Carcinoma of the tonsillar region: results of external irradiation

Additional parameters to improve the prognostic value of the 8th edition of the UICC classification for human papillomavirus-related oropharyngeal tumors

Background

The prognostic reliability of the UICC's TNM classification (8th edition) for human papillomavirus (HPV)‐positive tonsillar squamous cell carcinomas (TSCCs) compared to the 7th edition was explored, and its improvement by using additional anatomical and nonanatomical parameters.

Methods

One hundred and ten HPV‐positive and 225 HPV‐negative TSCCs were retrospectively analyzed. Survival was correlated with patient and tumor characteristics (7th and 8th edition UICC TNM classification).

Results

In HPV‐positive TSCCs, the 8th edition UICC's TNM classification correlated better with prognosis than the 7th edition. Also, smoking status was a stronger prognosticator of survival than UICC staging. Non‐ or former smokers had a 5‐year overall survival of 95.1% regardless of tumor stage. Furthermore, age (>65 years), cN3, and M1 classification were significant prognostic factors.

Conclusion

The prognostic value of the 8th edition UICC's TNM classification improved significantly when compared to the 7th edition. Nonetheless, further improvement is possible by adding nonanatomical factors (smoking, age >65 year) and separating N0‐N2 from N3.

Carcinoma of the oral pharynx: an analysis of subsite treatment heterogeneity

The data indicate that SCC of the various subsites of the oropharynx can be treated successfully with acceptable locoregional control and survival rates by using either surgery or primary radiotherapy for TI or T2 primary lesions. Treatment success data for late-stage disease (T3 and T4) are less encouraging. regardless of which modality is used or which treatment center is administering treatment. This finding may suggest an intrinsic property of these lesions or the patient that may be going unnoticed.One problem is that the diversity of approaches to these lesions hinders any meaningful comparisons between series from different treatment centers. There exists heterogeneity in patient populations and approaches to staging and characterization of these diseases. This situation has ensured the same heterogeneity in treatment philosophy, which is largely institutionally based.

Squamous cell carcinoma of the oropharynx: surgery, radiation therapy, or both

BACKGROUND

The treatment of patients with squamous cell carcinoma (SCC) of the oropharynx remains controversial. No randomized trial has addressed adequately the question of whether surgery (S), radiation therapy (RT), or combined treatment is most effective.

METHODS

Treatment results from North American academic institutions that used S with or without adjuvant RT (S +/- RT) or used RT alone or followed by neck dissection (RT +/- ND) for patients with SCC of the tonsillar region or the base of tongue were compiled through a MEDLINE search (from 1970 to August, 2000) and from the references cited in each report. Studies were eligible for inclusion if they contained direct, actuarial (life-table), or Kaplan-Meier calculations for the following end points: local control, local-regional control, 5-year absolute survival, 5-year cause specific survival, or severe or fatal treatment complications. Weighted average results, which took into account series size, were calculated for each end point for the purposes of treatment comparison. Results and conclusions were based on data from 51 reported series, representing the treatment of approximately 6400 patients from the United States and Canada.

RESULTS

The results for patients with SCC of the base of tongue who underwent S +/- RT versus RT +/- ND, respectively, were as follows: local control, 79% versus 76% (P = 0.087); local-regional control, 60% versus 69% (P = 0.009); 5-year survival, 49% versus 52% (P = 0.2); 5-year cause specific survival, 62% versus 63% (P = 0.4); severe complications, 32% versus 3.8% (P < 0.001); and fatal complications, 3.5% versus 0.4% (P < 0.001). The results for patients with SCC in the tonsillar region who underwent S +/- RT versus RT +/- ND, respectively, were as follows: local control, 70% versus 68% (P = 0.2); local-regional control, 65% versus 69% (P = 0.1); 5-year survival, 47% versus 43% (P = 0.2); 5-year cause specific survival, 57% versus 59% (P = 0.3); severe complications, 23% versus 6% (P < 0.001); and fatal complications, 3.2% versus 0.8% (P < 0.001).

CONCLUSIONS

The information in this article provides a useful benchmark for evidence-based counseling of patients with SCC of the oropharynx. The rates of local control, local-regional control, 5-year survival, and 5-year cause specific survival were similar for patients who underwent S +/- RT or RT +/- ND, whereas the rates of severe or fatal complications were significantly greater for the S +/- RT group. Furthermore, available data on the functional consequences of treatment suggest the superiority of RT +/- ND. The authors conclude that RT +/- ND is preferable for the majority of patients with SCC of the oropharynx.

Cancer of the tonsil: the results of ipsilateral radiation treatment

BACKGROUND AND PURPOSE

The use of ipsilateral irradiation techniques to treat patients with carcinoma of the tonsil reduces the acute radiation reaction in the contralateral pharynx and late damage to the contralateral salivary tissue. However, this may also spare microscopic disease in apparently uninvolved contralateral lymph nodes. The purpose of this study was to analyse the survival and recurrence rates and sites of recurrance in a group of patients with carcinoma of the tonsil treated with ipsilateral techniques.

MATERIALS AND METHODS

Between 1975 and 1993, 271 patients with invasive squamous cell cancer of the tonsil were referred to the Vancouver Cancer Centre (VCC). One hundred and seventy-eight received ipsilateral radiation treatment. Three received surgery only, six post-operative radiation, 12 supportive treatment only and 72 bilateral radiation treatment. In the absence of bilateral neck nodes and extensive lymphodenopathy, field sizes were generally kept small to include the primary tumour and the first echelon of nodes. The most common dose was 60 Gy in 25 daily fractions in 5 weeks (2.4 Gy per day).

RESULTS AND DISCUSSION

The disease specific survival for all patients treated by radical radiation treatment was 61% at 5 years. For the 178 patients who received ipsilateral radiation treatment the overall primary tumour control rate by ipsilateral radiation treatment alone was 75% and for T1 and T2 tumours 84%. Eight (7.5%) of 101 of these patients with N0 nodes at presentation and without prior failure at the primary site, developed nodal recurrence (four within the initially radiated high dose volume). Two developed contralateral nodes, and two developed field edge nodal recurrence, one cured by surgery. In 54 patients with N1 disease, five developed nodal recurrence, two within field, two contralateral, one of whom was cured by surgery, and one at field edge. In 23 patients with N2a, N2b or N3 disease node control was achieved from radiation treatment in 11 and two more were cured by surgery. All nodal failures were within the radiated volume. Overall, 10 of the 25 patients with nodal failure were cured by subsequent surgery.

CONCLUSIONS

Ipsilateral treatment of patients with carcinoma of the tonsil gives survival results that are at least as good as those reported with bilateral treatment with fewer side effects and a very low risk of failure in the contralateral neck.

DNA ploidy in nonmelanoma skin cancer

BACKGROUND

Patients with head and neck squamous cell carcinoma die of locoregional recurrence and those with basal cell carcinoma suffer cosmetic and functional changes from its treatment. Prognostic factors are based upon tumor characteristics and host factors. Flow cytometry can assist with prognostic characterization of nonmelanoma skin cancer.

METHODS

Specimens from 40 sequential patients with head and neck nonmelanoma skin cancers were prospectively obtained at the time of surgery. The patients were followed for four years for local recurrence and metastasis to regional lymph nodes. Samples were prepared from frozen specimens using a modification of the Vindelov procedure.

RESULTS

DNA aneuploidy or tetraploidy and histology of well differentiated squamous cell carcinoma were significantly associated with metastasis to regional lymph nodes. Direct extension of tumor below the adipose tissue was associated with an S-phase greater than 4.1 and a proliferative fraction greater than 5.5. No tumors recurred at the site of surgical resection.

CONCLUSIONS

The measurement of DNA ploidy of well differentiated squamous cell carcinoma, and proliferative capacity or S-phase of both basal cell and squamous cell carcinomas assists in predicting the biologic proclivity for locoregional invasion or metastasis of nonmelanoma skin cancer. Identification of aggressive tumors at the time of surgery may offer the opportunity for prevention of lethal metastasis by using adjunctive therapy.

Transhyoid resection of tongue base and tonsil tumors

Advanced lesions of the oropharynx are known to have increased survival with surgical excision combined with radiation therapy. Traditional surgery involves either a mandibular resection or, more recently, a mandibular sparing approach primarily through a lip-splitting incision. At our institution posterior oropharyngeal lesions are approached via a combined intraoral and transhyoid technique. Nineteen sequential procedures using this approach were compared with a similar number of previous, stage-matched controls in an attempt to obtain valid comparable information. No significant difference between the groups was noted with respect to surgical margins. A significant difference was, however, seen with respect to the need for flap closure with none required in the transhyoid group and five in the mandibulotomy group. Furthermore, a statistical difference was observed with respect to the presence of significant complications in favor of the transhyoid group. These results indicate that similar cure rates can be achieved with lower morbidity by use of a transhyoid pharyngotomy approach to tumors of the oropharynx.

Tonsil cancer. Patterns of failure after surgery alone and surgery combined with postoperative radiation therapy

BACKGROUND

The authors determined the patterns of treatment failure in patients treated with surgery alone or surgery combined with postoperative radiation therapy for squamous cell carcinoma of the tonsil.

METHODS

Seventy-two patients underwent surgery alone (56) or surgery and postoperative adjuvant radiation therapy (16). All patients were followed up until death (40 patients) or for a minimum of 3.5 years. For patients treated with surgery alone, clinic notes, operative notes, and pathology reports and slides were reviewed to identify clinical or pathologic predictors of recurrence above the clavicles, cause-specific survival, and overall survival. For patients undergoing postoperative adjuvant radiation therapy, demographic, treatment, and pathologic variables were analyzed to identify factors associated with control of disease above the clavicles, disease-free survival, and overall survival.

RESULTS

The main pattern of treatment failure was above the clavicles. It occurred in 39% of patients treated with surgery alone and was significantly related (P = 0.002) to the overall clinical TNM stage. Disease recurrence above the clavicles occurred in 31% of patients undergoing surgery and postoperative adjuvant radiation therapy, despite their more advanced neck disease. Five-year overall survival for patients with clinical Stage III and IV disease who were treated with surgery and post-operative adjuvant radiation therapy was 100% and 78%, respectively. Five-year overall survival for patients treated with surgery alone who had clinical Stage III, IVA, or IVB disease was 56%, 43%, and 50%, respectively.

CONCLUSION

We recommend postoperative adjuvant radiation therapy for patients with clinical Stage III or IV squamous cell carcinoma of the tonsil who have undergone complete surgical resection because this appears to improve control of disease above the clavicles and overall survival.

Long-term treatment results of postoperative radiation therapy for advanced stage oropharyngeal carcinoma

BACKGROUND

The authors report the long-term treatment results for advanced stage base of tongue (BOT) and tonsillar fossa (TF) carcinomas treated with surgery and postoperative radiation therapy (RT) at Memorial Sloan-Kettering Cancer Center.

METHODS

Between 1973 and 1986, 51 patients with squamous cell carcinoma of the BOT (n = 31 patients) and TF (n = 20 patients) were treated with surgery plus RT. Indication(s) for RT included: advanced disease (Stage T3/T4, 34 patients [66%]); close or positive margins (33 patients, 64%) and multiple positive neck nodes (43 patients, 84%).

RESULTS

The 7-year actuarial local control rates for BOT and TF lesions were 81% and 83%, respectively. Local control was achieved in 17 of 18 (94%) patients with T3 lesions, and 12 of 16 (75%) patients with T4 lesions. Among patients with positive or close margins who received postoperative doses of 60 Gy or more, the long-term control rate was 93%. The presence of a treatment interruption had a negative effect on the local control rates. The actuarial control among patients who required a treatment break was 64%; for those not requiring interruption of their treatment, the actuarial control was 93% (P = 0.05). At 7 years, the overall survival for all patients was 52%, and the disease-free survival was 64%. The actuarial incidence of neck failure was 21% and 18% for BOT and TF, respectively. The likelihood of having distant metastasis at 7 years for all patients was 30%. The actuarial incidence of having a second malignancy was 35% for patients with BOT disease. Second malignancy was not observed among patients with TF lesions.

CONCLUSIONS

The authors conclude that surgery and postoperative RT can provide excellent long-term, disease-control rates for patients with advanced BOT and TF tumors. However, current strategies for BOT lesions have been directed at tongue preservation without surgery.

Squamous cell carcinoma of the tonsillar region. A retrospective analysis of treatment results

Seventy-five patients treated for squamous cell carcinoma of the tonsillar region during 1958-1982 were reviewed retrospectively. Of the 75 patients, 30 received combined treatment with surgery and postoperative radiotherapy, and 45 radical radiotherapy alone. The 5-year survival rate for the entire patient series was 39%, the corresponding figure was 53% for the patients treated with combined therapy and 29% for the patients with radical radiotherapy. The radical radiotherapy group included more patients with advanced stage of the disease (stage III 27% and stage IV 66%) than the combined therapy group (47% and 23% respectively). Thirty-four patients (45%) died from uncontrolled disease.

A multivariate primary tumour control analysis in 465 patients treated by radical radiotherapy for cancer of the tonsillar region: clinical and treatment parameters as prognostic factors

Out of a consecutive series of 698 cases of squamous cell carcinomas of the tonsillar region treated by radical megavoltage radiotherapy, a determinate group of 465 cases remained eligible for a multivariate analysis of the pretreatment features of the disease and treatment-related parameters predictive of lasting control of the disease at the primary site. T-stage and initial site within the tonsillar region, were the significant pretreatment factors. Tumours arising from the glossopalatine sulcus which are characterized by involvement of the tongue, do significantly worse than those arising from other sites within the tonsillar region: i.e. the tonsil itself, posterior pillar and to a lesser extent the anterior pillar. As regards treatment-related parameters in the 465 cases which received tumour doses of at least 55 Gy, only the length of overall treatment time was found to be predictive. Combining both pretreatment and treatment variables, T-stage (p less than 0.0001), overall treatment time (p less than 0.0001) were by decreasing order of significance the predicting factors, followed by initial site (p = 0.006). When present, tumour extension to the anatomical structures anterior to the tonsillar region was also found to be significant (p = 0.05). Based on these factors, a multivariate model was constructed and tested by estimating the product-limit survival of the various categories of patients. Four groups are individualized with 3 years local control rates ranging from 90 to 21%. The predictive accuracy of the model was assessed by log-rank test significance levels. The model may help to select patients for whom conventional radical radiotherapy is inadequate, and combined modality or altered fractionation regimes should be tried particularly for advanced tumours of the glossopalatine sulcus, and any case with significant invasion of the oral cavity.

Squamous cell carcinoma of the tonsillar area treated with radical irradiation

This is an analysis of 136 patients treated with radiation therapy alone (104) or in conjunction with planned neck dissection (32) for squamous cell carcinoma of the tonsillar area between October 1964 and August 1983. All patients have a 2-year follow-up and 94 (69%) have a minimum 5-year follow-up. Patients were excluded from analysis of disease control at the primary site and/or neck if they died within 2 years of treatment with that site continuously disease-free. All patients were treated with continuous-course irradiation; those treated with the planned split-course technique are not included. Once-a-day fractionation was used in 105 patients and twice-a-day fractionation in 31 patients. External beam alone was used in 93 patients, and external beam followed by a radium needle implant boost to the primary site was employed in 43 patients. Rates of initial local control with irradiation and ultimate local control after surgical salvage of irradiation failures are as follows: T1, 10/12 (83%) and 12/12; T2, 36/46 (78%) and 41/46 (89%); T3, 28/39 (72%) and 28/39 (72%); T4, 5/16 (31%) and 5/16 (31%). Local control data are also presented as a function of tumor site within the tonsillar area, total dose, dose per fraction, and external beam alone versus external beam plus radium needle implant. The 5-year determinate survival rates by modified AJCC stage are as follows: I, 3/3; II, 13/14; III, 14/17; IVA, 6/14; and IVB, 4/19.

The place of brachytherapy in the treatment of carcinoma of the tonsil with lingual extension

One hundred forty-four of 170 patients (85%) were seen with cancer of the tonsil and received radical irradiation between 1959 and 1980. A 39% crude 3-year disease-free survival rate and a 51% locoregional control rate were observed. Locoregional relapse related to T Stage was 6, 43, 58, and 64% for T1, T2, T3, and T4, respectively. Fifty-four of 144 patients (37%) showed tongue extension, 20% in T1-T2 stages and 50% in T3-T4 stages. Local relapse was 64% and the 3-year disease-free survival rate was 23% in 39 patients with tongue extension treated with external irradiation alone, versus 33 and 43% respectively for 90 patients with no tongue extension. The increase of lymph node metastases or neck recurrences was not related to tongue extension. In 15 patients with tongue extension, treated with external radiation plus brachytherapy, the local relapse was 40% and the 3-year survival rate 60%. External irradiation plus brachytherapy was significantly related to lower local relapse and increased survival rate compared to external irradiation alone in cancer of the tonsil with tongue extension. The combined modality was not associated with increased risk of radiation complications.

Treatment of choice for squamous carcinoma of the tonsillar fossa

The records of 160 patients with squamous cell carcinoma of the tonsillar fossa treated from 1968 through 1979 were reviewed. Biologic behavior, local and regional findings, and other prognostic factors were evaluated. patients were treated by either radiation alone (112 patients), radiation followed by planned neck dissection (31 patients), surgery alone (11 patients), or surgery combined with radiation (6 patients). Analysis of the data supports the recommendation that radiation be used as treatment for T1, T2, and early T3 lesions, whereas surgery alone or combined with radiation is best employed for advanced T3 or T4 tumors. Primary tumor control rates with radiation as the initial modality were 100% for T1 lesions, 89% for T2, 68% for T3, and 24% for T4. In addition, the control of cervical metastases with radiation therapy for patients with neck disease staged N0 through N3b was excellent (95%). In instances where a planned neck dissection was done 5 weeks after radiation, the control of cancer in the neck was 100%. The incidence of distant metastases was 10% and was not affected by the selection of therapy. The 2- and 5-year determinate survival figures for 112 patients treated with radiation therapy alone was 67% and 48% respectively, while 31 patients treated with radiation therapy followed by neck dissection achieved survival rates of 70% (2 year) and 58% (5 year). The criteria for selection of treatment are discussed.

Prognostic value of histopathologic parameters in squamous cell carcinoma of the oropharynx

Seventy-seven patients with squamous cell carcinoma of the oropharynx were treated by preoperative radiation therapy (4000-5000 rad) followed by surgical resection. The original biopsy specimens were evaluated for degree of keratinization, nuclear pleomorphism, frequency of mitoses, inflammatory response, vascular invasion, and pattern of invasion. Multivariant analysis (Cox regression model) and life table survival function were used to determine the relative contributions of the clinical and histologic parameters to patient outcome. The results were as follows: (1) large tumor size, nodal metastases, and male sex were found to be predictive of a poorer survival (P = 0.004, 0.0167, and 0.0237, respectively); and (2) an analysis of a combination of clinical and histologic parameters demonstrated that the pattern of invasion was the only histologic factor that was predictive of survival (P = 0.0436). Neoplasms invading as large cohesive aggregates indicated a better prognosis than neoplasms invading as thin, irregular cords or individual cells. Restricting the statistical evaluation to only histologic factors (excluding clinical factors) demonstrated that increased frequency of mitoses also correlated with poor survival (P = 0.0218). Further restriction of the analysis to T2 and T3 neoplasms that have similar survival times indicated that both frequency of mitoses and pattern of invasion were of prognostic value in predicting survival (P = 0.0127 and 0.0168, respectively).

Radiation management of carcinoma of the tonsillar region

This is a retrospective analysis of 185 patients with squamous cell carcinoma of the tonsillar region treated at the Department of Radiation Oncology, University of Maryland Hospital from 1956 to 1977. All patients were treated by one of the following: (1) external beam therapy alone; or (2) combined external beam and interstitial brachytherapy. Five-year disease-free survivals, for early Stages (I and II), are 100% and 73%, comparable to the other series published in the literature. However, in advanced Stages III and IV, survival data showed 52% and 21%, respectively, 5-year disease-free survival better than any other reports. It is thought that the special interest of the authors in interstitial brachytherapy and a well-integrated plan of external beam and brachytherapy is responsible for this success. The local control rate for T1, T2, T3, and T4 was 94%, 88%, 62%, and 19%, respectively, with the overall regional control rate of 83%. The prognostic factors appear to be related to the T-factor, N-factor, radiation dose, and method of treatment given, and the degree of tongue involvement. The detailed analysis of survivals and failures in the light of dosimetric study is presented along with some example cases of interstitial brachytherapy.

Predicting the response of head and neck cancers to radiation therapy with a multivariate modelling system: an analysis of the RTOG head and neck registry

Two thousand and sixty-six patients with primary head and neck cancers were entered in the RTOG Head and Neck Cancer Registry between 1977 and 1980. Nine hundred and ninety-seven (997) evaluable patients were treated initially with radiation therapy alone. Tumor site, T-stage, N-stage, histology, degree of infiltration, degree of differentiation, patient age, sex and Karnofsky performance score were all prospectively recorded. T-stage (p less than .001), N-stage (p = .007), primary site (p less than .001), and initial Karnofsky performance score (p less than .001) proved to be significant factors independently predictive of primary tumor clearance. Using these factors, a multivariate response model was constructed to predict primary tumor response. The predictive accuracy of the model proved to be highly reliable, and was tested by comparing the predicted vs. observed complete tumor clearance rates for each independent variable. For primary sites, the predicted number of complete responses vs. observed were: oral cavity, 139.8 predicted vs. 139 observed; nasopharynx, 51.8 predicted vs. 51 observed; oropharynx, 174.8 predicted vs. 176 observed, supraglottic larynx, 314.4 predicted vs. 318 observed; glottic larynx, 314.4 predicted vs. 318 observed; and hypopharynx, 49.4 predicted vs. 46 observed. For the entire group of patients predicted to have a 90% or better complete primary tumor response (including T3 and T4 tumors), 94% remained in initial complete remission at the primary site at one year, and 87% at two years. An accurate multivariate response model, such as the one presented in this paper, should prove to be a useful tool in selecting patients with head and neck cancers suitable for treatment with radiation therapy alone.