Organ-function preservation in advanced oropharynx cancer: results with induction chemotherapy and radiation

PURPOSE

To evaluate the feasibility and efficacy of a strategy using induction chemotherapy followed by radiation therapy (RT) as a means of organ-function preservation in patients with advanced oropharynx cancer.

PATIENTS AND METHODS

From January 1983 to December 1990, 33 patients with advanced squamous cell oropharynx cancer whose appropriate surgical management would have required a tongue procedure and potential total laryngectomy were treated with one to three cycles of cisplatin (CDDP)-based induction chemotherapy. Patients with a complete response (CR) or partial response (PR) at the primary site then received definitive external-beam RT with or without interstitial implant with or without neck dissection with surgery to the primary tumor site reserved for disease persistence or relapse; patients with less than a PR after chemotherapy had appropriate surgery and postoperative RT recommended.

RESULTS

With a median follow-up period of 6.2 years, actuarial overall and failure-free survival rates at 5 years are 41% and 42%, respectively. Chemotherapy toxicity contributed to the death of two patients and was possibly a factor in two others. Local control was achieved in 14 patients (42%) without any surgery to the larynx or tongue. Among 13 patients currently alive, all had a preserved larynx and only one required tongue surgery; 12 of 13 have speech subjectively described as always understandable; and nine of 13 have no significant restrictions in their diet.

CONCLUSION

This treatment program is feasible and effective in patients with advanced oropharynx cancer and produces an excellent functional outcome in most long-term survivors. Modifications to optimize patient selection, minimize toxicity, and improve local control are indicated. The relative toxicity, efficacy, and functional outcome provided by this and other chemotherapy and RT programs versus either standard surgery and/or RT options can only be addressed in a randomized comparison of these therapies.

Prevalence and predictors of continued tobacco use after treatment of patients with head and neck cancer

BACKGROUND

Patients with head and neck cancer who continue to smoke after diagnosis and treatment are more likely than patients who quit to experience tumor recurrence and second primary malignancies. Therefore, information about patients' smoking status and the factors associated with continued tobacco use are important considerations in the comprehensive care patients with head and neck cancer.

METHODS

Study participants were 144 patients with newly diagnosed squamous cell carcinomas of the upper aerodigestive tract who underwent surgical treatment, with or without postoperative radiotherapy or chemotherapy, 3-15 months before assessment of their postoperative tobacco use.

RESULTS

Among the 74 patients who had smoked in the year before diagnosis, 35% reported continued tobacco use after surgery. Compared with patients who abstained from smoking, patients who continued to use tobacco were less likely to have received postoperative radiotherapy, to have had less extensive disease, to have had oral cavity disease, and to have had higher levels of education. Hierarchical regression analysis indicated that most of the explained variance in smoking status could be accounted for on the first step of analysis by disease site. Interest in smoking cessation was high, and most patients made multiple attempts to quit.

CONCLUSIONS

Although the diagnosis of a tobacco-related malignancy clearly represents a strong catalyst for smoking cessation, a sizable subgroup of patients continue to smoke. Patients with less severe disease who undergo less extensive treatment are particularly at risk for continued tobacco use. These data highlight the importance of developing smoking cessation interventions designed to meet the demographic, disease, treatment, and tobacco-use characteristics of this patient population.

Biopsy techniques in head and neck

The establishment of an accurate histologic diagnosis is extremely important in the management of patients with head and neck lesions. This article describes various biopsy techniques and discusses the clinical implications in relation to common lesions involving thyroid and salivary glands and cervical lymphadenopathy. The diagnostic pitfalls and pros and cons of needle biopsy are also discussed in detail.

Intermediate-risk group for differentiated carcinoma of thyroid

BACKGROUND

We have previously described prognostic factors in differentiated carcinoma of the thyroid gland relating to age, size and extrathyroid extension of the tumor, histologic grade, gender, and distant metastasis. These factors have identified patients in the low-risk group with excellent prognosis and the high-risk group with significant mortality. However, some patients fall within the intermediate-risk category where due deliberation in decision making is required for selection of appropriate treatment.

METHODS

A retrospective review of a consecutive series of 1038 previously untreated patients with differentiated carcinoma of thyroid treated during a period of 55 years was undertaken. Data gathered from review of the charts were subjected to univariate and multivariate analysis to assess prognostic factors. On the basis of the patient's age, presence of distant metastasis, and size, grade, and histologic characteristics of the tumor they could be classified into low-, intermediate-, and high-risk categories. Thus 403 (39%) patients were in the low-risk group, 232 (22%) patients in the high-risk category, and 403 (39%) patients in the intermediate-risk category.

RESULTS

With a median follow-up of 20 years, 99% survival was achieved in the low-risk group, whereas only 57% survived in the high-risk group. Interestingly, in the intermediate-risk category of 403 patients, the 20-year survival was only 85%. Our results clearly identify a distinct intermediate-risk category that includes low-risk patients with high-risk tumor or high-risk patients with low-risk tumor.

CONCLUSION

Patients in the intermediate-risk category should be considered for an aggressive treatment approach based on individual prognostic factors.

The role of comprehensive neck dissection with preservation of the spinal accessory nerve in the clinically positive neck

BACKGROUND

The most significant prognostic factor in patients with squamous cell carcinoma of the head and neck is the presence of cervical nodal metastases. Radical neck dissection is the standard by which all cervical lymphadenectomy procedures are judged. In the presence of clinically positive nodal metastasis, the benefit of preserving the spinal accessory nerve (SAN) has to be weighed against the possible risk of increased failure in the neck. We performed this retrospective study to determine if preservation of the SAN in patients with clinically evident nodal metastases was associated with increased risk of failure in the dissected neck.

PATIENTS AND METHODS

Between January 1, 1984 and December 31, 1991, 378 comprehensive neck dissections were performed in 366 patients with clinically and pathologically positive nodal metastases from squamous carcinoma of the upper aerodigestive tract. We compared survival, neck control rates, and other factors in patients who had a classic radical neck dissection (RND) to those who had modified radical neck dissection sparing only the SAN (MRND I).

RESULTS

Actuarial 5-year survival and neck failure rates for the RND group were 63% and 12%, compared to 71% and 8% for the MRND I group (P = NS). Survival and neck failure were not statistically different between the MRND I and RND groups when the analysis controlled for pathologic N stage, presence of extra capsular spread, and the presence of pathologically demonstrated metastatic nodes along the course of the SAN. Nor were there significantly different patterns of neck failure with RND versus MRND.

CONCLUSION

Modification RND to preserve an uninvolved SAN in the clinically positive neck does not adversely affect survival or neck control.

Angiosarcoma of the head and neck

BACKGROUND

Angiosarcoma (AS) is an uncommon, highly aggressive tumor with a poor prognosis.

METHODS

To study the impact of various treatment modalities, namely surgery, radiation, and chemotherapy, we reviewed our experience with AS of the head and neck.

RESULTS

From 1978 through 1992, we treated 13 men and 5 women with AS (median age 67 years). Sixteen tumors occurred on the scalp and face and 2 in the oropharynx. Two patients presented with cervical metastases, and a third had subsequent nodal involvement. Primary surgery was used in 9 patients, including 1 who received adjunctive systemic doxorubicin hydrochloride, and 2 who received adjunctive radiotherapy. The tumors of 9 patients were unresectable: 4 were treated with intra-arterial doxorubicin hydrochloride; and 5, with systemic doxorubicin hydrochloride. Twelve patients (67%) died of disease an average of 25 months after diagnosis. Overall 5-year survival was 33%, but only 20% of the patients were disease free. Size of the tumor was an important predictor of survival, as all patients with a lesion > 10 cm died of disease, compared with 67% with a lesion < 10 cm. Four of 6 patients treated with wide local excision for lesions < 10 cm survived 5 years.

CONCLUSIONS

We recommend surgery for resectable lesions with postoperative radiation for unsatisfactory margins, large tumor size, deep extension, and multicentricity. Elective treatment of the neck does not appear warranted.

Classification of neck dissection: variations on a new theme

BACKGROUND

Commencing in 1984, we initiated a head and neck service surgical database that included a classification system for neck dissection. The aim was to reduce the confusion in terminology resulting from growing interest in modifications of conventional radical neck dissection.

METHODS

We considered a neck dissection as radical when four or five lymph node levels were excised; this included patients who had an otherwise classical neck dissection for supraglottic larynx or hypopharyngeal cancer sparing level 1. Lymph-node levels removed, nonlymphatic structures preserved, and excised nonlymphatic structures not ordinarily included in a classical radical neck dissection were all specified by the operating surgeon. We defined as a selective neck dissection any lymphadenectomy that encompassed no more than three nodal levels, usually supraomohyoid (levels 1, 2, 3), or jugular (levels 2, 3, 4). We defined as a limited neck dissection any lymphadenectomy that involved removal of no more than two nodal levels.

RESULTS

At the 10-year mark, this database of 10,650 patients now includes 2,635 lymphadenectomies in 2,426 patients, the precise extent of which is accurately described in each patient.

CONCLUSIONS

The current classification of neck dissection does not cover all possibilities. If we define as radical those lymphadenectomies that resect four or five nodal levels and specify structures preserved or additional nonlymphatic structures sacrificed, we allow for the possibility that some procedures may be both modified and extended. Selective would describe the standard, three-level dissections (eg, supraomohyoid or jugular node dissections), and the term limited would be introduced to indicate a neck dissection that involves removal of no more than two nodal levels. Such a three-tiered classification would more accurately reflect the time and effort involved and provide a more equitable basis for reimbursement.

Cervical metastases of occult origin: the impact of combined modality therapy

BACKGROUND

We have updated our experience with metastatic carcinoma to the neck of occult origin to assess whether increasing use of adjunctive radiation therapy has had a significant impact.

METHODS

This retrospective review of 115 patients treated between 1977 and 1990 includes 73 (63%) with squamous cell carcinoma. These 73 patients were analyzed for survival, control of disease in the neck, and incidence of subsequent primary tumors.

RESULTS

There has been no change in the proportion of patients with advanced neck disease (N2/N3 = 52; 71%) when compared to our last report. Surgery included comprehensive neck dissection in 59 (81%) and adjunctive radiotherapy was employed in 54 (83% of surgically treated patients). Primary carcinomas within the head and neck were identified subsequently in 9 (12%) patients, including 4 of 11 (36%) who did not have adjunctive radiotherapy and 5 of 54 (9%) who did (P = 0.038). Control of the treated neck (54/73; 74%) has improved significantly (P = 0.005) when compared to our earlier experience (37/74; 50%), and this was most apparent in those with extensive neck disease. However, cumulative survival at 5 years (45%) was not significantly different from that previously reported.

CONCLUSION

Our data support the increased use of adjunctive radiation therapy for metastatic squamous cell carcinoma in the neck of occult origin. Control of neck disease has improved and the likelihood that a primary will be identified has been reduced, but there has been no improvement in survival when compared to historical controls.

The impact of patterns of nodal metastasis on modifications of neck dissection

BACKGROUND

Radical neck dissection (RND) is standard treatment for cervical metastasis from head and neck cancer. Although effective, RND produces significant morbidity. In an effort to reduce this morbidity, modifications of RND have been developed. These modifications can be comprehensive yet spare some or all of the nonlymphatic structures removed in RND, or they can remove less than all the lymph node groups removed in RND and are termed selective neck dissections. We have reviewed the literature regarding the patterns of nodal metastasis from head and neck cancer to define the indications for these modifications of RND.

METHODS

A review of the literature concerning patterns of nodal metastasis from head and neck cancer was performed. Using this information, recommendations on the use of modifications of neck dissection were formulated.

RESULTS

In squamous cancers, with clinically negative neck supraomohyoid neck dissection is an adequate node sampling procedure for oral cavity and oropharyngeal lesions, and lateral (jugular) neck dissection for primary lesions of the hypopharynx, and larynx. In the clinically positive neck comprehensive neck dissection with preservation of the spinal accessory nerve is oncologically sound.

CONCLUSIONS

Nodal metastasis of head and neck cancer occurs in predictable patterns. Based on these patterns of nodal metastasis, recommendations for the use of modifications of neck dissection are presented.

Larynx preservation with combined chemotherapy and radiation therapy in advanced hypopharynx cancer

Twenty-five untreated patients with advanced, resectable squamous cell carcinoma of the hypopharynx, for whom standard treatment would have required total laryngectomy, were treated with one to three cycles of cisplatin-based chemotherapy with larynx preservation as the goal. Patients with a major (complete or partial) response to chemotherapy at the primary site were treated with definitive radiation therapy, with total laryngectomy reserved for salvage; patients with less than a partial response to chemotherapy had total laryngectomy and postoperative radiation therapy recommended. Four patients had a poor response to chemotherapy and thus were not candidates for laryngectomy. Total laryngectomy was required for initial induction chemotherapy failure in five patients and for local recurrence in five others. Three additional patients had unresectable recurrence. Successful larynx preservation was achieved in 32% (8 of 25). With a median follow-up period of 41 months, the actuarial overall and failure-free 2-year survival rates were 44% and 32%, respectively. These preliminary data suggest larynx preservation is feasible in patients with advanced lesions of the hypopharynx. Improved local and regional control must be incorporated into the larynx preservation approach for hypopharyngeal lesions. A prospective, randomized study is necessary for a more valid comparison with conventional therapy, including comparative assessments of survival, morbidity, cost and functional results.

Complications of craniofacial resection for tumors involving the anterior skull base

BACKGROUND

A consecutive series of 85 patients undergoing craniofacial resection for malignant tumors involving the anterior cranial base between 1974 and 1992 was reviewed.

RESULTS

There were two (2%) postoperative deaths. Postoperative complications occurred in 33 (39%) patients. Local major complications occurred in 26 (31%) patients, local minor in 7 (8%), and systemic in 5 (6%). More than one complication occurred in a number of patients. Bacterial contamination led to a significant proportion of local, septic complications. Repair of the skull base defect with a pedicled pericranial flap was unsatisfactory and was associated with an increased incidence of local major complications. A local major complication was associated with a dramatic lengthening of hospitalization.

CONCLUSION

Future endeavors for prevention of complications should focus on antibiotic prophylaxis and reconstruction of the cranial base defect with better vascularized flaps.

Impact of therapeutic regional lymph node dissection for medullary carcinoma of the thyroid gland

BACKGROUND

Medullary carcinoma of the thyroid gland (MCT) is a disease commonly associated with regional metastases. Apart from surgical resection, there are limited therapeutic options for such patients. Given the variable and often prolonged survival of such patients, the benefit of surgical resection is difficult to evaluate. We have reviewed our experience with regional lymph node dissection for metastatic MCT.

METHODS

From Jan. 1, 1980, to Dec. 31, 1991, 36 patients underwent dissection of regional lymph node metastases for MCT at our institution. Survival was calculated by the Kaplan-Meier method and comparisons by log rank analysis. Significance was defined as p < 0.05.

RESULTS

Thirty-six patients (13 women), with a mean age of 48 years (range 16 to 78 years), underwent operation for clinically palpable or radiologically identified nodal disease. Median follow-up was 53 months, with an overall actuarial 5-year survival of 65%. Factors significantly associated with a poor outcome included the following: age greater than 40 years, mediastinal metastases, incomplete excision, extranodal disease, and failure to reduce the thyrocalcitonin level.

CONCLUSIONS

The resection of metastatic MCT to regional lymph nodes can be associated with appreciable survival. Prognostic parameters are identified that adversely affect survival.

Lobectomy versus total thyroidectomy for differentiated carcinoma of the thyroid: a matched-pair analysis

The extent of surgical resection for differentiated carcinoma of the thyroid gland confined to one lobe remains controversial. Although primary tumor size and extrathyroid extension are associated with a poor prognosis, the presence of multifocal lesions is not associated with an adverse prognosis. Therefore, the role of lobectomy versus total thyroidectomy must be studied in a prospective, randomized trial. Due to the need for long-term follow-up, such a trial has not yet been undertaken. As an alternative to such a trial, we have identified 146 patients from a consecutive series of 931 previously untreated patients undergoing surgical treatment at 1 institution between 1930 and 1980. For this study of matched-pair analysis, 73 patients, aged 45 years or older, were matched in each arm for significant prognostic factors. One group underwent lobectomy, and the other group underwent total thyroidectomy. The 20-year survival rate in the lobectomy group was 82% compared with 73% in the total thyroidectomy group (p = not significant). The patterns of failure in these two groups of patients were examined. A comparison of the patients who underwent lobectomy with an unmatched group of patients who underwent lobectomy showed similar survival rates. On the other hand, unmatched patients undergoing total thyroidectomy had a poorer survival rate than the matched group. This signifies a more aggressive nature of disease in the unmatched group of patients undergoing total thyroidectomy. We therefore conclude that low-risk patients undergoing lobectomy are likely to do as well as those undergoing total thyroidectomy and without the increased risk of the morbidity of total thyroidectomy.

Comparative evaluation of fixation methods after mandibulotomy for oropharyngeal tumors

Mandibulotomy for gaining access to the posterior aspect of the oral cavity and oropharynx for excision of tumors has been widely employed for several decades. However, the technical aspects of the procedure continue to evolve. This study compares the complications and bony union rates in a consecutive series of 135 patients undergoing mandibulotomy at 1 institution between 1987 and 1991, using wires and miniplates. The primary tumor sites were oral cavity in 35 patients, oropharynx in 98, and deep lobe of the parotid gland in 2. Twenty-eight patients were previously irradiated, and 62 received postoperative radiotherapy. Thirty-eight patients had a straight-line osteotomy, 31 had step osteotomy, and 66 had notched osteotomy. The fixation of the osteotomy site was done with wires in 59 patients and miniplates and screws in 76 patients. The duration of follow-up ranged from 1 to 5 years. No difference in complications or bony union was observed in patients who underwent repair with wires or miniplates. Due to the number of surgeons and their preferences for different types of osteotomies, as well as the differences in surgical techniques, we further studied the 2 methods of fixation employed by 1 surgeon who performed notched osteotomies on all of his patients (56 patients). Twenty-two underwent repair with wires, and 34 with miniplates. Four patients with wires and seven with miniplates developed wound complications requiring removal of wires in two and miniplates in one. Delayed union or nonunion was not observed in any patient. Fixation with wires or miniplates is equally satisfactory as long as adequate immobilization of the mandibular segments is achieved.

Management of occult neck metastases in oral cavity squamous carcinoma

A large experience with patients who had radical neck dissection for oral squamous carcinoma has been reviewed in order to compare elective lymphadenectomy results with those achieved when neck dissection was delayed until metastases appeared or was performed initially for limited N1 neck disease. No significant difference in survival rates was observed, but neck failure was a more significant problem when treatment was delayed. This was most obvious in patients treated for tongue cancer. Although the impact of elective neck treatment on "cure" rates will require prospective studies, it seems clear that elective lymphadenectomy can enhance regional control of cancer and improve the quality of the patients' survival.

Improved survival in the treatment of squamous carcinoma of the oral tongue

During the past 15 years, newer trends in the management of oral tongue cancer have included increased use of elective neck dissection and mandible-sparing procedures, as well as a commitment to postoperative radiotherapy in patients with stage III and IV tumors. We retrospectively reviewed the records of 297 consecutive patients who underwent primary treatment of a squamous cancer of the oral tongue at our institution between 1978 and 1987 to determine the effects of the aforementioned therapeutic approaches on patients' survival. Determinate 5-year survival was 65% overall (82% for stages I and II, 49% for stages III and IV), which represents a significant improvement when compared with the survival rates we reported for the preceding 10-year period, despite the fact that the distribution of patients according to stage was about the same. Some type of lymphadenectomy was performed in 130 patients, 63 of whom underwent elective node dissection for T1 or T2 lesions. Forty-one percent of the latter had positive nodes, which upstaged the disease in a significant proportion of N0 patients. The number of positive nodes (more than two positive nodes) was a significant predictor of survival (p = 0.03). Postoperative radiotherapy was performed in 70% of patients with stage III or IV tumors. In this group of patients, the incidence of neck recurrence was reduced (13% versus 29% for patients who did not receive radiotherapy). The only long-term survivors among patients with stage IV tumors were those who received postoperative radiotherapy. Our results strongly suggest that the improvement in results is related to a more aggressive and effective treatment of the neck.

Selective jugular node dissection in patients with squamous carcinoma of the larynx or pharynx

We reviewed our experience with 66 patients who had 85 jugular node dissections (JND) between 1984 and 1991. When JND was used as a staging procedure in 56 patients with N0 squamous carcinoma of the larynx or hypopharynx, it identified 15 of 19 patients (79%) who had occult metastases. The pattern of neck failure in six patients after JND strongly suggests that the dissection must be carried posterior to the internal jugular vein in order to achieve adequate sampling. Neck failure was a relatively minor problem in this patient population, and the indications for elective JND may be less than compelling in most patients with N0 class laryngeal or pharyngeal squamous carcinomas. Our very limited experience with JND for resection of N1 disease supports a growing consensus that limited lymphadenectomy and aggressive radiotherapy may yield comparable results in carefully selected patients with palpable metastases. Obviously, these are issues that can only be resolved by prospective, randomized studies.

Posterior triangle metastases of squamous cell carcinoma of the upper aerodigestive tract

The trend toward function-conserving surgery in the treatment of squamous cell carcinoma of the head and neck has led to a progression from radical neck dissection to modified neck dissection and selective neck dissection has growing support. These surgical modifications have resulted from an effort to spare structures uninvolved with malignancy. Level V dissection can be associated with spinal accessory dysfunction in some patients even when the nerve remains intact. In this study, we have attempted to address the need for level V dissection by determining the prevalence of level V metastases in a large series of patients undergoing radical neck dissection. There were 1,123 patients who underwent 1,277 neck dissections between 1965 and 1986. A review of pathologic and clinical records revealed 40 patients (3%) with positive nodes at level V. The prevalence of level V metastases was greatest with hypopharynx and oropharynx primary tumors (7% and 6%, respectively). Level V metastases were found in 1% of patients with oral cancers and 2% of those with larynx cancers. Groups were divided into N0 (282), N+ (719), and subsequent N+ (276), depending on the clinical status at the time of surgery. Thirty-seven of 40 patients with posterior triangle metastases were clinically N+. The prevalence of metastases at level V was 1% for N0, 5% for N+, and 0% for subsequent N+. This large series shows minimal involvement of metastases at level V. The low likelihood of metastases at level V, even in N+ disease, should be considered when performing lymphadenectomy for squamous cell carcinoma of the upper aerodigestive tract.

Innervation of the trapezius muscle by the intra-operative measurement of motor action potentials

Although the surgical anatomy of the spinal accessory nerve and the cervical plexus has been extensively described, the exact motor innervation of the trapezius has been controversial. Attempts to resolve this question have involved anatomic or electrophysiologic studies in human embryos and animals. Extrapolation of the results to adult humans may not be correct. Accurate identification of muscle innervation is obtainable by intra-operative measurement of motor action potentials produced by direct stimulation of the accessory nerve and the cervical plexus. The study involved 14 patients undergoing supraomohyoid or modified neck dissections. Under direct vision, stimulating electrodes were placed on the identified nerves and motor action potentials, and latencies were recorded by surface electrodes placed over the three portions of the trapezius. In 13 patients, when the accessory nerve was stimulated, motor action potentials were obtained in 13 of 13 in the first portion, 11 of 13 in the second portion, and 10 of 13 in the third portion of the trapezius. In the last patient, the accessory nerve ended in the sternocleidomastoid muscle, and innervation of the trapezius was via C3 as demonstrated by motor action potentials. Responses when the roots of the cervical plexus were stimulated varied. Three patterns were seen: In the first group (seven patients), motor action potentials were distinct from those recorded when the accessory nerve was stimulated. Additionally, latencies were different from those of the accessory nerve. The second group (four patients) had motor action potentials that were similar to those obtained from stimulation of the accessory nerve, although their corresponding latencies were different.(ABSTRACT TRUNCATED AT 250 WORDS)

Postoperative radiation therapy for squamous cell carcinomas of the oral cavity and oropharynx: impact of therapy on patients with positive surgical margins

PURPOSE

The presence of a positive or close margin after resection of a squamous cancer of the head and neck is associated with a significant risk of local recurrence. To determine the efficacy of postoperative radiation therapy for patients with advanced oral cavity and oropharyngeal cancers with inadequate margins of resection, the present retrospective analysis was undertaken.

METHODS AND MATERIALS

One hundred and two patients were treated with surgery and postoperative radiation therapy for advanced squamous cell carcinomas of the oral cavity and oropharynx. The anatomic subsites treated include oral tongue (n = 29), floor of mouth (n = 22), base of tongue (n = 31) and tonsillar fossa (n = 20). Twenty-five patients (25%) had positive margins, 41 patients (40%) had close margins (< or = 0.5 cm from the surgical margin) and 36 (35%) had negative margins. The median radiation dose was 6000 cGy.

RESULTS

With a median follow-up of 7 years, the actuarial control rate for patients with positive, close and negative margins was 79%, 71%, and 79%, respectively. When postoperative doses of > or = 60 Gy were delivered to patients with positive/close margins (excluding patients with oral tongue lesions), the 7-year actuarial control was 92%. In similar patients receiving < 60 Gy, the actuarial control was 44% (p = 0.0007). Compared to other anatomic subsites, inferior control rates were obtained with oral tongue lesions. For this subsite, the control rates for positive, close, and negative margins were 50%, 62% and 69% respectively.

CONCLUSION

We conclude that excellent local control can be achieved with postoperative radiation therapy, despite the presence of inadequate margins of resection, when doses of > or = 60 Gy are used. Future strategies must be directed at further improving these results in patients with oral tongue lesions.

Prognostic factors in differentiated carcinoma of the thyroid gland

A retrospective review of a consecutive series of 931 previously untreated patients with differentiated thyroid carcinoma treated over a 50-year period was undertaken to analyze prognostic factors. Data pertaining to demographic status, clinical, operative, and pathologic findings, and survival were analyzed. Univariate statistical analysis was performed based on the Kaplan-Meier method and the log-rank test. Multivariate analysis was performed to assess the independent effect of these variables using the Cox model. There were 630 female and 301 male patients, with an average age of 43 years. A total of 532 patients were younger than 45 years. Seven hundred thirty-one patients had either pure or mixed papillary carcinoma, and 200 had follicular carcinoma. In 153 patients, lesions were larger than 4 cm. Extrathyroidal extension was noted in 71 patients. Multifocal lesions were present in 159 patients. Regional lymph node metastasis was present on admission in 451 patients, and distant metastases were noted on presentation in 45 patients. Determinate survival for all patients was 87% at 10 years. Favorable prognostic factors using univariate analysis included female gender, multifocal primary tumors, and regional lymph node metastases. Adverse prognostic factors included age over 45 years, follicular histology, extrathyroidal extension, tumor size exceeding 4 cm, and the presence of distant metastases. On multivariate analysis, the only factors that affected the prognosis were patient age, histology, tumor size, extrathyroidal extension, and distant metastases. These observations support findings of reports from the Mayo Clinic and Lahey Clinic regarding the significance of prognostic factors for differentiated carcinoma of the thyroid gland.