Mehanna HM, Ang KK. Head and Neck Cancer Recurrence: Evidence-based, Multidisciplinary Management. First ed. Thieme; 2012; 316 pgs.; 358 illustrations; $199.99.
This book is written by two clinicians: Dr. Mehanna, who is a head and neck surgeon at the University Of Birmingham School Of Cancer Sciences, and Dr. Ang, who is a radiation oncologist at the University of Texas MD Anderson Cancer Center. As such, this is a book directed at clinicians. However, as imaging now plays such an important role in cancer surveillance, this book offers many salient points for any radiologist involved in imaging and following head and neck cancer patients.
In addition to the two editors, there are 48 well known international contributors, and the book is divided into 21 chapters. It is clear that the editors wanted to present a very thorough and up-to-date discussion of the entire subject of recurrent head and neck cancer. The illustration and images throughout the book are of very good quality, and there are extensive references for each chapter.
Chapter 1, “Introduction,” is precisely what it says: namely, a quick overview of the clinical assessment and imaging evaluation of recurrences. It also discusses examination under anesthesia and both needle and open biopsies.
Chapter 2, “The Molecular Biology of Recurrence,” provides a brief overview of the current knowledge of the methodology of hematogenous and lymphatic metastasis. It emphasizes the importance of chemokine gradiants in the process of metastasis. There is mention of the premetastatic sites and their role in the selection of which organs will likely receive distant metastases. Although there is not a definitive description of this biology, it does present a nice overview with references so that anyone interested in more detail has readily available information.
Chapter 3, “Imaging Modalities for Head and Neck Cancer Recurrence,” is the most imaging-oriented chapter in this book. The chapter starts with a nice presentation of therapy-related changes as seen on CT, MRI, and PET/CT studies. In an atlas format, the variety of post-treatment, non-cancerous changes that can mimic tumor recurrence are shown. This is followed by a section on the detection of tumor recurrence, again presented in a pictorial atlas format. Next, there are sections on imaging of differentiated thyroid cancer recurrence, lymph node extracapsular spread, skull base invasion, perineural spread, and in-transit metastasis, which are characterized by tumor dissemination by satellite deposits in cutaneous or subcutaneous tissue located between the primary tumor and the primary lymphatic drainage basin.
Chapter 4, “Concurrent Chemotherapy and Re-irradiation for Recurrent Head and Neck Cancer,” discusses reasons for tumor recurrences after definitive treatment and the pros and cons of concurrent chemotherapy with re-irradiation as well as patient selection. It briefly discusses both the associated acute and chronic toxicities, and there is a discussion of the radiation techniques to employ in these cases.
Chapter 5, “Systemic Therapy in the Treatment of Recurrent and Metastatic Head and Neck Carcinoma,” discusses clinical treatment algorithms and current choices of chemotherapy and their side effects. There is also a brief section on “Special Issues in End-of Life Supportive Care.” This is an ever important topic in the literature.
Chapter 6, “Principles and Concepts of Reconstruction in the Recurrent Setting,” discusses the principles to consider and the complications of salvage surgery in the previously treated patient. How to manage blood vessels in a previously vessel-depleted neck is also discussed. Although this chapter is entirely surgically oriented, it does address the difficulties in treating these patients.
Chapter 7, “Patient Selection for Treatment,” discusses the decision-making regarding retreatment for cure and providing the best supportive care. Questions reviewed include: Does the patient have a new primary tumor? and What are the considerations for revision surgery and what are the considerations for re-irradiation? Each of these topics is then dealt with in more detail.
Chapter 8, “Recurrent Laryngeal Cancer,” discusses the diagnosis, staging, and principles of management in recurrent laryngeal carcinoma. The decisions necessary to perform salvage treatment or palliative treatment are reviewed. Finally, the choices of the different types of laryngeal surgery are discussed.
Chapter 9, “Management of Recurrent Hypopharyngeal Cancer,” is a short chapter that discusses how to detect recurrent hypopharyngeal tumor, and the principles of management, including recurrence after radiotherapy and chemoradiation and lymph node recurrence. Surgical techniques are then reviewed. Measures to prevent fistulas and re-irradiation are also discussed.
Chapter 10, “Carcinoma of the Oral Cavity,” details the objectives of post-treatment surveillance and the management of early-stage and then advanced-stage recurrences, as well as relapse after surgery or radiation alone or after combined therapy. Avoiding carotid artery rupture, infection, and the limitations of salvage surgery are then discussed. Importantly, outcomes and quality-of-life issues after re-treatment are reviewed.
Chapter 11, “Carcinoma of the Oropharynx,” is a more robust chapter, discussing epidemiology and prognostic factors of this disease. Importantly to radiologists, it discusses the present controversies regarding post-radiation planned neck dissection and the role of FDG PET/CT in selecting patients. Principles of management are then discussed, including minimally invasive surgical techniques such as transoral laser microsurgery and transoral robotic surgery. Patient selection for salvage surgery is reviewed, as is patient selection for re-irradiation. Finally, outcomes and quality-of-life issues after re-treatment are discussed, including complications of retreatment.
Chapter 12, “Management of Nodal Recurrence,” discusses the incidence and distribution of nodal recurrences and the reliance on FDG PET/ CT to detect such recurrences. It suggests that nodal recurrence can be treated successfully in about 50% of patients. The use of needle and open biopsies is then addressed. The management of recurrences in both an untreated and a previously treated neck are also discussed. The problem of carotid artery tumor encasement is addressed in addition to outcomes of treatment.
Chapter 13, “Carcinoma of the Nasopharynx,” emphasizes the importance of early detection of recurrent tumor and the use of Epstein-Barr and viral titers as well as endoscopic examinations. Principles of management are then addressed for each of the different locations of tumor recurrence. Treatment options, including surgery, external beam re-irradiation, bachytherapy, chemotherapy, and targeted therapies, are discussed along with treatment outcomes.
Chapter 14, “Skull Base and Sinonasal Cancer,” discusses the work-up and principles of management, including treatment after failed irradiation and failed combined treatment, as well as outcomes and quality-of-life issues, especially in the presence of cranial nerve deficits as a result of re-treatment.
Chapter 15, “Recurrent Differentiated Thyroid Cancer,” discusses the papillary, follicular, and Hurthle cell cancers, which comprise 90% of thyroid cancers. There is a discussion of epidemiology, classification of recurrences, prognostic factors, and methods of surveillance and principles of management. Treatments include surgery, radioactive iodine, external beam radiation, and targeted therapies.
Chapter 16, “Recurrent Salivary Gland Carcinoma and Pleomorphic Adenoma,” discusses each of the major tumor types and the likelihood of recurrences. The diagnostic work-up in looking for a recurrence is discussed with an emphasis on CT, MRI, and FDG PET/CT. Treatment options are then described, including irradiation, surgery, and the limited use of chemotherapy. Lastly, there is a section discussing recurrent pleomorphic adenomas and the rare entity of metastatic pleomorphic adenoma.
Chapter 17, “Recurrent Melanotic and Nonmelanotic Skin Cancer,” discusses both nonmelanotic skin cancers as well as skin melanomas. Prognosis and patterns of recurrence are then reviewed. Sections on treatment options and prognosis follow, with an emphasis on surgical approaches.
Chapter 18, “Prognosis of Recurrent Head and Neck Cancer,” discusses factors that affect recurrences as well as prognosis, the most important factors being the occurrence, its initial tumor stage, localization, histologic markers, primary treatment, biomarkers, and genomic markers. In addition, the timing of local, regional, or distant recurrences influences prognosis. The earlier the recurrence, the worse the prognosis.
Chapter 19, “Rehabilitation after Treatment for Recurrent Head and Neck Cancer,” emphasizes the importance of a supportive care team’s involvement in the treatment of cancer recurrences. A review of the various symptoms these patients exhibit and the scales and questionnaires used to assess the degree of disability are examined. Problems include dysphagia, odynophagia, mucositis, xerostomia, thickened saliva, dysgeusia (taste disturbances), trismus, and radionecrosis. Concepts of management for each of these problems are presented. A brief discussion about videocervical esophagrams and their role in assessing swallowing disorders is also given.
Chapter 20, “Psychosocial Aspects of Recurrent Head and Neck Cancer,” addresses the important issues of treating the psychological and social aspects of the patient with tumor recurrences. The psychological trauma is particularly high for recurrent head and neck cancer due to its effect on mastication, swallowing, speech, taste, smell, and appearance. Approximately 19-33% of head and neck cancer patients will experience a recurrence. How to deal with these psychosocial aspects, in part, determines quality of life for these patients. The reactions of the doctor, the patient, and the patient’s partner are described, and concepts for coping with these reactions are presented.
Chapter 21, “Palliative and Psychosocial Issues in Advanced Head and Neck Cancer,” addresses the ever important topic of near end-of life issues. The need for an integrated multidisciplinary approach is emphasized. Dealing with pain control, xerostomia, drooling, stomatitis, mucositis, dysphagia, and the potential use of a G-tube for feeding are all problems that are addressed. In addition, the management of complex wounds, the problem of malodor, bleeding, pain, pruritus, anxiety and depression, suicidal ideation, disfigurement, family issues, communication, and airway obstruction are briefly discussed. This chapter provides a very nice overview of the often serious problems faced by these patients.
As can be seen by the above overview, this is a strongly clinically oriented book. There are brief areas that discuss the use of present imaging and its use in the detection of recurrences, but the average radiologist likely will not encounter these problems in their imaging population. Those radiologists in academic centers who deal with head and neck cancer center patients may find that the clinical pearls related in this book are useful adjuncts to their knowledge and their ability to understand the problems faced by these patients.
