During the period from 1990 to 1999 inclusive, 368 cases of head and neck cancer had been registered at the outpatient clinic of Clinical Oncology and Nuclear Medicine Department of Mansoura University Hospital.
Reliable data concerning the clinico-epidemiological and therapeutic features of only 188 cases of squamous cell carcinoma out of 302 was available. Patient and tumor characteristics of the 188 cases are shown in table 1.
Table 1: Patient and tumor characteristics
The majority of our cases presented in the 6th decade and above. The mean age at diagnosis was 53.5±13.8 years. Males accounted for 88.3% of the patients. Hoarseness and dysphagia were the commonest presenting symptoms (82%). The majority of the cases (66.3%) had performance status III. The larynx was the most frequent primary site involved (55.3%), followed by the nasopharynx (22.3%).
Advanced stages (III and IV) constituted 75.5%; while tumors of 4 cm size or more existed in 55.3% of cases. Grade II was the commonest grade encountered (42.6%). The majority of patients were chronic smokers (88.3%). Moreover all the females were passive smokers. The number of smokers consuming both goza and cigarettes exceeded those consuming either type alone. Ninety-seven percent of all the smokers have been smoking for more than 20 years.
Regularity of the radiotherapy treatment course
Twenty cases (11%) of the present series had experienced unscheduled treatment breaks, in 12 cases it was due to machines’ function problems, in 5 cases due to toxicity reactions and in 3 cases due to official holidays. This treatment breaks ranged from 1 to 12 days.
Survival data of the 188 cases
The median event-free survival was 14 month (range: 1 to 143 months). On the other hand, the median overall survival duration was 22 months (range: 5 to 144 months). The 5-year event-free and overall survival of the 188 cases was 45% and 53%, respectively (Figures 1 and 2).
Fig 1: Event-free survival of all cases
Fig 2: Overall survival of all cases
Prognostic factors affecting event-free and overall survival of 188 cases
On univariate analysis, the significant prognostic factors affecting event-free survival were performance status (p <0.001), for grade I versus grade II (p=0.002) and for grade II versus III (p=0.031) and tumor size (P=0.033). Stage, sex and age were non significant (p=0.13, 0.2 and 0.4, respectively). On multivariate analysis performance status and grade were of statistical significance (p=0.017 and 0.023).
On univariate analysis, the significant prognostic factors affecting overall survival were performance status (p <0.001), size (p=0.005), grade (p=0.004 and 0.041) and stage (p=0.012). Age and sex were non significant (p=0.5, 0.5, respectively). On the other hand, multivariate analysis detected two significant factors that were performance status (p < 0.001) and stage (p=0.0013).
Tables 2-5 present the prognostic factors of both eventfree and overall survival.
Table 2: Univariate analysis of prognostic factors affecting event-free survival
Table 3: Multivariate analysis of prognostic factors affecting event-free survival
Table 4: Univariate analysis of prognostic factors affecting event-free survival
Table 5: Multivariate analysis of prognostic factors affecting overall survival of 188 cases
Pattern of failure
Local failure in the present study exceeded in incidence both nodal and distant failure and was diagnosed in 40% of the cases, while nodal and distant failure occurred in 12.6% of cases. None of the cases had more than one type of failure.
The high grades of acute and late toxicities of the present study are shown in tables 6 and 7. Mucositis was the commonest acute toxicity while xerostomia was the commonest late toxicity. Generally higher grade of toxicity were rare.
Table 6: Grades 3 and 4 acute toxicity of radiotherapy
Table 7: Grades 3 and 4 late toxicity of radiotherapy
Laryngeal squamous cell carcinomas
The larynx was the commonest site of primary tumor in this study as the laryngeal squamous cell carcinoma cases constituted 55.3% of the study population. Advanced staged tumors predominated (69%) and were treated by two treatment modalities, surgery followed by radiotherapy in 60 cases and radical radiotherapy in 12 cases.
The difference in the 5-year event-free survival was statistically non-significant (p=0.058) while the difference in the 5-year overall survival was statistically significant (p= 0.036). The 5-year overall survival of all our laryngeal squamous cell carcinoma cases was 60% (Figure 3).
Fig 3: Overall survival of laryngeal and nasopharyngeal cases
Nasopharyngeal squamous cell carcinomas
The nasopharynx was the second most common site of primary tumor constituting 22.3% of the study population.
Similar to laryngeal squamous cell carcinomas, the advanced stages predominated (81%) and were treated by either radical radiotherapy alone (28 cases) or by concomitant chemoradiotherapy (6 cases).
The differences in response rates and the 5-year overall survival of the two treatment modalities were statistically non-significant (p=0.1 and 0.4, respectively). The 5-year overall survival of the nasopharyngeal squamous cell carcinoma cases as a whole was 42% (Figure 3).