Management of cervical lymph node metastases in squamous cell carcinoma of the tonsillar fossa, base of tongue, supraglottic larynx, and hypopharynx

Combined radiotherapy and surgery in the treatment of neck node metastases from squamous cell carcinoma of the head and neck

A prospectively recorded series of 107 patients with clinical neck node metastases from head and neck squamous cell carcinomas, treated in 1983-1988, and with initial local control, is evaluated. Eighty-eight patients received preoperative, and were operated 4-6 weeks after radiotherapy, and 19 received postoperative radiotherapy. Forty-four of the neck specimens in the preoperatively treated patients showed vital tumor tissue, 7 with positive and 37 with negative resection margins. Nine of the latter 37 patients died due to regional recurrence. Twenty-three of the preoperatively treated patients had no palpable residual tumor following radiotherapy, but histological examination showed vital tumor tissue in five, of whom two had N1 neck disease. The overall regional failure rate was 19%. Eleven patients (10%) died from local recurrence and 11 from distant metastases. Forty-one patients (38%) are alive without evidence of disease and three (3%) alive with disease (mean observation time 30 months). Combined treatment is recommended for all cases of neck node metastases.

The influence of dose and time on wound complications following post-radiation neck dissection

Data on 205 patients who were treated with a planned unilateral neck dissection following radiation therapy were analyzed with the purpose of understanding how treatment factors affect the incidence of wound complications. There were 27 occurrences of wound complication in the patient series. Logistic regression was used to analyze the data. We found that the surgical technique of flap reconstruction gave a significant increase in wound complications. There was a suggestion, although not statistically significant, that higher total doses increased the complication rate, that lower fraction sizes reduced the complication rate, and that longer overall radiotherapy treatment times were associated with higher complication rates. There was no association between the incidence of complications and the time interval between the end of radiotherapy and surgery.

Advances in radiation therapy for head and neck cancer

Radiation therapy either as a single modality or as part of multimodality plans remains an integral part of curative treatment for cancers of the head and neck. This paper traces the modernization of radiation therapy regarding tumors of the head and neck using examples of sites of malignancy where radiation therapy is the sole modality or where radiation therapy can be combined with surgery and chemotherapy for optimal results. As local-regional control rates have improved with the use of combined radiation therapy and surgery and aggressive hyperfractionation schemes for advanced primary tumors, distant metastases and second primary neoplasms are now accounting for a larger proportion of treatment failures. Until such time as more effective systemic therapy and cancer control mechanisms are developed to address these problems, radiation therapy will continue to play a major role in the overall management of patients with cancers of the head and neck.

Radical neck dissection: a 19-year experience

A series of 394 radical neck dissections performed over the 17 year period 1969-1986 is presented. The shortest period of follow-up is two years. Of the major complications reviewed, wound breakdown was associated with T stage, prior radiotherapy and incision used but not with age or N stage. Cervical recurrence was associated with N stage, prior radiotherapy and surgical incision and inversely associated with age. Wound breakdown and recurrence were lowest in parotid primary tumours. Carotid artery rupture occurred in 17 patients (4.3 per cent), was fatal in all cases and was strongly associated with wound breakdown and previous radiotherapy. The importance of the choice of incision, clearance of the posterior belly of the digastric muscle and carotid artery protection are discussed.

Radical radiation alone versus radical radiation plus microwave hyperthermia for N3 (TNM-UICC) neck nodes: a prospective randomized clinical trial

Between September 1985 and December 1986, 44 N3 (TNM-UICC) metastatic squamous cell cervical lymph-nodes were randomized to receive conventionally fractionated radical irradiation (RT) to a total dose of 64-70 Gy, or conventionally fractionated radical irradiation plus twice a week local microwave hyperthermia (Ht). The two major end points of this study were (a) local control rates evaluated at 3 months after the end of combined therapy and (b) incidence of acute local toxicity. Thirty-six nodes (82%) were evaluable as of December 1986, at which time there was a premature closure of this study due to ethical reasons. An interim analysis had revealed a statistically significant difference in complete response rates in favor of the combined arm (p = 0.0152). The complete response rates were 82.3% (14/17) for the combined treatment arm versus 36.8% (7/19) for the control irradiation arm, leading to an iso-dose thermal enhancement ratio (TER) value of 2.23. Both arms are comparable in average total RT dose delivered (RT: 67.05 Gy; RT + Ht: 67.85 Gy) and in average maximum node diameter (RT arm: 4.81 cm; RT + Ht: 4.88 cm). Acute local toxicities were similar in irradiated and heated plus irradiated neck regions; only one skin burn was observed. As possible treatment related death, one patient in the RT + Ht arm died 2 months after completion of therapy with a carotid rupture associated with extensive tumor necrosis. These results confirm previous non-randomized reports suggesting that hyperthermia in combination with full dose conventionally fractionated irradiation significantly enhances the chance of early local control of fixed N3 neck nodes without exhibiting an increase of acute local toxicity.

Squamous cell carcinoma of the head and neck treated with radiotherapy: does planned neck dissection reduce the change for successful surgical management of subsequent local recurrence?

For patients with squamous cell carcinoma of the head and neck whose primary lesion is managed with radiotherapy, radiotherapy alone or in combination with neck dissection may be used to treat clinically positive neck nodes. Although these two treatment options produce similar control rates for small mobile nodes, it is our impression that radiotherapy plus neck dissection is the preferred treatment for more advanced neck disease. The question that arises is whether the addition of a neck dissection after radiotherapy will decrease the likelihood of successful surgical management of a subsequent recurrence at the primary site. In an effort to answer this question, the records of 227 patients with squamous cell carcinoma of the head and neck were reviewed. All patients had clinically positive neck nodes and were treated with radiotherapy alone to the primary lesion. There was no apparent difference in the rate of disease control at the primary site or in the ability to manage patients successfully who developed a local recurrence when comparing patients initially treated with radiotherapy alone to those managed by radiotherapy and neck dissection. We conclude that postradiotherapy neck dissection does not decrease the likelihood of successfully managing a recurrence at the primary site.

Primary radiotherapy of squamous cell carcinoma of the oropharynx and pharyngolarynx: tentative multivariate modelling system to predict the radiocurability of neck nodes

In a series of 1251 cases of squamous cell carcinomas of oropharynx and pharyngolarynx with clinically positive neck and treated primarily by radiation therapy a determinate group of 798 cases remained eligible for a multivariate analysis of the prognostic factors related to the regional outcome. Node size (p less than 0.0001), node fixity (p = 0.016) and T stage (p = 0.02) were the significant pretreatment factors independently predictive of neck node control. when regarding the treatment modalities in this determinate group of patients who received tumor doses of at least 55 Gy, only the treatment duration was found to be predictive (p = 0.002). Based on these factors, a multivariate model was constructed and tested by estimating the product-limit survival of the various groups of patients. The predictive accuracy of the equation was assessed by the log-rank test significance levels. The model may help to select, in many clinical situations, the appropriate approach of the management of metastatic neck disease, either by definitive radiation therapy or by combined modalities.

The prognostic significance of lymph node involvement in pyriform sinus and supraglottic cancers

Three hundred and thirty-three patients with carcinoma of the pyriform sinus or supraglottis were reviewed with regard to lymph node involvement and prognosis. All patients were treated with curative intent and had a minimum follow-up of 3 years. Every patient was restaged according to the AJCC, 1983 recommendations. In addition, nodal fixation to cervical fascia or muscle was evaluated with regard to prognosis. Seventy-five percent (89/119) of the pyriform sinus cancer and 47% (101/214) of the supraglottic cancer patients presented with clinically palpable cervical nodes. The distribution of patients according to N stage was 143 (43%), 84 (25%), 58 (17%), 48 (14%) for N0, N1, N2, N3 respectively. In patients where information on nodal fixation was available, 29% had fixed nodes. No difference in prognosis was noted between N0 and N1 or N2 and N3 stages, and these groups were therefore combined. The 3-year survival was 85% for T1 (N0/N1), 77% for T2 (N0/N1), 63% for T3 (N0/N1), and 65% for T4 (N0/N1) cases compared to 19% for T1 (N2/N3), 34% for T2 (N2/N3), 33% for T3 (N2/N3), and 32% for T4 (N2/N3) cases demonstrating that N stage predominates over T stage with respect to survival. Both the local recurrences and distant metastases increased as N stage advanced. A noteworthy difference between patients with fixed nodes and mobile nodes was found with regard to neck recurrence (35% versus 17%), distant metastases (33% versus 19%) and survival (27% versus 58%). In conclusion, nodal stage is a highly significant determinant of survival independent of T stage in cancers of the pyriform sinus and supraglottis. N0, N1 status and mobility were predictive of a favorable prognosis as opposed to N2, N3 status and fixation. These findings were consistent when the pyriform sinus cancers and supraglottic cancers were analyzed separately.

Current status of neck dissection in the management of squamous carcinoma of the head and neck

Classical radical neck dissection (RND) remains the primary treatment for clinically positive lymph nodes among patients with squamous carcinoma of the upper aerodigestive tract. Recurrence rates following RND range from 20 to 70% depending on the number of nodes involved and the extent of extracapsular spread. Modified radical neck dissection (MRND) is associated with less cosmetic and functional morbidity than RND but, used alone, MRND is only appropriate when clinical neck disease is absent or minimal. Both RND and MRND should be combined with adjuvant postoperative radiotherapy when more than one node is positive or extracapsular spread is present. This approach will significantly decrease regional failure, but may not improve survival because of an increased incidence of distant metastases. MRND is especially useful as an elective procedure to stage the clinically negative neck. A survival benefit from elective neck dissection, however, remains to be demonstrated.

The effectiveness of treatment of lymph nodes in cancers of the pyriform sinus and supraglottis

Three hundred and twelve patients with pyriform sinus or supraglottic cancer were reviewed with respect to effectiveness of therapy upon nodal control. All patients had a minimum 3-year follow-up. Combined modality therapy (radiotherapy and surgery) conferred a higher neck control rate for both N0/N1 and N2/N3 nodes than moderate dose (50 to 60 Gy) radiotherapy alone. Neck dissection appeared to be a significant component of therapy for all neck stages. Fixed nodes, a subset of N2/N3 disease with a very poor prognosis, required combined modality therapy for the best nodal control rates. Downstaging to pN0 with preoperative radiotherapy provided superior nodal control and survival rates.

Achievement of superior survival for histologically negative versus histologically positive clinically complete responders to cisplatin combination in patients with locally advanced head and neck cancer

In a series of three consecutive pilot studies conducted between 1977 and 1982 at Wayne State University, Detroit, Michigan, 191 consecutive patients with previously untreated, locally advanced head and neck cancer were treated with cisplatin (CDDP), vincristine, and bleomycin or CDDP and 5-fluorouracil (5-FU) infusion before definite surgery or radiation. A 39% (75/191) rate of complete clinical responses was achieved. Thirty-two of the chemotherapy-induced complete responders underwent radical surgery. Thirteen had no histologic evidence of residual disease in the surgically resected specimen. The CDDP and 5-FU infusion combination achieved the highest histologic complete response rate. All histologically complete responders who had completed local radiation therapy are clinically free of disease at median follow-up of 36 months. Patients who achieved complete response both clinically and histologically had superior survival as compared to patients who achieved complete response clinically and were subsequently found to have residual tumor in their surgically resected specimen (P = 0.01). An analysis of the clinical and pathological pretreatment characteristics was performed to identify factors predictive of histologic complete response. Advanced nodal disease correlated inversely with the achievement of negative histology in the surgically resected specimen (P = 0.02). No other factors were significant in predicting response.

A method of radiation treatment for advanced neck node metastases

Thirty-one advanced cervical node metastases (staged N3 according the U.I.C.C. system; 4 N2A, 27N3A according the A.J.C. system) were treated using a particular schedule consisting in two courses: in the first, only the palpable tumor was irradiated with several low energy beams (3.3 mm Al HVL), using as X ray tube operated at 60 kV; in the second course, the whole lymphatic area was treated with 60 Co and conventional fractionation. Palpable disease received 7500 to 10,500 cGy in a overall time of 45-55 days. The local control rate was 87%, without any severe complication. The four (13%) failures were all related to the lowest dose levels.

Neck dissection with and without radiotherapy: prognostic factors, patterns of recurrence, and survival

A group of 179 patients who had 205 neck dissections between 1979 and 1984 has been reviewed to assess the influence of adjuvant radiotherapy on survival. Lymph nodes were histologically involved in 91 of 107 radical neck dissections (85 percent) and 55 of 98 modified neck dissections (56 percent). Eighty-two patients received adjuvant radiotherapy of 5,000 rads or more. Patients with involved nodes had significantly lower survival rates than those with uninvolved nodes. Among patients with involved nodes, survival was significantly lower when two or more nodes were involved, when there was nodal involvement at multiple levels, or when extracapsular spread was present. Adjuvant radiotherapy was associated with a reduced recurrence rate in the ipsilateral neck but the incidence of distant metastases was higher. When patients with involved nodes were subgrouped according to prognostic factors, the survival of irradiated patients was improved only in the highest risk group, but this was not statistically significant. When radiotherapy is added to neck dissection for treatment of cervical metastases it can be expected to reduced ipsilateral neck recurrence and prevent relapse in the contralateral neck. Improved survival may depend on an ability to detect and treat occult distant metastases.

Regional outcome in oropharyngeal and pharyngolaryngeal cancer treated with high dose per fraction radiotherapy. Analysis of neck disease response in 1646 cases

Out of a series of 1666 consecutive patients with squamous cell carcinoma of oropharynx and pharyngolarynx, 1646 were evaluable at a 3-year interval following radical radiation therapy. The actuarial 3-year nodal control rate using the AJC classification was: N0 98%, N1 90%, N2 88%, N3 71% when the primary was controlled. The regional outcome is influenced by clinical features such as nodal size, multiplicity and fixity. Cervical recurrence frequency is higher for pharyngolaryngeal carcinoma than for oropharyngeal cancer. The impact of the treatment planning on regional control is discussed. Due to the of concomitant boosting of nodes, cervical metastases were treated according to a type of accelerated fractionation schedule with weekly doses of 12-15 Gy for a total of 70-85 Gy in 75% of the cases. Clear-cut dose control relationships are demonstrated for nodes larger than 3 cm in diameter. Overboosting residual cervical disease fails to yield a better nodal control. Comparative analysis is established between results obtained with this high dose per fraction radiotherapy schedule, conventional regimens of irradiation and other new approaches, combining chemical and physical agents. Therapeutic implications are also derived to define adequate field coverage.

Salvage surgery for recurrent neck carcinoma after multimodality therapy

Recurrent carcinoma of the neck after treatment by radical neck dissection and radiotherapy leads to a progressive downhill course if no further therapy is instituted. Nine such patients having fixed, recurrent neck tumors with carotid artery involvement underwent 10 salvage procedures with carotid artery resection and replacement. One patient developed a transient hemiparesis that resolved in 3 days, and in another, a permanent hemiparesis occurred. Three patients have survived longer than 12 months. One patient is free of disease at 42 months following two salvage operations. We attribute the low operative morbidity to the frequent use of the subclavian artery for proximal anastomosis and myocutaneous flaps to resurface cutaneous and mucosal defects. We conclude that salvage surgery with carotid artery replacement can be performed on selected patients who have failed combined therapy as a palliative and possibly curative measure.

Squamous cell carcinoma of the head and neck treated with radiation therapy: the role of neck dissection for clinically positive neck nodes

This is an analysis of 161 patients with squamous cell carcinoma of the head and neck treated with irradiation to the primary site and neck followed by a neck dissection(s) for clinically positive neck nodes. Patients were treated between October 1964 and December 1982; there was a minimum 2-year follow-up. Fifty-two patients were deleted from analysis of neck disease control because they died of intercurrent disease or cancer less than 2 years from treatment with the neck continuously disease-free. All patients are included in the analysis of complications. Neck disease control rate was the same for radiation plus neck dissection or radiation therapy alone for solitary nodes less than 3 cm. As the size and number of nodes increased, there was a higher rate of neck disease control for combined treatment as compared with irradiation alone. The neck disease control rate, size for size, was lower for patients with fixed nodes and for those with residual tumor in the pathologic specimen. There was no difference in neck disease control as a function of the interval between irradiation and neck dissection. For nodes less than or equal to 6 cm, a minimum node dose of 5000 rad appeared to be sufficient for control, whereas for nodes greater than 6 cm, at least 6000 rad appeared to be required for optimal control. Fixed nodes required a higher dose compared to mobile masses. The incidence of postoperative complications was increased with maximum subcutaneous doses of greater than or equal to 6000 rad. There was also an increased incidence of postoperative complications for patients undergoing simultaneous, as compared with staged, bilateral neck dissection.

Elective neck irradiation for squamous cell carcinoma of the head and neck: analysis of time-dose factors and causes of failure

This is an analysis of 190 patients who were treated with radiation therapy alone at the University of Florida, between October 1964 and December 1982, for T1-4 N0 squamous cell carcinoma of the head and neck; in all patients, the primary lesion was permanently controlled and the neck was evaluable for at least 2 years following radiation therapy. The control of neck node disease is analyzed as a function of elective neck irradiation, the dose of radiation delivered to the first-echelon lymph nodes, and the likelihood that occult disease was present in the neck prior to treatment.

N3 (TNM-UICC) metastatic neck nodes managed by combined radiation therapy and hyperthermia: clinical results and analysis of treatment parameters

In an attempt to improve the control of N3 (TNM-UICC) fixed and inoperable metastatic nodes, local microwave hyperthermia (HT) was combined with radiation therapy (RT). From February 1981 to January 1985, 34 patients, with N3 metastatic nodes from primary tumours in the head and neck, were treated according to two different prospective, non-randomized protocols: 23 patients received HT combined with the first course of conventionally fractionated radical RT (40 Gy + HT--2 week interval--20-30 Gy), and 11 patients received HT combined with palliative RT (20-50 Gy + HT). All the patients were treated with the same microwave applicator (MA-150) on the BSD-1000 unit, at a frequency of 280-300 MHz. Temperatures were measured by means of 2-3 Bowman probes placed within the tumour (core and periphery) and 5-6 probes on the skin surface. HT sessions were delivered after RT (less than 20 min), 2 or 3 times weekly, for a duration of 30 min after steady-state temperatures were obtained. Twenty-seven patients out of 34 were evaluable, with a follow-up of at least 3 months (range 3-39 months; median 10 months). Clinical results at 3 months revealed 59 per cent complete responses, 30 per cent partial responses, and 11 per cent with progressive disease. Analyses of response rates showed: a marginally significant difference (P = 0.095) between RT alone (historical control) and the entire group of patients treated with RT plus HT; a significant difference (P = 0.034) if RT alone is compared with Protocol A (RT greater than or equal to 60 Gy + HT); no significant difference between the two protocols employing HT, despite the different RT doses utilized; no significant differences in response rates, as a function of minimal intratumoural temperatures achieved, number of weekly HT sessions or total number of HT sessions; and a significantly lower response rate for nodes with maximum diameter greater than 6 cm (P = 0.043). No important differences in acute side effects between irradiated and heated regions in the same patient were noted. Late side effects in patients treated with RT plus HT included three cases (9 per cent) of severe fibrosis, possibly as a consequence of excessive maximum tumour temperature (greater than 46 degrees C).

Transcapsular spread of metastatic squamous cell carcinoma from cervical lymph nodes

The incidence, extent, and selected clinicopathologic correlations of transcapsular spread from metastatic tumor in the cervical lymph nodes have been investigated in 210 specimens obtained by radical neck dissection from 203 patients with squamous cell carcinomas of the head and neck. Transcapsular spread was detected in 137 of 159 (86 percent) positive specimens, and classified as macroscopic in 74 (54 percent) and microscopic in 63 (46 percent). Macroscopic transcapsular spread was seen most frequently in association with large nodal masses more than 3 cm in diameter (48 of 70 specimens, 69 percent), but also occurred in some specimens with smaller lymph nodes less than 3 cm in diameter (26 of 67 specimens, 39 percent). Anatomic structures most commonly invaded in areas of neck dissection with macroscopic spread from nodal metastases were skeletal muscle (39 dissections) and the adventitial coat of the internal jugular vein (27 dissections). Macroscopic transcapsular infiltration was associated with a high incidence (44 percent) of recurrent tumor in the ipsilateral neck, particularly within 12 months of surgery. Microscopic transcapsular growth was associated with a lower incidence (25 percent) of recurrent tumor in the ipsilateral neck but the difference did not reach statistical significance. Similar recurrence figures (32 percent) were found in the minority of patients whose nodal disease was intracapsular at the time of neck dissection. More precise definition of the morphologic extent of transcapsular spread could be important in clarifying its clinicopathologic correlations.

Improved complete response rate and survival in advanced head and neck cancer after three-course induction therapy with 120-hour 5-FU infusion and cisplatin

In a series of three consecutive pilot studies carried out between 1977 and 1981 at Wayne State University, Detroit, Michigan, designed to test the feasibility of multimodality therapy in patients with previously untreated advanced squamous cell carcinoma of the head and neck, patients received three different induction chemotherapy regimens: cisplatin + Oncovin (vincristine) + bleomycin (COB) for two courses; 96-hour 5-fluorouracil (5-FU) infusion and cisplatin for two courses, or 120-hour 5-FU infusion + cisplatin for three courses. Over-all response rates (complete response + partial response) to each of the three induction chemotherapy regimens were high: 80%, 88%, and 93%, respectively. Superior complete response rate in the group receiving three courses of 120-hour 5-FU infusion + cisplatin was 54% versus 29% for COB and 19% for two-course 96-hour 5-FU infusion + cisplatin (P = 0.04). Significant survival advantage at 18 months minimum follow-up for the group receiving three courses of 120-hour 5-FU + cisplatin induction therapy was found. Actual T and N stage may influence the clinical complete response rate. Responders to initial chemotherapy have significantly better survival as compared to nonresponders regardless of subsequent surgery and/or radiotherapy. These studies show that a multimodality approach to management of advanced head and neck cancer is feasible. Superior complete response rate and survival in one of the treatment groups suggest that choice of induction chemotherapy regimens and/or number of courses is of prime importance in such multimodality treatment programs.

Superior clinical response and survival rates with initial bolus of cisplatin and 120 hour infusion of 5-fluorouracil before definitive therapy for locally advanced head and neck cancer

One hundred ninety-one patients were treated by one of three cisplatin-containing multidrug protocols. The initial 77 patients received two courses of cisplatin and vincristine plus bleomycin. The next 26 patients received two courses of 5-fluorouracil and cisplatin, and the final 88 patients were placed on a three course 5-fluorouracil and cisplatin protocol. Overall response rates were similar for each of the three protocols. The complete response rate, however, was much better (54 percent) for three course 5-fluorouracil and cisplatin versus cisplatin vincristine, and bleomycin (29 percent) and two course 5-fluorouracil and cisplatin (19 percent). Survival curves were also better for the three course 5-fluorouracil and cisplatin segment of this nonrandomized pilot study.

Analysis of time-dose factors in clinically positive neck nodes treated with irradiation alone in squamous cell carcinoma of the head and neck

This is a retrospective analysis of time-dose factors in 139 patients with 238 evaluable clinically positive lymph nodes treated with external beam radiation therapy alone to the primary lesion and neck for squamous cell carcinoma of the head and neck at the University of Florida from October 1964 through April 1980. Lymph node control by lymph node size was 8/8 (100%) for less than 1.0 cm, 51/62 (82%) for 1.0 cm, 68/82 (83%) for 1.5-2.0 cm, 24/40 (60%) for 2.5-3.0 cm, 24/38 (63%) for 3.5-6.0 cm, and 0/8 (0%) for greater than or equal to 7.0 cm. Lymph node control was also influenced by dose, overall treatment time, and fractionation schedule; these factors were interrelated and appeared to increase in importance as the size of the lymph node increased.

Lucy Wortham James Lecture. Subclinical disease

A number of patients with cancer later develop metastases in the draining lymphatics, which initially were clinically negative. These occult deposits represent subclinical disease in lymphatic areas accessible to palpation, like the neck, axillae, and groin. The concept applies also to the microscopic disease left in an area after a surgical procedure is known to have removed all gross cancer, yet some patients later develop a recurrence. The term "subclinical disease" refers only to disease in a specific anatomic area, based on clinical facts. Radiobiological parameters account for the fact that subclinical disease requires less irradiation to be eradicated than gross cancer. The concept has two main applications, elective irradiation of clinically negative peripheral lymphatics and locoregional irradiation combined with surgery, which are determined by site and disease. The concept of subclinical disease also has implications for chemotherapy, which bear a direct relationship between chemotherapy both with radiation therapy and surgery.

The fixed cervical lymph node

A series of almost 2000 patients with squamous carcinoma of the head and neck is presented. Seven percent of the patients had massive fixed glands at the time of presentation. The incidence of fixed nodes varied between sites, and increased with increasing T-stage of the primary tumor. Forty percent of the patients were treated; the most common cause for withholding treatment was advanced age. Radiotherapy did not produce a significant prolongation of survival, but surgery did. Resection of the mandible, the skin of the neck, and the external carotid artery proved to be valuable procedures both in terms of palliation and survival; radical surgery produced a 5-year survival of approximately 15%.

Current concepts in radiotherapy and their impact on oncology

The constant emphasis on the need for breakthroughs and new modalities of treatments seems to imply that nothing has been achieved, and unless new beams or radiation sensitizers or whatever are discovered, radiation therapy is ineffective. A great amount of information has been acquired in the past 20 years, and innumerable treatment schemes are being used with doubtful outcomes. The fact that patients are at high risk for development of distant metastases is irrelevant if one does not have a treatment that is effective. Multimodality treatments are very popular, but multimodality per se does not make a treatment effective. Medical research is anxious for early and repeated milestones. Cancer is a disease that requires follow-up and, in some areas, like breast cancer, a long follow-up. Baclesse, the great radiotherapist from the Curie Foundation, used to say in his teaching clinics that he was working for the next generation. Radiotherapy exists within the framework of medical practice. To emphasize systemic treatments because of the possibility of distant metastases and, by so doing, to deemphasize freedom of disease in the local area leads to abandoning methods of treatment that have proved effective for control of local-regional disease. An example is the abandonment of postoperative irradiation following mastectomy. It is not disputed that it achieves a very high degree of local and regional control, but it is disputed that it increases survival. Survival benefits with elective chemotherapy are marginally proved in small subsets of patients but do not demonstrably affect the survival rates of the overall population, and there is very little information concerning the local-regional control with elective chemotherapy. Survival benefits are not the only criteria of usefulness of a treatment. Gross recurrence is more difficult to eradicate than subclinical disease by elective irradiation, and there are a number of publications on the poor control of local-regional recurrences in breast cancer. Furthermore, some recurrences, such as invasion of the brachial plexus, are intractable to treatment; recurrences on the chest wall present a terrible problem of management as well as make the patient absolutely miserable prior to death. The present knowledge, primarily of the combination of radiation and surgery in certain diseases, is not applied except to a very small segment of the cancer patient population. The spread of information and the increased use of effective methods should be encouraged.

The value of postoperative radiotherapy as an adjuvant to radical neck dissection

In this study the results of combined radiotherapy and surgery are compared with the results of surgery alone in patients with neck node metastases from squamous cell carcinomas of the head and neck region. Postoperative radiotherapy decreases the recurrence rate in the neck, especially in cases with histologically established extranodal spread. Results of preoperative radiotherapy were similar to those of irradiation after surgery. Postoperative radiotherapy is favored, because it allows a selection of patients for extra treatment on the base of prognostic information, provided by the histologic characteristics of the neck dissection specimen.

Fixed, bilateral cervical nodes

A series of 1,726 previously untreated patients with squamous carcinoma of the Head and Neck is presented. 64 patients (3.7 per cent) had bilateral mobile nodes in the neck (N2). 128 (7.4 per cent) had unilateral fixed nodes (N3) and 24 (1.4 per cent) had bilateral nodes, one or more of which were fixed ('N4'). The N2 and N4 groups were similar with respect to the characteristics of the patient and his tumour such as primary site, etc., but the N3 group differed significantly: more patients were in poor general health and this group contained almost all the patients with no known primary tumour. The proportion of patients treated fell from 75 per cent for N2 to 47 per cent for N3 and 25 per cent for N4. The survival fell significantly with N stage: at one year the survivals were respectively 44 per cent, 30 per cent and 6 per cent. Very few patients in the N4 group survive to one year, and it is doubtful if this group should be treated at all.

The value of combining radiotherapy with surgery in the treatment of hypopharyngeal and laryngeal cancers

Two-hundred and six cases of hypopharyngeal and laryngeal squamous cell carcinoma treated at the Institut Gustave-Roussy were retrospectively analyzed. All of them were treated by surgery and they were divided into three therapeutic groups following the adjuvant radiotherapy: (A) Postoperative radiotherapy at doses equal to or greater than 4500 rad; (B) Postoperative radiotherapy at doses less than 4500 rad; and (C) Preoperative irradiation at doses less than 4500 rad. Group A included a greater proportion of patients with hypopharyngeal cancer and patients with advanced tumors (T3, T4; N1b, N2, N3). However, the local and regional control rate in this group is significantly higher than those of the other groups in spite of the poor prognostic factors. The survival rate is comparable in all the three groups, with distant metastases more frequently found in group A. The results showing a significant improvement in lymph node control with postoperative radiotherapy, this adjuvant therapy is used systematically in this center in patients being operated on for hypopharyngeal and laryngeal cancer with incomplete histologically defined resection and/or with lymph nodes histologically involved.

The prognostic relevance of various factors at the time of the first admission of the patient. Retrospective DOSAK study on carcinoma of the oral cavity

In a retrospective study, on a sample of 1021 patients with carcinoma of the lips, oral cavity and oropharynx, the clinically available factors at the time of the patient's first admission are analysed with reference to their prognostic relevance. Prognostically relevant factors are determined by both univariate and multivariate analyses. Of the 18 factors analysed, the following seven finally proved to be prognostically relevant: tumour size, degree of infiltration, degree of histological differentiation and site by organ of the primary tumour, the combination of evidence + clinical appearance + degree of fixation of the regional lymph nodes, age of the patient, and evidence of distant metastases. On the basis of these results it will be possible to create a prognostic index. This prognostic index should be eligible for use in clinical practice, as opposed to usual classification models.

The management of squamous cell carcinoma in cervical lymph nodes in the clinical absence of a primary lesion by combined surgery and irradiation

Sixty-three patients who had either previously treated primary tumors or unknown primary tumors and developed metastatic cervical adenopathy in their previously untreated necks received the combination of surgery and megavoltage irradiation. Within two years, 12 patients died of intercurrent disease, nine patients died with distant metastases only, and five patients had disease recur at a primary site. The remaining 37 patients were evaluable for control of neck disease; 26 patients had previous treatment to a primary head and neck cancer that was under control at the time cervical adenopathy was treated; and 11 patients had an unknown primary tumor that was believed to be in the head and neck area. The combination of pre- or postoperative irradiation and surgery controlled neck disease in 86% of the evaluable patients. Because of the extent of neck disease, these patients would have been at a high risk of failure in the treated area if only a single modality of treatment were used. Analysis of the data shows an association of extranodal connective tissue involvement with both a decreased rate of control within the treated area and distant metastases.

Incidence of lymph node metastasis in elective (prophylactic) neck dissection for oral carcinoma

For cancers of the tongue, floor of mouth, mandibular gingiva and buccal mucosa, in which the widest diameter is greater than 2 cm, we perform neck dissection in continuity with resection of the primary growth as a part of the planned therapy,regardles of the clinical state of the cervical lymph nodes. Whenever the lesion is so situated that an in-continuity neck dissection cannot be performed (cancer of the palate) it may be wise to delay neck dissection until the lymph nodes become clinically apparent.

The role of irradiation in the management of squamous-cell carcinomas of the mouth and throat

Fundamental precepts of radiation biology are presented to provide a basis for the comprehension of radiotherapy. These precepts include cell viability, randomness of cell killing by radiation, the influence of molecular oxygen on radiosensitivity, phases of the cell cycle, and repopulation. The combined-treatment concept is developed, and preoperative and postoperative irradiation options, as well as the optimal extent of the surgical procedure, are discussed. These principles of combined treatment are first applied to the management of neck disease, which is a common denominator to all sites. The anatomic sites of the mouth and throat are then discussed. The capabilities of radiotherapy have greatly altered treatment planning for carcinomas of the mouth and throat; one must now develop an initial overall plan that varies with the extent and anatomic site of the primary lesion, the extent of neck disease, and the probability of spread to clinically uninvolved lymphatic areas.

Prognostic factors in pyriform sinus carcinoma

In the 48-month survival analysis of 76 evaluable pyriform sinus carcinoma cases, nodal stage and size played the most significant prognosis-affecting roles. N3 stage and node greater than 3 cm decreased the survival fourfold and threefold, respectively, at statistically significant levels. The difference between the 35 per cent preoperative radiation therapy and 3 per cent radical radiation therapy cumulative 48-mouth survivals was significant at p less than 0.01. Complication rates were 6 per cent with radical radiation, 35 per cent with preoperative radiation and 43 per cent with curative surgery.

Squamous cell carcinoma of the tonsil in young adults

Squamous cell carcinoma of the tonsil is rare in people under 40 years of age. Only 11 cases have been treated at the M.D. Anderson Hospital since 1944. Their 5-year survival was decreased (14%) when compared to the total group of patients treated for squamous cell carcinoma of the tonsil (48%). Young adults had higher clinical staging than the total group. Ninety-one percent of the young patients had neck nodal metastasis, with 55% staged N3. Of the entire group, 76% had neck nodal metastasis with 23% staged N3. Case histories indicate a lack of suspicion of tonsillar cancer on the part of patients and physicians. The average total delay from symptoms to diagnosis was 11 months. Response rates of radiotherapy alone were excellent (no failures) in patients with staging T1, T2, TX, N0, and N1. However, five (45%) of the 11 young patients had T3 or T4 primaries and all died, four with regional failure. Six of the 11 young patients had N3 staging and five of these died, all with regional failure except one. Planned combined treatment should be used more frequently in young adults with high staging.

Treatment of the neck in patients with squamous cell carcinoma of the head and neck

A retrospective study of 702 patients with clinically positive nodes associated with squamous cell carcinoma of the oral cavity, supraglottic larynx, and hypopharynx observed from 1954 to 1968 was done. The policies of treatment for the neck were not standardized during those years. Three hundred eleven patients who survived 24 months with the primary lesion controlled were divided into two groups: 1) those whose neck was treated by surgery alone; and 2) those who had combined radiation therapy and surgery to the neck, to test the efficacy of the two forms of treatment. For the three sites, the recurrence rate in the necks for the surgically treated group was 14% for stage N1, 26% for N2 and 34% N3. Rates for the group receiving combined treatment were 2%, 11% and 25% respectively. Results of the study also showed that elective irradiation, 5,000 rads in five weeks, will prevent metastasis from occurring in the NO staged neck.

The efficacy of combining radiation therapy with a surgical procedure in patients with cervical metastasis from squamous cancer of the oropharynx and hypopharynx

To determine whether combining radiation therapy and a surgical procedure was superior to either modality alone, the authors reviewed the records of 345 patients who had primary cancers of the base of the tongue, tonsillar fossa, or pyriform sinus associated with clinically positive nodes at the time of their first observation. Combining the two modalities of therapy produced a local and regional control of the disease in twice as many patients as did one modality alone. The absolute 5-year survival did not reflect this same trend, however, since as local and regional control increased, more patients lived longer but died before five years from distant metastases. Immunochemotherapy is suggested as a possible adjunct therapy to prevent distant metastases.