General Medical Information

Resectable Cancer of the Head and Neck

Bruce E. Brockstein
Everett. E. Vokes

Until quite recently, chemoradiation therapy has had a lesser role in the management of resectable cancer of the head and neck. It is becoming evident that at least some intensive chemoradiation therapy programs used to treat patients who are medically fit can yield results that appear to be comparable with and in some cases better than those of surgery plus radiation therapy. As of this writing, however, this concept has not yet gained widespread acceptance. Even when primary-site surgery is not initially used, the head and neck surgeon still has an important role in diagnostic procedures, follow-up evaluation, neck dissection for some patients, and surgical salvage when chemoradiation therapy fails.

No randomized data have been analyzed to compare the results of chemoradiation therapy with surgery with or without radiation therapy. Results of several indirect comparisons suggest chemoradiation therapy can be an alternative to surgery. Adelstein et al. randomized 100 patients, mostly with stage IV disease, to undergo radiation therapy alone or radiation therapy with concomitant cisplatin and 5-FU administration during weeks 1 and 4 of radiation therapy. In the chemoradiation therapy arm, the 5-year survival rate was 50%. Eleven patients needed surgical salvage, and 8 underwent successful procedures. The overall survival rate with primary site preservation was 42%. Although the survival rate was equivalent in the radiation therapy only arm, 27 patients needed surgical salvage, which was successful for 17 patients. Brizel et al. randomized 116 patients to receive hyperfractionated radiation therapy alone or to receive chemotherapy (cisplatin and 5-FU) plus hyperfractionated radiation therapy. The 3-year survival rate was 55% in the chemoradiation therapy arm. This percentage is comparable with that achieved in most surgical series. Although the survival rate among the patients with resectable disease (47% of patients) was not reported, it was likely as good or better than that for the entire group. In a similar study, 130 patients with mostly stage IV disease underwent hyperfractionated radiation therapy with or without daily administration of cisplatin. Forty-seven percent of the patients who underwent chemoradiation therapy had resectable lesions and likely had an overall survival rate better than the 46% 5-year survival for the entire group.

Several phase II trials also have examined the issue of chemoradiation therapy for resectable disease. Kies et al. administered three cycles of induction chemotherapy of cisplatin, 5-FU, leucovorin, and interferon-a followed by chemoradiation therapy with 5-FU, hydroxyurea, and radiation therapy (FHX) to 93 patients with stage IV cancer of the head and neck. Although not specifically reported, a large number of patients had potentially resectable disease. The 5-year survival rate for the entire group was 62%. Because patients with resectable disease usually have less biologically aggressive disease, it is likely that the patients with resectable disease not specifically described had an even better survival rate. Several other studies have yielded similar results. We believe that patients with stage III or IV resectable disease who are likely to have functional or cosmetic sequelae of the surgery and who need postoperative radiation therapy should be offered an aggressive chemoradiation therapy regimen if they are medically able.