Japanese Clinical Practice Guideline for Head and Neck CancerKen-ichi - PDF document

Japanese Clinical Practice Guideline for
Japanese Clinical Practice Guideline for Head and Neck CancerKen-ichi Nibu,, Ryuichi Hayashi Takahiro Asakage Hiroya OjiriYoshihiro Kimata Takeshi Kodaira Toshitaka Nagao Torahiko NakashimaTakashi Fujii Hirofumi Fujii Akihiro Homma Kazuto MatsuuraNobuya Monden Takeshi Beppu Nobuhiro Hanai Tadaaki KiritaYuzuru Kamei Naoki Nasus Larynx xxx (2017) xxx–xxx Corresponding author at: Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kobe University, Kusunoki-Cho 7-5-1, Chuo-Ku, Kobe 650-0017, Japan. Fax: +81 78 382 6039.E-mail address:nibu@med.kobe-u.ac.jp(K.-i. Nibu).G ModelANL-2246;Please cite this article in press as: Nibu K-i, et al. Japanese Clinical Practice Guideline for Head and Neck Cancer. Auris Nasus Larynx (2017),http://dx.doi.org/10.1016/j.anl.2017.02.004ScienceDirecte/anl1. IntroductionSince critical organs for communication, swallowing andrespiratory functions are located in head and neck, to balance“cure” with “quality of life” is required in the treatment of headand neck cancers. To address this issue, multimodal strategiesconsisting of surgery, radiotherapy and chemotherapy havebeen advocated from individual institutes since early 1970s.However, treatment policies varied among institutes and therewas no nation wide consensus in the treatment of head and neckcancer until recently. To standardize the treatment of theJapanese patients with head and neck cancer, the first edition of“Japanese Clinical Practice Guideline for Head and NeckCancer” was published in 2009 by the clinical practiceguideline committee of Japan Society for Head and NeckCancer.In response to the revision of the TNM classification ofmalignant tumors, the first revision was made in 2013. To catchup with the recent remarkable advances in functional surgery,chemotherapy, targeted therapy, radiotherapy and supportivecare during these four years, 34 CQs (Clinical Questions) werenewly adopted to describe the diagnosis and treatment methodscurrently considered most appropriate, and offered recommen-dation grade made by the consensus of the committee. Due tothe limitation of provided pages, in this article, we describe therevised guideline on oral, maxillary, pharyngeal and larynge

alcancers and presented six most relevan
alcancers and presented six most relevant CQs. Other topics canbe seen in “Clinical Practice Guideline for Head and NeckCancer 2013”[1]or at the official website of Japan Society ofClinical Oncology[2]in Japanese.2. Criteria for determining recommendation gradesThirty-four CQs were newly raised to describe the diagnosisand treatment methods currently considered most appropriate.A comprehensive literature search was performed for studiespublished between 2001 and 2012. Databases used werePubMed. Free-hand searches were also performed as indicated.The searches were executed primarily between January2012 and December 2012. Primary index words used for eachCQ were shown at the end of respective CQ. Qualified studieswere analyzed and the results were evaluated, consolidated andcodified by all the committee members.Levels of evidence I–V were determined as follows: I:Systematic review/RCT meta-analysis, II: randomized con-trolled trials, III: Prospective comparative Study, IV: Casecontrol study/Retrospective comparative study, V: Case report/Case series and VI: Expert opinion. “NCCN clinical PracticeGuideline in Oncology: Head and Neck Cancers Version I.2012” was also used as reference.Recommendation grades were classified to six grades asfollows: Grade A: Strongly recommended for use in clinicalAvailableG ModelANL-2246; No. of Pages 6Please cite this article in press as: Nibu K-i, et al. Japanese Clinical Practice Guideline for Head and Neck Cancer. Auris Nasus Larynx (2017),http://dx.doi.org/10.1016/j.anl.2017.02.0043.1. Oral cancer (tongue cancer)Due to the limited number of facilities for brachytherapy,surgery is the mainstay of treatment for oral cancers.[Radiotherapy] Interstitial irradiation (brachytherapy) isindicated for T1 and T2, and superficial T3 cases (Grade C1).[Surgery] Operative procedures are classified into 5 catego-ries: partial glossectomy, hemiglossectomy (oral tongue),subtotal glossectomy (oral tongue), subtotal glossectomy (oraltongue + tongue base) and total glossectomy (oral tongue+ tongue base). Elective, or prophylactic, neck dissection (ND)for stages I/II cases have been often performed in cases withdeep invasion (Grade C1). Recommended reconstructiveprocedure f

or unilateral resection of the mobile po
or unilateral resection of the mobile portion ofthe tongue is primary suturing or reconstruction using a thinskin flap such as a forearm flap or an antero-lateral thigh flap(Grade C1). For (sub) total glossectomy, a voluminous materialsuch as a free rectus abdominis musculocutaneous flap can beselected for use in reconstruction (Grade B).[Chemotherapy]Platinum-basedchemotherapyperformedinductionchemotherapyforadvancedcancer(GradeC1).G ModelANL-2246; No. of Pages 6Please cite this article in press as: Nibu K-i, et al. Japanese Clinical Practice Guideline for Head and Neck Cancer. Auris Nasus Larynx (2017),http://dx.doi.org/10.1016/j.anl.2017.02.004 CRT or induction chemotherapy is per-formed. Usually, monotherapy or combination therapy withplatinum agent is performed.3.5. Hypopharyngeal cancerIn early-stages, with the aim of preserving larynx, a choice ismade among radical irradiation and larynx-preserving surgery(open or endoscopic) according to the extent of disease (GradeB). Surgical treatment is the first choice for advanced cancercases. From the viewpoint of QOL, CRT (Grade B) or larynx-sparing surgery is also performed.[Radiation therapy] Usually, 60–70 Gy of external beamirradiation (30–35 fractions given over 6–7 weeks) is carriedout, which is basically indicated in T1–T2 cases. The irradiationfield includes metastatic lymph nodes. However, in case wherethe control of cervical metastasis is considered to be difficult byradiotherapy with or without chemotherapy, ND may beperformed prior to chemoradiotherapy. Even if there is noclinical lymph node metastasis, the radiation field shouldprophylactically include lateral neck lymph nodes, especially.Chemotherapy is concomitantly performed for advancedcancers.[Surgery] Operative procedures are classified into 4 catego-ries: endoscopic transoral resection, partial pharyngectomywith larynx preservation, partial pharyngectomy with totallaryngectomy, and total laryngopharyngectomy. For advancedcases, total laryngopharyngectomy is the standard surgicalprocedure. However, larynx-preserving surgery is alsoattempted in the selected cases. ND is performed for levelII–IV or V. When total laryngectomy is performed, ipsilaterallobe of the thyroid

and paratracheal lymph nodes are dissect
and paratracheal lymph nodes are dissected.For reconstruction following total laryngopharyngectomy, freejejunal flap is commonly used in Japan (Grade B). Forsuperficial cancers initially confirmed by a magnifyingendoscope or narrow band imaging, endoscopic transoralresection has been recently performed.[Chemotherapy] CCRT or induction chemotherapy isperformed. Monotherapy or combination therapy with platinumagent is performed (Grade B).3.6. Laryngeal cancerFor early-stage cancers, either radiotherapy or larynx-sparing surgery is recommended to preserve the larynx (GradeA). Until recently, total laryngectomy has been mostlyperformed in advanced cancers. However, from a perspectiveof QOL, nowadays, taking full account of the patient’s age andgeneral condition, CCRT (Grade B) and larynx-sparing surgeryare increasingly performed.[Radiation therapy] Radical irradiation is indicated for T1N0 and T2 N0 cases. Commonly, for T1 cases, 60–66 Gy ofexternal beam radiation (30–33 fractions given over 6–7 weeks)is performed, and for T2 and more advanced cases, 70 Gy(35 fractions given over 7 weeks) is performed. The radiationfield does not include the cervical lymph node in glottic cancers,but does include the bilateral upper- and middle-cervical lymphnodes in supraglottic cancers. For advanced cancers, CCRT iscommonly performed.[Surgery]Operativeproceduresareroughlyclassifiedcategories:larynx-preservingsurgerysuchmicrolaryngealsurgeryandpartiallaryngectomy,andtotallaryngectomy.early-stagecancers,oncologicaloutcomeslarynx-preservingsurgeryareequivalentradiotherapy(Graderecurrencesfollowingradiotherapyearly-stagecancer,larynx-preservingsurgeryoftenperformedsalvagesurgery(GradeB).Forcasesinvasionsofttissueoverthyroidcartilage,totallaryngectomycommonlyperformed.progressivesubglotticcancers,ipsilaterallobesthethyroidandparatrachealnodesaredissectedthetimetotallaryngectomy.performedlevell CCRT (Grade B) or induction chemother-apy (Grade C1) is performed. Monotherapy or combinationtherapy with platinum agent is used.4. Clinical questionsIn the revised guideline, CQ section consists of 12 categoriesand 34 CQs are described in total. Due to the limitation ofprovided pages, ix CQs are related to pretreatment di

agnoses,7 CQs are related to chemotherap
agnoses,7 CQs are related to chemotherapy and/or radiotherapy and2 CQs are related to supportive care. Other CQs are relatedto respective primary site. Here we describe the six mostrelevant CQs.4.1. CQ2-2: does elective neck dissection contribute toimprovement of survival compared with watchful waiting withneck dissection after recurrence in patients with stage I/IItongue cancer?GradeCommentsnts. END also has anadvantage to provide useful pathological information fordetermining adjuvant treatment, such as postoperative chemor-adiotherapy.Index words: tongue, elective neck dissection.4.2. CQ3-2: what is the role of superselective arterial infusionchemotherapy in head and neck cancer?GradeG ModelANL-2246; No. of Pages 6Please cite this article in press as: Nibu K-i, et al. Japanese Clinical Practice Guideline for Head and Neck Cancer. Auris Nasus Larynx (2017),http://dx.doi.org/10.1016/j.anl.2017.02.004Commentsnts. High-dosecisplatin is infused, followed by sodium thiosulfate to neutralizethe cisplatin and reduce adverse reactions. Infusions areprovided weekly in combination with radiation. Locallyadvanced cancers in sites such as the maxillary sinus and thebase of the tongue are believed to be the best indicationsbecause of their relatively simple vascular patterns [5].Index wordsGradeCommentsnts, and theEORTC 22931 trial considered stage III/IV, extranodal spread,microscopically positive margins, perineural invasion, intra-vascular tumor embolism, and level IV–V lymph nodessecondary to tumors arising in the oral cavity or oropharynxas risk factors [7]. Both trials demonstrated the superiority ofchemoradiotherapy. Integrated analysis of results from the twotrials showed the advantage of adjuvant chemoradiotherapy forcases with extranodal spread and microscopically positivemargins [8], risk factors that were included in both trials.Feasibility of adjuvant chemoradiotherapy with 3-weeklycisplatin for Japanese patients also has been confirmed bymulti-institutional clinical trial [9].Index wordsGradeCommentsnts. Another trial comparing chemo-therapy (CDDP or CBDCA/5-FU) alone with chemotherapy(CDDP or CBDCA/5-FU) and Cmab for untreated recurrent ormetastatic squamous cell carcinoma of the h

ead and neckshowed a significant additiv
ead and neckshowed a significant additive effect on overall survivalcompared with chemotherapy alone [12,13]. Due caution mustbe exercised when using Cmab because it may cause seriouscomplications unique to antibody drugs, including infusionreactions and interstitial lung disease.Index wordsCommentsts. In addition, oral care in chemoradiotherapy alsoreduces oral complications such as stomatitis, xerostomia, andtaste disturbances and improve the rate of treatment completion.Index wordsCommentsts.Index wordsG ModelANL-2246; No. of Pages 6Please cite this article in press as: Nibu K-i, et al. Japanese Clinical Practice Guideline for Head and Neck Cancer. Auris Nasus Larynx (2017),http://dx.doi.org/10.1016/j.anl.2017.02.004AcknowledgementReferencesrences Japan Head and Neck Cancer Society.. Japan Society of Clinical Oncology.http://www.jsco-cpg.jp/item/15/in-dex.html,html, D’Cruz AK, VaishElectiveversusnode-negativecancer.. Robbins KT,KerberVicarioselectiveadvancedcancer.. Homma A, Oridate N, Suzuki F, TakiYoshidaSuperselectiveadvancedcavityexperience.rience. Cooper JS, PajakTF,Forastiere9501/Intergroup.operativeve Bernier J, Domenge C, Ozsahin M, MatuszewskaOrganizationTreatmentTrialPostoperativeadvancedcancer.. Bernier J, Cooper JS, Pajak TF,vanForastierelevelsadvancedcomparativepostoperativeEORTC(#22931)andRTOG(#9501).(#9501). Kiyota N, TaharaKawashimaOnozawaYoshimuraadjuvantpost-operativee Bonner JA,OveYoussouanRowinskywinsky Okano S, YoshinoOnozawaKodairaTaharaadvancedanced VermorkenRiveraKaweckiRotteycancer.. YoshinoHasegawaTakahashiMondenHommaOkamiOnozawaFujiiTaguchiBlasBeierTaharaPlatinum-basedchemotherapypluscetuximabtherst-linetreatmentJapa-nesepatientswithrecurrentand/ormetastaticsquamouscellcarcinomaoftheheadandneck:resultsphasetrial.JpnClinOncol2013;43:524–31.. Sato J, Goto J, Harahashi A, Murata T, Hata H, Yamazakipostoperativeve NibuKawabataTreatmentLymphCancer.G ModelANL-2246; No. of Pages 6Please cite this article in press as: Nibu K-i, et al. Japanese Clinical Practice Guideline for Head and Neck Cancer. Auris Nasus Larynx (2017),http://dx.doi.org/10.1016/j.anl.2017.02.004guide.medlive.cnguide.medlive.cnguide.medlive.cnguide.medlive.cnguide.medlive.cnguide.medli