Advanced Nodal Disease Research Articles

The role of sleeve resections in advanced nodal disease

The aim of this study was to compare the short-term and long-term results of sleeve resections depending on limited nodal disease (N0/N1, LND) and advanced nodal disease (N2/N3, AND) for non-small cell lung cancer (NSCLC) at a single institution. We retrospectively reviewed our prospective database of all NSCLC patients undergoing sleeve resections between January 1999 and December 2008. Patients' characteristics, morbidity, mortality, locoregional recurrence, distant recurrence, and survival were analyzed corresponding to LND and AND. The indication was NSCLC for 170 sleeve resections (LND: n=120; AND: n=50) out of 213 consecutive sleeve resections. Both groups were statistically equal with regard to age (LND 61.8±12.4 vs AND 60.8±9.6 years), gender, co-morbidities, type of sleeve resection (bronchial vs bronchovascular), number of dissected lymph nodes (LND 40.0±12.4 vs AND 36.7±14.0), histology and completeness of resection (LND 96.7% vs AND 98.0%), respectively. More patients had induction chemotherapy in AND group (p=0.049). The short-term results were equal on the subject of morbidity rate (LND: 34.2%, AND: 44.0%), secondary pneumonectomy (LND: 1.7%, AND: 4.0%), and mortality rate (LND: 5.0%, AND: 6.0%), respectively. LND was associated with a better 5-year-survival rate (LND: 67%; AND: 42%) and mean survival (LND: 80.8 months; AND: 37.7 months; p=0.014). In the long-term follow-up, more distant metastases were detected in AND group (26.0% vs 14.2%, p=0.079) in contrast to identical locoregional recurrence (LND: 1.7%; AND: 0%). In the event of metastazing, the mean time to the development of distant metastases was similar (LND: 19.1 months; AND: 12.4 months; p=0.2). Lymph node involvement is a negative prognostic factor concerning long-term survival. Sleeve resections in AND do not result in higher morbidity and mortality. But even in AND, sleeve resections are associated with promising long-term survival and extraordinary local control of the disease as a result of high complete resection rates. High rate of distant failure warrants further investigation for the systemic control of the disease.

Prognostic factors in patients with high‐risk locally advanced salivary gland cancers treated with surgery and postoperative radiotherapy

This study was designed to identify the factors associated with the outcome after standard treatment with surgery and postoperative radiotherapy (RT) for locally advanced salivary gland cancers. We conducted a retrospective review of patients with salivary gland cancers registered in the University of Pittsburgh databases from 1990 to 2006. A total of 74 patients were analyzed. Histologic types included salivary duct carcinoma, 24%; adenoid cystic carcinoma, 23%; and adenocarcinoma, 19%; N2, 39%; N0-1, 58%; and major salivary gland origin, 80%. With a median follow-up of 4.1 years, the 5-year recurrence-free survival (RFS) was 49%, and the 5-year overall survival (OS) was 55%. The 5-year local RFS was 76% and the 5-year distant RFS was 60%. Using Cox-regression analysis, advanced N classification (N2) was the only significant predictor of both RFS and OS. The long-term survival of patients with high-risk, locally advanced salivary gland cancers is unsatisfactory. Advanced nodal disease is strongly associated with patient outcome and should be considered as a stratification factor in future trials in locally advanced salivary gland cancers.

Eph-A2 and Eph-A4 expression in human benign and malignant thyroid lesions: An immunohistochemical study

SummaryBackgroundEphrin receptors (Ephs) are frequently overexpressed in a wide variety of human malignant tumors, being associated with tumor growth, invasion, metastasis and angiogenesis. The aim of the present study was to evaluate the clinical significance of Eph-A2 and Eph-A4 expression in human benign and malignant thyroid lesions.Material/MethodsEph-A2 and Eph-A4 protein expression was assessed immunohistochemically on paraffin-embedded thyroid tissues from 131 patients with benign and malignant lesions.ResultsEph-A2 was significantly overexpressed in malignant compared to benign thyroid lesions (p<0.001). Papillary carcinoma cases presented significantly increased Eph-A2 expression compared to those with hyperplasia nodules (p<0.001). Eph-A4 expression was not differentiated between cases with malignant or benign thyroid lesions. Papillary carcinoma cases presented significantly increased Eph-A4 expression compared to those with hyperplasia nodules (p=0.006). In the subgroup of malignant thyroid lesions, Eph-A2 and Eph-A4 expression was not associated with TNM stage, capsular, lymphatic or vascular invasion.ConclusionsThe present data suggest that Eph-A2, but not Eph-A4, overexpression may be associated with the malignant transformation of thyroid neoplasia. Further studies conducted on cohorts including a higher proportion of patients with advanced nodal and metastatic disease are recommended to draw definite conclusions on the clinical significance of Eph proteins in thyroid neoplasia.

Predictive value of the Delphian and level VI nodes in papillary thyroid cancer

Recent published data has shown that metastatic involvement of the prelaryngeal or Delphian lymph node (DLN), the highest of the central (level VI) cervical lymph nodes, is highly predictive of advanced nodal disease in papillary thyroid cancer (PTC). The aims of this study were to determine the diagnostic accuracy of all the level VI cervical nodes in PTC and to determine which node group, if any, is the most accurate in predicting lateral node (N1b) disease. This was a retrospective cohort study. Data were obtained from the University of Sydney Endocrine Surgical Unit Database and through a review of the histopathology records. The study cohort was composed of 177 consecutive patients with a final diagnosis of PTC who underwent total thyroidectomy and lymph node dissection, spanning the period from May 2001 to December 2006. Of the 177 patients with PTC, 86 had the DLN removed, 51 had a pretracheal node removed and 76 had the paratracheal group removed. DLN, paratracheal and pretracheal node disease was present in 21%, 39% and 46%, respectively. Lateral node (N1b) disease was present in 35%. Paratracheal node involvement was mildly predictive of further disease with patients 1.7 times more likely to have lateral node involvement (sensitivity=55%, specificity=68%). Pretracheal node involvement was moderately predictive of further disease with patients three times more likely to have lateral node involvement (sensitivity=72%, specificity=74%). DLN involvement was highly predictive of further node involvement with patients nine times more likely to have lateral node disease (sensitivity=53%, specificity=94%) and 40 times more likely to have any nodal disease (sensitivity=41%, specificity=100%). This is the first study to examine the diagnostic accuracy of all level VI lymph nodes in PTC. While, metastatic involvement of all central nodal groups is indicative of further disease, the DLN is the most accurate predictor.

Prospective Assessment of Postoperative Complications and Associated Costs Following Inguinal Lymph Node Dissection (ILND) in Melanoma Patients

We prospectively assessed the incidence, risk factors, and costs associated with wound complications and lymphedema in melanoma patients undergoing inguinal lymph node dissection (ILND). A total of 53 melanoma patients were accrued to 2 trials (June 2005 to July 2008) that included prospective evaluations of postoperative complications; 30-day wound complications included infection, seroma, and/or dehiscence. There were 20 patients who underwent limb volume measurement and completed a 19-item lymphedema symptom assessment questionnaire preoperatively and 3months postoperatively. A multivariate analysis was performed to evaluate potential risk factors for complications. A microcosting analysis was also performed to evaluate the direct costs associated with wound complications. The 30-day wound complications were noted in 77.4% of patients. A BMI≥30 (n=28) increased the risk for wound complications (odds ratio [OR]=11.4, 95% confidence interval [95%CI] 1.6-78.5, P=.01), while advanced nodal disease approached significance (OR=9.0, 95%CI: 0.79-103.1, P=.08). Other risk factors, including diabetes, smoking, and the addition of a deep pelvic (iliac/obturator) dissection to ILND, were not significant. Of 20 patients, 9 (45%) developed limb volume change (LVC) ≥5% at 3months, with associated mean symptom scores of 6.1 versus 4.6 for those without LVC. Costs for patients with wound complications were significantly higher than for those without wound complications. Postoperative wound complications and early onset lymphedema occur frequently following ILND for melanoma. Obesity is an adverse risk factor for 30-day wound complications that can significantly increase postoperative costs, as is likely the case for advanced disease. Risk reduction practices and novel treatment approaches are needed to reduce postoperative morbidity.

Clinically Apparent Internal Mammary Nodal Metastasis in Patients With Advanced Breast Cancer: Incidence and Local Control

To investigate the incidence and local control of internal mammary lymph node metastases (IMN+) in patients with clinical N2 or N3 locally advanced breast cancer. We retrospectively reviewed the records of 809 breast cancer patients diagnosed with advanced nodal disease (clinical N2-3) who received radiation treatment at our institution from January 2000 December 2006. Patients were considered IMN+ on the basis of imaging studies. We identified 112 of 809 patients who presented with IMN+ disease (13.8%) detected on ultrasound, computed tomography (CT), positron emission tomography/CT (PET/CT), and/or magnetic resonance imaging (MRI) studies. All 112 patients with IMN+ disease received anthracycline and taxane-based chemotherapy. Neoadjuvant chemotherapy (NCT) resulted in a complete response (CR) on imaging studies of IMN disease in 72.1% of patients. Excluding 16 patients with progressive disease, 96 patients received adjuvant radiation to the breast or the chest wall and the regional lymphatics including the IMN chain with a median dose of 60 Gy if the internal mammary lymph nodes normalized after chemotherapy and 66 Gy if they did not. The median follow-up of surviving patients was 41 months (8-118 months). For the 96 patients able to complete curative therapy, the actuarial 5-year IMN control rate, locoregional control, overall survival, and disease-free survival were 89%, 80%, 76%, and 56%. Over ten percent of patients with advanced nodal disease will have IMN metastases on imaging studies. Multimodality therapy including IMN irradiation achieves excellent rates of control in the IMN region and a DFS of more than 50% after curative treatment.

Induction Chemotherapy and Cetuximab for Locally Advanced Squamous Cell Carcinoma of the Head and Neck: Results From a Phase II Prospective Trial

PURPOSE To determine the potential efficacy of combining cetuximab with chemotherapy in patients with advanced nodal disease, we conducted a phase II trial with induction chemotherapy (ICT) consisting of six weekly cycles of paclitaxel 135 mg/m(2) and carboplatin (area under the curve = 2) with cetuximab 400 mg/m(2) in week 1 and then 250 mg/m(2) (PCC). PATIENTS AND METHODS Forty-seven previously untreated patients (41 with oropharynx primaries; 33 men, 14 women; median age, 53 years; performance status of 0 or 1) with squamous cell carcinoma of the head and neck (SCCHN; T1-4, N2b/c/3) were treated and evaluated for clinical and radiographic response. After ICT, patients underwent risk-based local therapy, which consisted of either radiation, concomitant chemoradiotherapy, or surgery, based on tumor stage and site at diagnosis. Results After induction PCC, nine patients (19%) achieved a complete response, and 36 patients (77%) achieved a partial response. The most common grade 3 or 4 toxicity was skin rash (45%), followed by neutropenia (21%) without fever. At a median follow-up time of 33 months, locoregional or systemic disease progression was observed in six patients. The 3-year progression-free survival (PFS) and overall survival (OS) rates were 87% (95% CI, 78% to 97%) and 91% (95% CI, 84% to 99%), respectively. Human papillomavirus (HPV) 16, found in 12 (46%) of 26 biopsies, was associated with improved PFS (P = .012) and OS (P = .046). CONCLUSION ICT with weekly PCC followed by risk-based local therapy seems to be feasible, effective, and well tolerated. PFS is promising, and this sequential treatment strategy should be further investigated. Patients with HPV-positive tumors have an excellent prognosis.

Definitive Radiotherapy for T1–2 Hypopharyngeal Cancer: A Single Institution Experience

Definitive Radiotherapy for T1–2 Hypopharyngeal Cancer: A Single Institution Experience

Target Volume Definition in Head and Neck IMRT Treatment Planning: Can We Omit High Dose Clinical Target Volume (CTV HD)?

Results: The 3-year overall survival rate was 70%. The cause-specific survival rates at 3 years were as follows: Stage I–II, 96%; Stage III, 75%; Stage IVA, 69%; and Stage IVB, 53%. All of loco-regional recurrences occurred within 2 years after radiotherapy. Twelve patients (2 with T1 disease and 10 with T2 disease) developed local recurrence and 6 of them were successfully salvaged with surgery. The 3-year local control rates for T1 and T2 disease were 89% and 83%, respectively. Nodal recurrence was observed in 16 patients. Among patients with N2b–N3 disease, the 3-year regional control rates were 87% for patients with neck dissection and 43% for patients without neck dissection. Conclusions: Patients with T1–2 hypopharyngeal cancer achieved a high chance of local control after definitive radiotherapy. For patients with advanced nodal disease, pre-radiotherapy planned neck dissection is an effective treatment resulting in high regional control. Author Disclosure: A. Nakajima, None; S. Nakamura, None; O. Suzuki, None; M. Morimoto, None; K. Nishiyama, None.

8514 SPECTRUM, a phase III trial for patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck (SCCHN) receiving chemotherapy with or without panitumumab: interim pooled safety analysis

Concurrent chemotherapy and radiation has improved the outcome for patients presenting with locally advanced squamous cell carcinomas of the head and neck (SCCHN). These improvements have come at a cost of increased treatment-related toxicities. We previously reported the results of a phase II trial examining the role of concurrent carboplatin, paclitaxel, and daily radiotherapy (RT) in SCCHN. In an attempt to decrease these side effects, we conducted a prospective phase II trial evaluating the role of amifostine (Ethyol, MedImmune Oncology, Inc, Gaithersburg, MD) in patients treated with this concurrent chemoRT scheme. From April 2002 to September 2004, 19 patients with stage III-IV SCCHN were enrolled on a prospective phase II trial. Treatment consisted of daily RT delivered to 70.2 Gy (1.8 Gy/fx) with amifostine 500 mg IV (<1 hour before RT), and concurrent weekly carboplatin (100 mg/m2) and paclitaxel (40 mg/m2). Median age was 58.5 years (range, 48 to 70 years); male to female ratio was, 83%:17%; Caucasian versus other was, 61%/39%. Tumor characteristics based on histology were: primary cancers of the oropharynx (55.6%); supraglottic larynx (16.7%); hypopharynx (16.7%); oral cavity (5.6%); and unknown primaries (5.6%). All patients presented with locally advanced, unresectable disease T4 (50%), T3 (27.8%), and advanced nodal disease (N2b-N3) (78%). Toxicities were measured weekly during treatment and at each follow-up visit. Disease response to therapy was determined 2 months after completion of therapy. Seventeen patients are evaluable for response and survival at 2 months following completion of RT. Eighty-four percent completed the prescribed radiation treatment, and 84% of patients received more than six cycles of chemotherapy. The median number of missed chemotherapy cycles was 1.5 (range, 0 to 5 cycles). Fifty-six percent of patients received more than 90% of prescribed amifostine doses, with chemoRT-related toxicity being the most common reason for withholding the dose (77%). Median doses of missed amifostine were three (range, 0 to 30 doses). Grade 3 toxicities associated with therapy were: mucositis and dysphagia (40% of patients each), dehydration (27%), xerostomia (20%), and dermatitis (20%); 53% of patients experienced grade 3 leukopenia, while grade 3/4 neutropenia developed in 20%/13%. No grade 4/5 nonhematologic toxicities were encountered. Forty percent of patients completed RT without unscheduled treatment breaks secondary to treatment-related toxicity. Median treatment-break time was 5 days (range, 0 to 20 days). Clinical complete response at both the primary site of disease and neck was achieved in 75% of patients 2 months following completion of RT. Weekly carboplatin and paclitaxel administered concurrently with definitive RT and daily amifostine is well tolerated, with over 85% of patients completing therapy with acceptable toxicity. The addition of amifostine appears to decrease treatment-related toxicity without impacting efficacy.

8513 Image guidance with bone matching alone is insufficient for conformal radiation of early glottic cancers – an analysis of laryngeal positional uncertainty based on daily cone beam CT

Concurrent chemotherapy and radiation has improved the outcome for patients presenting with locally advanced squamous cell carcinomas of the head and neck (SCCHN). These improvements have come at a cost of increased treatment-related toxicities. We previously reported the results of a phase II trial examining the role of concurrent carboplatin, paclitaxel, and daily radiotherapy (RT) in SCCHN. In an attempt to decrease these side effects, we conducted a prospective phase II trial evaluating the role of amifostine (Ethyol, MedImmune Oncology, Inc, Gaithersburg, MD) in patients treated with this concurrent chemoRT scheme. From April 2002 to September 2004, 19 patients with stage III-IV SCCHN were enrolled on a prospective phase II trial. Treatment consisted of daily RT delivered to 70.2 Gy (1.8 Gy/fx) with amifostine 500 mg IV (<1 hour before RT), and concurrent weekly carboplatin (100 mg/m2) and paclitaxel (40 mg/m2). Median age was 58.5 years (range, 48 to 70 years); male to female ratio was, 83%:17%; Caucasian versus other was, 61%/39%. Tumor characteristics based on histology were: primary cancers of the oropharynx (55.6%); supraglottic larynx (16.7%); hypopharynx (16.7%); oral cavity (5.6%); and unknown primaries (5.6%). All patients presented with locally advanced, unresectable disease T4 (50%), T3 (27.8%), and advanced nodal disease (N2b-N3) (78%). Toxicities were measured weekly during treatment and at each follow-up visit. Disease response to therapy was determined 2 months after completion of therapy. Seventeen patients are evaluable for response and survival at 2 months following completion of RT. Eighty-four percent completed the prescribed radiation treatment, and 84% of patients received more than six cycles of chemotherapy. The median number of missed chemotherapy cycles was 1.5 (range, 0 to 5 cycles). Fifty-six percent of patients received more than 90% of prescribed amifostine doses, with chemoRT-related toxicity being the most common reason for withholding the dose (77%). Median doses of missed amifostine were three (range, 0 to 30 doses). Grade 3 toxicities associated with therapy were: mucositis and dysphagia (40% of patients each), dehydration (27%), xerostomia (20%), and dermatitis (20%); 53% of patients experienced grade 3 leukopenia, while grade 3/4 neutropenia developed in 20%/13%. No grade 4/5 nonhematologic toxicities were encountered. Forty percent of patients completed RT without unscheduled treatment breaks secondary to treatment-related toxicity. Median treatment-break time was 5 days (range, 0 to 20 days). Clinical complete response at both the primary site of disease and neck was achieved in 75% of patients 2 months following completion of RT. Weekly carboplatin and paclitaxel administered concurrently with definitive RT and daily amifostine is well tolerated, with over 85% of patients completing therapy with acceptable toxicity. The addition of amifostine appears to decrease treatment-related toxicity without impacting efficacy.

Revisiting the role of positron-emission tomography/computed tomography in determining the need for planned neck dissection following chemoradiation for advanced head and neck cancer

Planned neck dissection following chemoradiation (CR) has been advocated in patients with head and neck squamous cell cancer (HNSCC) with advanced nodal disease and a clinical complete response to CR because of the potential for residual occult nodal disease. The utility of positron-emission tomography/computed tomography (PET-CT) in identifying occult nodal disease in this scenario is controversial. The medical records of all patients treated with CR for advanced HNSCC with N2 or N3 disease from December 2003 to June 2007 were reviewed. Patients with a complete clinical response were included if PET-CT performed 8 to 11 weeks after CR showed no distant disease and they underwent planned neck dissection. Thirty-two patients met study criteria. PET-CT was positive for residual nodal disease in 20 patients (63%). Pathology revealed carcinoma in 10 patients (31%): six of 20 patients with positive PET-CT scans (30%) and four of 12 patients with negative PET-CT scans (33%). The sensitivity and specificity of PET-CT was 60% and 36%. Regional recurrence developed in two patients (6%) who were not successfully salvaged. PET-CT performed 8 to 11 weeks after CR does not reliably predict the need for planned post-treatment neck dissection in patients with a complete clinical response following CR. Regional recurrence rates are comparable to those reported for patients observed with PET-CT, suggesting no advantage for planned neck dissection, and salvage rates were poor. These data suggest that delaying the timing of PET-CT, with surgery reserved for positive findings, is a reasonable alternative to planned neck dissection to avoid unnecessary surgery.

Association between human papillomavirus (HPV) status with serum cytokine and angiogenic factor (CAF) profile after induction chemotherapy in head and neck squamous cell carcinoma (HNSCC)

6081 Background: Human papillomavirus has been implicated in the development of head and neck squamous cell carcinoma and is associated with a more favorable clinical outcome. Previously, we identified a serum hypoxia signature associated with HNSCC progression (Byers et al, Proc ASCO. 2008). We investigated the association between HPV status, serum biomarkers, and clinical outcome in patients treated with induction chemotherapy. Methods: 47 previously untreated patients with locally advanced nodal disease (T0–4, N2b/c/3, M0) received 6 weekly cycles of paclitaxel (135 mg/m2), carboplatin (AUC 2), and cetuximab (400 mg/m2 week 1; 250 mg/m2 weeks 2–6) followed by definitive local therapy. 46 (98%) patients had a complete or partial response to induction chemotherapy (Kies et al, Proc ASCO. 2006), and 6 have had tumor progression (PD) after a minimum follow-up of two years. Formalin fixed biopsies were available for HPV testing by in situ hybridization with non-radioisotopic chromogen for 25 patients (including 5/6 with PD). 38 CAFs were measured by multiplex bead assay before and during treatment. Results: 12/25 patients were HPV-positive, all male and six were never smokers; of the 13 HPV-negative patients, four were male and three were never smokers. Among those with available data, all 5 patients with PD were HPV-negative (p = 0.02). There were four study deaths, all in the HPV-negative group. Overall survival was superior in HPV-positive patients (p = 0.04). There was no significant association between HPV status and serum CAF markers. However, among HPV-negative patients, PD was associated with the CAF hypoxia signature (5/8 patients with the hypoxia signature progressed versus 0/5 signature-negative). Of the individual CAFs, osteopontin was significantly elevated in all HPV-negative patients with PD. Conclusions: HPV positivity was associated with a longer progression-free survival and overall survival. Among HPV-negative patients, only those with a serum hypoxia signature had disease progression. These data suggest that the combination of HPV status and CAF profiling may identify patients at risk for relapse after sequential therapy. No significant financial relationships to disclose.

The Role of Neck Dissection in the Combined Modality Therapy Setting

No method reliably detects residual low-volume nodal disease in a patient with a complete response (CR) to treatment. Control of the N0-1 neck is to be expected after CR; no treatment is needed. Positron emission tomography (PET) may improve patient selection, but neck dissection should still be performed for patients with good performance status and residual masses. Neck dissection reduces the incidence of regional recurrence, although the impact on survival is small. Whether the risk of tumor recurrence or the morbidity of neck dissection should be of greater concern for patients with N2-3 disease in CR is a matter of individual judgment. Combined modality therapy will control most nodal metastases (even for patients with advanced nodal disease). Neck dissection in patients presenting with bulky nodal disease who achieve a CR after combined modality therapy will diminish the regional recurrence rate by about 15%. Nowadays, patients with N3 disease and CR often still have residual neck tumor. Node dissection is to be advised. Neck dissection should still be considered an important treatment modality for patients who undergo combined modality therapy with advanced nodal disease, even if they have achieved a CR.

High‐dose‐rate brachytherapy plus neck dissection for nodal disease

Regional control for advanced nodal disease has been only marginally affected by concurrent chemoradiation, hyperfractionation, concomitant boost, or accelerated external radiation. Twenty-five necks in 24 patients received brachytherapy treatment (20 Gy in 10 twice-daily fractions) in addition to external radiation, neck dissection +/- chemotherapy. Indications for brachytherapy included initial treatment of bulky disease (n = 12), recurrence of neck disease in a previously treated patient with at least a 3-month disease-free interval (n = 6), persistent disease after a curative efforts (n = 4), inadequate external radiation (ie, <40 Gy) due to either intolerance or noncompliance (n = 3). Overall actuarial regional control was 67% at 2 years. Regional control for those receiving brachytherapy as part of their initial treatment was 82% despite a mean nodal diameter of 8.7 cm (range, 5-15 cm). The 2-year actuarial regional control was 56% for the patients with a disease-free interval of at least 3 years. High-dose-rate brachytherapy produced excellent regional control. (c) 2008 Wiley Periodicals, Inc. Head Neck, 2008.

Pedicled Anterolateral Thigh Flap for Reconstruction After Radical Groin Dissection

Inguinal lymphadenectomy is performed for the treatment of nodal metastases from squamous cell carcinoma of the penis and other tumors of the trunk and lower extremity. Malignant skin infiltration requires wide resection, producing a defect requiring complex soft-tissue reconstruction. We have used a pedicled anterolateral thigh flap as our first-choice flap for these cases. We report a prospective series of cases using this recently described flap for reconstruction of groin defects after radical groin dissection. From May 2001, 6 patients with locally advanced inguinal disease underwent wide skin excision and en bloc nodal resection with immediate reconstruction using a pedicled anterolateral thigh flap. Data were collected prospectively, and the data of 4 of 6 patients were reviewed at 6 months postoperatively. No flap losses occurred. Complete healing was achieved in all patients. The mean hospital stay was 18 days. The median time to complete healing was 33.5 days. The complications were seroma leading to flap congestion, wound dehiscence, wound infection, and delayed healing. The donor sites were either closed primarily or split skin grafted. Reconstruction using a pedicled anterolateral thigh flap in patients with advanced inguinal nodal disease is a useful adjunct in selected patients. We present our indications for the procedure, our rational for the choosing this technique over other methods of reconstruction, and the difficulties we experienced.

Mandatory Indication for Neck Dissection Based on Long-Term Results

The cervical lymph node status is one of the most important prognostic factors in oral tongue SCC. To assess the nodal status, CT, MRI, ultrasonography, and PET have been used, and currently good quality of CT is the imaging study of choice for nodal stage. However, even these imaging modalities hardly detect micrometastases. When a “wait and see” policy is used for the neck at risk for metastases, patients tend to fail with advanced nodal disease, even with close follow-up. So in light of the tumor characteristics influencing the propensity for nodal metastases, it has been suggested that if the probability of metastases to cervical lymph nodes exceeds 20%, then neck dissection is warranted. However, the probability of metastases is hardly determined. In general, for clinically N- patients with T1 or early T2 tumor, “wait and see” is adopted. For clinically N- patients with late T2 or more disease, supraomohyoid neck dissection (SOHND) is recommended, and extended SOHND clearing nodal level IV in addition to levels I, II and III is indicated in selected patients. Sentinel lymph node biopsy is under investigation in clinically N- patients. In clinically N+ patients, neck dissection is the most widely accepted treatment. Various types of neck dissection are performed depending on the nodal stage and minimizing the morbidity of the procedure. In this setting, radical neck dissection (RND) or modified RND sparing the SAN, IJV or SCM is indicated. SOHND in clinically N+ patients is controversial, however, it is often advocated in N1 patients whose metastasis involves the level I node without evidence of extracapsular spread (ECS) of tumor. Lingual lymph nodes, small, interrupting nodules located deeply above the suprahyoid region along the course of the lymphatic vessels draining the tongue are infrequently involved, so they should be included in dissection in selected patients. Risk factors for failure in the neck or distant sites are the presence of ECS of tumor, and presence of multiple nodes involved at multiple levels of the neck. In patients with such advanced neck disease, postoperative chemoradiotherapy may decrease the rate of failure.

Concurrent platinum-based chemotherapy with intensity modulated radiation therapy (IMRT) for locally advanced squamous cell carcinoma of the head and neck (SCCHN): A retrospective single institution analysis

16511 Background: Randomized clinical and meta-analysis data support the use of concurrent chemoradiation for treatment of locally advanced (SCCHN). IMRT is increasingly being used in treating SCCHN. We present outcome data from Emory University Winship Cancer Institute (WCI) with concurrent platinum based chemotherapy and IMRT, and analyze results according to primary site and nodal status. Methods: Between February 2003, and November 2005, 87 patients with locally advanced SCCHN underwent concurrent IMRT and platinum based chemotherapy. A total of 62 patients were treated with Cisplatin 100 mg/m2 d1,21,43, while 19 were treated with paclitaxel and carboplatin weekly for 7 weeks. Five patients were treated with other platinum based regimens. Follow up was documented in all cases with a median of 520 days (range 107 - 1269 days). Results: Patients were distributed among primary sites as follows: Hypopharynx (HP) 7 (8.0%), Larynx (L) 11(12.4%), Nasopharynx (NP) 13 (14.6%), and Oropharynx (OP) 56 (63.0%). T stage distribution was: T1: 16 patients (18.0%); lesions more advanced than T1 (&gt;T1): 68 (76.4%). N stage distribution was, N0 :16 patients (18.0%), N1: 8 (9.0 %),nodal stage N2a or higher: 61 (68.5%). Median age was 57 years (range 32–75), and 63 patients (71.0%) were male. The median overall survival (OS) and disease-free survival (DFS) post-therapy was not reached. The 3 year OS rate for the entire cohort was 86% (L 82%, NP 89 %, OP 86 % HP 80%). The 3 year DFS rate for the entire cohort was 74%, (L 85%, NP 60%, and OP 75%, HP 76%). There was no correlation between OS and T or N stage (p=0.143 and 0.44 respectively), or between DFS and T-stage (p=0.4). A significant correlation was found between DFS and N stage (p=0.008). Conclusion: With moderate follow up, this retrospective analysis reveals an excellent outcome for patients with locally advanced SCCHN treated with chemotherapy and IMRT concurrently, supporting concurrent therapy as the current standard of care. The significant correlation of DFS and nodal status suggests a possible greater impact future approaches such as induction therapy may have on patients with advanced nodal disease. No significant financial relationships to disclose.

Gastric adenocarcinoma in young patients: A population-based appraisal

4547 Background: While gastric adenocarcinoma is uncommon in young patients, reports of their outcomes remain inconsistent. We performed a population-based study of survival outcomes for gastric cancer in young adults (&lt;45 years). Methods: Patients with gastric adenocarcinoma who underwent cancer directed surgery were identified from the Surveillance Epidemiology and End Results registry from 1991 to 2002. Patient demographics, tumor grade, AJCC stage and use of radiation were categorized by age to &lt;45 years, 45 to 70 years and &gt;70 years old. Cancer-specific survival (CSS) was evaluated using Kaplan-Meier analysis with log rank comparisons. Cox multiple regression analysis was performed to adjust for confounder effects. Results: A total of 20,830 patients were identified: 1,051 (5%) &lt;45 years old [Grp 1], 8,456 (40.6%) 45–70 years old [Grp 2], and 11,323 (54.4%) &gt;70 years old [Grp 3]. Grp 1 was more likely than Grp 2 to have advanced nodal disease (multinomial odds ratio [OR]=1.5 for N2 vs N0, 95% confidence interval [CI] 1.14–2.0, p=0.004; OR=2.0 for N3 vs N0, CI 1.4–3.0, p=0.0002) and more likely to have metastases at presentation (OR 1.5, p&lt;0.00001). Stage-stratified 3-year cancer- specific survival [CSS] was not associated with age at diagnosis except for stage IV disease ( Table ). On Cox regression, young age did not impact survival (OR 0.95, CI 0.87–1.03, p=0.19). However, female gender, Asian race, earlier disease stage, lower grade, cancer- directed surgery and use of radiotherapy were predictors of better outcome (all p=0.003). Conclusions: Although young patients with gastric cancer in this population-based study present with more advanced disease, their stage-stratified cancer specific survival is similar to that of older patients. Stage-dependent, but not age-dependent, treatment should therefore be performed in young patients with gastric cancer. [Table: see text] No significant financial relationships to disclose.

ES03 THE DELPHIC LYMPH NODE AND THYROID CANCER

Background Named after the oracle of Delphi, the Delphic (or prelaryngeal) lymph node has long been regarded as a predictor of malignancy in thyroid cancer. It also has a notorious reputation for being a marker of advanced nodal disease. There is no current medical literature to support or refute these claims. The aim of this study was to determine the true significance of Delphic lymph node involvement in thyroid cancer.Methods 1,000 consecutive patients undergoing total thyroidectomy formed the study population. All information was obtained from a prospectively maintained database as well as from review of the histopathology records.Results 227 of 1,000 (22.7%) had a final diagnosis of thyroid cancer. In 63 of 227 (27.8%), the final diagnosis of cancer was unsuspected. The Delphic lymph node was removed in 112 of 227 patients, with 22 of 112 cancerous. Thus, 19.6% of patients had involvement of the Delphic lymph node when it was removed. Delphic node involvement was associated with significantly greater nodal disease (10.1 vs 1.4 nodes; p &lt; 0.05). No patient in either group had Delphic node involvement diagnosed on clinical grounds preoperatively.Conclusion Despite its reputation, the Delphic lymph node is not itself an independent predictor of the presence of thyroid cancer. It is however a useful marker of extensive local nodal disease. Identifying intra‐operatively whether the Delphic node is involved may assist in planning the extent of neck dissection during total thyroidectomy.