زائر
ip and a avity ane
aneMai fm the Natina ane Institte
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Infmatin fm PDQ -- f Heath Pfessinas
GENEA INFMATIN
Nte: Sepaate PDQ smmaies n Peventin f a ane and Seening f a ane ae as avaiabe.
The a avity extends fm the skin-vemiin jntins f the antei ips t the jntin f the had and sft paates abve and t the ine f imvaate papiae bew and is divided int the fwing speifi aeas: ip
antei 23 f tnge
ba msa
f f mth
we gingiva
etma tigne
ppe gingiva
had paate
The main tes f ymph nde dainage ae int the fist statin ndes (binat, jg-digasti, sbmandiba, and sbmenta). Sites se t the midine ften dain biateay. Send statin ndes inde the patid, jga, and the ppe and we pstei evia ndes.
Eay anes (stages I and II) f the ip and a avity ae highy abe by sgey by adiatin theapy, and the hie f teatment is ditated by the antiipated fntina and smeti ests f teatment and by the avaiabiity f the patia expetise eqied f the sgen adiatin theapist f the individa patient.[1-3] The pesene f a psitive magin a tm depth geate than 5 miimetes signifianty ineases the isk f a eene and sggests that mbined mdaity teatment may be benefiia.[4]
Advaned anes (stages III and IV) f the ip and a avity epesent a wide spetm f haenges f the sgen and adiatin theapist. Exept f patients with sma T3 esins and n egina ymph nde and n distant metastases wh have n ymph ndes age than 2 entimetes, f whm teatment by adiatin theapy ane sgey ane might be apppiate, mst patients with stage III IV tms ae andidates f teatment by a mbinatin f sgey and adiatin theapy.[2] Ftheme, bease a eene and distant metastases ae mmn in this gp f patients, they shd be nsideed f inia tias. Sh tias evaate the ptentia e f adiatin mdifies mbinatin hemtheapy mbined with sgey and adiatin theapy.
Patients with head and nek anes have an ineased hane f deveping a send pimay tm f the ppe aedigestive tat.[5,6] A stdy has shwn that daiy teatment f these patients with mdeate dses f istetinin (13-is-etini aid) f 1 yea an signifianty ede the inidene f send tms. N sviva advantage has yet been demnstated, hweve, in pat de t eene and death fm the pimay maignany. Additina tias ae nging.[7]
The ate f abiity f anes f the ip and a avity vaies depending n the stage and speifi site. Mst patients pesent with eay anes f the ip, whih ae highy abe by sgey by adiatin theapy with e ates f 90% t 100%. Sma anes f the etma tigne, had paate, and ppe gingiva ae highy abe by eithe adiatin theapy sgey, with sviva ates f p t 100%. a nt ates f p t 90% an be ahieved with eithe adiatin theapy sgey in sma anes f the antei tnge, the f f the mth, and ba msa.[8]
Mdeatey advaned and advaned anes f the ip as an be nted effetivey by sgey adiatin theapy a mbinatin f these. The hie f teatment is geneay ditated by the antiipated fntina and smeti ests f the teatment. Mdeatey advaned esins f the etma tigne witht evidene f spead t evia ymph ndes ae say abe, with a nt ates f p t 90%; sh esins f the had paate, ppe gingiva, and ba msa have a a nt ate f p t 80%. In the absene f inia evidene f spead t evia ymph ndes, mdeatey advaned esins f the f f the mth and antei tnge ae geneay abe, with sviva ates f p t 70% and 65% espetivey.[8,9]
efeenes:
* mmings W, Fediksn JM, Hake A, et a.: taynggy - Head and Nek Sgey. Saint is: Msby-Yea Bk, In., 1998.
* Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* Wang , Ed.: adiatin Theapy f Head and Nek Nepasms: Indiatins, Tehniqes and ests. ittetn, MA: Jhn Wight-PSG, In., 2nd ed., 1990.
* Jnes K, dge-iga D, eddik , et a.: Pgnsti fats in the eene f stage I and II sqams e ane f the a avity. Ahives f taynggy, Head and Nek Sgey 118(5): 483-485, 1992.
* Day G, Bt WJ: Send pimay tms in patients with a ane. ane 70(1): 14-19, 1992.
* van de T IG, de Visshe JG, Jvanvi A, et a.: isk f send pimay ane fwing teatment f sqams e ainma f the we ip. a ngy 35(6): 571-574, 1999.
* Hng WK, ippman SM, Iti M, et a.: Peventin f send pimay tms with istetinin in sqams-e ainma f the head and nek. New Engand Jna f Mediine 323(12): 795-801, 1990.
* Wane PE, Hanks GE, Kame S, et a.: Pattens f ae stdy: anaysis f tme svey data -- antei tw-thids f tnge and f f mth. Ameian Jna f inia ngy 9(1): 50-57, 1986.
* Takagi M, Kayan T, Yamamt H, et a.: ases f a tnge ane teatment faies: anaysis f atpsy ases. ane 69(5): 1081-1087, 1992.EA ASSIFIATIN
Mst head and nek anes ae f the sqams e vaiety and may be peeded by vais peanes esins. Min saivay gand tms ae nt nmmn in these sites. Speimens emved fm the esins may shw the ainmas t be nninvasive, in whih ase the tem "ainma-in-sit" is appied. An invasive ainma wi be eithe we-diffeentiated, mdeatey we-diffeentiated, py diffeentiated ndiffeentiated.
Tm gading is emmended sing Bde's assifiatin (Tm Gade (G)): G1: we-diffeentiated
G2: mdeatey we-diffeentiated
G3: py diffeentiated
G4: ndiffeentiated [1]
N statistiay signifiant eatin between degee f diffeentiatin and the bigi behavi f the ane exists. Hweve, vasa invasin is a negative pgnsti fat.[2]
the tms f ganda epitheim, dntgeni appaats, ymphid tisse, sft tisse, and bne and atiage igin eqie speia nsideatin and ae nt inded in this setin f PDQ. efeene t the Wd Heath ganizatin nmenate is emmended.
The tem "ekpakia" shd be sed ny as a iniay desiptive tem meaning that the bseve sees a white path that des nt b ff, the signifiane f whih depends n the histgi findings. ekpakia an ange fm hypekeatsis t an ata eay invasive ainma may ny epesent a fnga infetin, ihen pans, the benign a disease.
efeenes:
* Bansbeg SF, sen KD, Gaffey TA: High-gade ainma f the a avity. taynggy and Head and Nek Sgey 100(1): 41-48, 1989.
* se G, Bwn PM, Vith MF, et a: Mivasa invasin and sviva in ane f the a avity and phaynx. Ahives f taynggy, Head and Nek Sgey 115(11): 1304-1309, 1989.STAGE INFMATIN
The staging systems ae a inia staging, based n the best pssibe estimate f the extent f disease befe teatment. The assessment f the pimay tm is based n inspetin and papatin when pssibe and by bth indiet mi examinatin and diet endspy when neessay. The tm mst be nfimed histgiay, and any the pathgi data btained n bipsy may be inded. The apppiate nda dainage aeas ae examined by aef papatin. Infmatin fm diagnsti imaging stdies may be sed in staging. Magneti esnane imaging ffes an advantage ve mpted tmgaphi sans in the detetin and aizatin f head and nek tms and in the distintin f ymph ndes fm bd vesses.[1] If a patient eapses, mpete estaging mst be dne t seet the apppiate additina theapy.[2,3]
The Ameian Jint mmittee n ane (AJ) has designated staging by TNM assifiatin.[4]
TNM definitins
Pimay tm (T)
TX: Pimay tm annt be assessed
T0: N evidene f pimay tm
Tis: ainma in sit
T1: Tm 2 m ess in geatest dimensin
T2: Tm me than 2 m bt nt me than 4 m in geatest dimensin
T3: Tm me than 4 m in geatest dimensin
T4: (ip) Tm invades adjaent sttes (e.g., thgh tia bne, infei avea neve, f f mth, skin f fae)
(a avity) Tm invades adjaent sttes (e.g., thgh tia bne, int deep (extinsi) mses f tnge, maxiay sins, skin. Spefiia esin ane f bnetth sket by gingiva pimay is nt sffiient t assify as T4)
egina ymph ndes (N)
NX: egina ymph ndes annt be assessed
N0: N egina ymph nde metastasis
N1: Metastasis in a singe ipsiatea ymph nde, 3 m ess in geatest dimensin
N2: Metastasis in a singe ipsiatea ymph nde, me than 3 m bt nt me than 6 m in geatest dimensin; in mtipe ipsiatea ymph ndes, nne me than 6 m in geatest dimensin; in biatea ntaatea ymph ndes, nne me than 6 m in geatest dimensin
N2a: Metastasis in a singe ipsiatea ymph nde me than 3 m bt nt me than 6 m in dimensin
N2b: Metastasis in mtipe ipsiatea ymph ndes, nne me than 6 m in geatest dimensin
N2: Metastasis in biatea ntaatea ymph ndes, nne me than 6 m in geatest dimensin
N3: Metastasis in a ymph nde me than 6 m in geatest dimensin
In inia evaatin, the ata size f the nda mass shd be meased and awane shd be made f intevening sft tisses. Mst masses age than 3 entimetes in diamete ae nt singe ndes bt ae nfent ndes tms in sft tisses f the nek. Thee ae 3 stages f iniay psitive ndes: N1, N2, and N3. The se f sbgps a, b, and is nt eqied bt emmended. Midine ndes ae nsideed hmatea ndes.
Distant metastasis (M)
MX: Pesene f distant metastasis annt be assessed
M0: N distant metastasis
M1: Distant metastasis
AJ stage gpings
Stage 0
Tis, N0, M0
Stage I
T1, N0, M0
Stage II
T2, N0, M0
Stage III
T3, N0, M0
T1, N1, M0
T2, N1, M0
T3, N1, M0
Stage IVA
T4, N0, M0
T4, N1, M0
Any T, N2, M0
Stage IVB
Any T, N3, M0
Stage IV
Any T, Any N, M1
efeenes:
* nsenss nfeene. Magneti esnane imaging. JAMA: Jna f the Ameian Media Assiatin 259(14): 2132-2138, 1988.
* <A name=EF.3.2>Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* Wang , Ed.: adiatin Theapy f Head and Nek Nepasms: Indiatins, Tehniqes and ests. ittetn, MA: Jhn Wight-PSG, In., 2nd ed., 1990.
* ip and a avity. In: Ameian Jint mmittee n ane: AJ ane Staging Mana. Phiadephia, Pa: ippintt-aven Pbishes, 5th ed., 1997, pp 24-30.TEATMENT PTIN VEVIEW
Depending n the site and extent f the pimay tm and the stats f the ymph ndes, the teatment f ip and a avity ane may be by sgey ane, adiatin theapy ane, a mbinatin f these. Sme genea nsideatins ae as fws.[1-5]
F esins f the a avity, sgey mst adeqatey enmpass a f the gss as we as the pesmed mispi extent f the disease. If egina ndes ae psitive, evia nde dissetin is say dne in ntinity. With mden appahes, the sgen an sessfy abate age pstei a avity tms and with ensttive methds an ahieve satisfaty fntina ests. Psthdnti ehabiitatin is imptant, patiay in eay-stage anes, t asse the best qaity f ife.
adiatin theapy f ip and a avity anes an be by extena-beam theapy intestitia impantatin ane, bt f many sites the se f bth mdaities pdes bette nt and fntina ests. Sma spefiia anes an be vey sessfy teated by a impantatin sing any ne f sevea adiative ses, by intaa ne adiatin theapy, by eetns. age esins ae feqenty managed sing extena-beam adiatin theapy t inde the pimay site and egina ymph ndes even if they ae nt iniay invved. Sppementatin with intestitia adiatin ses may be neessay t ahieve adeqate dses t age pimay tms and bky nda metastases. A eview f pbished inia ests f adia adiatin theapy f head and nek ane sggests a signifiant ss f a nt when the administatin f adiatin theapy was pnged; theefe, engthening f standad teatment shedes shd be avided wheneve pssibe.[6]
Eay anes (stages I and II) f the ip, f f mth, and etma tigne ae highy abe by sgey adiatin theapy. The hie f teatment is ditated by the antiipated fntina and smeti ests and by the avaiabiity f the patia expetise eqied f the sgen adiatin theapist f the individa patient. Advaned anes (stages III and IV) f the ip, f f mth, and etma tigne epesent a wide spetm f haenges f the sgen and adiatin theapists. Exept f patients with sma T3 esins and n egina ymph nde and n distant metastases wh have n ymph ndes age than 2 entimetes, f whm teatment by adiatin theapy ane sgey ane might be apppiate, mst patients with stage III IV tms ae andidates f teatment by a mbinatin f sgey and adiatin theapy. Ftheme, bease a eene and distant metastases ae mmn in this gp f patients, they shd be nsideed f inia tias evaating the fwing: the ptentia e f adiatin mdifies t impve a nt deease mbidity f mbinatins f hemtheapy with sgey and adiatin theapy bth t impve a nt and t deease the feqeny f distant metastases.
Eay anes f the ba msa ae eqay abe by adiatin theapy by adeqate exisin. Patient fats and a expetise infene the hie f teatment. age anes eqie mpsite esetin with ensttin f the defet by pedie faps.
Eay esins (T1 and T2) f the antei tnge may be managed by sgey by adiatin theapy ane. Bth mdaities pde 70% t 85% e ates in eay esins. Mdeate exisins f tnge, even hemigssetmy, an ften est in spisingy itte speeh disabiity pvided the wnd se is sh that the tnge is nt bnd dwn. If, hweve, the esetin is me extensive, pbems may inde aspiatin f iqids and sids and diffity in swawing in additin t speeh diffities. asinay, patients with tm f the tnge eqie amst tta gssetmy. age esins geneay eqie mbined sgia and adiatin teatment. The nt ates f age esins ae abt 30% t 40%. Ading t inia and adigia evidene f invvement, anes f the we gingiva that ae exphyti and amenabe t adeqate a exisin may be exised t inde ptins f bne. Me advaned esins eqie segmenta bne esetin, hemimandibetmy, maxietmy, depending n the extent f the esin and its atin.
Eay esins f the ppe gingiva had paate witht bne invvement an be teated with eqa effetiveness by sgey by adiatin theapy ane. Advaned infitative and eating esins shd be teated by a mbinatin f adiatin theapy and sgey. Mst pimay anes f the had paate ae f min saivay gand igin. Pimay sqams e ainma f the had paate is nmmn, and these tms geneay epesent invasin f sqams e ainma aising n the ppe gingiva, whih is mh me mmn. Ths, management f sqams e ainma f the ppe gingiva and had paate ae say nsideed tgethe. Sgia teatment f ane f the had paate say eqies exisin f ndeying bne pding an pening int the antm. This defet an be fied and veed with a denta psthesis, a maneve that estes satisfaty swawing and speeh.
Patients wh smke whie n adiatin theapy appea t have we espnse ates and shte sviva datins than thse wh d nt;[7] theefe, patients shd be nseed t stp smking befe beginning adiatin theapy. Denta stats evaatin shd be pefmed pi t theapy t pevent ate seqeae.
The designatins in PDQ that teatments ae "standad" "nde inia evaatin" ae nt t be sed as a basis f eimbsement deteminatins.
efeenes:
* Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* Wang , Ed.: adiatin Theapy f Head and Nek Nepasms: Indiatins, Tehniqes and ests. ittetn, MA: Jhn Wight-PSG, In., 2nd ed., 1990.
* Sen JY, Myes EN: ane f the Head and Nek. New Yk: hhi ivingstne, 1981.
* Fend H: Pinipes f Head and Nek Sgey. New Yk: Appetn-enty-fts, 2nd ed., 1979.
* e JM, Wabnitz , Eds.: An Atas f Head and Nek Sgey. Phiadephia: W.B. Sandes mpany, 3d ed., 1988.
* Fwe JF, indstm MJ: ss f a nt with pngatin in aditheapy. Intenatina Jna f adiatin ngy, Bigy, Physis 23(2): 457-467, 1992.
* Bwman GP, Wng G, Hdsn I, et a.: Infene f igaette smking n the effiay f adiatin theapy in head and nek ane. New Engand Jna f Mediine 328(3): 159-163, 1993.STAGE I IP AND A AVITY ANE
Sgey and adiatin theapy may be sed, depending n the exat site.[1,2]
Sma esins f the ip
Standad teatment ptins:
Sgey and adiatin theapy pde simia e ates, and the methd f teatment is ditated by the antiipated smeti and fntina ests.
Sma antei tnge esins
Standad teatment ptins:
1. Wide a exisin is pefeed f sma esins that an be eseted
tansay.
2. F age T1 esins, eithe sgey adiatin theapy is an aeptabe
teatment. Intestitia impantatin ane with extena-beam adiatin theapy shd be nsideed. nsideatin shd be given t iadiating the nek.
Sma esins f the ba msa
Standad teatment ptins:
1. esins ess than 1 entimete in diamete may be managed by sgey ane
if the mmisse is nt invved. If the mmisse is invved, adiatin theapy (inding bahytheapy) shd be nsideed.
2. age T1 esins may be teated by sgia exisin with spit thikness
skin gaft adiatin theapy.
Sma esins f the f f mth
Standad teatment ptins:
1. Sgey and adiatin theapy pde simia e ates f T1 esins.
2. In genea f esins ess than 0.5 entimetes, exisin ane is adeqate
if thee is a magin f nma msa between the esin and the gingiva.
3. F age esins, sgey is pefeed if the esin is attahed t the
peistem, wheeas adiatin theapy is pefeed if the esin enahes n the tnge.
Sma esins f the we gingiva
Standad teatment ptins:
1. Sma esins may be teated by intaa esetin with witht a im
esetin f bne and epaied with a spit thikness skin gaft.
2. adiatin theapy may be sed f sma esins bt ests ae geneay
bette afte sgey ane.
Sma tms f the etma tigne
Standad teatment ptins:
1. F eay esins witht detetabe bne invasin, imited esetin f the
mandibe is pefmed.
2. If imited esetin is nt feasibe, adiatin theapy may be sed
initiay with sgey eseved f adiatin faie.
Sma esins f the ppe gingiva and had paate
Standad teatment ptins:
1. Mst sma esins ae teated by sgia esetin.
2. Pstpeative adiatin theapy may be sed if apppiate.
efeenes:
* Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* Gey T, Siveman S, Ded HH: abn dixide ase esetin f spefiia a ainma: indiatins, tehniqe, and ests. Annas f tgy, hingy, and aynggy 95(6, Pat 1): 547-555, 1986.STAGE II IP AND A AVITY ANE
Sgey and adiatin theapy may be sed, depending n the exat site.[1]
Sma esins f the ip
Standad teatment ptins:
1. Sgey is sed f smae T2 esins n the we ip if simpe se
pdes an aeptabe smeti est.
2. If a ensttive sgia pede is eqied, adiatin theapy has
the advantage f pding a eativey bette fntina and smeti est with intat skin and mse innevatin.
3. adiatin theapy may inde extena-beam and intestitia tehniqes
as apppiate.
Sma antei tnge esins
Standad teatment ptins:
1. adiatin theapy is say seeted f T2 esins that have minima
infitatin t peseve speeh and swawing. Sgey is eseved f patients f whm adiatin teatment faied. Nek dissetin may be nsideed when pimay bahytheapy is sed.[2]
2. Deepy infitative esins ae best teated by sgey, adiatin theapy,
a mbinatin f bth.
Sma esins f the ba msa
Standad teatment ptins:
1. Sma T2 esins (<= 3 entimetes) ae say teated by adiatin
theapy.
2. age T2 esins (> 3 entimetes) may be teated by sgey, adiatin
theapy, a mbinatin f these, if indiated. adiatin theapy is pefeed if the esin invves the mmisse. Sgey is pefeed if tm invades the mandibe maxia.
Sma esins f the f f mth
Standad teatment ptins:
1. F sma T2 esins (<= 3 entimetes), sgey is pefeed if the esin
is attahed t the peistem, wheeas adiatin theapy is pefeed if the esin enahes n the tnge.
2. F age T2 esins (> 3 entimetes), sgey and adiatin theapy ae
atenative methds f teatment, the hie f whih depends pimaiy n the expeted extent f disabiity fm sgey.
3. Extena-beam with witht intestitia adiatin theapy shd be
nsideed pstpeativey f age esins.
Sma esins f the we gingiva
Standad teatment ptins:
1. Sma esins may be teated by intaa esetin with witht a im
esetin f bne and epaied with a spit thikness skin gaft.
2. adiatin theapy may be sed f sma esins bt ests ae geneay
bette afte sgey ane.
Sma tms f the etma tigne
Standad teatment ptins:
1. F eay esins witht detetabe bne invasin, imited esetin f the
mandibe is pefmed.
2. If imited esetin is nt feasibe, adiatin theapy may be sed
initiay with sgey eseved f adiatin faie.
Sma esins f the ppe gingiva and had paate
Standad teatment ptins:
Mst esins ae teated by sgia esetin with pstpeative adiatin theapy as apppiate.
efeenes:
* Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* Pent M, Maissad , Aetti P, et a.: Iidim-192 bahytheapy in the management f 147 T2N a tnge ainmas teated with iadiatin ane: mpaisn f tw teatment tehniqes. aditheapy and ngy 23(4): 223-228, 1992.STAGE III IP AND A AVITY ANE
Sgey and adiatin theapy ae sed, depending n the exat tm site.[1,2] Neadjvant hemtheapy, as given in inia tias, has been sed t shink tms and theeby ende them me definitivey teatabe with eithe sgey adiatin. Neadjvant hemtheapy is given pi t the the mdaities, as ppsed t standad adjvant hemtheapy, whih is given afte ding definitive theapy with adiatin afte sgey. Many dg mbinatins have been sed as neadjvant hemtheapy.[3-6] Hweve, andmized, pspetive tias have yet t demnstate a benefit in eithe disease-fee vea sviva f patients eeiving neadjvant hemtheapy.[7]
Advaned esins f the ip
These esins, inding thse invving bne, neves, and ymph ndes, geneay eqie a mbinatin f sgey and adiatin theapy. Sh patients ae apppiate andidates f inia tias.
Standad teatment ptins:
1. Sgey: a vaiety f sgia appahes an be sed depending n the size
and atin f the esin and the needs f ensttin.
2. adiatin theapy: a vaiety f adiatin theapy tehniqes an be sed as
ditated by the size and atin f the esin. ptins inde extena-beam iadiatin with witht bahytheapy.
Teatment ptins nde inia evaatin:
1. inia tias f advaned tms evaating the se f hemtheapy
pepeativey, befe adiatin theapy, as adjvant theapy afte sgey, as pat f mbined mdaity theapy ae apppiate.[3-6,8-10]
2. Spefatinated adiatin theapy [11]
Mdeatey advaned (ate T2, sma T3) esins f the antei tnge
Standad teatment ptins:
1. Minimay infitative esins: extena-beam adiatin theapy with
witht intestitia impant.
2. Deepy infitative esins: sgey with pstpeative adiatin
theapy.[2]
Advaned esins f the ba msa
Standad teatment ptins:
1. adia sgia esetin ane.
2. adiatin theapy ane.
3. Sgia esetin + adiatin theapy, geneay pstpeative.
Teatment ptins nde inia evaatin:
inia tias f advaned tms evaating the se f hemtheapy pepeativey, befe adiatin theapy, as adjvant theapy afte sgey, as pat f mbined mdaity theapy ae apppiate.[3-6,8-10]
Mdeatey advaned esins f the f f mth
Standad teatment ptins:
1. Sgey: im esetin ps nek dissetin patia mandibetmy with
nek dissetin as apppiate.
2. adiatin theapy: extena-beam adiatin theapy ane extena-beam
adiatin theapy ps an intestitia impant.
Teatment ptins nde inia evaatin:
1. inia tias f advaned tms evaating the se f hemtheapy
pepeativey, befe adiatin theapy, as adjvant theapy afte sgey, as pat f mbined mdaity theapy ae apppiate.[3-6,8-10]
2. inia tias sing nve adiatin theapy fatinatin shemas.[12]
Mdeatey advaned esins f the we gingiva
Standad teatment ptins:
Extensive esins with mdeate bne desttin and nda metastases shd be teated by mbined adiatin theapy and adia esetin by adia esetin ane. adiatin theapy may be eithe pepeative pstpeative.
Advaned esins f the etma tigne
Standad teatment ptins:
Sgia mpsite esetin that may be fwed by pstpeative adiatin theapy.
Teatment ptins nde inia evaatin:
1. inia tias f advaned tms evaating the se f hemtheapy
pepeativey, befe adiatin theapy, as adjvant theapy afte sgey, as pat f mbined mdaity theapy ae apppiate.[3-6,8-10]
2. inia tias sing nve adiatin theapy fatinatin shemas.[12]
Mdeatey advaned esins f the ppe gingiva
Standad teatment ptins:
1. Spefiia esins with extensive invvement f the gingiva, had paate,
sft paate may be teated by adiatin theapy ane.
2. Deepy invasive esins invving bne shd be teated by a mbinatin f
sgey and adiatin theapy.
Mdeatey advaned esins f the had paate
Standad teatment ptins:
1. Spefiia esins with extensive invvement f the gingiva, had paate,
sft paate may be teated by adiatin theapy ane.
2. Deepy invasive esins invving bne shd be teated by a mbinatin f
sgey and adiatin theapy by sgey ane.
Teatment ptins f management f ymph ndes:[1] Patients with advaned esins shd have eetive ymph nde adiatin theapy nde dissetin. The isk f metastases t ymph ndes is ineased by high-gade histgy, age esins, spead t invve the wet msa f the ip the ba msa in patients with eent disease, and invasin f mse (biais is).
Standad teatment ptins:
1. adiatin theapy ane nek dissetin:
N1 (0-2 entimetes)
N2b N3; a ndes ess than 2 entimetes. (A mbined sgia and adiatin theapy appah shd as be nsideed.)
2. adiatin theapy and nek dissetin:
N1 (2-3 entimetes), N2a, N3
3. Sgey fwed by adiatin theapy, indiatins f whih ae as fws:
mtipe psitive ndes
ntaatea sbinia metastases
invasin f tm thgh the apse f the ymph nde
N2b N3 (ne me ndes in eah nek, as apppiate, > 2 entimetes)
4. adiatin theapy pi t sgey:
age fixed ndes
Teatment ptins nde inia evaatin (a stage III esins):
1. hemtheapy has been mbined with adiatin theapy in patients wh have
ay advaned disease that is sgiay nesetabe.[8,10,13,14]
A meta-anaysis f 63 andmized pspetive tias pbished between 1965 and 1993 shwed an 8% abste sviva advantage in the sbset f patients eeiving nmitant hemtheapy and adiatin theapy.[15][eve f evidene: 2A] Patients eeiving adjvant neadjvant hemtheapy had n sviva advantage. Hweve, st, qaity f ife, and mbidity data wee nt avaiabe; thee was n standad egimen; and the tias wee fet t be t hetegens t pvide definitive emmendatins. The ests f 18 nging tias may fthe aify the e f nmitant hemtheapy and adiatin theapy in the management f a avity ane.
The best hemtheapy t se and the apppiate way t integate the 2 mdaities is sti nesved.[16]
Simia appahes in the patient with esetabe disease, whee esetin wd ead t a maj fntina defiit, ae as being exped in andmized tias bt annt be emmended at this time as standad.
Nve fatinatin adiatin theapy inia tias ae nde inia evaatin.[12]
efeenes:
* Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* Faneshi D, Gpta , Spi H, et a.: Impved sviva in the teatment f sqams ainma f the a tnge. Ameian Jna f Sgey 166(4): 360-365, 1993.
* Evin TJ, ak J, Weihsebam , et a.: An anaysis f indtin and adjvant hemtheapy in the mtidisipinay teatment f sqams-e ainma f the head and nek. Jna f inia ngy 5(1): 10-20, 1987.
* A-Kainy K, Kish J, Ensey J, et a.: Ahievement f spei sviva f histgiay negative vess histgiay psitive iniay mpete espndes t ispatin mbinatin in patients with ay advaned head and nek ane. ane 59(2): 233-238, 1987.
* Head and Nek ntats Pgam: Adjvant hemtheapy f advaned head and nek sqams ainma: fina ept f the Head and Nek ntats Pgam. ane 60(3): 301-311, 1987.
* Ensey J, issman J, Kish J, et a.: The impat f nventina mphgi anaysis n espnse ates and sviva in patients with advaned head and nek anes teated initiay with ispatin-ntaining mbinatin hemtheapy. ane 57(4): 711-717, 1986.
* Mazen JJ, Matin M, Bn B, et a.: Indtin hemtheapy in head and nek ane: ests f a phase III tia. Head and Nek 14(2): 85-91, 1992.
* A-Saaf M, Pajak TF, Maia VA, et a.: nent aditheapy and hemtheapy with ispatin in inpeabe sqams e ainma f the head and nek: an TG stdy. ane 59(2): 259-265, 1987.
* Bwman GP, ipps , Hdsn DI, et a.: Paeb-nted andmized tia f infsina fai ding standad aditheapy in ay advaned head and nek ane. Jna f inia ngy 12(12): 2648-2653, 1994.
* Mean M, Benass M, v , et a.: Five-yea pdate f a andmized tia f atenating aditheapy and hemtheapy mpaed with aditheapy ane in teatment f nesetabe sqams e ainma f the head and nek. Jna f the Natina ane Institte 88(9): 583-589, 1996.
* Jhnsn , Khandewa S, Shmidt-ih K, et a.: The infene f qantitative tm vme measements n a nt in advaned head and nek ane sing nmitant bst aeeated spefatinated iadiatin. Intenatina Jna f adiatin ngy, Bigy, Physis 32(3): 635-641, 1995.
* Stshke M, Thames HD: Hypefatinated aditheapy f hman tms: veview f the andmized inia tias. Intenatina Jna f adiatin ngy, Bigy, Physis 37(2): 259-267, 1997.
* Bahad J, David J, Bssin G, et a.: mbined pstpeative aditheapy and weeky ispatin infsin f ay advaned sqams e ainma f the head and nek: peiminay ept f a andmized tia. Intenatina Jna f adiatin ngy, Bigy, Physis 20(2): 243-246, 1991.
* Mean M, v , Magain G, et a.: mbined hemtheapy and adiatin theapy in advaned inpeabe sqams e ainma f the head and nek: the fina ept f a andmized tia. ane 67(4): 915-921, 1991.
* Pignn JP, Bhis J, et a., n behaf f the MAH-N abative Gp: hemtheapy added t egina teatment f head and nek sqams-e ainma: thee meta-anayses f pdated individa data. anet 355(9208): 949-955, 2000.
* Tay SG, Mthy AK, Vannetze JM, et a.: andmized mpaisn f neadjvant ispatin and fai infsin fwed by adiatin vess nmitant teatment in advaned head and nek ane. Jna f inia ngy 12(2): 385-395, 1994.STAGE IV IP AND A AVITY ANE
andmized, pspetive tias have yet t demnstate a benefit in eithe disease-fee vea sviva f patients eeiving neadjvant hemtheapy.[1] The se f istetinin (13-is-etini aid) daiy f 1 yea t pevent devepment f send ppe aedigestive tat pimaies is nde inia evaatin.[2]
Advaned esins f the ip
These esins, inding thse invving bne, neves, and ymph ndes, geneay eqie a mbinatin f sgey and adiatin theapy. Sh patients ae apppiate andidates f inia tias.
Standad teatment ptins f pimay tms:
1. Sgey: a vaiety f sgia appahes an be sed depending n the size
and atin f the esin and the need f ensttin. Teatment f bth sides f the nek is indiated f seeted patients.
2. adiatin theapy: a vaiety f adiatin theapy tehniqes an be sed as
ditated by the size and atin f the esin. ptins inde extena-beam iadiatin with witht bahytheapy.
Teatment ptins nde inia evaatin:
Spefatinated adiatin theapy [3]
Advaned esins f the antei tnge
Standad teatment ptins:
1. Seeted patients: mbined sgey (tta gssetmy, smetimes eqiing
ayngetmy) that may be mbined with pstpeative adiatin theapy.[4]
2. Patients with vey advaned esins: paiative adiatin theapy.
Advaned esins f the ba msa
Standad teatment ptins:
1. adia sgia esetin ane.
2. adiatin theapy ane.
3. Sgia esetin + adiatin theapy, geneay pstpeative.
Advaned esins f the f f mth
Standad teatment ptins:
1. A mbinatin f sgey and adiatin theapy, geneay pstpeative, is
pefeed.
2. F fixed ndes (eqa t >5 entimetes) pepeative adiatin theapy
is pefeed.
Advaned esins f the we gingiva
Standad teatment ptins:
Fa-advaned tms with extensive desttin f the mandibe and with nda metastases ae py nted by sgey, adiatin theapy, a mbinatin f bth.
Advaned esins f the etma tigne
Standad teatment ptins:
Sgia mpsite esetin fwed by pstpeative adiatin theapy.
Advaned esins f the ppe gingiva
Standad teatment ptins:
esins that ae extensive and infitating geneay eqie teatment by sgey in mbinatin with adiatin theapy.
Advaned esins f the had paate
Standad teatment ptins:
esins that ae extensive and infitating geneay eqie teatment by sgey in mbinatin with adiatin theapy.
Teatment ptins f management f ymph ndes:[5] Patients with advaned esins shd have eetive ymph nde adiatin theapy nde dissetin. The isk f metastases t ymph ndes is ineased by high-gade histgy, age esins, spead invving the wet msa f the ip the ba msa in patients with eent disease, and invasin f mse (biais is).
Standad teatment ptins:
1. adiatin theapy ane nek dissetin:
N1 (0-2 entimetes)
N2b N3; a ndes ess than 2 entimetes. (A mbined sgia and
adiatin theapy appah shd as be nsideed.)
2. adiatin theapy and nek dissetin:
N1 (2-3 entimetes), N2a, N3
3. Sgey fwed by adiatin theapy is indiated f the fwing:
mtipe psitive ndes
ntaatea sbinia metastases
invasin f tm thgh the apse f the ymph nde
N2b N3 (ne me ndes in eah nek, as apppiate, geate than 2 entimetes)
4. adiatin theapy pi t sgey:
age fixed ndes
Teatment ptins nde inia evaatin (a stage IV esins):
1. hemtheapy has been mbined with adiatin theapy in patients wh
have ay advaned disease that is sgiay nesetabe.[6-9]
A meta-anaysis f 63 andmized pspetive tias pbished between 1965 and 1993 shwed an 8% abste sviva advantage in the sbset f patients eeiving nmitant hemtheapy and adiatin theapy.[10][eve f evidene: 2A] Patients eeiving adjvant neadjvant hemtheapy had n sviva advantage. Hweve, st, qaity f ife, and mbidity data wee nt avaiabe; thee was n standad egimen; and the tias wee fet t be t hetegens t pvide definitive emmendatins. The ests f 18 nging tias may fthe aify the e f nmitant hemtheapy and adiatin theapy in the management f a avity ane.
The best hemtheapy t se and the apppiate way t integate the 2 mdaities is sti nesved.[11]
Simia appahes in the patient with esetabe disease, whee esetin wd ead t a maj fntina defiit, ae as being exped in andmized tias bt annt be emmended at this time as standad.
2. inia tias f advaned tms evaating the se f hemtheapy
pepeativey, befe adiatin theapy, as adjvant theapy afte sgey ae apppiate.[6,12-19]
3. Nve fatinatin adiatin theapy inia tias ae nde inia
evaatin.[20]
efeenes:
* Mazen JJ, Matin M, Bn B, et a.: Indtin hemtheapy in head and nek ane: ests f a phase III tia. Head and Nek 14(2): 85-91, 1992.
* Hng WK, ippman SM, Iti M, et a.: Peventin f send pimay tms with istetinin in sqams-e ainma f the head and nek. New Engand Jna f Mediine 323(12): 795-801, 1990.
* Jhnsn , Khandewa S, Shmidt-ih K, et a.: The infene f qantitative tm vme measements n a nt in advaned head and nek ane sing nmitant bst aeeated spefatinated iadiatin. Intenatina Jna f adiatin ngy, Bigy, Physis 32(3): 635-641, 1995.
* Faneshi D, Gpta , Spi H, et a.: Impved sviva in the teatment f sqams ainma f the a tnge. Ameian Jna f Sgey 166(4): 360-365, 1993.
* Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* A-Saaf M, Pajak TF, Maia VA, et a.: nent aditheapy and hemtheapy with ispatin in inpeabe sqams e ainma f the head and nek: an TG stdy. ane 59(2): 259-265, 1987.
* Bahad J, David J, Bssin G, et a.: mbined pstpeative aditheapy and weeky ispatin infsin f ay advaned sqams e ainma f the head and nek: peiminay ept f a andmized tia. Intenatina Jna f adiatin ngy, Bigy, Physis 20(2): 243-246, 1991.
* Mean M, v , Magain G, et a.: mbined hemtheapy and adiatin theapy in advaned inpeabe sqams e ainma f the head and nek: the fina ept f a andmized tia. ane 67(4): 915-921, 1991.
* Mean M, Benass M, v , et a.: Five-yea pdate f a andmized tia f atenating aditheapy and hemtheapy mpaed with aditheapy ane in teatment f nesetabe sqams e ainma f the head and nek. Jna f the Natina ane Institte 88(9): 583-589, 1996.
* Pignn JP, Bhis J, et a., n behaf f the MAH-N abative Gp: hemtheapy added t egina teatment f head and nek sqams-e ainma: thee meta-anayses f pdated individa data. anet 355(9208): 949-955, 2000.
* Tay SG, Mthy AK, Vannetze JM, et a.: andmized mpaisn f neadjvant ispatin and fai infsin fwed by adiatin vess nmitant teatment in advaned head and nek ane. Jna f inia ngy 12(2): 385-395, 1994.
* A-Kainy K, Kish J, Ensey J, et a.: Ahievement f spei sviva f histgiay negative vess histgiay psitive iniay mpete espndes t ispatin mbinatin in patients with ay advaned head and nek ane. ane 59(2): 233-238, 1987.
* Head and Nek ntats Pgam: Adjvant hemtheapy f advaned head and nek sqams ainma: fina ept f the Head and Nek ntats Pgam. ane 60(3): 301-311, 1987.
* Thi J, Dnavage JA, Main T, et a.: The effets f deay in standad teatment de t indtin hemtheapy in tw andmized pspetive stdies. ayngspe 97(4): 407-412, 1987.
* Ensey J, issman J, Kish J, et a.: The impat f nventina mphgi anaysis n espnse ates and sviva in patients with advaned head and nek anes teated initiay with ispatin-ntaining mbinatin hemtheapy. ane 57(4): 711-717, 1986.
* F KK, Phiips T, Sivebeg IJ, et a.: mbined aditheapy and hemtheapy with bemyin and methtexate f advaned inpeabe head and nek ane: pdate f a Nthen aifnia ngy Gp andmized tia. Jna f inia ngy 5(9): 1410-1418, 1987.
* yan F, Kementz ET, Tesdae G: Savage f stage IV intaa sqams e ainmas with pepeative 5-fai. ane 57(4): 699-705, 1986.
* Evin TJ, ak J, Weihsebam , et a.: An anaysis f indtin and adjvant hemtheapy in the mtidisipinay teatment f sqams-e ainma f the head and nek. Jna f inia ngy 5(1): 10-20, 1987.
* Bwman GP, ipps , Hdsn DI, et a.: Paeb-nted andmized tia f infsina fai ding standad aditheapy in ay advaned head and nek ane. Jna f inia ngy 12(12): 2648-2653, 1994.
* Stshke M, Thames HD: Hypefatinated aditheapy f hman tms: veview f the andmized inia tias. Intenatina Jna f adiatin ngy, Bigy, Physis 37(2): 259-267, 1997.EENT IP AND A AVITY ANE
F esins f the ip, antei tnge, ba msa, f f mth, etma tigne, ppe gingiva, and had paate, teatment wi be ditated by the atin and size f the eent esin as we as pi teatment.[1,2]
Standad teatment ptins:
1. If adiatin theapy was sed initiay, sgey is the pefeed teatment.
2. If sgey was sed t teat the esin initiay, sgey, adiatin
theapy, a mbinatin f these may be nsideed.
3. Athgh hemtheapy has been shwn t inde espnses, n inease in
sviva has been demnstated.[3]
Teatment ptins nde inia evaatin:
Bease sgia savage afte pimay teatment by adiatin theapy and adiatin theapy afte pimay sgey give p ests, inia tias evaating new hemtheapy dgs, hemtheapy and e-iadiatin, hypethemia shd be nsideed.[4,5]
efeenes:
* Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* Vikam B, Stng EW, Shah JP, et a.: Intapeative aditheapy in patients with eent head and nek ane. Ameian Jna f Sgey 150(4): 485-487, 1985.
* Jabs , yman G, Veez-Gaia E, et a.: A phase III andmized stdy mpaing ispatin and fai as singe agents and in mbinatin f advaned sqams e ainma f the head and nek. Jna f inia ngy 10(2): 257-263, 1992.
* Hng WK, Bme : hemtheapy in head and nek ane. New Engand Jna f Mediine 308(2): 75-79, 1983.
* Vkes EE, Athanasiadis I: hemtheapy f sqams e ainma f head and nek: the fte is nw. Annas f ngy 7(1): 15-29, 1996.Date ast Mdified: 012002
This infmatin fm PDQ is eviewed egay by membes f the PDQ Editia Bads. If y have speifi mments n the ntent f this infmatin, diet them t: PDQ Editia Bad, IPSNI, 6116 Exetive Bevad, Site 3002B, MS-8321, 20892-8321, fax: 301-480-8105. * * The PDQ database as ntains istings f inia tia pts and dieties f ganizatins and physiians wh teat ane patients, bt this infmatin is nt avaiabe thgh aneMai. F me infmatin n aessing PDQ, nst the aneMai ntents ist.
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Infmatin fm PDQ -- f Heath Pfessinas
GENEA INFMATIN
Nte: Sepaate PDQ smmaies n Peventin f a ane and Seening f a ane ae as avaiabe.
The a avity extends fm the skin-vemiin jntins f the antei ips t the jntin f the had and sft paates abve and t the ine f imvaate papiae bew and is divided int the fwing speifi aeas: ip
antei 23 f tnge
ba msa
f f mth
we gingiva
etma tigne
ppe gingiva
had paate
The main tes f ymph nde dainage ae int the fist statin ndes (binat, jg-digasti, sbmandiba, and sbmenta). Sites se t the midine ften dain biateay. Send statin ndes inde the patid, jga, and the ppe and we pstei evia ndes.
Eay anes (stages I and II) f the ip and a avity ae highy abe by sgey by adiatin theapy, and the hie f teatment is ditated by the antiipated fntina and smeti ests f teatment and by the avaiabiity f the patia expetise eqied f the sgen adiatin theapist f the individa patient.[1-3] The pesene f a psitive magin a tm depth geate than 5 miimetes signifianty ineases the isk f a eene and sggests that mbined mdaity teatment may be benefiia.[4]
Advaned anes (stages III and IV) f the ip and a avity epesent a wide spetm f haenges f the sgen and adiatin theapist. Exept f patients with sma T3 esins and n egina ymph nde and n distant metastases wh have n ymph ndes age than 2 entimetes, f whm teatment by adiatin theapy ane sgey ane might be apppiate, mst patients with stage III IV tms ae andidates f teatment by a mbinatin f sgey and adiatin theapy.[2] Ftheme, bease a eene and distant metastases ae mmn in this gp f patients, they shd be nsideed f inia tias. Sh tias evaate the ptentia e f adiatin mdifies mbinatin hemtheapy mbined with sgey and adiatin theapy.
Patients with head and nek anes have an ineased hane f deveping a send pimay tm f the ppe aedigestive tat.[5,6] A stdy has shwn that daiy teatment f these patients with mdeate dses f istetinin (13-is-etini aid) f 1 yea an signifianty ede the inidene f send tms. N sviva advantage has yet been demnstated, hweve, in pat de t eene and death fm the pimay maignany. Additina tias ae nging.[7]
The ate f abiity f anes f the ip and a avity vaies depending n the stage and speifi site. Mst patients pesent with eay anes f the ip, whih ae highy abe by sgey by adiatin theapy with e ates f 90% t 100%. Sma anes f the etma tigne, had paate, and ppe gingiva ae highy abe by eithe adiatin theapy sgey, with sviva ates f p t 100%. a nt ates f p t 90% an be ahieved with eithe adiatin theapy sgey in sma anes f the antei tnge, the f f the mth, and ba msa.[8]
Mdeatey advaned and advaned anes f the ip as an be nted effetivey by sgey adiatin theapy a mbinatin f these. The hie f teatment is geneay ditated by the antiipated fntina and smeti ests f the teatment. Mdeatey advaned esins f the etma tigne witht evidene f spead t evia ymph ndes ae say abe, with a nt ates f p t 90%; sh esins f the had paate, ppe gingiva, and ba msa have a a nt ate f p t 80%. In the absene f inia evidene f spead t evia ymph ndes, mdeatey advaned esins f the f f the mth and antei tnge ae geneay abe, with sviva ates f p t 70% and 65% espetivey.[8,9]
efeenes:
* mmings W, Fediksn JM, Hake A, et a.: taynggy - Head and Nek Sgey. Saint is: Msby-Yea Bk, In., 1998.
* Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* Wang , Ed.: adiatin Theapy f Head and Nek Nepasms: Indiatins, Tehniqes and ests. ittetn, MA: Jhn Wight-PSG, In., 2nd ed., 1990.
* Jnes K, dge-iga D, eddik , et a.: Pgnsti fats in the eene f stage I and II sqams e ane f the a avity. Ahives f taynggy, Head and Nek Sgey 118(5): 483-485, 1992.
* Day G, Bt WJ: Send pimay tms in patients with a ane. ane 70(1): 14-19, 1992.
* van de T IG, de Visshe JG, Jvanvi A, et a.: isk f send pimay ane fwing teatment f sqams e ainma f the we ip. a ngy 35(6): 571-574, 1999.
* Hng WK, ippman SM, Iti M, et a.: Peventin f send pimay tms with istetinin in sqams-e ainma f the head and nek. New Engand Jna f Mediine 323(12): 795-801, 1990.
* Wane PE, Hanks GE, Kame S, et a.: Pattens f ae stdy: anaysis f tme svey data -- antei tw-thids f tnge and f f mth. Ameian Jna f inia ngy 9(1): 50-57, 1986.
* Takagi M, Kayan T, Yamamt H, et a.: ases f a tnge ane teatment faies: anaysis f atpsy ases. ane 69(5): 1081-1087, 1992.EA ASSIFIATIN
Mst head and nek anes ae f the sqams e vaiety and may be peeded by vais peanes esins. Min saivay gand tms ae nt nmmn in these sites. Speimens emved fm the esins may shw the ainmas t be nninvasive, in whih ase the tem "ainma-in-sit" is appied. An invasive ainma wi be eithe we-diffeentiated, mdeatey we-diffeentiated, py diffeentiated ndiffeentiated.
Tm gading is emmended sing Bde's assifiatin (Tm Gade (G)): G1: we-diffeentiated
G2: mdeatey we-diffeentiated
G3: py diffeentiated
G4: ndiffeentiated [1]
N statistiay signifiant eatin between degee f diffeentiatin and the bigi behavi f the ane exists. Hweve, vasa invasin is a negative pgnsti fat.[2]
the tms f ganda epitheim, dntgeni appaats, ymphid tisse, sft tisse, and bne and atiage igin eqie speia nsideatin and ae nt inded in this setin f PDQ. efeene t the Wd Heath ganizatin nmenate is emmended.
The tem "ekpakia" shd be sed ny as a iniay desiptive tem meaning that the bseve sees a white path that des nt b ff, the signifiane f whih depends n the histgi findings. ekpakia an ange fm hypekeatsis t an ata eay invasive ainma may ny epesent a fnga infetin, ihen pans, the benign a disease.
efeenes:
* Bansbeg SF, sen KD, Gaffey TA: High-gade ainma f the a avity. taynggy and Head and Nek Sgey 100(1): 41-48, 1989.
* se G, Bwn PM, Vith MF, et a: Mivasa invasin and sviva in ane f the a avity and phaynx. Ahives f taynggy, Head and Nek Sgey 115(11): 1304-1309, 1989.STAGE INFMATIN
The staging systems ae a inia staging, based n the best pssibe estimate f the extent f disease befe teatment. The assessment f the pimay tm is based n inspetin and papatin when pssibe and by bth indiet mi examinatin and diet endspy when neessay. The tm mst be nfimed histgiay, and any the pathgi data btained n bipsy may be inded. The apppiate nda dainage aeas ae examined by aef papatin. Infmatin fm diagnsti imaging stdies may be sed in staging. Magneti esnane imaging ffes an advantage ve mpted tmgaphi sans in the detetin and aizatin f head and nek tms and in the distintin f ymph ndes fm bd vesses.[1] If a patient eapses, mpete estaging mst be dne t seet the apppiate additina theapy.[2,3]
The Ameian Jint mmittee n ane (AJ) has designated staging by TNM assifiatin.[4]
TNM definitins
Pimay tm (T)
TX: Pimay tm annt be assessed
T0: N evidene f pimay tm
Tis: ainma in sit
T1: Tm 2 m ess in geatest dimensin
T2: Tm me than 2 m bt nt me than 4 m in geatest dimensin
T3: Tm me than 4 m in geatest dimensin
T4: (ip) Tm invades adjaent sttes (e.g., thgh tia bne, infei avea neve, f f mth, skin f fae)
(a avity) Tm invades adjaent sttes (e.g., thgh tia bne, int deep (extinsi) mses f tnge, maxiay sins, skin. Spefiia esin ane f bnetth sket by gingiva pimay is nt sffiient t assify as T4)
egina ymph ndes (N)
NX: egina ymph ndes annt be assessed
N0: N egina ymph nde metastasis
N1: Metastasis in a singe ipsiatea ymph nde, 3 m ess in geatest dimensin
N2: Metastasis in a singe ipsiatea ymph nde, me than 3 m bt nt me than 6 m in geatest dimensin; in mtipe ipsiatea ymph ndes, nne me than 6 m in geatest dimensin; in biatea ntaatea ymph ndes, nne me than 6 m in geatest dimensin
N2a: Metastasis in a singe ipsiatea ymph nde me than 3 m bt nt me than 6 m in dimensin
N2b: Metastasis in mtipe ipsiatea ymph ndes, nne me than 6 m in geatest dimensin
N2: Metastasis in biatea ntaatea ymph ndes, nne me than 6 m in geatest dimensin
N3: Metastasis in a ymph nde me than 6 m in geatest dimensin
In inia evaatin, the ata size f the nda mass shd be meased and awane shd be made f intevening sft tisses. Mst masses age than 3 entimetes in diamete ae nt singe ndes bt ae nfent ndes tms in sft tisses f the nek. Thee ae 3 stages f iniay psitive ndes: N1, N2, and N3. The se f sbgps a, b, and is nt eqied bt emmended. Midine ndes ae nsideed hmatea ndes.
Distant metastasis (M)
MX: Pesene f distant metastasis annt be assessed
M0: N distant metastasis
M1: Distant metastasis
AJ stage gpings
Stage 0
Tis, N0, M0
Stage I
T1, N0, M0
Stage II
T2, N0, M0
Stage III
T3, N0, M0
T1, N1, M0
T2, N1, M0
T3, N1, M0
Stage IVA
T4, N0, M0
T4, N1, M0
Any T, N2, M0
Stage IVB
Any T, N3, M0
Stage IV
Any T, Any N, M1
efeenes:
* nsenss nfeene. Magneti esnane imaging. JAMA: Jna f the Ameian Media Assiatin 259(14): 2132-2138, 1988.
* <A name=EF.3.2>Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* Wang , Ed.: adiatin Theapy f Head and Nek Nepasms: Indiatins, Tehniqes and ests. ittetn, MA: Jhn Wight-PSG, In., 2nd ed., 1990.
* ip and a avity. In: Ameian Jint mmittee n ane: AJ ane Staging Mana. Phiadephia, Pa: ippintt-aven Pbishes, 5th ed., 1997, pp 24-30.TEATMENT PTIN VEVIEW
Depending n the site and extent f the pimay tm and the stats f the ymph ndes, the teatment f ip and a avity ane may be by sgey ane, adiatin theapy ane, a mbinatin f these. Sme genea nsideatins ae as fws.[1-5]
F esins f the a avity, sgey mst adeqatey enmpass a f the gss as we as the pesmed mispi extent f the disease. If egina ndes ae psitive, evia nde dissetin is say dne in ntinity. With mden appahes, the sgen an sessfy abate age pstei a avity tms and with ensttive methds an ahieve satisfaty fntina ests. Psthdnti ehabiitatin is imptant, patiay in eay-stage anes, t asse the best qaity f ife.
adiatin theapy f ip and a avity anes an be by extena-beam theapy intestitia impantatin ane, bt f many sites the se f bth mdaities pdes bette nt and fntina ests. Sma spefiia anes an be vey sessfy teated by a impantatin sing any ne f sevea adiative ses, by intaa ne adiatin theapy, by eetns. age esins ae feqenty managed sing extena-beam adiatin theapy t inde the pimay site and egina ymph ndes even if they ae nt iniay invved. Sppementatin with intestitia adiatin ses may be neessay t ahieve adeqate dses t age pimay tms and bky nda metastases. A eview f pbished inia ests f adia adiatin theapy f head and nek ane sggests a signifiant ss f a nt when the administatin f adiatin theapy was pnged; theefe, engthening f standad teatment shedes shd be avided wheneve pssibe.[6]
Eay anes (stages I and II) f the ip, f f mth, and etma tigne ae highy abe by sgey adiatin theapy. The hie f teatment is ditated by the antiipated fntina and smeti ests and by the avaiabiity f the patia expetise eqied f the sgen adiatin theapist f the individa patient. Advaned anes (stages III and IV) f the ip, f f mth, and etma tigne epesent a wide spetm f haenges f the sgen and adiatin theapists. Exept f patients with sma T3 esins and n egina ymph nde and n distant metastases wh have n ymph ndes age than 2 entimetes, f whm teatment by adiatin theapy ane sgey ane might be apppiate, mst patients with stage III IV tms ae andidates f teatment by a mbinatin f sgey and adiatin theapy. Ftheme, bease a eene and distant metastases ae mmn in this gp f patients, they shd be nsideed f inia tias evaating the fwing: the ptentia e f adiatin mdifies t impve a nt deease mbidity f mbinatins f hemtheapy with sgey and adiatin theapy bth t impve a nt and t deease the feqeny f distant metastases.
Eay anes f the ba msa ae eqay abe by adiatin theapy by adeqate exisin. Patient fats and a expetise infene the hie f teatment. age anes eqie mpsite esetin with ensttin f the defet by pedie faps.
Eay esins (T1 and T2) f the antei tnge may be managed by sgey by adiatin theapy ane. Bth mdaities pde 70% t 85% e ates in eay esins. Mdeate exisins f tnge, even hemigssetmy, an ften est in spisingy itte speeh disabiity pvided the wnd se is sh that the tnge is nt bnd dwn. If, hweve, the esetin is me extensive, pbems may inde aspiatin f iqids and sids and diffity in swawing in additin t speeh diffities. asinay, patients with tm f the tnge eqie amst tta gssetmy. age esins geneay eqie mbined sgia and adiatin teatment. The nt ates f age esins ae abt 30% t 40%. Ading t inia and adigia evidene f invvement, anes f the we gingiva that ae exphyti and amenabe t adeqate a exisin may be exised t inde ptins f bne. Me advaned esins eqie segmenta bne esetin, hemimandibetmy, maxietmy, depending n the extent f the esin and its atin.
Eay esins f the ppe gingiva had paate witht bne invvement an be teated with eqa effetiveness by sgey by adiatin theapy ane. Advaned infitative and eating esins shd be teated by a mbinatin f adiatin theapy and sgey. Mst pimay anes f the had paate ae f min saivay gand igin. Pimay sqams e ainma f the had paate is nmmn, and these tms geneay epesent invasin f sqams e ainma aising n the ppe gingiva, whih is mh me mmn. Ths, management f sqams e ainma f the ppe gingiva and had paate ae say nsideed tgethe. Sgia teatment f ane f the had paate say eqies exisin f ndeying bne pding an pening int the antm. This defet an be fied and veed with a denta psthesis, a maneve that estes satisfaty swawing and speeh.
Patients wh smke whie n adiatin theapy appea t have we espnse ates and shte sviva datins than thse wh d nt;[7] theefe, patients shd be nseed t stp smking befe beginning adiatin theapy. Denta stats evaatin shd be pefmed pi t theapy t pevent ate seqeae.
The designatins in PDQ that teatments ae "standad" "nde inia evaatin" ae nt t be sed as a basis f eimbsement deteminatins.
efeenes:
* Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* Wang , Ed.: adiatin Theapy f Head and Nek Nepasms: Indiatins, Tehniqes and ests. ittetn, MA: Jhn Wight-PSG, In., 2nd ed., 1990.
* Sen JY, Myes EN: ane f the Head and Nek. New Yk: hhi ivingstne, 1981.
* Fend H: Pinipes f Head and Nek Sgey. New Yk: Appetn-enty-fts, 2nd ed., 1979.
* e JM, Wabnitz , Eds.: An Atas f Head and Nek Sgey. Phiadephia: W.B. Sandes mpany, 3d ed., 1988.
* Fwe JF, indstm MJ: ss f a nt with pngatin in aditheapy. Intenatina Jna f adiatin ngy, Bigy, Physis 23(2): 457-467, 1992.
* Bwman GP, Wng G, Hdsn I, et a.: Infene f igaette smking n the effiay f adiatin theapy in head and nek ane. New Engand Jna f Mediine 328(3): 159-163, 1993.STAGE I IP AND A AVITY ANE
Sgey and adiatin theapy may be sed, depending n the exat site.[1,2]
Sma esins f the ip
Standad teatment ptins:
Sgey and adiatin theapy pde simia e ates, and the methd f teatment is ditated by the antiipated smeti and fntina ests.
Sma antei tnge esins
Standad teatment ptins:
1. Wide a exisin is pefeed f sma esins that an be eseted
tansay.
2. F age T1 esins, eithe sgey adiatin theapy is an aeptabe
teatment. Intestitia impantatin ane with extena-beam adiatin theapy shd be nsideed. nsideatin shd be given t iadiating the nek.
Sma esins f the ba msa
Standad teatment ptins:
1. esins ess than 1 entimete in diamete may be managed by sgey ane
if the mmisse is nt invved. If the mmisse is invved, adiatin theapy (inding bahytheapy) shd be nsideed.
2. age T1 esins may be teated by sgia exisin with spit thikness
skin gaft adiatin theapy.
Sma esins f the f f mth
Standad teatment ptins:
1. Sgey and adiatin theapy pde simia e ates f T1 esins.
2. In genea f esins ess than 0.5 entimetes, exisin ane is adeqate
if thee is a magin f nma msa between the esin and the gingiva.
3. F age esins, sgey is pefeed if the esin is attahed t the
peistem, wheeas adiatin theapy is pefeed if the esin enahes n the tnge.
Sma esins f the we gingiva
Standad teatment ptins:
1. Sma esins may be teated by intaa esetin with witht a im
esetin f bne and epaied with a spit thikness skin gaft.
2. adiatin theapy may be sed f sma esins bt ests ae geneay
bette afte sgey ane.
Sma tms f the etma tigne
Standad teatment ptins:
1. F eay esins witht detetabe bne invasin, imited esetin f the
mandibe is pefmed.
2. If imited esetin is nt feasibe, adiatin theapy may be sed
initiay with sgey eseved f adiatin faie.
Sma esins f the ppe gingiva and had paate
Standad teatment ptins:
1. Mst sma esins ae teated by sgia esetin.
2. Pstpeative adiatin theapy may be sed if apppiate.
efeenes:
* Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* Gey T, Siveman S, Ded HH: abn dixide ase esetin f spefiia a ainma: indiatins, tehniqe, and ests. Annas f tgy, hingy, and aynggy 95(6, Pat 1): 547-555, 1986.STAGE II IP AND A AVITY ANE
Sgey and adiatin theapy may be sed, depending n the exat site.[1]
Sma esins f the ip
Standad teatment ptins:
1. Sgey is sed f smae T2 esins n the we ip if simpe se
pdes an aeptabe smeti est.
2. If a ensttive sgia pede is eqied, adiatin theapy has
the advantage f pding a eativey bette fntina and smeti est with intat skin and mse innevatin.
3. adiatin theapy may inde extena-beam and intestitia tehniqes
as apppiate.
Sma antei tnge esins
Standad teatment ptins:
1. adiatin theapy is say seeted f T2 esins that have minima
infitatin t peseve speeh and swawing. Sgey is eseved f patients f whm adiatin teatment faied. Nek dissetin may be nsideed when pimay bahytheapy is sed.[2]
2. Deepy infitative esins ae best teated by sgey, adiatin theapy,
a mbinatin f bth.
Sma esins f the ba msa
Standad teatment ptins:
1. Sma T2 esins (<= 3 entimetes) ae say teated by adiatin
theapy.
2. age T2 esins (> 3 entimetes) may be teated by sgey, adiatin
theapy, a mbinatin f these, if indiated. adiatin theapy is pefeed if the esin invves the mmisse. Sgey is pefeed if tm invades the mandibe maxia.
Sma esins f the f f mth
Standad teatment ptins:
1. F sma T2 esins (<= 3 entimetes), sgey is pefeed if the esin
is attahed t the peistem, wheeas adiatin theapy is pefeed if the esin enahes n the tnge.
2. F age T2 esins (> 3 entimetes), sgey and adiatin theapy ae
atenative methds f teatment, the hie f whih depends pimaiy n the expeted extent f disabiity fm sgey.
3. Extena-beam with witht intestitia adiatin theapy shd be
nsideed pstpeativey f age esins.
Sma esins f the we gingiva
Standad teatment ptins:
1. Sma esins may be teated by intaa esetin with witht a im
esetin f bne and epaied with a spit thikness skin gaft.
2. adiatin theapy may be sed f sma esins bt ests ae geneay
bette afte sgey ane.
Sma tms f the etma tigne
Standad teatment ptins:
1. F eay esins witht detetabe bne invasin, imited esetin f the
mandibe is pefmed.
2. If imited esetin is nt feasibe, adiatin theapy may be sed
initiay with sgey eseved f adiatin faie.
Sma esins f the ppe gingiva and had paate
Standad teatment ptins:
Mst esins ae teated by sgia esetin with pstpeative adiatin theapy as apppiate.
efeenes:
* Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* Pent M, Maissad , Aetti P, et a.: Iidim-192 bahytheapy in the management f 147 T2N a tnge ainmas teated with iadiatin ane: mpaisn f tw teatment tehniqes. aditheapy and ngy 23(4): 223-228, 1992.STAGE III IP AND A AVITY ANE
Sgey and adiatin theapy ae sed, depending n the exat tm site.[1,2] Neadjvant hemtheapy, as given in inia tias, has been sed t shink tms and theeby ende them me definitivey teatabe with eithe sgey adiatin. Neadjvant hemtheapy is given pi t the the mdaities, as ppsed t standad adjvant hemtheapy, whih is given afte ding definitive theapy with adiatin afte sgey. Many dg mbinatins have been sed as neadjvant hemtheapy.[3-6] Hweve, andmized, pspetive tias have yet t demnstate a benefit in eithe disease-fee vea sviva f patients eeiving neadjvant hemtheapy.[7]
Advaned esins f the ip
These esins, inding thse invving bne, neves, and ymph ndes, geneay eqie a mbinatin f sgey and adiatin theapy. Sh patients ae apppiate andidates f inia tias.
Standad teatment ptins:
1. Sgey: a vaiety f sgia appahes an be sed depending n the size
and atin f the esin and the needs f ensttin.
2. adiatin theapy: a vaiety f adiatin theapy tehniqes an be sed as
ditated by the size and atin f the esin. ptins inde extena-beam iadiatin with witht bahytheapy.
Teatment ptins nde inia evaatin:
1. inia tias f advaned tms evaating the se f hemtheapy
pepeativey, befe adiatin theapy, as adjvant theapy afte sgey, as pat f mbined mdaity theapy ae apppiate.[3-6,8-10]
2. Spefatinated adiatin theapy [11]
Mdeatey advaned (ate T2, sma T3) esins f the antei tnge
Standad teatment ptins:
1. Minimay infitative esins: extena-beam adiatin theapy with
witht intestitia impant.
2. Deepy infitative esins: sgey with pstpeative adiatin
theapy.[2]
Advaned esins f the ba msa
Standad teatment ptins:
1. adia sgia esetin ane.
2. adiatin theapy ane.
3. Sgia esetin + adiatin theapy, geneay pstpeative.
Teatment ptins nde inia evaatin:
inia tias f advaned tms evaating the se f hemtheapy pepeativey, befe adiatin theapy, as adjvant theapy afte sgey, as pat f mbined mdaity theapy ae apppiate.[3-6,8-10]
Mdeatey advaned esins f the f f mth
Standad teatment ptins:
1. Sgey: im esetin ps nek dissetin patia mandibetmy with
nek dissetin as apppiate.
2. adiatin theapy: extena-beam adiatin theapy ane extena-beam
adiatin theapy ps an intestitia impant.
Teatment ptins nde inia evaatin:
1. inia tias f advaned tms evaating the se f hemtheapy
pepeativey, befe adiatin theapy, as adjvant theapy afte sgey, as pat f mbined mdaity theapy ae apppiate.[3-6,8-10]
2. inia tias sing nve adiatin theapy fatinatin shemas.[12]
Mdeatey advaned esins f the we gingiva
Standad teatment ptins:
Extensive esins with mdeate bne desttin and nda metastases shd be teated by mbined adiatin theapy and adia esetin by adia esetin ane. adiatin theapy may be eithe pepeative pstpeative.
Advaned esins f the etma tigne
Standad teatment ptins:
Sgia mpsite esetin that may be fwed by pstpeative adiatin theapy.
Teatment ptins nde inia evaatin:
1. inia tias f advaned tms evaating the se f hemtheapy
pepeativey, befe adiatin theapy, as adjvant theapy afte sgey, as pat f mbined mdaity theapy ae apppiate.[3-6,8-10]
2. inia tias sing nve adiatin theapy fatinatin shemas.[12]
Mdeatey advaned esins f the ppe gingiva
Standad teatment ptins:
1. Spefiia esins with extensive invvement f the gingiva, had paate,
sft paate may be teated by adiatin theapy ane.
2. Deepy invasive esins invving bne shd be teated by a mbinatin f
sgey and adiatin theapy.
Mdeatey advaned esins f the had paate
Standad teatment ptins:
1. Spefiia esins with extensive invvement f the gingiva, had paate,
sft paate may be teated by adiatin theapy ane.
2. Deepy invasive esins invving bne shd be teated by a mbinatin f
sgey and adiatin theapy by sgey ane.
Teatment ptins f management f ymph ndes:[1] Patients with advaned esins shd have eetive ymph nde adiatin theapy nde dissetin. The isk f metastases t ymph ndes is ineased by high-gade histgy, age esins, spead t invve the wet msa f the ip the ba msa in patients with eent disease, and invasin f mse (biais is).
Standad teatment ptins:
1. adiatin theapy ane nek dissetin:
N1 (0-2 entimetes)
N2b N3; a ndes ess than 2 entimetes. (A mbined sgia and adiatin theapy appah shd as be nsideed.)
2. adiatin theapy and nek dissetin:
N1 (2-3 entimetes), N2a, N3
3. Sgey fwed by adiatin theapy, indiatins f whih ae as fws:
mtipe psitive ndes
ntaatea sbinia metastases
invasin f tm thgh the apse f the ymph nde
N2b N3 (ne me ndes in eah nek, as apppiate, > 2 entimetes)
4. adiatin theapy pi t sgey:
age fixed ndes
Teatment ptins nde inia evaatin (a stage III esins):
1. hemtheapy has been mbined with adiatin theapy in patients wh have
ay advaned disease that is sgiay nesetabe.[8,10,13,14]
A meta-anaysis f 63 andmized pspetive tias pbished between 1965 and 1993 shwed an 8% abste sviva advantage in the sbset f patients eeiving nmitant hemtheapy and adiatin theapy.[15][eve f evidene: 2A] Patients eeiving adjvant neadjvant hemtheapy had n sviva advantage. Hweve, st, qaity f ife, and mbidity data wee nt avaiabe; thee was n standad egimen; and the tias wee fet t be t hetegens t pvide definitive emmendatins. The ests f 18 nging tias may fthe aify the e f nmitant hemtheapy and adiatin theapy in the management f a avity ane.
The best hemtheapy t se and the apppiate way t integate the 2 mdaities is sti nesved.[16]
Simia appahes in the patient with esetabe disease, whee esetin wd ead t a maj fntina defiit, ae as being exped in andmized tias bt annt be emmended at this time as standad.
Nve fatinatin adiatin theapy inia tias ae nde inia evaatin.[12]
efeenes:
* Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* Faneshi D, Gpta , Spi H, et a.: Impved sviva in the teatment f sqams ainma f the a tnge. Ameian Jna f Sgey 166(4): 360-365, 1993.
* Evin TJ, ak J, Weihsebam , et a.: An anaysis f indtin and adjvant hemtheapy in the mtidisipinay teatment f sqams-e ainma f the head and nek. Jna f inia ngy 5(1): 10-20, 1987.
* A-Kainy K, Kish J, Ensey J, et a.: Ahievement f spei sviva f histgiay negative vess histgiay psitive iniay mpete espndes t ispatin mbinatin in patients with ay advaned head and nek ane. ane 59(2): 233-238, 1987.
* Head and Nek ntats Pgam: Adjvant hemtheapy f advaned head and nek sqams ainma: fina ept f the Head and Nek ntats Pgam. ane 60(3): 301-311, 1987.
* Ensey J, issman J, Kish J, et a.: The impat f nventina mphgi anaysis n espnse ates and sviva in patients with advaned head and nek anes teated initiay with ispatin-ntaining mbinatin hemtheapy. ane 57(4): 711-717, 1986.
* Mazen JJ, Matin M, Bn B, et a.: Indtin hemtheapy in head and nek ane: ests f a phase III tia. Head and Nek 14(2): 85-91, 1992.
* A-Saaf M, Pajak TF, Maia VA, et a.: nent aditheapy and hemtheapy with ispatin in inpeabe sqams e ainma f the head and nek: an TG stdy. ane 59(2): 259-265, 1987.
* Bwman GP, ipps , Hdsn DI, et a.: Paeb-nted andmized tia f infsina fai ding standad aditheapy in ay advaned head and nek ane. Jna f inia ngy 12(12): 2648-2653, 1994.
* Mean M, Benass M, v , et a.: Five-yea pdate f a andmized tia f atenating aditheapy and hemtheapy mpaed with aditheapy ane in teatment f nesetabe sqams e ainma f the head and nek. Jna f the Natina ane Institte 88(9): 583-589, 1996.
* Jhnsn , Khandewa S, Shmidt-ih K, et a.: The infene f qantitative tm vme measements n a nt in advaned head and nek ane sing nmitant bst aeeated spefatinated iadiatin. Intenatina Jna f adiatin ngy, Bigy, Physis 32(3): 635-641, 1995.
* Stshke M, Thames HD: Hypefatinated aditheapy f hman tms: veview f the andmized inia tias. Intenatina Jna f adiatin ngy, Bigy, Physis 37(2): 259-267, 1997.
* Bahad J, David J, Bssin G, et a.: mbined pstpeative aditheapy and weeky ispatin infsin f ay advaned sqams e ainma f the head and nek: peiminay ept f a andmized tia. Intenatina Jna f adiatin ngy, Bigy, Physis 20(2): 243-246, 1991.
* Mean M, v , Magain G, et a.: mbined hemtheapy and adiatin theapy in advaned inpeabe sqams e ainma f the head and nek: the fina ept f a andmized tia. ane 67(4): 915-921, 1991.
* Pignn JP, Bhis J, et a., n behaf f the MAH-N abative Gp: hemtheapy added t egina teatment f head and nek sqams-e ainma: thee meta-anayses f pdated individa data. anet 355(9208): 949-955, 2000.
* Tay SG, Mthy AK, Vannetze JM, et a.: andmized mpaisn f neadjvant ispatin and fai infsin fwed by adiatin vess nmitant teatment in advaned head and nek ane. Jna f inia ngy 12(2): 385-395, 1994.STAGE IV IP AND A AVITY ANE
andmized, pspetive tias have yet t demnstate a benefit in eithe disease-fee vea sviva f patients eeiving neadjvant hemtheapy.[1] The se f istetinin (13-is-etini aid) daiy f 1 yea t pevent devepment f send ppe aedigestive tat pimaies is nde inia evaatin.[2]
Advaned esins f the ip
These esins, inding thse invving bne, neves, and ymph ndes, geneay eqie a mbinatin f sgey and adiatin theapy. Sh patients ae apppiate andidates f inia tias.
Standad teatment ptins f pimay tms:
1. Sgey: a vaiety f sgia appahes an be sed depending n the size
and atin f the esin and the need f ensttin. Teatment f bth sides f the nek is indiated f seeted patients.
2. adiatin theapy: a vaiety f adiatin theapy tehniqes an be sed as
ditated by the size and atin f the esin. ptins inde extena-beam iadiatin with witht bahytheapy.
Teatment ptins nde inia evaatin:
Spefatinated adiatin theapy [3]
Advaned esins f the antei tnge
Standad teatment ptins:
1. Seeted patients: mbined sgey (tta gssetmy, smetimes eqiing
ayngetmy) that may be mbined with pstpeative adiatin theapy.[4]
2. Patients with vey advaned esins: paiative adiatin theapy.
Advaned esins f the ba msa
Standad teatment ptins:
1. adia sgia esetin ane.
2. adiatin theapy ane.
3. Sgia esetin + adiatin theapy, geneay pstpeative.
Advaned esins f the f f mth
Standad teatment ptins:
1. A mbinatin f sgey and adiatin theapy, geneay pstpeative, is
pefeed.
2. F fixed ndes (eqa t >5 entimetes) pepeative adiatin theapy
is pefeed.
Advaned esins f the we gingiva
Standad teatment ptins:
Fa-advaned tms with extensive desttin f the mandibe and with nda metastases ae py nted by sgey, adiatin theapy, a mbinatin f bth.
Advaned esins f the etma tigne
Standad teatment ptins:
Sgia mpsite esetin fwed by pstpeative adiatin theapy.
Advaned esins f the ppe gingiva
Standad teatment ptins:
esins that ae extensive and infitating geneay eqie teatment by sgey in mbinatin with adiatin theapy.
Advaned esins f the had paate
Standad teatment ptins:
esins that ae extensive and infitating geneay eqie teatment by sgey in mbinatin with adiatin theapy.
Teatment ptins f management f ymph ndes:[5] Patients with advaned esins shd have eetive ymph nde adiatin theapy nde dissetin. The isk f metastases t ymph ndes is ineased by high-gade histgy, age esins, spead invving the wet msa f the ip the ba msa in patients with eent disease, and invasin f mse (biais is).
Standad teatment ptins:
1. adiatin theapy ane nek dissetin:
N1 (0-2 entimetes)
N2b N3; a ndes ess than 2 entimetes. (A mbined sgia and
adiatin theapy appah shd as be nsideed.)
2. adiatin theapy and nek dissetin:
N1 (2-3 entimetes), N2a, N3
3. Sgey fwed by adiatin theapy is indiated f the fwing:
mtipe psitive ndes
ntaatea sbinia metastases
invasin f tm thgh the apse f the ymph nde
N2b N3 (ne me ndes in eah nek, as apppiate, geate than 2 entimetes)
4. adiatin theapy pi t sgey:
age fixed ndes
Teatment ptins nde inia evaatin (a stage IV esins):
1. hemtheapy has been mbined with adiatin theapy in patients wh
have ay advaned disease that is sgiay nesetabe.[6-9]
A meta-anaysis f 63 andmized pspetive tias pbished between 1965 and 1993 shwed an 8% abste sviva advantage in the sbset f patients eeiving nmitant hemtheapy and adiatin theapy.[10][eve f evidene: 2A] Patients eeiving adjvant neadjvant hemtheapy had n sviva advantage. Hweve, st, qaity f ife, and mbidity data wee nt avaiabe; thee was n standad egimen; and the tias wee fet t be t hetegens t pvide definitive emmendatins. The ests f 18 nging tias may fthe aify the e f nmitant hemtheapy and adiatin theapy in the management f a avity ane.
The best hemtheapy t se and the apppiate way t integate the 2 mdaities is sti nesved.[11]
Simia appahes in the patient with esetabe disease, whee esetin wd ead t a maj fntina defiit, ae as being exped in andmized tias bt annt be emmended at this time as standad.
2. inia tias f advaned tms evaating the se f hemtheapy
pepeativey, befe adiatin theapy, as adjvant theapy afte sgey ae apppiate.[6,12-19]
3. Nve fatinatin adiatin theapy inia tias ae nde inia
evaatin.[20]
efeenes:
* Mazen JJ, Matin M, Bn B, et a.: Indtin hemtheapy in head and nek ane: ests f a phase III tia. Head and Nek 14(2): 85-91, 1992.
* Hng WK, ippman SM, Iti M, et a.: Peventin f send pimay tms with istetinin in sqams-e ainma f the head and nek. New Engand Jna f Mediine 323(12): 795-801, 1990.
* Jhnsn , Khandewa S, Shmidt-ih K, et a.: The infene f qantitative tm vme measements n a nt in advaned head and nek ane sing nmitant bst aeeated spefatinated iadiatin. Intenatina Jna f adiatin ngy, Bigy, Physis 32(3): 635-641, 1995.
* Faneshi D, Gpta , Spi H, et a.: Impved sviva in the teatment f sqams ainma f the a tnge. Ameian Jna f Sgey 166(4): 360-365, 1993.
* Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* A-Saaf M, Pajak TF, Maia VA, et a.: nent aditheapy and hemtheapy with ispatin in inpeabe sqams e ainma f the head and nek: an TG stdy. ane 59(2): 259-265, 1987.
* Bahad J, David J, Bssin G, et a.: mbined pstpeative aditheapy and weeky ispatin infsin f ay advaned sqams e ainma f the head and nek: peiminay ept f a andmized tia. Intenatina Jna f adiatin ngy, Bigy, Physis 20(2): 243-246, 1991.
* Mean M, v , Magain G, et a.: mbined hemtheapy and adiatin theapy in advaned inpeabe sqams e ainma f the head and nek: the fina ept f a andmized tia. ane 67(4): 915-921, 1991.
* Mean M, Benass M, v , et a.: Five-yea pdate f a andmized tia f atenating aditheapy and hemtheapy mpaed with aditheapy ane in teatment f nesetabe sqams e ainma f the head and nek. Jna f the Natina ane Institte 88(9): 583-589, 1996.
* Pignn JP, Bhis J, et a., n behaf f the MAH-N abative Gp: hemtheapy added t egina teatment f head and nek sqams-e ainma: thee meta-anayses f pdated individa data. anet 355(9208): 949-955, 2000.
* Tay SG, Mthy AK, Vannetze JM, et a.: andmized mpaisn f neadjvant ispatin and fai infsin fwed by adiatin vess nmitant teatment in advaned head and nek ane. Jna f inia ngy 12(2): 385-395, 1994.
* A-Kainy K, Kish J, Ensey J, et a.: Ahievement f spei sviva f histgiay negative vess histgiay psitive iniay mpete espndes t ispatin mbinatin in patients with ay advaned head and nek ane. ane 59(2): 233-238, 1987.
* Head and Nek ntats Pgam: Adjvant hemtheapy f advaned head and nek sqams ainma: fina ept f the Head and Nek ntats Pgam. ane 60(3): 301-311, 1987.
* Thi J, Dnavage JA, Main T, et a.: The effets f deay in standad teatment de t indtin hemtheapy in tw andmized pspetive stdies. ayngspe 97(4): 407-412, 1987.
* Ensey J, issman J, Kish J, et a.: The impat f nventina mphgi anaysis n espnse ates and sviva in patients with advaned head and nek anes teated initiay with ispatin-ntaining mbinatin hemtheapy. ane 57(4): 711-717, 1986.
* F KK, Phiips T, Sivebeg IJ, et a.: mbined aditheapy and hemtheapy with bemyin and methtexate f advaned inpeabe head and nek ane: pdate f a Nthen aifnia ngy Gp andmized tia. Jna f inia ngy 5(9): 1410-1418, 1987.
* yan F, Kementz ET, Tesdae G: Savage f stage IV intaa sqams e ainmas with pepeative 5-fai. ane 57(4): 699-705, 1986.
* Evin TJ, ak J, Weihsebam , et a.: An anaysis f indtin and adjvant hemtheapy in the mtidisipinay teatment f sqams-e ainma f the head and nek. Jna f inia ngy 5(1): 10-20, 1987.
* Bwman GP, ipps , Hdsn DI, et a.: Paeb-nted andmized tia f infsina fai ding standad aditheapy in ay advaned head and nek ane. Jna f inia ngy 12(12): 2648-2653, 1994.
* Stshke M, Thames HD: Hypefatinated aditheapy f hman tms: veview f the andmized inia tias. Intenatina Jna f adiatin ngy, Bigy, Physis 37(2): 259-267, 1997.EENT IP AND A AVITY ANE
F esins f the ip, antei tnge, ba msa, f f mth, etma tigne, ppe gingiva, and had paate, teatment wi be ditated by the atin and size f the eent esin as we as pi teatment.[1,2]
Standad teatment ptins:
1. If adiatin theapy was sed initiay, sgey is the pefeed teatment.
2. If sgey was sed t teat the esin initiay, sgey, adiatin
theapy, a mbinatin f these may be nsideed.
3. Athgh hemtheapy has been shwn t inde espnses, n inease in
sviva has been demnstated.[3]
Teatment ptins nde inia evaatin:
Bease sgia savage afte pimay teatment by adiatin theapy and adiatin theapy afte pimay sgey give p ests, inia tias evaating new hemtheapy dgs, hemtheapy and e-iadiatin, hypethemia shd be nsideed.[4,5]
efeenes:
* Hais B, Sessins B, Hng WK, Eds.: Head and Nek ane: A Mtidisipinay Appah. Phiadephia: ippintt-aven, 1998.
* Vikam B, Stng EW, Shah JP, et a.: Intapeative aditheapy in patients with eent head and nek ane. Ameian Jna f Sgey 150(4): 485-487, 1985.
* Jabs , yman G, Veez-Gaia E, et a.: A phase III andmized stdy mpaing ispatin and fai as singe agents and in mbinatin f advaned sqams e ainma f the head and nek. Jna f inia ngy 10(2): 257-263, 1992.
* Hng WK, Bme : hemtheapy in head and nek ane. New Engand Jna f Mediine 308(2): 75-79, 1983.
* Vkes EE, Athanasiadis I: hemtheapy f sqams e ainma f head and nek: the fte is nw. Annas f ngy 7(1): 15-29, 1996.Date ast Mdified: 012002
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