now been published. The various combinatorial multimodality strategies to achieve less intensive and toxic therapy are many. Has the time come for de-escalation as a standard approach to HPV+ OPC? The pros and cons, as well as the best approaches for de-escalated treatment of HPV+ OPC, are debated here.
Topics: Clinical Decision-Making; Clinical Trials as Topic; Combined Modality Therapy; Disease Management; Humans; Incidence; Oropharyngeal Neoplasms; Papillomaviridae; Papillomavirus Infections; Time-to-Treatment; Treatment Outcome
PubMed: 31099643
DOI: 10.1200/EDBK_238315 -
JAMA Network Open Jun 2021Definitive chemoradiotherapy and upfront surgical treatment are both accepted as the standard of care for advanced-stage oropharyngeal squamous cell carcinoma. However,...
IMPORTANCE
Definitive chemoradiotherapy and upfront surgical treatment are both accepted as the standard of care for advanced-stage oropharyngeal squamous cell carcinoma. However, the optimal primary treatment modality remains unclear.
OBJECTIVE
To evaluate the comparative effectiveness of definitive chemoradiotherapy and upfront surgical treatment for advanced-stage oropharyngeal cancer.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective comparative effectiveness analysis used data from the population-based Taiwan Cancer Registry. Included patients were diagnosed with clinical stage III or IV oropharyngeal squamous cell carcinoma from 2007 to 2015 and were identified from the registry. Patients with T4b or N3 disease were excluded. Data were analyzed from June 2019 through December 2020.
INTERVENTIONS
Definitive chemoradiotherapy or upfront surgical treatment.
MAIN OUTCOMES AND MEASURES
The primary outcome was overall survival, for which data were available through December 31, 2018. Secondary outcomes were progression-free survival, locoregional recurrence-free survival, and distant metastasis-free survival.
RESULTS
Among 1180 patients, 694 patients (58.8%) were in the definitive chemoradiotherapy group and 486 patients (41.2%) were in the upfront surgical treatment group. The median (interquartile range) follow-up was 3.62 (1.63-5.47) years, and most patients were men (1052 [89.1%] men) with a primary tumor in the tonsils (712 patients [60.3%]), moderately differentiated histology (604 patients [51.2%]), clinical N2 disease (858 patients [72.7%]), and clinical stage IVA disease (938 patients [79.5%]). The mean (SD) age was 54.59 (10.35) years. Primary treatment with an upfront surgical procedure was associated with a decreased risk of death during the study period (hazard ratio [HR], 0.81; 95% CI, 0.69-0.97; P = .02). However, when adjusted for age, subsite, histological grade, and T and N classification, upfront surgical treatment was no longer associated with an increased risk of death during the study period (HR, 0.96; 95% CI, 0.80-1.16; P = .70). Progression-free survival was worse in the group receiving upfront surgical treatment than in the group receiving chemoradiotherapy (HR, 1.64; 95% CI, 1.09-2.46; P = .02), and this difference persisted after adjusting for other factors associated with prognosis (ie, age, tumor subsite, histological grade, and T and N classification) (HR, 1.72; 95% CI, 1.12-2.66; P = .01).
CONCLUSIONS AND RELEVANCE
This study found that definitive chemoradiotherapy was associated with effectiveness that was comparable with that of upfront surgical treatment when adjusted for baseline factors associated with prognosis. These findings suggest that definitive chemoradiotherapy should be considered to avoid accumulating toxic effects associated with surgical treatment and chemoradiotherapy.
Topics: Carcinoma, Squamous Cell; Chemoradiotherapy; Chemotherapy, Adjuvant; Female; Humans; Male; Middle Aged; Neoplasm Staging; Oropharyngeal Neoplasms; Prognosis; Risk Factors; Taiwan; Treatment Outcome
PubMed: 34061201
DOI: 10.1001/jamanetworkopen.2021.12067 -
Biomedical Papers of the Medical... Dec 2023HPV16 status in oropharyngeal cancer (OPC) is an important prognostic factor. Its determination, based on immunistochemical analysis of p16 oncoprotein requires an... (Review)
Review
HPV16 status in oropharyngeal cancer (OPC) is an important prognostic factor. Its determination, based on immunistochemical analysis of p16 oncoprotein requires an invasive biopsy. Thus, alternative methods are being sought. Determining oral HPV16 status appears to be a promising alternative. However, it is not used routinely. This prompted us to perform a systematic literature review enabling us to evaluate the diagnostic and predictive ability of this approach. Thirty-four relevant studies were finally selected. For determination of HPV status in OPC, the calculated average sensitivity and specificity for oral sampling was 74% and 91%, respectively, with p16 tumour tissue marker being the gold standard. The method appears to be valuable in monitoring treatment response as well as the biological activity of the tumour, enabling early detection of persistent or relapsing carcinoma sufficiently long before its clinical and/or radiological manifestation. It can also contribute to identification of the primary tumour in cases of metastases of unknown origin. Last but not least, the screening HPV oral testing would help to identify individuals with persistent HPV oral infection who are at increased risk of development of OPC.
Topics: Humans; Papillomavirus Infections; Neoplasm Recurrence, Local; Oropharyngeal Neoplasms; Carcinoma; Sensitivity and Specificity; Biomarkers, Tumor
PubMed: 37901925
DOI: 10.5507/bp.2023.040 -
Acta Otorhinolaryngologica Italica :... Aug 2022This study aims to provide real-world data on oncologic and functional outcomes of the most modern surgical and non-surgical treatments of locally advanced HPV-positive... (Review)
Review
Upfront transoral robotic surgery (TORS) intensity-modulated radiation therapy (IMRT) in HPV-positive oropharyngeal cancer: real-world data from a tertiary comprehensive cancer centre.
OBJECTIVE
This study aims to provide real-world data on oncologic and functional outcomes of the most modern surgical and non-surgical treatments of locally advanced HPV-positive oropharyngeal cancer.
METHODS
We reviewed data on patients treated for stage III and IV HPV-positive oropharyngeal squamous cell carcinoma with either endoscopic surgery (Transoral Robotic Surgery, TORS; Transoral Laser Microsurgery, TLM - group A) or intensity-modulated radiotherapy (IMRT - group B). The minimum follow-up required was 6 months. Survival outcomes and toxicities of treatments were evaluated.
RESULTS
30 patients in group A and 66 in group B were eligible for the analysis. 28% of patients in group A underwent a unimodal treatment, while 42% needed trimodal treatment. 90% of patients in group B underwent concurrent chemoradiation. We found no statistically significant difference in survival outcomes (group A: overall survival 97%, progression-free survival 83%; group B: OS 98%, PFS 86%) or toxicities between groups.
CONCLUSIONS
Both transoral surgery and IMRT provide excellent outcomes in HPV-positive oropharyngeal cancer. Because of the good prognosis, treatments need to be refined to reduce toxicities while preserving oncologic soundness.
Topics: Carcinoma, Squamous Cell; Head and Neck Neoplasms; Humans; Oropharyngeal Neoplasms; Papillomavirus Infections; Radiotherapy, Intensity-Modulated; Retrospective Studies; Robotic Surgical Procedures
PubMed: 35938555
DOI: 10.14639/0392-100X-N2144 -
Journal of B.U.ON. : Official Journal... 2018Human papillomavirus (HPV)-mediated cervical carcinogenesis represents a well analyzed model of viral implication in epithelial malignant transformation. Mechanisms of...
Human papillomavirus (HPV)-mediated cervical carcinogenesis represents a well analyzed model of viral implication in epithelial malignant transformation. Mechanisms of high risk (HR) HPV-related infection seem to demonstrate a similar action regarding its implication in head and neck (HN) carcinomas, predominantly in squamous cell carcinoma (SCC) histological type. The prevalence of HR HPV subtypes - mainly HPV16 - is characterized by a broad geographic heterogeneity. Furthermore, HPV-associated HNSCCs demonstrate differences regarding sexual, molecular, epidemiological, and prognostic features compared to alcohol and tobacco dependent ones. Based on these differences, HPV-derived HNSCC appear to be a specific well-defined entity mostly affecting young to middle-aged - male mainly - non-smokers. This is a strong reason of detecting an increased HR-HPV DNA levels -due to viral transmission - in oropharyngeal and laryngeal anatomic regions. Additionally, different response rates to chemoradiation and targeted therapeutic regimens are another significant field for handling these SCC malignancies in the corresponding patients. In the current special article we explored the role of HPV-related carcinogenesis in oropharyngeal and laryngeal SCC focused on the latest molecular aspects.
Topics: Carcinoma, Squamous Cell; DNA, Viral; Head and Neck Neoplasms; Humans; Male; Middle Aged; Oropharyngeal Neoplasms; Papillomaviridae; Papillomavirus Infections
PubMed: 29552754
DOI: No ID Found -
Radiation Oncology (London, England) Apr 2023Local recurrence is the most common pattern of failure in head and neck cancer. It can therefore be hypothesised that some of these patients would benefit from an... (Comparative Study)
Comparative Study
BACKGROUND
Local recurrence is the most common pattern of failure in head and neck cancer. It can therefore be hypothesised that some of these patients would benefit from an intensified local treatment, such as radiation dose escalation of the primary tumour. This study compares treatment and toxicity outcomes from two different boost modalities in oropharyngeal cancer: simultaneous integrated boost (SIB) and brachytherapy boost.
METHODS
Two hundred and forty-four consecutive patients treated with > 72 Gy for oropharyngeal squamous cell carcinoma between 2011 and 2018 at our institution were retrospectively analysed. Data on side effects were collected from a local quality registry and supplemented with a review of medical records. Patients receiving a brachytherapy boost first had external beam radiotherapy consisting of 68 Gy in 2 Gy fractions to the gross tumour volume (GTV), and elective radiotherapy to the neck bilaterally. The brachytherapy boost was typically given using pulsed dose rate, 15 fractions and 0.56-0.66 Gy per fraction [total dose in EQD2 = 75.4-76.8 Gy (α/β = 10)]. The typical dose escalated radiotherapy with external beam radiotherapy only, was delivered using SIB with 74,8 Gy in 2.2 Gy fractions [EQD2 = 76.0 Gy (α/β = 10)] to the primary tumour, 68 Gy in 2 Gy fractions to GTV + 10 mm margin and elective radiotherapy to the neck bilaterally.
RESULTS
Dose escalation by SIB was given to 111 patients and brachytherapy boost to 134 patients. The most common type of cancer was base of tongue (55%), followed by tonsillar cancer (42%). The majority of patients had T3- or T4-tumours and 84% were HPV-positive. The 5-year OS was 72,4% (95% CI 66.9-78.3) and the median follow-up was 6.1 years. Comparing the two different dose escalation modalities we found no significant differences in OS or PFS and these results remained after a propensity-score matched analysis was performed. The analysis of grade ≥ 3 side effects showed no significant differences between the two different dose escalation techniques.
CONCLUSIONS
We found no significant differences in survival or grade ≥ 3 side effects comparing simultaneous integrated boost and brachytherapy boost as alternative dose escalation modalities in the treatment of oropharyngeal cancer.
Topics: Humans; Brachytherapy; Head and Neck Neoplasms; Neoplasm Recurrence, Local; Neoplasm Staging; Oropharyngeal Neoplasms; Radiotherapy Dosage; Retrospective Studies; Squamous Cell Carcinoma of Head and Neck
PubMed: 37029424
DOI: 10.1186/s13014-023-02256-x -
Clinical Imaging Jan 2023To evaluate the agreement between pathological and radiological staging in oropharyngeal cancer by comparing the 7th and the 8th edition of the AJCC TNM system.
PURPOSE
To evaluate the agreement between pathological and radiological staging in oropharyngeal cancer by comparing the 7th and the 8th edition of the AJCC TNM system.
METHODS
This retrospective cohort study included 57 cases of oropharyngeal cancer with lymph node metastases staged with the 7th and 8th editions of the AJCC TNM system. Comparison between clinical and radiological features and differences in agreement rates were calculated between radiological and pathological staging for the primary tumor (T) and lymph nodes (N) in HPVpos and HPVneg cases.
RESULTS
Comparison of HPVpos and HPVneg revealed a significantly different distribution between early and advanced stages in the 8 th edition, with a relevant number of HPVpos patients redefined from advanced stages whit the 7 th ed. to early stages with 8 th ed. (p < 0.01); no significant differences were found when comparing all diagnostic methods for T and N.
CONCLUSIONS
The 8th edition of the AJCC TNM seems to lead to better pretreatment staging. For both HPVpos and HPVneg, the agreement between pretreatment radiological and pathological staging.
Topics: Humans; Neoplasm Staging; Papillomavirus Infections; Retrospective Studies; Oropharyngeal Neoplasms; Lymph Nodes; Prognosis
PubMed: 36375362
DOI: 10.1016/j.clinimag.2022.10.010 -
The British Journal of Oral &... Jul 2019The management of enlarged retropharyngeal lymph nodes (RLN) in patients with confirmed oral, oropharyngeal, or nasopharyngeal squamous cell carcinoma (SCC) has... (Review)
Review
Current thinking on the management of abnormal retropharyngeal nodes in patients with oral, oropharyngeal, and nasopharyngeal squamous cell carcinoma: a structured review.
The management of enlarged retropharyngeal lymph nodes (RLN) in patients with confirmed oral, oropharyngeal, or nasopharyngeal squamous cell carcinoma (SCC) has prognostic relevance and is a challenge for the clinical teams. There is, however, no consensus regarding their clinical management or radiographic evaluation. The aim of this review therefore was to present the current thinking on management to help improve outcomes. We searched several online databases using the key terms "retropharyngeal node", "oral cancer", "head and neck cancer", "oropharyngeal cancer", "nasopharyngeal cancer", "nasopharynx", "oral cavity", "oropharynx", "TORS", and "radiotherapy". A total of 1024 papers were screened, of which 32 were eligible. There was no consensus about the management of RLN. There is a lack of randomised studies and a lack of consistency in the presentation of results. Management should be tailored in patients with nasopharyngeal carcinoma (NPC), and prophylactic irradiation is warranted as these nodes are at high risk of metastasis. In patients with non-NPC tumours, we prefer to resect them during primary operations when there is radiological uncertainty or evidence that they are affected, as the combination of radiological and histological outcomes will further our understanding. In both NPC and non-NPC tumours, sampling may also help to standardise the radiological criteria for the diagnosis of RLN by contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) CT.
Topics: Carcinoma, Squamous Cell; Humans; Lymph Nodes; Lymphatic Metastasis; Magnetic Resonance Imaging; Mouth Neoplasms; Nasopharyngeal Neoplasms; Neck; Neoplasm Staging; Oropharyngeal Neoplasms; Tomography, X-Ray Computed
PubMed: 31076218
DOI: 10.1016/j.bjoms.2019.04.017 -
JAMA Otolaryngology-- Head & Neck... Jun 2016Comorbidity affects the prognosis of patients with cancer through the direct effects of the comorbid illness and by influencing the patients' ability to tolerate...
IMPORTANCE
Comorbidity affects the prognosis of patients with cancer through the direct effects of the comorbid illness and by influencing the patients' ability to tolerate treatment and mount a host response. However, the prognostic importance of comorbidity in oropharyngeal squamous cell carcinoma is not well characterized in the era of human papillomavirus infection.
OBJECTIVE
To determine the prognostic importance of comorbidity in both p16-positive and p16-negative oropharyngeal squamous cell carcinoma and to explore the relationship between comorbidity and p16.
DESIGN, SETTING, AND PARTICIPANTS
Retrospective cohort study of 305 patients at a single tertiary referral center diagnosed as having oropharyngeal squamous cell carcinoma between June 1996 and June 2010, but without a history of head and neck cancer or distant metastasis at time of diagnosis. The data were analyzed from August 1, 2014, through April 30, 2015.
EXPOSURES
Patients were grouped according to p16 status.
MAIN OUTCOMES AND MEASURES
Overall survival, defined as the time from diagnosis to death from any cause. Disease-free survival, defined as the time from diagnosis to either death from any cause or the first documented local, regional, or distant recurrence.
RESULTS
Of the 305 patients who met eligibility criteria, 230 were p16-positive, 70 were p16-negative, and 5 were not evaluable for p16 status. The final cohort of 300 patients had a mean (SD) age of 56.3 (9.3) years and 262 (87%) were male. In Kaplan-Meier analysis, the 5-year overall survival rates were 71% (95% CI, 65%-76%) for 232 patients with no comorbidity to mild comorbidity and 49% (95% CI, 36%-61%) for 63 patients with moderate to severe comorbidity. In multivariate Cox proportional hazards analysis, moderate to severe comorbidity was associated with an increased risk of death from any cause (adjusted hazards ratio [aHR], 1.52 [95% CI, 0.99-2.32]) and increased risk of death or recurrence (aHR, 1.71 [95% CI, 1.13-2.59]). After stratifying by p16 status and controlling for other variables, moderate to severe comorbidity was significantly associated with increased risk of death from any cause among p16-negative patients (aHR, 1.90 [95% CI, 1.03-3.50]) but not among p16-positive patients (aHR, 1.11 [95% CI, 0.61-2.02]).
CONCLUSIONS AND RELEVANCE
Comorbidity is important to consider when assessing the prognosis of patients with oropharyngeal squamous cell carcinoma and is of greater prognostic value in p16-negative than p16-positive cancer.
Topics: Carcinoma, Squamous Cell; Cohort Studies; Comorbidity; Disease-Free Survival; Female; Human papillomavirus 16; Humans; Male; Middle Aged; Multivariate Analysis; Neoplasm Recurrence, Local; Oropharyngeal Neoplasms; Prognosis; Retrospective Studies; Smoking; Washington
PubMed: 27077485
DOI: 10.1001/jamaoto.2016.0347