Neck Failure Research Articles

Patterns of failure and clinical outcomes of post-operative buccal mucosa cancers treated with adjuvant ipsilateral radiotherapy.

PurposeAdjuvant radiotherapy (RT) in buccal mucosa cancers is guided by histopathological factors. The decision to treat ipsilateral or bilateral draining lymph node is on physician discretion and guidelines do not have a defined indication regarding this. We aimed to analyze the failure patterns and survival in buccal mucosa cancers treated with adjuvant ipsilateral RT.Materials and MethodsOne hundred sixteen cases of post-operative buccal mucosa cancers—pT3 or more, node positive, close margins (1–5 mm), lymphovascular invasion positive, perineural invasion positive, depth of invasion >4 mm—treated with RT to primary and ipsilateral nodes from May 2013 to May 2019 were retrospectively analyzed. Patients were treated to a dose of 60–66 Gy (44 Gy in the first phase and a coned down boost of 16–22 Gy in the second phase) with three-dimensional conformal radiotherapy on a linear accelerator. Primary end point was to assess control rates and secondary end point was to evaluate the overall survival (OS) and disease-free survival (DFS) outcomes. ResultsMedian age was 46 years with male; female ratio of 110:6. The edition of the American Joint Committee on Cancer stage distributions were I (3.4%), II (34.4%), III (24.1%), and IV (37.9%). At a median follow-up of 22 months, crude rates of local failure, regional failure, and contralateral neck failure were 9.4%, 10.3%, and 3.4%, respectively. The 2-year contralateral neck control rate was 94.9%. Pathological positive node portended poorer OS (86.6% vs. 68.6%; p = 0.015) and DFS (86.5% vs. 74.9%; p = 0.01).ConclusionIncidence of contralateral recurrence with ipsilateral irradiation in buccal mucosa cancers is low with descent survival outcomes, particularly in node negative cases.

Low risk of contralateral lymph node recurrence in lateralized head and neck carcinoma after postoperative ipsilateral radiotherapy.

The role of postoperative irradiation to contralateral non-involved neck nodes in lateralized carcinoma of the head and neck is not clear. The contralateral neck failure rate in head and neck carcinoma treated postoperatively with ipsilateral neck irradiation only was evaluated. Patients with carcinoma of the oral cavity, oropharynx, or hypopharynx without midline extension treated between 1990 and 2016 were analyzed. After tumor resection and neck dissection (ND), radiotherapy was given to the primary tumor site and ipsilateral neck. High-risk patients additionally received concurrent chemotherapy. Freedom from contralateral neck recurrence (FCNR), locoregional control rate (LRC), overall survival (OS), and disease-free survival (DFS) were evaluated. 197 patients (median age 60.7 years, 66.5% males, 52.8% oropharyngeal carcinomas) were analyzed. Complete resection (R0) was achieved in 85.8% of cases. Ipsilateral ND was performed in all patients and contralateral ND in 144 patients (73.1%). Concurrent chemotherapy was given to 59patients (30.0%). After amedian follow-up of 45.5 months, OS and DFS of all patients were 73.6% and 70.9% at 5years, respectively. Atotal of 45patients (22.8%) suffered from alocoregional recurrence, lymph node metastases of the contralateral neck developed in 12patients (6.1%) only. There was no significant difference in contralateral nodal failure rate with or without performance of contralateral ND. Regional failure of the contralateral neck was low after surgery and ipsilateral neck irradiation in head and neck carcinomas without midline extension, supporting evidence that contralateral neck radiotherapy can safely be omitted in selected cases.

Risk of post-operative, pre-radiotherapy contralateral neck recurrence in patients treated with surgery followed by adjuvant radiotherapy for human papilloma virus-associated tonsil cancer.

One approach to reduce treatment-related morbidity for human papilloma virus (HPV)-associated tonsil cancer is omitting radiotherapy to the contralateral neck. Pathologic risk factors for early contralateral neck disease, however, are poorly understood. We report on the risk contralateral neck failures from the time of pre-operative diagnostic imaging to time of planning for adjuvant radiation in a single institution series of HPV-associated tonsillar cancer patients undergoing surgery followed by radiotherapy (RT). Retrospective analysis of 123 patients with T1-T3 HPV-positive tonsillar squamous cell carcinoma treated between 2010 and 2016 with transoral robotic surgery and selective ipsilateral neck dissection followed by adjuvant RT. Contralateral neck recurrence was classified as the detection of a pathologic node in the contralateral neck prior to initiation of adjuvant RT. Seven patients (5.7%) developed contralateral neck disease/failure between the time of pre-operative diagnostic neck imaging and time of planning of adjuvant radiation. Increased ratio of positive/resected nodes [odds ratio (OR) 1.073, p = 0.005] was significantly associated with increased risk of contralateral neck recurrence, with a trend found for close/positive margins (OR 5.355, p = 0.06), tumor size (OR 2.046, p = 0.09), and total number of nodes positive (OR 1.179, p = 0.062). Patients who develop very early contralateral neck disease, between completion of ipsilateral neck dissection and the initiation of radiotherapy, have a higher ratio of positive nodes to total nodes resected in the ipsilateral neck. These findings suggest that proper selection of patients for omission of treatment of the contralateral, node-negative neck should be made with this in mind, with future studies needed to document the impact on toxicity and disease outcomes from such an approach. Pathologic risk factors in the dissected, ipsilateral neck in patients with tonsil cancer may inform the risk of contralateral neck failure. Patient selection for future, prospective efforts to examine sparing of the contralateral neck need to be based with these risk factors in mind.

Should an elective neck dissection be performed for maxillary sinus squamous cell carcinoma?

Should an elective neck dissection be performed for maxillary sinus squamous cell carcinoma?

Initial human experience with the GORE EXCLUDER Conformable AAA Endoprosthesis

Endovascular repair has become the standard of care for treatment of abdominal aortic aneurysms. The endografts and delivery systems for endovascular aneurysm repair have undergone multiple generations of technologic advancements. However, a significant remaining challenge for a satisfactory long-term outcome is to improve the performance of these devices in nonideal proximal sealing zones. In particular, short (<15 mm) and highly angulated (>60 degrees) necks can threaten long-term exclusion of the aneurysm even with the current generation of endografts. One of the main reasons for proximal infrarenal neck failure is the inability to accurately position the endograft precisely below both renal arteries. This is a report of the first-in-human implantations of the GORE EXCLUDER Conformable AAA Endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz), an investigational device, in anatomies with standard neck lengths and angulation. This device has been designed to provide repositionability, conformability, and, for the first time, optional angulation control. This device is commercially available in Europe.

Influence of interval between biopsy and surgery on prognosis of patients with early-stage oral squamous cell carcinoma: A preliminary study

ObjectiveRecent studies have suggested that preoperative interventions such as tooth extraction, incision and curettage may be associated with poor prognosis in patients with oral malignancies. Although biopsy is another preoperative intervention, its influence on the prognosis of patients with oral squamous cell carcinoma (OSCC) has remained unclear. We investigated the prognosis of stage I and II OSCC patients, with special reference to the influence of the interval between biopsy and surgery. Materials and methodsThe cases of 47 patients diagnosed with primary early-stage (T1 or T2N0M0) OSCC were reviewed retrospectively. ResultsPrimary surgery was performed ≤21 days after biopsy for 17 patients, and >21 days after biopsy for 30 patients. Incidence of local recurrence or delayed cervical lymph node metastasis was significantly higher among the long-interval group (p = 0.03). Patients with local or neck failure displayed a significantly longer interval (33.6 days) than patients who were stable (21.9 days; p < 0.01). Five-year survival rates in groups with and without recurrence or metastasis were 66.7% and 90.6%, respectively (p < 0.05). ConclusionTreatment delay can worsen the prognosis of patients with early-stage OSCC by increasing the incidence of local and neck failure. Prompt treatment after biopsy is thus recommended to optimize the outcomes.

Challenging the Requirement to Treat the Contralateral Neck in Cases With >4 mm Tumor Thickness in Patients Receiving Postoperative Radiation Therapy for Squamous Cell Carcinoma of the Oral Tongue or Floor of Mouth.

While treating patients with postoperative radiotherapy (RT) for squamous cell carcinoma of the oral tongue or floor of mouth, we hypothesized a low risk of tumor recurrence in the contralateral neck in the absence of contralateral neck RT when the primary tumor is >1 cm from the midline regardless of tumor thickness (TT) or depth of invasion (DOI)>4 mm. The policy at our institution for many years has been to limit postoperative RT to the ipsilateral side when the primary tumor does not cross the midline, regardless of TT or DOI. We report the rate of isolated contralateral neck failure in this group. We retrospectively reviewed all patients treated with postoperative RT at our institution between 1998 and 2014 for pathologic stage T1-T4 N1-N2b squamous cell carcinoma of the oral tongue or floor of mouth that did not cross the midline and thus were treated with RT limited to the primary site +/- ipsilateral neck. Our study population included 32 patients: 75% with close (<5 mm) or positive margins and 38% with perineural invasion. No patients had a tumor that crossed the midline. TT was ≥4 mm in 75% of patients. DOI was >5 mm in 68% of patients. There were no isolated contralateral neck recurrences with a median follow-up of 5 years. While delivering postoperative RT for oral tongue or floor of mouth cancer with pathologic neck stage N0-2b, the risk of not irradiating the contralateral neck is very low when the primary tumor does not cross the midline, regardless of other factors at the primary site, such as TT and DOI.

Outcomes after Salvage Therapy in Oral Cavity Squamous Cell Carcinoma (OCSCC) Patients Who Developed Locoregional Failure (LRF) after Definitive Surgery and Adjuvant (chemo)Radiotherapy: A Multi-Institutional Collaborative Study

We conducted a multi-institutional study to review salvage therapy outcomes in OCSCC patients who developed LRF after upfront surgery and adjuvant (chemo)radiotherapy. A collaborative patient database with primary OCSCC stage I-IVB (AJCC 7th Ed) treated with primary surgical resection between 1/1/2005 and 1/1/2015 was collected from 6 academic centers. From a total of 1282 patients, we identified patients who developed LRF after primary surgery and adjuvant (chemo)radiotherapy. The exclusion criteria were: missing information on LRF, distant failure within 30 days of LRF, and LRF before completing initial adjuvant therapy. Cox proportional hazard analysis was performed to estimate hazard ratio (HR). 156 patients were selected: 60 females (38%), 126 Whites (81%), and 63 (40%) oral tongue primaries. Median age at initial diagnosis was 61 years. 152 (97%) smoked or chewed tobacco and 103 (66%) used alcohol. 54 (34 %) had pT4 and 76 (49%) pN2b-c disease. 33 (21%) had a positive margin at the initial surgery and 55 (15%) had extranodal spread. All received adjuvant radiation with a median dose of 60Gy and 66 (42%) patients also had concurrent chemotherapy. With a median follow up of 22.5 months, 82 (53%) developed only local failure, 39 (25%) had only neck failure, and 35 (22%) had both local and regional nodal failures. The median time to LRF was 13 months (range: 4-130). 104 of 156 (67%) underwent salvage surgery and 28 (27%) of surgically salvaged patients also received adjuvant re-irradiation. Patients who had any regional failure were more likely to receive adjuvant re-irradiation than those without (88% vs 11%, p=0.001). 49 (31%) patients received salvage chemotherapy. 38 (24%) patients had a 2nd LRF after salvage therapy. Median OS after 1st LRF for all patients was 7.7 months. Time from initial diagnosis to 1st LRF was not associated with OS. In multivariable analysis controlling for age, gender, re-irradiation, and salvage chemotherapy, lack of salvage surgery was independently associated with worse OS (HR=4.3, 95%CI=2.5-7.1). About 30% of surgically salvaged patients were alive at 125 months after 1st LRF. Among those who received salvage surgery, positive surgical margin (HR=2.3, 95%CI=1.1-4.8) and perineural invasion (PNI) (HR=2.3, 95%CI=1.1-4.6) were independently correlated with worse OS. Receipt of adjuvant re-irradiation showed a trend toward more favorable OS (HR=0.5, 95%CI=0.2-1.0) after further accounting for nodal failure status. Patients who were selected to receive salvage surgery had more favorable outcomes than those who were not. Positive salvage surgical margin and PNI were associated with worse OS. Adjuvant re-irradiation showed a trend towards improved OS after accounting for nodal failure status.

Challenging the Requirement to Treat the Contralateral Neck with >4-Mm Tumor Thickness in Patients Receiving Postoperative Radiation Therapy for Squamous Cell Carcinoma of the Oral Tongue or Floor of Mouth

In patients with oral tongue or floor of mouth squamous cell carcinoma (SCC), the policy at our institution for many years has been to limit postoperative radiotherapy (RT) to the ipsilateral side when the primary tumor does not cross the midline, regardless of tumor thickness or depth of tumor invasion. We report the rate of contralateral neck failure in this group. We retrospectively reviewed the medical records of patients with T1-4 N1-N2b SCC of the oral tongue or floor of mouth who underwent postoperative RT to the primary site +/− ipsilateral neck RT between 1998 and 2014. No patients received radiation to the contralateral neck. All patients received resection of the primary site with or without ipsilateral and/or bilateral neck dissection. Our study population was 32 patients: 75% with close (<5 mm) or positive margins; 38% with perineural invasion. No patient had a tumor that crossed the midline. Tumor thickness was ≥4 mm in 75% of patients. Depth of invasion was >5 mm in 68% of patients. The rate of isolated contralateral neck recurrence was 3% (1/32). When delivering postoperative RT for oral tongue or floor of mouth cancer, the risk of not irradiating the contralateral neck is very low when the primary tumor does not cross the midline, regardless of other factors at the primary site, including tumor thickness and depth of invasion.

What Factors Are Associated With Regional Recurrence After Operative Treatment of Oral Squamous Cell Carcinoma?

A considerable proportion of oral squamous cell carcinoma (OSCC) recurrences involve the neck, which has a substantial impact on prognosis and is poorly understood.The purpose of this study was to analyze clinical and pathologic characteristics of regional recurrence of OSCC and identify possible risk factors. A single-center retrospective cohort study was designed to address the study purpose. All patients who were treated surgically for primary OSCC with or without adjuvant therapy between 2010 and 2015 were considered for inclusion with respect to predefined criteria, and demographic, clinical, and pathologic variables were collected. The lymph node status after primary OSCC treatment (pN) was defined as the predictor variable, and the occurrence of regional recurrence served as the primary outcome variable. Further variables of special interest were the histologic differentiation (G status) of the primary OSCC and the values of the lymph node ratio and log odds of positive lymph nodes. Descriptive, inferential, and appropriate time-dependent (Kaplan-Meier analysis, Cox regression model) statistics were computed. The level of statistical significance was set at P≤.05. The study sample was composed of 171 patients (70 women and 101 men; average age, 62.4years). Neck failure occurred in 18 patients (11%) either in combination with local recurrence (15patients) or in isolation (3 patients).Poor histologic differentiation of the primary tumor was identified as an independent risk factor for regional recurrence. Most neck recurrences manifested in previously unaddressed levels (IV and V). Regional recurrence of OSCC might be associated with specific clinicopathologic parameters of the primary tumor. The importance of these parameters for OSCC prognosis assessment and recurrence prediction should be elucidated in further studies.

(OA29) Low Rate of Contralateral Neck Failure in T1-2N2B TONSIL PATIENTS Treated With Ipsilateral Neck Radiation

Treatment of advanced oropharyngeal carcinomas generally entails bilateral radiation therapy. However, multiple single institutional retrospective studies have demonstrated low rates of contralateral neck failure in patients treated with radiation to the primary tumor and ipsilateral neck for well-lateralized tonsil cancer with N0-N2a (up to 1 lymph node, LN) disease. Avoidance of the contralateral neck results in both decreased acute and long-term side effects from treatment, however this reduction in radiation field must be balanced against the possibility of increased local recurrence There is little data specifically examining the possibility of omission of contralateral neck radiation in tonsil patients with N2b disease (>1 small LN). The purpose of our study is to review the institutional experiences at The University of Cincinnati and the University of Texas, MD Anderson Cancer Center in treating patients specifically with T1-T2N2b squamous cell carcinoma of the tonsil with ipsilateral neck irradiation to evaluate the rates of contralateral neck failure and assess treatment-related toxicities. We retrospectively reviewed the records of patients with squamous cell carcinoma of the tonsil who received definitive radiation between 1999 and 2017 at The MD Anderson Cancer Center and The University of Cincinnati. A total of 86 patients with T1-T2N2b were included and all other T and N stages were excluded. Of the 86 patients, 57 patients were p16+, 2 were p16 negative, and 27 had unknown p16 status. The rate of contralateral neck failure was determined. Radiation-related acute and late toxicities were documented. Of the 86 patients treated with ipsilateral radiation, 2 patients failed in the contralateral neck, for an absolute contralateral neck failure rate of 2.5%. One patient failed in the contralateral neck 3.6 months after treatment and the other patient failed in the contralateral neck at 21.1 months. There were no other contralateral failures after 21.1 months. The median follow-up was 78.7 months (range 3.4 – 205 months). Both of the contralateral neck failures were successfully salvaged. One patient underwent a salvage neck dissection followed by adjuvant ipsilateral neck radiotherapy and the other was salvaged with contralateral neck radiation. There were two patients with disease recurrence within the treatment field; one patient had persistent disease at the end of treatment and the second patient was found to have an in-field recurrence at 9 months. 33% received concurrent chemotherapy and 15% received induction chemotherapy. 7% required a feeding tube at the end of treatment. The contralateral neck failure rate in T1-T2N2b tonsil patients treated with ipsilateral neck RT is low. Feeding tube requirement is also low compared to historical controls from randomized trials (ranging from 15-50%). Moreover, both of the patients in our study who recurred within the contralateral neck were successfully salvaged. As multiple ongoing studies attempt to de-escalate treatment in the HPV+ oropharyngeal cancer population to reduce morbidities of treatment, our data supports decreasing the treatment volume in an effort to minimize toxicity. Ipsilateral neck irradiation should be considered in patients with well-lateralized T1-T2N2b tonsillar cancer, particularly those that are HPV+.

Neck recurrence in clinically node-negative oral cancer: 27-year experience at a single institution

ObjectivesNeck failure in patients with oral squamous cell carcinoma (OSCC) carries a poor outcome, yet the management of patients who initially present with clinically node-negative (cN0) neck is not clearly defined. Patients and methodsRetrospective review of patients with cN0 OSCC treated at Memorial Sloan Kettering Cancer Center from 1985 to 2012, focusing on rate, pattern and predictors of neck failure, salvage treatment, and survival outcomes. ResultsOf 1,302 patients, 806 (62%) underwent elective neck dissection (END) and 496 (38%) had observation. 190 patients (15%) developed neck recurrence. Median follow-up was 58.5 months (range 1–343); 5-year neck recurrence-free survival (NRFS) was 85% and 80% for the END and observation group respectively (p = .06). Patients with neck failure had poorer outcomes than patients without neck failure (5-year overall survival, 37% vs. 74% [p < .001]; disease-specific survival [DSS], 41% vs. 91% [p < .001]). Independent predictors of neck failure were smoking, primary tumor subsite (hard palate and upper gum), and extranodal extension. 87% of patients underwent salvage treatment (END: 81.1%; observation: 94%). Salvage surgery with adjuvant (chemo) radiation had better DSS than surgery alone or nonsurgical salvage. ConclusionsIn our cohort of patients with initially cN0 OSCC triaged to END vs. observation using clinical parameters, 15% developed neck failure. Salvage treatment was feasible in most cases but survival was poorer compared to patients without neck failure. Surgery followed by adjuvant (chemo) radiation resulted in the best outcome.

Long-term survivorship of the Corail™ standard stem

IntroductionThe Corail™ stem, which was first introduced in 1986, has since been modified twice: first to make the neck thinner and then to change the location of the laser markings. The survival and complications of the first-generation straight, titanium, hydroxyapatite-coated stem are known; however, there is little specific information about the latest-generation stem. This led us to conduct a retrospective study to determine the: (1) long-term survival; (2) clinical and radiographic outcomes; (3) complications; and (4) risk factors for revision of the newest Corail™ stem. HypothesisThe newest Corail™ AMT (Articul/EZE™ Mini Taper) standard stem has comparable survival to prior models. Patients and methodsThis single-center, retrospective study included 133 patients (140 hips), who underwent primary total hip arthroplasty (THA), between January and December 2004, in which a Corail™ Standard stem was implanted using a posterolateral approach. Patients who underwent revision THA, THA due to femoral neck fracture or who received lateralized (offset) stems were excluded. The mean age at the time of THA was 69±13 years [35–92] in 85 men (61%) and 55 women (39%) who had a mean BMI of 27kg/m2±11 [16–39]. At the latest follow-up, 32 patients (32 hips) had died and 8 patients (8 hips) had less than 3 years’ follow-up, thus were not included in the clinical evaluation. The Merle d’Aubigné (PMA) score was collected. The stem's survivorship was calculated using the Kaplan-Meier method with revision for aseptic loosening and revision or implant removal for any reason as the end-points. The Cox model was used to analyze risk factors for revision. The mean follow-up was 10±3 years [3–12]. ResultsThe PMA score was 12±2.6 [5–17] preoperatively and 16±2.7 [7–18] at the last follow-up (P<0.00001). Eighteen complications (12.8%) were recorded at the last follow-up. There were 15 early complications: 6 dislocations, 5 calcar fractures (4 treated by wire cerclage and 1 by stem change plus wire cerclage), 2 greater trochanter fractures (treated non-surgically) and 2 cases of sciatic nerve palsy. There were 3 late complications: 2 cases of iliopsoas irritation and 1 ceramic insert fracture. Stem survival for surgical revision due to aseptic loosening was 98% (95% CI: [0.96–1]). At 12 years, 95% of stems had not been revised or removed (95% CI: [0.92–0.99]). Being less than 58 years of age at the time of surgery was the only risk factor significantly associated with stem revision for any reason (P=0.04). ConclusionSurvival of the Corail™ Standard stem is similar to that of previous generation stems. The changes made in this stem solved the neck failure problem and did not induce new complications. Level of evidenceLevel IV (retrospective study).

The pattern of failure and predictors of locoregional control in lateralized buccogingival cancer after postoperative radiation therapy

BackgroundTo evaluate the failure pattern and identify predictors of locoregional control in lateralized buccogingival cancer after postoperative radiotherapy (RT) at a single institution. MethodsWe retrospectively reviewed the clinical data of 150 patients with lateralized oral squamous cell carcinoma, including carcinoma of the buccal mucosa, gingiva and retromolar trigone. All patients underwent radical surgery followed by postoperative RT with or without concurrent chemotherapy. We registered planning computer tomography images with images obtained at recurrence and categorized the failure pattern as in-field, marginal, or out-field recurrence. ResultsThe median follow-up duration was 47 months (range, 2–131 months). Twenty-eight patients (19%) experienced locoregional failure, including 20 local failure, 5 regional failure and 3 with both. Among the 24 patients who had image studies at recurrence, 15 patients had in-field recurrence, 5 were marginal recurrence and 4 were out-field recurrence. Seven patients (5%) had contralateral neck failure. Four of 5 patients with marginal failure had recurrent tumors in the infratemporal fossa. In multivariate analysis, extracapsular spread and positive or close surgical margin were associated with poor locoregional control. ConclusionLocal in-field recurrence is the most common failure pattern in lateralized buccogingival cancer after postoperative RT. The infratemporal fossa is a risk area for marginal failure and should be encompassed adequately in the postoperative RT field. Extracapsular spread and positive or close margin are predictors of locoregional control for lateralized oral cancer. Patients exhibiting such adverse features require more aggressive treatment.

Low rates of contralateral neck failure in unilaterally treated oropharyngeal squamous cell carcinoma with prospectively defined criteria of lateralization

Unilateral radiotherapy (RT) of oropharyngeal carcinomas is accepted for patients with lateralized primary and low-volume nodal disease. Utilizing prospectively defined criteria of laterality and staging positron emission tomography (PET)/CT, we studied outcomes in patients with advanced-stage oropharyngeal cancer undergoing unilateral RT. Thirty-seven patients with oropharyngeal tumors >1 cm from midline regardless of node status underwent unilateral RT and were followed prospectively. Patient characteristics: T1 = 11; T2 = 22; T3 = 4; N0 = 3; N1 = 9; N2a = 3; N2b = 21; and Nx = 1. Dosimetry were determined and weekly National Comprehensive Cancer Network (NCCN) distress thermometer data were collected. At median follow-up of 32 months, 3-year locoregional control, contralateral regional failure, distant metastasis-free survival, and disease-free survival were 96%, 0%, 7%, and 93%, respectively. Low rates of contralateral neck failure are demonstrated utilizing prospectively defined criteria for unilateral RT. The tolerances of contralateral organs are respected and patients report low to moderate levels of distress throughout treatment.

Neck failure after elective neck dissection in patients with oral squamous cell carcinoma

Analysis of the incidence and clinical relevance of neck failure after elective neck dissection (END) in patients with oral squamous cell carcinoma (OSCC). A retrospective study of 188 patients with OSCC without cervical lymph node metastases was conducted; these patients had undergone END from 2005 to 2015. The most common primary tumor location was lower gingiva, followed by tongue. Supraomohyoid neck dissection (SOHND) was the most common procedure. Neck failure developed in 4 pathologic negative (pN[-]) and 3 pathologic positive (pN[+]) patients. The site of neck recurrence was beyond the dissected field in all cases. The site of recurrence in pN(-) patients was ipsilateral in 2 patients and contralateral in 2, whereas the site in pN(+) patients was ipsilateral in 1 patient and contralateral in2. Although neck failure after END can occur, SOHND is appropriate for END for OSCC. For tongue carcinoma, level IV dissection is recommended, and for tumors close to the midline, contralateral neck dissection is also recommended.

Re-evaluation of Ipsilateral Radiation for T1-T2N0-N2b Tonsil Carcinoma at the Princess Margaret Hospital in the Human Papillomavirus Era, 25 Years Later

To report the outcome of ipsilateral radiation therapy (RT) in human papillomavirus (HPV)-positive (HPV+) patients and HPV-negative (HPV-) patients with T1-T2N0-N2b tonsillar cancer treated 25years after our initial historical cohort. Patients with T1-T2N0-N2b tonsillar cancer who received ipsilateral RT or bilateral RT between 1999 and 2014 were reviewed. Overall survival (OS), local control (LC), regional control (RC), and grade 3 to 4 late toxicity (LT) were compared between ipsilateral RT and bilateral RT within HPV+ and HPV- patients, separately. HPV status was ascertained in 379/427 (88%) consecutive patients (ipsilateral RT: 62 HPV+, 34 HPV-; bilateral RT: 240 HPV+ 240, 41 HPV-). The proportion of ipsilateral RT by N category for HPV+ and HPV- patients were as follows: N0: 24/37 (65%) versus 28/48 (74%); N1: 21/49 (43%) versus 4/9 (44%); N2a: 10/39 (26%) versus 1/4 (25%); and N2b: 7/177 (4%) versus 1/24 (4%), respectively. Of the patients receiving ipsilateral RT, 94/96 (98%) were treated with RT alone. The median follow-up time was 5.03years. The respective 5-year rates of OS, LC, RC, and LT were similar between ipsilateral RT and bilateral RT for the HPV+patients (OS: 89% vs 87%, P=.55; LC: 97% vs 98%, P=.65; RC: 98% vs 97%, P=.27; LT: 17% vs 12%, P=.83) and HPV- patients (OS: 63% vs 48%, P=.27; LC: 90% vs 80%, P=.19; RC: 94% vs 83%, P=.14; LT: 15% vs 22%, P=.36). Of the 96 patients receiving ipsilateral RT, contralateral neck failure (CNF) occurred in 1/52 HPV+patients and 1/34 HPV- patients. The 5-year CNF rates were 2% (95% CI: 1-9) (HPV+: 2% [0-14]; HPV-: 3% [0-21], P=.66). Five local failures (2 HPV+; 3 HPV-) and no distant failures were seen. The 5-year rates of LC, RC, and LT were 97% versus 90% (P=.24), 98% versus 94% (P=.25), and 18% versus 15% (P=.75) for the HPV+ and HPV- cohorts, respectively. Osteoradionecrosis occurred in 9 patients: 6/47 (13%) treated with conventional RT and 3/49 (6%) with intensity modulated RT (P=.32). Ipsilateral radiation to selected patients with T1-T2N0-N2b tonsillar cancer results in equally excellent outcomes regardless of tumor HPV status.

Comment on: Modular titanium alloy neck failure in total hip replacement

To the Editor of the SICOT-J Orthopaedic Journal, I am writing to you as I would like to kindly express some considerations on the case-report of Dr. Marco Ceretti on “Modular titanium alloy neck failure in total hip replacement” published in your on-line journal last April (M. Ceretti and F. Falez SICOT J 2016, 2, 20). The Authors report on “a case of a repetitive modular femoral neck prosthesis fracture”; they had initially revised a broken modular Metha stem with a MODULUS stem, neck 135° long, head 36 medium in a 43-year-old woman with body mass index (BMI) 38.6 kg/m2 (weight 110 kg, height 170 cm); both stems presented modular necks in titanium alloy. The MODULUS stem was then revised with a Wagner monoblock uncemented titanium stem following the fracture at the neck-stem junction. This article reports a clinical case but it does not include any laboratory evidence in terms of fracture analysis to support the Authors’ conclusions and to elucidate the mechanisms of failure. No retrieval analysis on the two stems seems to have been in fact carried out, such as standard macroscopic inspection and observations, standard corrosion testing, micro analysis of the implant alloy, light microscopy, Scanning Electron Microscopy (SEM) and patient’s blood sample to check the release of metal ions. Besides, several publications nowadays report comparative analysis of cobalt-chromium and titanium modular femoral necks, showing that the first material present “improved resistance against fretting” with “lower incidence of surface micromotions” (e.g. [1, 2]). Nevertheless, the fracture of these two modular necks should be attributable to an error of indication and not to a failure of the devices themselves, meant to be used in patients with lower BMI. The surgical technique of the MODULUS stem reports: “Complications or failures of the total hip replacement may occur in heavy and highly active patients and high offset combinations. The surgeon should perform a careful evaluation of the patient’s clinical condition and level of physical activity before performing hip replacement. Patients who are overweight and/or have high activity levels may not be candidates for hip replacement with modular stems. Alternative devices, such as monoblock hip stems, should be used, when possible, in these patients.” The available literature sources clearly support these indications on the use of modular stems in the current clinical practice: “Among patients treated with the titanium alloy neck adapter, a combination of different parameters was identified as risk factors of implant failure. The parameters are intraoperative particle contamination of the cone connection, excessive loading due to a patient weight above 100 kg or high activity level, and male gender. In addition, the risk for failure rises with CCD angles of the cone adapter of 135° and smaller.” “Contamination with cortical bone particles in the interface was found to be the main influence factor on the fatigue behaviour of the titanium alloy neck adapter.” [1] “Various circumstances such as large femoral head with a long varus neck, corrosion, patients’ BMI, and activity level may participate in creating the necessary environment for fatigue failure of a modular hip replacement implant.” [3] Furthermore, I would like to take this opportunity to kindly bring to the attention of your Editorial Office that no failures of the MODULUS stem are recorded in some series of publications concerning clinical experience with this medical device, as indicated in the following articles [4–7]. Conflict of interest One of the author is a consultant of Lima Corporate as a Scientific Adviser.

Radiotherapy alone or combined with chemotherapy as definitive treatment for squamous cell carcinoma of the tonsil.

This study is aimed at updating our institution's experience with definitive radiotherapy (RT) for squamous cell carcinoma of the tonsil. We reviewed 531 patients treated between 1983 and 2012 with definitive RT for squamous cell carcinoma of the tonsil. Of these, 179 patients were treated with either induction (n=19) or concomitant (n=160) chemotherapy. Planned neck dissection was performed on 217 patients: unilaterally in 199 and bilaterally in 18 patients. Median follow-up was 5.2years for all patients (range 0.1-31.6years) and 8.2years for living patients (range 1.9-31.6years). The 5-year local control rates by T stage were as follows: T1, 94%; T2, 87%; T3 79%; T4, 70%; and overall, 83%. Multivariate analysis revealed that local control was significantly influenced by T stage and neck dissection. The 5-year cause-specific survival rates by overall stage were as follows: I, 94%; II, 88%; III, 87%; IVA, 75%; IVB, 52%; and overall, 78%. Multivariate analysis revealed that cause-specific survival was significantly influenced by T stage, N stage, overall stage, fractionation, neck dissection, sex, and ethnicity. Of 77 patients treated with ipsilateral fields only, contralateral neck failure occurred in 1%. The rate of severe complications was 12%. Definitive RT for patients with tonsillar squamous cell carcinoma provides control rates equivalent to other modalities with a comparatively low incidence of late complications. Patients with anterior tonsillar pillar or tonsillar fossa primaries that are well lateralized with no base of tongue or soft palate extension may be treated with ipsilateral fields.

Clinicopathological evaluation of pre-operative chemoradiotherapy with S-1 as a treatment for locally advanced oral squamous cell carcinoma.

The administration of pre-operative chemotherapy with S-1 and concurrent radiotherapy at a total dose of 30 Gy was clinicopathologically evaluated as a treatment for locally advanced oral squamous cell carcinoma (OSCC) in the present study. The participants comprised 81 patients with OSCC, consisting of 29 patients with stage II disease, 12 patients with stage III disease and 40 patients with stage IV disease. All patients received a total radiation dose of 30 Gy in daily fractions of 2 Gy, 5 times a week, for 3 weeks, and the patients were concurrently administered S-1 at a dose of 80-120 mg, twice daily, over 4 consecutive weeks. Radical surgery was performed in all cases at 2-6 weeks subsequent to the end of pre-operative chemoradiotherapy. The most common adverse event was oropharyngeal mucositis, but this was transient in all patients. No severe hematological or non-hematological toxicities were observed. The clinical and histopathological response rates were 70.4 and 75.3%, respectively. Post-operatively, local failure developed in 6 patients (7.4%) and neck failure developed in 2 patients (2.5%). Distant metastases were found in 7 patients (8.6%). The overall survival rate, disease-specific survival rate and locoregional control rate at 5 years were 87.7, 89.9 and 90.6%, respectively. Locoregional recurrence occurred more frequently in patients that demonstrated a poor histopathological response compared with patients that demonstrated a good response (P<0.01). These results indicate that pre-operative S-1 chemotherapy with radiotherapy at a total dose of 30 Gy is feasible and effective for patients with locally advanced OSCC, and that little or no histopathological response may be a risk factor for locoregional recurrence in this treatment.