Successful treatment of head and neck cancer involving the prevertebral fascia.

Abstract: Chemotherapy with radiation has become more popular than radiotherapy alone for patients with locally advanced head and neck cancer because of the successful results associated with it. We report the case of a 67-year-old man with hypopharyngeal cancer invading the prevertebral fascia who became free of disease after chemoradiation. This uncommon, positive observation supports the impression that combined therapy is efficacious in some patients with advanced stage carcinoma of the upper aerodigestive tract.

Key Words: chemotherapy, head and neck cancer, prevertebral fascia, radiotherapy.

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Chemoradiation has become an accepted standard of care for locally advanced malignant tumors of the upper aerodigestive tract. Head and neck cancer with prevertebral fascia involvement (HNC-PFI) is considered an inoperable disease. (1) The effects of nonoperative treatment of this particular neoplastic condition are not well documented in the literature. Herein, we present a case of HNC-PFI that was successfully treated by chemoradiation.

Case Report

A 67-year-old man presented to the hospital in September 2001 with a 2-month history of dysphagia. Physical examination showed a large tumor occupying the posterior pharyngeal wall. Lymph nodes were not palpable in the neck. Axial computed tomographic (CT) scan revealed a tumor involving the posterior pharyngeal wall with extension into the prevertebral space. A biopsy proved the lesion to be a grade 2 squamous cell carcinoma. A chest radiograph was normal. The tumor was staged as T4N0M0 according to the American Joint Committee on Cancer staging system.

The patient was treated by induction chemotherapy followed by concomitant chemoradiation (details of this bimodal treatment regimen have been described in a previous report (2)). The primary tumor received 62 Gy (given in 30 fractions) and the neck 50 Gy (given in 25 fractions). Comparison of the CT scan of September 2001 with that of October 2002 (Figure) shows complete resolution of HNC-PFI.

At the time of last follow-up (June 2003), the patient was well and found free of tumor recurrence.

Discussion

The prevertebral fascia (of the deep cervical fascia) lies just anterior to the bodies of the vertebrae from the base of the skull to the coccyx, and laterally attaches to the transverse process of the cervical vertebrae.

Malignant tumors of the nasopharynx, oropharynx, and hypopharynx may involve the prevertebral fascia. Chemoradiation is the preferred first-line therapy for HNC-PFI because the prevertebral musculature apparently interdigitates with the fascia of the prevertebral column, making complete resection difficult to achieve. Also, the prognosis in stage IV cancers of the upper aerodigestive tract is generally poor when these particular neoplasms are managed by single-modality therapy. Studies that use chemotherapy and radiotherapy for advanced oropharyngeal, nasopharyngeal, and hypopharyngeal cancers do not mention cases of HNC-PFI. Moreover, in three retrospective studies (3-5) determining tumor invasion or fixation to the prevertebral muscles/space by CT scan or magnetic resonance imaging, outcomes of those patients with detected muscle or space involvement were not stated. Therefore, we find it interesting to describe a case managed by combined, nonoperative treatments.

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Conclusion

Since HNC-PFI is not often encountered in clinical practice, the long-term prognosis in this select disease condition has not been ascertained; however, we acknowledge it to be poor. Management of this particular condition by chemotherapy with radiotherapy successfully resolved the neoplasm in our case. Prospective validation will be essential in determining the true worth of chemoradiation for inoperable head and neck cancer with prevertebral fascia involvement.

Accepted December 16, 2003.

References

1. Gullane P. Hypopharynx, in Gluckman J, Gullane P, Johnson J (eds): Practical Approach to Head and Neck Tumors. New York, Raven Press, 1994, pp 149-160.

2. Ampil FL, Mills GM, Caldito G, et al. Induction chemotherapy followed by concomitant chemoradiation-induced regression of advanced cervical lymphadenopathy in head and neck cancer as a predictor of outcome. Otolaryngol Head Neck Surg 2002;126:603-606.

3. Loevner LA, Ott IL, Yousem DM, et al. Neoplastic fixation to the prevertebral compartment by squamous cell carcinoma of the head and neck. Am J Roentgenol 1998; 170:1389-1394.

4. Van Den Hoogen FJA, Balm AJM, Hilgers FJM, et al. The value of computed tomography scan versus an explorative surgical approach for the removal of squamous cell carcinoma of the posterior pharyngeal wall. Am J Surg 1996;172:701-703.

5. Righi PD, Kelley DJ, Ernst R, et al. Evaluation of prevertebral muscle invasion by squamous cell carcinoma. Arch Otolaryngol Head Neck Surg 1996;122:660-663.

RELATED ARTICLE: Key Points

* Head and neck cancer involving the prevertebral fascia does not occur frequently, and usually signifies inoperable disease.

* Significant resolution of a similar kind of voluminous malignant tumor was observed in our patient, who was treated with chemoradiation.

* The positive effects of combined treatment in individuals with carcinoma of the upper aerodigestive tract and affected prevertebral fascia have not been widely reported.

Federico Ampil, MD, Glenn Mills, MD, Gary Burton, MD, Anil Malik, MD, and R. Murty Krishnamsetty, MD

From the Departments of Radiology and Medicine, Louisiana State University Health Sciences Center, Shreveport, LA.

Reprint requests to Federico L. Ampil, MD, Division of Therapeutic Radiology, Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA 71130. Email: [e-mail]