As shown in Table 2 , all associations identified at univariate analysis persisted after multivariate analysis. Because only a subgroup of patients with head and neck cancer underwent surgical neck dissection, data on pathologic stage pN and extracapsular spread were available for only subjects.
Survival After Distant Metastasis in Head and Neck Cancer.
These data are presented separately in Table 3. Both variables were significantly associated with a risk of distant metastases. In this study, results from a large series of patients with head and neck squamous cell carcinoma are presented. To our knowledge, the present study represents one of the largest series on this topic. Results from our study confirm that head and neck squamous cell carcinoma has mainly a locoregional growth. The incidence of distant metastases is relatively small compared with other malignancies such as stomach, pancreas, lung, breast, or kidney cancer. Specifically, the rate of distant metastases in our series was 9.
In our study, only patients who completed the follow-up period were included; it could be argued that this inclusion criteria might influence the rate of distant metastases. Indeed, we cannot eliminate the possibility that patients who were lost to follow-up may be at increased or decreased risk of distant metastases. Overall, we do not believe that this bias relevantly influenced the results. As shown in Table 4 , the rate of distant metastases observed in our study is in line with rates in recent clinical series on this topic.
As distant metastases develop, the chance of cure is very low and the survival dramatically decreases.
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Detecting distant metastases even at an early stage and subjecting them to metastasectomy or radiation therapy would not be sufficient to obtain higher cure rates. Alvi and Johnson 8 reported an average time to death of only 5 months.
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As a consequence, it was suggested that it would be useful to identify groups of patients who are at high risk for the development of distant metastases to target them for adjuvant chemotherapy. Results from studies 21 - 23 investigating the role of this combined approach are currently discrepant. Findings from a study by Shingaki et al 23 showed improved survival rates and decreased distant metastases with adjuvant chemotherapy. Conversely, Laramore et al 21 reported a significant reduction of distant metastases in patients who received chemotherapy, but no benefit of survival was observed.
Similar results have been recently confirmed in a randomized study 24 comparing radiation therapy alone with radiation therapy plus concurrent treatment with cisplatin. It might be argued that the inclusion criteria used in these studies could be, at least in part, responsible for these conflicting results. Adequately powered trials enrolling only the subjects at greatest risk are warranted to elucidate this issue. A current task in the field of head and neck squamous carcinoma is thus to properly identify risk factors for distant metastases to determine a subgroup of patients for whom establishing different therapeutic strategies is mandatory.
Risk factors for distant metastases are a matter of debate.
This aspect has been recently exhaustively reviewed by Leon et al 9 and is beyond the scope of the present study. Overall, our results confirmed that the locoregional control and N stage are markedly associated with an increased probability of developing distant metastases. There is a general consensus on these specific risk factors. Indeed, cancer localization, histologic grade, local extension of tumor T stage , and, to a lesser extent, younger age were significantly associated with the risk of distant metastases.
Results from the present study suggest that the hypopharynx is the site at highest risk of subsequent distant metastases. Specifically, this localization was associated with a relative risk of There are reports 9 - 11 , 27 that some localizations in the head and neck, such as in the nasopharynx and hypopharynx, had a greater risk. Leon et al 9 found that cancers of hypopharynx and supraglottis were independent risk factors for distant metastases.
Conversely, according to other authors, 8 , 13 , 20 , 22 , 28 the site of the tumor had no significant influence on the development of distant metastases. Furthermore, there is disagreement as to the influence of the histologic grade and local extension of the tumor in the appearance of distant metastases.
Finally, to our knowledge, an increased risk in patients younger than 45 years has not been previously reported. Overall, it may be speculated that the role of younger age is presumably of limited importance. Discrepancies among studies are difficult to explain. It might be hypothesized that the reduced sample size and thus the low power of many currently available studies may in part explain these conflicting results. Differences in the epidemiological profile of patients among studies may also play a role.
Survival After Distant Metastasis in Head and Neck Cancer
In conclusion, this study confirms that the incidence of distant metastases in subjects with head and neck squamous cell carcinoma is relatively small. Moreover, our study suggests that locoregional control of the cancer and N stage, and also localization to the hypopharynx, histologic grade, local extension of tumor, and, to a lesser extent, younger age are factors associated with the risk of distant metastases. August 4, ; final revision received January 9, ; accepted January 31, Hazard ratio of distant metastases in patients with head and neck carcinoma.
Patterns of relapse in locally advanced head and neck cancer patients who achieved complete remission after combined modality therapy. The effect of local-regional control on distant metastatic dissemination in carcinoma of the head and neck: Delayed regional metastases, distant metastases, and secondary primary malignancies in squamous cell carcinomas of the larynx and hypopharynx. Clinical nodal stage is an independently significant predictor of distant failure in patients with squamous cell carcinoma of the larynx. Adjuvant chemotherapy for resectable squamous cell carcinoma of the head and neck: Impact of lymph node metastasis on the pattern of failure and survival in oral carcinomas.
Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. Back to top Article Information. Sign in to access your subscriptions Sign in to your personal account. Create a free personal account to download free article PDFs, sign up for alerts, and more. Purchase access Subscribe to the journal. One underwent a craniotomy for a solitary brain metastasis, while the other two patients underwent thoracoscopic wedge resection of solitary pulmonary metastases.
Incidence and sites of distant metastases from head and neck cancer.
The mean survival time after diagnosis of distant metastases was 7. The 1- and 2-year overall survival rates after diagnosis of distant metastasis were Cox regression analysis showed no significant predictors for prolonged survival, however, the three patients surviving at the time of data collection were treated by surgical resection of solitary metastases. The localization of distant metastasis and the development of single-site versus multiple sites of distant metastasis were not predictive of a higher life expectancy.
- Incidence and sites of distant metastases from head and neck cancer.;
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The mean follow-up after diagnosis of distant metastasis for the three patients who remained alive was Patients developing distant metastases after treatment of head and neck cancer with curative intent have a poor prognosis and short life expectancy. There are currently no standards on screening for distant metastasis, although it would seem to be useful as it allows for prognostication and adaptation of patient counseling and, in the case of early detection, the impact on prognosis of patients may be beneficial. Moreover, a need exists to define high-risk groups of patients so that intensive adjuvant therapy can be given when the initial diagnosis is confirmed.
Identifying these high-risk groups for distant metastasis also helps head and neck oncologist to pay attention to symptoms that suggest the possibility of metastasis. Therefore, control for distant disease is mainly focused on the lungs in patients with head and neck carcinoma, and metastasis to other sites is typically not as closely monitored.
As a result, it should be considered whether isolated screening of the lung makes sense, or whether routine surveillance imaging should also include the skeleton. Furthermore, it is unclear whether all types of distant metastasis have the same prognosis. For this reason, the metastatic site currently has little impact on therapeutic management. In the present study, there was no difference in survival between patients with different metastastic sites; however, the analyzed patient cohort was small.
The chance of cure for patients with head and neck cancer who developed distant metastasis is very low. Palliative chemotherapy is the most frequently used treatment, although response rates are not satisfying. Studies showed that palliative chemotherapy can prolong the median survival of patients with distant metastasis 9 , However, due to the short life expectancy of such patients, due to the unclear benefit of chemotherapy and to chemotherapy-induced toxicities, treatment remains controversial.
Moreover, patients must be healthy enough at diagnosis of distant metastasis in order to receive chemotherapy. Radiotherapy is typically used to treat single metastases to relieve symptoms caused by them or to avoid further complications. Resection of solitary metastases in patients with head and neck cancer is controversial.
The cases discussed in the present study suggest that a surgical approach to a solitary metastasis of head and neck cancer may prolong survival in certain patient sub-groups. Several reports exist of prolonged survival after surgical resection of solitary metastases in patients with head and neck cancer 11 , Hence, in patients with a good performance status, a treatment approach with curative intent, including surgical interventions, could be tried.
However, as long as the impact of solitary metastasis remains unclear, screening programs for distant metastasis will not be established.
Standard treatment strategies for metachronous distant metastatic disease in head and neck cancer have not yet been established because of the limited number of cases. Therefore, randomized controlled studies are needed to implement a treatment strategy for such patients. The limitations of our study were that it was a retrospective, non-randomized study which was conducted at a single center, and that the prevalence of human papilloma virus was unknown.
Moreover, due to the retrospective nature of the study, patients with a longer survival may have received multiple regimens and long-term treatments. Survival after diagnosis of distant metastasis from head and neck cancer. In summary, the lung is the most frequent site when patients present with distant metastases after treatment of head and neck cancer with curative intent. Most patients have multiple metastases; in cases of a single metastasis, long-term survival is possible. Prospective randomized studies are required to optimize treatment strategies.
User Name Password Sign In. Previous Section Next Section. In this window In a new window. Characteristics of the primary tumors included in this study. Distribution of distant metastases from head and neck cancer. Adjuvant postoperative radiotherapy with or without chemotherapy for locally advanced squamous cell carcinoma of the head and neck: Cancer Res Treat Regional lymph node involvement and its significance in the development of distant metastases in head and neck carcinoma. CrossRef Medline Google Scholar. Distant metastases in head and neck cancer patients who achieved locoregional control.
Risk factors for distant metastases in head and neck squamous cell carcinoma. Arch Otolaryngol Head Neck Surg Prognostic value of level IV metastases from head and neck squamous cell carcinoma. Alvi A , Johnson JT:
Related Metastases in Head and Neck Cancer
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