Concurrent chemoradiotherapy (CCRT) is the standard approach for the treatment of locally advanced head and neck squamous cell carcinoma. Despite its undisputed advantages, CCRT is associated with acute and late toxicities, leading to unfavorable implications (eg, unplanned interruptions and noncancer-related mortality). The former prolongs the overall treatment time leading to a detrimental effect on tumor control. The latter consists of several noncancer morbidities arising from treatment-related toxicities, identifying a new pathway in cancer fate. This pathway has been termed noncancer mortality or competing mortality and consists of a series of treatment-competing morbidities, which nullify all therapeutic efforts aimed at curing these patients. The management of patients with head and neck squamous cell carcinoma who experience treatment-related toxicities is complex and requires expertise in oncological treatment as well as supportive care. The optimal management of these patients should start with knowledge regarding the most important competing morbidities developing during all phases of the disease (ie, from diagnosis to follow-up) to minimize treatment interruptions, ensure appropriate psychological support, and achieve the best oncological result. The purpose of the present review is to analyze the most important competing morbidities due to patient’s condition at baseline and CCRT, which could result in noncancer mortality. A multidisciplinary team approach is strongly required in the management of this disease.

The aim of the present study was to report an unusual case of multiple lower cranial nerve palsies in a patient with Wegener's granulomatosis (WG) during radiotherapy for glottic cancer. WG is an autoimmune disease characterized by necrotizing granulomas mainly in the upper and lower respiratory tract or kidneys; however, the involvement of cranial nerves is not uncommon. Prior to the use of cyclophosphamide (CYC) the 1-year mortality rate was ~82%; the introduction of rituximab (RTX) has revolutionized the course of the WG, with remission rates comparable to those of CYC and superior effectiveness in relapsing patients. Hypogammaglobulinemia and B-cell depletion are the best known monitored side effects affecting survival due to secondary infections. Immunodepression and relapse with lower cranial nerve palsy have a negative impact on prognosis. We herein present the case of a heavily pre-treated GPA patient with secondary immunosuppression, who underwent radiotherapy for glottic cancer and developed multiple low cranial nerve palsies during treatment, which was interrupted at 60 Gy. The possible related causes and the association between previous immunosuppressive treatments and radiotherapy were also analyzed to elucidate the cause of this complication.

Wegener’s granulomatosis (WG) is an autoimmune disorder characterized by necrotizing granulomas involving mainly the upper–lower respiratory and renal tracts, albeit a potentially life-threatening involvement of other body parts is not rare. Furthermore, there are several reports accounting for an increased risk of solid malignancies due to the autoimmune disease per se, or the immunosuppressive therapies. Among treatments, radiotherapy could be a therapeutic option as proven by its use in typical WG lesions such as solitary granulomas or subglottic stenosis, successfully treated with low radiation dose. Herein, we report a case of squamous cell carcinoma of the glottis–subglottic larynx, T3 N0 M0 stage, occurring in a patient with a long-standing WG, heavily treated in the past with cyclophosphamide and rituximab, who achieved a complete response of the tumor using a low-dose radiation therapy and no concurrent chemotherapy. The hypothesis is that this cancer probably arose from a subglottic stenosis as a late manifestation of WG and exhibited more radiosensitivity than a naïve tumor. If so, solid tumors occurring on granulomas within an autoimmune disease course should be treated with a lower radiation dose.