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  Table of Contents  
COMMENTARY
Year : 2011  |  Volume : 48  |  Issue : 3  |  Page : 279-281
 

Uncommon versus taken for granted: Both need to be addressed


1 Department of Medical Oncology, AMRI, Kolkata, India
2 Chittaranjan National Cancer Institute, Kolkata, India
3 Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, India
4 Department of Medical Oncology, Sahyadri Hospital, Pune, India

Date of Web Publication14-Sep-2011

Correspondence Address:
G S Bhattacharyya
Department of Medical Oncology, AMRI, Kolkata
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.84909

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How to cite this article:
Bhattacharyya G S, Biswas J, Govindbabu K, Ranade A A. Uncommon versus taken for granted: Both need to be addressed. Indian J Cancer 2011;48:279-81

How to cite this URL:
Bhattacharyya G S, Biswas J, Govindbabu K, Ranade A A. Uncommon versus taken for granted: Both need to be addressed. Indian J Cancer [serial online] 2011 [cited 2019 Dec 12];48:279-81. Available from: http://www.indianjcancer.com/text.asp?2011/48/3/279/84909


This issue contains two important articles on cancer affecting the head and neck region, one of which is rare and the other common. [1],[2] This editorial will comment on both of them.

Adult soft-tissue sarcomas of the head and neck are rare mesenchymal malignant tumours, accounting for less than 10% of all soft tissue sarcomas, and accounting for approximately 1% of all Head and Neck neoplasias. Nonetheless, they represent an important group of tumours associated with significant morbidity and mortality. The disease is more common in men than in women. [3]

The histology of sarcoma is complex and immune-histochemical analysis is often required to differentiate one subtype from another. Head and Neck soft tissue sarcomas are a diagnostic and therapeutic challenge. Therefore a multi-disciplinary team approach is essential for accurate diagnosis and treatment. [4] These tumours are relatively uncommon, which is reflected by a scarcity of studies, misdiagnoses, along with patient neglect, which, not uncommonly, contributes to an advanced stage at presentation and a limited survival. [5]

The present journal has an article by Sidappa and Krishnamurthy. The article highlights the uncommonness of the disease. The commonest subtype in this study was spindle cell type sarcoma, however, available data from literature show that malignant fibrous histiocytosis and malignant peripheral nerve sheath tumours are as common as spindle cell sarcomas. The article lacks immune-histochemistry results, which are essential to differentiate one from the other.

Inspite of advances in oncology, surgery is generally recommended as the primary method of treatment [3] to achieve local control, except in high grade tumours arising in sites not amenable to resection. Exceptions to this principle include masticator space disease, rhabdomyosarcoma of the paranasal sinuses and orbit, and extensive angio-sarcomas of the scalp, where multi-agent chemotherapy and radiotherapy are included along with salvage surgery. This approach is mainly to avoid the functional and cosmetic impact of surgery. [4]

The local failure rate of surgery is as high as 40% in literature, which is consistent with the present study. Local recurrence is dependent on the "margins" achieved during primary surgery. [6] Intra-lesional margins followed by marginal margins are the most dangerous. High grade tumours, greater than 5 cm are important factors in recurrence. Although not mentioned in the article, the site of the tumour in terms of depth is an important parameter, that is, tumours occurring below the subcutaneous region are more dangerous. [5]

The advent of more advanced reconstructive techniques, including free tissue transfer has made possible a more aggressive surgical resection of these tumours. [3]

Adjuvant radiotherapy improves disease control and overall survival, and is generally recommended for high grade sarcomas, large tumours, close or positive surgical margins and certain histological subtypes. [3] The impact of radiotherapy is visible in this article.

This article does not throw any light on chemotherapy. Systemic chemotherapy is recommended in an adjuvant situation for those tumours with a significant risk of distant metastasis. Increasingly neo-adjuvant chemotherapy is being used to test chemo-sensitivity. [3] Recurrence is commonly local, at times distal. Local recurrence is best handled with surgery and forms the main modulus of treatment.

Obtaining local control is paramount in managing head and neck sarcoma. The article shows that the commonest site is the lung, hence, monitoring this is going to be very, very important.

The watchword is "early detection and referral to a multidisciplinary team or experienced centre". For sarcomas of the head and neck an urgent referral should be made for a palpable lump, which has not been diagnosed before and one which has changed over a period of 3 - 6 weeks. Similarly, for an existing lump greater than 5 cm in size, deep to the fascia, fixed or mobile, painful, increasing in size and recurring after a previous excision, the referral must be urgent. [7]

Head and Neck Squamous Cell Carcinoma is the commonest malignancy seen in India. It is related to the use of tobacco, and is considered to be a model of life-style disease and, therefore, one of the most preventable of cancers. A subset of head and neck cancer, mainly cancers of the oral cavity and oropharynx, is related to an infective agent, the Human Papillomavirus (HPV).

Radiation forms the main stay of Head and Neck Squamous Cell Cancer in early stages, advanced stages and for palliation. This issue of the journal also carries an important article that comments on the not-very-often talked about change in the saliva of patients treated with radiation - in other words, "spit does matter".

Head and Neck cancer patients are always symptomatic at presentation. In some cases, a serious or potentially life threatening complication may be the first manifestation of the cancer. Throughout the course of therapy, be it surgery, radiation and/or chemotherapy, complications can arise which can compound the problem. [8] Due to the anatomical location of the vital organs of speech, swallowing and respiration, patients with head and neck cancer tend to have a higher incidence of side effects as compared to patients with cancers at other sites.

Radiotherapy for head and neck cancers damage normal tissue, as a result of which acute and long term sequelae are known to occur. The acute reactions that occur during radiation include mucositis, odynophagia, dysphagia and hoarseness - all related to xerostomia (dry mouth - lack of saliva). The majority of these side effects are self-limiting. Unfortunately, such acute side effects can lead to the interruption of planned treatment with deleterious effects. A 5-day delay in radiotherapy affects local control by as much as 8%. These effects are greater in tumours with a higher probability of local failure. [9]

Such side effects also majorly affect the Quality of Life. The temporary loss of saliva is significant after an exposure of 10Gy to salivary glands, while administration of 40Gy - 50Gy causes permanent loss. Xerostomia causes an alteration in taste and reduces dietary intake. Inspite of knowing this the exact physical and biochemical changes in saliva are not well documented, nor is their impact on the quality of life. [10]

This issue also carries an article by Tiwana et al that fills these lacunae. The method of amelioration, as suggested in this article, is the use of Intensity Modulated Radiation Therapy (IMRT). It is also worthwhile to explore this hypothesis further. Will it really reduce the intensity and duration of xerostomia? Will other factors like the use of Amifostine [11],[12] (given I.V. to patients receiving radiotherapy alone, or possibly subcutaneously, which will be of importance when I.V. access is difficult) and Pilocarpine add value? We need radiation oncologists to get together and design investigator initiated trials to answer some of these important questions.

 
  References Top

1.Sidappa and Krishnamurthy: Adult soft tissue sarcomas of the head and neck. Indian J Cancer 2011;48:284-8.  Back to cited text no. 1
    
2.Tiwana MS, Mahajan MK, Uppal B, Koshy G, Sachdeva J, Lee HN, et al. Whole saliva changes and quality of life following RT in head and neck cancer patients. Indian J Cancer;2011;48:289-95.  Back to cited text no. 2
    
3.Colville RJ, Charlton F, Kelly CG, Nicoll JJ, McLean NR. Multidisciplinary Management of H and N Cancer Sarcomas; Head Neck 2005;27;814-24.  Back to cited text no. 3
    
4.Mendenhall WM, Mendenhall CM, Werning JW, Riggs CE, Mendenhall NP. Adult head and neck soft tissue sarcomas, Head Neck 2005;27:916-22.  Back to cited text no. 4
    
5.Dudhat SB, Mistry RC, Varughese T, Fakih AR, Chinoy RF. Prognostic factors in head and neck soft tissue sarcoma. Cancer 2000;89:868-72.  Back to cited text no. 5
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6.Eles RA, Fisher C, A'Hern RP, Robinson M, Rhys-Evans P, Henk JM, et al. Head and neck sarcoma, prognostic factors - an implication for treatment. Br j cancer, 1993;68:201-7.  Back to cited text no. 6
    
7.National Institute of Health and Excellence, Referral Guidelines for suspected cancer, available from: http://www.nice.org.uk/page.aspx?o=cg027 [Last cited on 2005 Jun]  Back to cited text no. 7
    
8.Vokes EE, Weichselbaum RR, Lippman SM, Hong WK. Nead and Neck Cancer. N Engl J Med 1993;328:184.  Back to cited text no. 8
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9.Mittal BB, Pauloski BR, Haraf DJ, Pelzer HJ, Argiris A, Vokes EE, et al. Swallowing dysfunction, preventive rehabilitative strategies in patients with head and neck cancer treated with surgery, radiotherapy and chemotherapy, A critical review. Int J Radiat Oncol Biol Phys 2003;57:1219-30.  Back to cited text no. 9
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10.Franzen L, Funegård U, Ericson T, Henriksson R. Parotid gland functions during and following radiotherapy of malignancies in head and neck , A consecutive flow of salivary discomfort, Eur J Cancer 1992;28:457-62.  Back to cited text no. 10
    
11.Antonadou D, Pepelassi M, Synodinou M, Puglisi M, Throuvalas N, Prophylactical use of amifostine to prevent radiotherapy induced mucositis, and xerostomia in head and neck cancer patients. Int J Radiat Oncol Biol Phys 2002;52:739-47.  Back to cited text no. 11
    
12.Wasserman TH, Brizel DM, Henke M, Monnier A, Eschwege F, Sauer R, et al. The influence of intra-venous amifostine on xerostomia, tumor control and survival after Radiation Therapy for Head and Neck Cancer, 2 years follow-up of a prospective randomized phase 3 trial. Int J Radiat Oncol Biol Phys 2005;63:985-90.  Back to cited text no. 12
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