Treatment of recurrent and advanced stage squamous cell carcinoma of the head and neck

https://doi.org/10.1053/j.semradonc.2004.03.001Get rights and content

Abstract

Despite advances in our ability to safely treat patients with recurrent cancer of the upper aerodigestive tract, outcomes for retreatment are generally poor and the first chance to cure these patients remains the best chance. Thorough knowledge of the outlook and options for patients with recurrent disease is also of significance in choosing therapy for patients with newly diagnosed disease. This is especially true for newly diagnosed patients making the choice between surgery and nonsurgical (“organ-sparing”) options, who need to know the outlook for salvage surgery, should they recur after radiation with or without concomitant chemotherapy. Salvage surgery is generally the best option for previously irradiated patients who are faced with resectable, recurrent disease. Unfortunately, the results of surgical salvage are generally poor for patients with advanced stage recurrence and for those who recur after treatment of advanced disease. The site of initial and recurrent disease is important. Surgical salvage is most effective for patients with recurrent laryngeal cancer, least effective for recurrent cancer of the pharynx, and is intermediate for recurrence in the oral cavity. Patients choosing nonsurgical treatment for newly diagnosed cancer of the pharynx cannot rely on salvage surgery in the event of recurrence. Reirraditation for patients who have failed initial treatment that included radiation therapy has been used at a number of institutions with some success. Experience using reirradiation with or without concomitant chemotherapy continues to evolve. Palliative chemotherapy is an option for most patients, but response rates are generally poor and of short duration, after failure of initial treatment that includes radiation therapy. The best approach for many patients and families who face advanced recurrent disease is honest but compassionate communication and supportive care with the help of a hospice organization.

Section snippets

Options

The options for patients who have failed definitive treatment for squamous cell carcinoma of the upper aerodigestive tract include (1) salvage surgery; (2) repeat radiation therapy (reirradiation), with or without chemotherapy; (3) palliative chemotherapy; and (4) supportive care. In the following discussion, we will focus on salvage surgery and discuss the others only to place salvage surgery within the full context of options available to the patient. The other options, although important,

Salvage surgery

Salvage surgery is generally considered to be the first option if the recurrent disease is resectable and the patient is able to undergo the required surgery. We have previously reported the results of a meta-analysis of the available literature on this subject, along with a prospective review of 109 consecutive patients undergoing salvage surgery for the treatment of recurrent squamous cell carcinoma of the upper aerodigestive tract at the University of Miami Sylvester Comprehensive Cancer

Limitations of salvage surgery

It is also important to understand the specific limits of surgical resection as they exist today. Although technically feasible, the value of resecting the common or internal carotid artery, distal trachea, esophagus, and prevertebral soft tissue is controversial. The chance of cure is small when these structures are involved, and each of these maneuvers greatly increases operative risk. The patient and family rely on the surgeon’s judgment, and the crucial question becomes whether the surgery

Larynx

Total laryngectomy is clearly a life-altering surgical procedure. As advances in the diagnosis and treatment of laryngeal cancer have progressed, the use of partial laryngectomy or radiation therapy for stage I and II cancers, and more recently, the use of chemotherapy and radiation for stage III and early stage IV disease, have provided good cure rates and saved many patients from suffering the natural sequelae of total laryngectomy. In early staged disease, most experienced head and neck

Reirradiation

Traditional wisdom has dictated that a specific type and volume of tissue can only receive a given amount radiation without subjecting the patient to unacceptable risk of long-term toxicity. Because definitive radiation therapy approaches generally accepted levels of tissue tolerance, it follows that recurrence of cancer within the treatment fields cannot be safely and effectively treated with repeat irradiation. But there is a growing body of evidence that this is not the case. Reirradiation

Palliative chemotherapy

Palliative chemotherapy is almost always an option. This can generally be expected to elicit clinical response in about one third of patients with recurrent head and neck malignancy. Duration of response rarely exceeds 6 months, and long-term control is rare. A relatively nontoxic regimen may be useful in patients who desire some active cancer therapy but are unable to tolerate more aggressive treatment protocols.

Supportive care

The least aggressive treatment, and often the most humane option, is to provide comfort measures and psychological support. Supportive care, facilitated by a hospice organization, can provide great comfort to the patient and family in the final months of life. This is often facilitated by a tracheotomy for relief of airway distress and a percutaneous gastrostomy for alleviation of hunger, ease of hydration, and the delivery of medications.

Conclusion

Recurrent advanced stage malignancy of the upper aerodigestive tract is a challenging problem for all involved with its treatment. Low rates of cure and high morbidity, both from the disease and its current best treatments, make careful consideration of how and when to treat these patients a complex issue. Surgical salvage can be a useful option in patients with resectable disease. Treatment protocols that include reirradiation are gaining more acceptance. The high stakes involved make

References (15)

There are more references available in the full text version of this article.

Cited by (0)

View full text