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

An comparison of acute toxicities and patient-reported outcomes between intensity-modulated proton therapy and volumetric-modulated arc therapy after ipsilateral radiation for head and neck cancers

BACKGROUND

Intensity-modulated proton therapy (IMPT) demonstrates superior dose distribution over volumetric-modulated arc therapy (VMAT) for sparing organs-at-risk (OARs) in ipsilateral radiotherapy. To determine a clinical benefit, assessment of patient-reported outcomes (PRO) and physician-reported toxicities alongside a dosimetric analysis is needed.

METHODS

Plans were analyzed for dosimetric differences. PROs were compared for patients undergoing ipsilateral curative-intent radiotherapy for tonsil and salivary gland cancers with VMAT or IMPT from 2015 to 2020. Physician-reported toxicities were compared.

RESULTS

In 40 patients, IMPT was associated with decreased dose to multiple OARs and less deterioration in the following PROs: pain, swallowing function, dry mouth, sticky saliva, sensory change, cough, speech, feeling ill, and social eating. Physician-reported toxicities demonstrated less oral pain.

CONCLUSION

IMPT is associated with decreased dose to OARs and less patient-reported acute deterioration in multiple head and neck domains. A strong consideration for IMPT in ipsilateral head and neck patients with cancer is warranted.

Outcomes of HPV-Negative Oropharyngeal Cancer Treated With Transoral Robotic Surgery

OBJECTIVE

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is increasing secondary to human papillomavirus (HPV)-related disease. Despite this, outcomes of patients with HPV-negative OPSCC undergoing transoral robotic surgery (TORS) are largely unknown.

STUDY DESIGN

Analysis of the National Cancer Database (NCDB).

SETTING

Not applicable.

METHODS

The 2015 participant user file from the NCDB was analyzed between 2010 and 2015 for patients with OPSCC who underwent TORS and neck dissection. Kaplan-Meier survival analysis was used to estimate overall survival of the study population. Univariable Cox survival analyses was used to determine significant associations between demographic, tumor, and treatment characteristics and overall survival (OS).

RESULTS

There were 164 patients (124 male and 40 female) with a mean age of 58 years (30-89 years). Median follow-up was 34 months. Five-year OS was 78% (95% CI, 70%-86%). Patients with early stage disease (pT1-2, N0-1) had significantly improved OS compared to patients with advanced T- or N-stage disease (log-rank 0.011; 5-year OS: 88% [95% CI, 78%-98%] vs 66% [95% CI, 50%-82%]).

CONCLUSION

Very few patients in the NCDB underwent TORS for HPV-negative OPSCC, but those who did had favorable outcomes, especially in early stage disease. Based on these findings, TORS may be considered in the treatment algorithm for patients with HPV-negative OPSCC.

LEVEL OF EVIDENCE

Level IV.

Evolution in the management of oropharyngeal squamous cell carcinoma: systematic review of outcomes over the last 25 years

The treatment of oropharyngeal squamous cell carcinoma (SCC) has evolved over the last 25years, from open surgery to combined chemoradiotherapy, and now to the development of minimally invasive procedures, but evidence for the best treatment is lacking. We therefore did a systematic search of the MEDLINE database for studies published between 1992 and 2017 that reported oncological or functional outcomes, or both. Predefined inclusion and exclusion criteria were used for screening and selection, and 45 studies were chosen. Only one was a randomised controlled trial, all the rest were prospective or retrospective case series. The heterogeneities in their characteristics made meta-analysis impossible and only qualitative analysis was feasible. We found no conclusive evidence to suggest the advantage of one therapeutic approach over another, so we still cannot offer patients the "ideal" treatment. We have, however, raised the possibility of there being two different entities: human papillomavirus (HPV)-positive and HPV-negative disease.

Radiotherapy alone or combined with chemotherapy as definitive treatment for squamous cell carcinoma of the tonsil

This study is aimed at updating our institution's experience with definitive radiotherapy (RT) for squamous cell carcinoma of the tonsil. We reviewed 531 patients treated between 1983 and 2012 with definitive RT for squamous cell carcinoma of the tonsil. Of these, 179 patients were treated with either induction (n = 19) or concomitant (n = 160) chemotherapy. Planned neck dissection was performed on 217 patients: unilaterally in 199 and bilaterally in 18 patients. Median follow-up was 5.2 years for all patients (range 0.1-31.6 years) and 8.2 years for living patients (range 1.9-31.6 years). The 5-year local control rates by T stage were as follows: T1, 94 %; T2, 87 %; T3 79 %; T4, 70 %; and overall, 83 %. Multivariate analysis revealed that local control was significantly influenced by T stage and neck dissection. The 5-year cause-specific survival rates by overall stage were as follows: I, 94 %; II, 88 %; III, 87 %; IVA, 75 %; IVB, 52 %; and overall, 78 %. Multivariate analysis revealed that cause-specific survival was significantly influenced by T stage, N stage, overall stage, fractionation, neck dissection, sex, and ethnicity. Of 77 patients treated with ipsilateral fields only, contralateral neck failure occurred in 1 %. The rate of severe complications was 12 %. Definitive RT for patients with tonsillar squamous cell carcinoma provides control rates equivalent to other modalities with a comparatively low incidence of late complications. Patients with anterior tonsillar pillar or tonsillar fossa primaries that are well lateralized with no base of tongue or soft palate extension may be treated with ipsilateral fields.

Relapse patterns after transoral laser microsurgery and postoperative irradiation for squamous cell carcinomas of the tonsil and tongue base

OBJECTIVES

We evaluated relapse patterns after transoral laser microsurgery (TLM) in squamous cell carcinoma (SCC) of the tonsil and tongue base and evaluated the indications for adjuvant irradiation.

METHODS

Between December 1, 1996, and December 31, 2005, 79 patients with previously untreated SCC of the tonsil or tongue base underwent TLM with or without neck dissection. Thirty-eight patients (48%) underwent postoperative irradiation (median, 62 Gy) to the primary site and the neck. Analysis of relapse patterns was performed on the basis of adverse risk factors and the presence or absence of adjuvant irradiation.

RESULTS

The median follow-up for living patients was 47 months (range, 10 to 107 months), and patients were monitored for at least 2 years or until recurrence or death. Local, regional, and distant treatment failures numbered 4, 6, and 4 for surgery alone (n = 41) and 0, 2, and 6 for adjuvant irradiation (n = 38), respectively. Patients with high-risk features (extracapsular extension or at least 2 adverse factors) had locoregional control rates at 2 or more years of 66% and 94% for TLM alone and TLM plus adjuvant irradiation, respectively.

CONCLUSIONS

Adjuvant irradiation after TLM resection of oropharyngeal SCC with intermediate- or high-risk features improves locoregional control compared with TLM alone.

Long-term follow-up and a detailed prognostic analysis of patients with oropharyngeal cancer treated with radiotherapy

PURPOSE

To find a prognostic factor for patients with oropharyngeal cancer (OPC) who were followed for long term after definitive radiotherapy.

METHODS

OPC patients that had been treated with radiotherapy at our institution were reviewed. Sex, age, performance status (PS), subsite, disease stage, T-stage, N-stage, RT dose, concurrent chemotherapy, the duration of RT, hemoglobin concentration before any treatment, and a double cancer were assessed for their impact on overall survival (OS) and locoregional control (LRC).

RESULTS

Among a total of 141 patients enrolled into this retrospective study, the disease of most patients (81%) was stage III or IV. The median follow-up time of the surviving patients was 56 months (range 5-175 months). Radiotherapy was administered in conventional fractionation, and the median RT dose was 66 Gy. Most patients (90%) received systemic chemotherapy. The 5-year estimates of progression-free survival, LRC, and OS were 66.0, 72.7, and 65.1%, respectively. In the univariate analysis, LRC and OS in the lateral wall at the primary site, T-stage <or=3, and PS <or=1 groups were significantly superior to those in the other groups, and OS in age <or=60 or the hemoglobin level >13.0 g/dL groups were also significantly superior to those in the other groups. In the multivariate analysis, age and T-stage remained significant factors for OS.

CONCLUSIONS

Primary radiotherapy was recommended for OPC patients with the lateral wall at the primary site because of good LRC. The treatment method to the older population and T4 tumor is future tasks.

Prevalence, Morphology, and Prognosis of Human Papillomavirus in Tonsillar Cancer

Objectives:

We sought to identify the prevalence of human papillomavirus (HPV) in tonsillar squamous cell carcinoma, and to examine the relationship of HPV to prognosis and tumor morphology.

Methods:

We performed in situ hybridization for HPV and retrospective clinical outcome analysis.

Results:

Of the 48 patients with tonsillar carcinoma, in situ hybridization identified 35% as HPV-positive tumors. Age-matched controls had no evidence of HPV. There was no significant difference between HPV-positive and HPV-negative patients regarding age (p = 0.34), tobacco consumption (p = 0.59), alcohol consumption (p = 0.91), or treatment method (p = 0.39). Forty-four patients were eligible for outcome analysis. The overall rate of recurrence in this population was 25%, and the disease-specific survival rate was 84%. There was no significant difference between the two groups either in the incidence of recurrence (p = 0.14) or in the disease-specific survival rate (p = 0.19). HPV-associated tumors developed from the tonsillar crypts significantly more frequently than did HPV-negative tumors (p = 0.01).

Conclusions:

As previously described, HPV is significantly associated with squamous cell carcinoma of the tonsil; however, HPV status in our series did not correlate with clinical outcome. Morphologically, we found that HPV-positive tumors had their origin in the tonsillar crypts, whereas HPV-negative tumors arose from the surface epithelium.

Intensity-modulated chemoradiation for treatment of stage III and IV oropharyngeal carcinoma: the University of California-San Francisco experience

BACKGROUND

Treatment outcomes for stage III and IV oropharyngeal carcinoma treated with intensity-modulated radiotherapy (IMRT) and concurrent chemotherapy without prior surgical resection were reviewed.

METHODS

Between April 2000 and September 2004, 71 patients underwent IMRT concurrent with chemotherapy without prior surgical resection for stage III and IV oropharyngeal carcinoma. Chemotherapy was platinum based. The gross tumor volume (GTV) received 70 Gy in 2.12 Gy per fraction. The high-risk clinical tumor volume (CTV) received 59.4 Gy in 1.80 Gy per fraction, and the low-risk CTV received 54 Gy in 1.64 Gy per fraction.

RESULTS

With a median follow-up of 33 months, the 3-year local, regional, and locoregional progression-free probabilities were 94%, 94%, and 90%, respectively. The 3-year overall survival estimate was 83%. Locoregional failures occurred in the GTV in 7 patients. Acute grade 3 or 4 toxicity developed in 35 patients. A feeding gastrostomy was placed in 25 patients. Late xerostomia was grade 0 in 16 patients, grade 1 in 31 patients, and grade 2 in 24 patients at last follow-up. No patients experienced grade 3 or 4 late toxicity, except for 1 who developed osteoradionecrosis of the mandible.

CONCLUSIONS

Excellent local and regional control was achieved with IMRT and concurrent chemotherapy without prior surgical resection in the treatment of stage III and IV oropharyngeal carcinoma. Significant sparing of the parotid glands and other critical normal tissues was possible using IMRT with moderate acute toxicities and minimal severe late effects.

Definitive radiotherapy for tonsillar squamous cell carcinoma

PURPOSE

The purpose of this study is to update our experience with definitive radiotherapy (RT) for carcinoma of the tonsillar area.

PATIENTS AND METHODS

There were 503 patients treated between October 1964 and May 2003 (potential follow-up for at least 2 years). Of these, 198 patients underwent a planned neck dissection and 57 patients received induction (18 patients) or concomitant (39 patients) chemotherapy.

RESULTS

The 5-year local control rates were as follows: T1, 88%; T2, 84%; T3, 78%; and T4, 61%. Multivariate analysis revealed that local control was significantly influenced by T stage, primary site, and fractionation. Local control after RT for early stage cancers was higher for tonsillar fossa/posterior pillar tumors than for those arising from the anterior tonsillar pillar. The 5-year cause-specific survival rates were as follows: I, 100%; II, 86%; III, 84%; IVA, 73%; and IVB, 46%. Multivariate analysis revealed that cause-specific survival was significantly influenced by T stage, overall stage, neck dissection, race, and gender. The incidence of severe late complications was 9%.

CONCLUSION

Based on our data and a review of the literature, definitive RT provides cure rates that are as good as those after surgery, and is associated with a lower rate of severe complications. Patients with lateralized tumors may be safely treated with ipsilateral field arrangements. Our limited experience with intensity modulated radiotherapy suggests that it is as efficacious as conventional RT.

Exclusive brachytherapy for T1 and T2 squamous cell carcinomas of the velotonsillar area: Results in 44 patients

PURPOSE

To evaluate the role of interstitial brachytherapy as an exclusive radiotherapy modality for primary T1-T2 squamous cell carcinomas (SCC) of the velotonsillar area.

METHODS AND MATERIALS

Between 1992 and 2000, 44 patients with T1-T2 SCC of the tonsil (n = 36) and soft palate (n = 8) were treated to the primary with brachytherapy alone (37 patients) or after a limited resection (7 patients). Eight patients had prior external beam radiation therapy (EBRT) for previous head-and-neck carcinoma. Nineteen patients had initial neck dissection. The mean brachytherapy dose was 58.7 Gy, and the mean reference dose rate and Ir-192 linear activity were 58.2 cGy/h and 1.51 mCi/cm respectively.

RESULTS

With a 75-month median follow-up, 1 patient recurred locally. Isolated nodal relapses occurred in 4 patients, none of whom had initial neck dissection, and salvage therapy was successful in 2. Five-year overall and progression-free survival rates were 76% and 68%, respectively. Full-course radiation therapy was possible in 7 of 12 patients who developed a second primary head-and-neck carcinoma. Late toxicity was limited to 6 mild soft-tissue necroses, and was significantly associated with previous surgery to the primary and high linear activity.

CONCLUSIONS

Exclusive brachytherapy for T1-T2 velotonsillar carcinomas is safe and effective, and permits definitive reirradiation for a second head-and-neck cancer. Initial neck dissection should be performed for optimal selection for exclusive brachytherapy.

The use of intensity-modulated radiation therapy in the treatment of oropharyngeal carcinoma

PURPOSE OF REVIEW

The management of oropharyngeal cancers continues to evolve. Due to the functional consequences of surgery, organ preservation strategies with radiation combined with chemotherapy have been developed. Newer strategies to diminish the acute and late toxicities and improve the functional outcome of organ preservation strategies are being developed. Intensity-modulated radiation therapy is a relatively new, advanced form of radiation therapy that is being studied in an effort to improve local control rates and minimize the late effects of treatment.

RECENT FINDINGS

Several recent studies have further supported the role for radiation therapy and chemotherapy as part of organ preservation strategies for cancers of the oropharynx. With the intensification of treatment, however, toxicities and functional impairment occur and have not been well documented in the past. Several recent studies report on the toxicities of traditional treatment methods. In addition, data show that intensity-modulated radiation therapy may be superior in terms of limiting toxicity compared with standard radiation therapy techniques. The integration of intensity-modulated radiation therapy with chemotherapeutic and radioprotective agents to further improve the therapeutic window for radiation therapy is being actively pursued.

SUMMARY

This paper reviews recent advances in radiotherapy for oropharynx cancer and the use of intensity-modulated radiation therapy.

Retrospective analysis of the treatment results for patients with squamous cell carcinoma of tonsil

PURPOSE

There has been no definitive randomized study to identify the optimal therapeutic regimen for treating squamous cell carcinoma of tonsil. The purpose of this study was to retrospectively evaluate the treatment outcome according to various combinations of surgery, radiation therapy and chemotherapy.

MATERIALS AND METHODS

Fifty-six patients with tonsillar carcinoma, who were treated at Seoul National University Hospital from March 1985 to August 2001, were the subjects of this study. Twenty-one patients received surgery followed by radiation therapy (SRT), 16 patients underwent radiation therapy alone (RT), and 19 patients received neoadjuvant chemotherapy and radiation therapy (CRT). The median radiation dose was 66.6 Gy for the SRT group and 70.2 Gy for the RT and CRT groups. Surgery comprised extended tonsillectomy and modified radical neck dissection of the involved neck. Cisplatin and 5-fluorouracil were used every three weeks for 3 cycles in the SRT group. The median follow-up was 73.2 months.

RESULTS

The distribution of T-stage was 4 cases of T1, 14 cases of T2, 1 case of T3 and 2 cases of T4 staging in the SRT group, 2 cases of T1, 6 cases of T2, 5 cases of T3 and 3 cases of T4 staging in the RT group and 0 cases of T1, 7 cases of T2, 9 cases of T3 and 3 cases of T4 staging in the CRT group. The distribution of N-stage was 5 cases of N0, 2 cases of N1, 13 cases of N2 and 1 case of N3 staging in the SRT group, 6 cases of N0, 5 cases of N1, 5 cases of N2 and 0 cases of N3 staging in the RT group, and 2 cases of N0, and 7 cases of N1, 9 cases of N2 and 1 case of N3 staging in the CRT group. The five-year overall survival rate (OSR) for all patients was 78%. The five-year OSR was 80% for the SRT group, 71% for the RT group, and 80% for the CRT group (p=ns). The five-year disease-free survival rate was 93% for the CRT group and 71% for the RT group (p=0.017). Four patients developed local failure and one patient failed at a regional site in the RT group, and one patient failed at a primary site in the CRT group. The five-year DFS was 84% for patients who had undergone neck dissection and 76% for patients who had not undergone neck dissection (p=ns). Treatment-related complications of grade 3 or 4 occurred in 15 patients, and the incidence of complication was not different between each of the treatment methods.

CONCLUSION

Although the patients with more advanced T stage were included in the RT and CRT groups, the OSR was not statistically different according to the treatment methods. In the radical radiation therapy group, the addition of neoadjuvant chemotherapy showed an improvement in the disease-free survival. Because of the retrospective nature of our study and the small number of patients, this study cannot draw any definite conclusions, but it suggests that radiation therapy with chemotherapy can be a good alternative option for squamous cell carcinoma of tonsil. Controlled randomized study is necessary to confirm this hypothesis.

Radiation therapy for early-stage carcinoma of the oropharynx

PURPOSE

To evaluate the outcomes of radiation therapy treatment of patients with Stage I and II squamous cell carcinoma (SCC) of the oropharynx and discover adverse prognostic factors that may help select a subgroup of patients for a different management approach.

METHODS AND MATERIALS

A search of the database maintained by the Department of Radiation Oncology of The University of Texas M. D. Anderson Cancer Center for patients with Stage I or II SCC of the oropharynx was performed. This search identified 175 patients treated between 1970 and 1998 who met the inclusion criteria for this retrospective study. Distribution of primary sites was: tonsillar fossa/pillar, 60 patients; soft palate, 55 patients; base of tongue, 40 patients; and pharyngeal wall, 20 patients. Twenty-five patients were stage T1, 124 were T2, and 26 were Tx. All patients were treated with fractionated radiation to a median dose of 66 Gy. Eighty-five patients were treated with conventionally fractionated radiation, 73 were treated with the concomitant boost fractionation schedule, and the remaining 17 were treated with other altered fractionation schedules or with intraoral or interstitial boosts.

RESULTS

The median follow-up for all patients was 76 months (range, 2-302 months). The actuarial 5-year local control (LC), regional control, locoregional control (LRC), and disease-free survival (DFS) rates were 85%, 93%, 81%, and 77%, respectively. Only 7 patients (5%) with LC developed nodal metastases, and 10 patients (7%) with LRC developed distant metastases. Eleven patients (32%) with locoregional recurrence were rendered without evidence of disease after a surgical salvage procedure, resulting in a 5- year ultimate LRC rate of 87%. T-stage classification was statistically significant (p = 0.03) in univariate analysis for actuarial 5-year LRC, 88% for Stage I vs. 72% for Stage II. The 5- and 10-year disease-specific survival rates were 85% and 79%, respectively, while the actuarial 5- and 10-year overall survival rates were 70% and 43%, respectively. Fifty-one patients (29%) developed second primary tumors, 86% of which were cancers of the upper aerodigestive tract (UADT). Heavy alcohol consumption was associated with both an increased risk of disease recurrence and development of a second cancer of the UADT.

CONCLUSIONS

Patients with early-stage oropharynx cancer have high rates of disease control when treated with radiation. Lymphatic and hematogenous metastases are uncommon. Surgical salvage of disease recurrence is successful in approximately one-third of patients. As the majority of recurrences occur within the first 2 years from treatment, close observation during this time period is important. The development of second primary tumors of the UADT adversely impacts survival in these patients to as great a degree as the index cancer.

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 tonsillar region. Retrospective study and review of the literature]

It has been carried out a retrospective analysis of 34 patients suffering from carcinoma epidermoid of the tonsillar fossa being treated with two different therapies from 1989 to 1996. Twenty three of them were treated with surgery (transoral resection or bloc radical tonsillectomy with myocutaneous flap reconstruction and ipsilateral lymph node dissection). Eleven of them were treated with chemotherapy and radiotherapy. The rate of overall survival at 5 years were 41.2%. Actuarial survival rates were (71.4%) in stages I-II and 33.3% in stages III-IV (p = 0.08). On multivariate analysis, age (p = 0.28) and modality of treatment (p = 0.80) were not significant effect on survival. Advanced stages (III-IV) showed 3.4 times much more risk of death than early stages (I-II) (p = 0.11).

Radiation therapy for squamous cell carcinoma of the tonsillar region: a preferred alternative to surgery?

PURPOSE

There are no definitive randomized studies that compare radiotherapy (RT) with surgery for tonsillar cancer. The purpose of this study was to evaluate the results of RT alone and RT combined with a planned neck dissection for carcinoma of the tonsillar area and to compare these data with the results of treatment with primary surgery.

PATIENTS AND METHODS

Four hundred patients were treated between October 1964 and December 1997 and observed for at least 2 years. One hundred forty-one patients underwent planned neck dissection, and 18 patients received induction (17 patients) or concomitant (one patient) chemotherapy.

RESULTS

Five-year local control rates, by tumor stage, were as follows: T1, 83%; T2, 81%; T3, 74%; and T4, 60%. Multivariate analysis revealed that local control was significantly influenced by tumor stage (P =.0001), fractionation schedule (P =.0038), and external beam dose (P =.0227). Local control after RT for early-stage cancers was higher for tonsillar fossa/posterior pillar cancers than for those arising from the anterior tonsillar pillar. Five-year cause-specific survival rates, by disease stage, were as follows: I, 100%; II, 86%; III, 82%; IVa, 63%; and IVb, 22%. Multivariate analysis revealed that cause-specific survival was significantly influenced by overall stage (P =.0001), planned neck dissection (P =.0074), and histologic differentiation (P =.0307). The incidence of severe late complications after treatment was 5%.

CONCLUSION

RT alone or combined with a planned neck dissection provides cure rates that are as good as those after surgery and is associated with a lower rate of severe complications.

Surgery versus radiation therapy as single-modality treatment of tonsillar fossa carcinoma: the Roswell Park Cancer Institute experience (1971-1991)

OBJECTIVE

To compare the efficacy and treatment outcomes in patients with tonsillar fossa cancer using surgery or radiation as a single modality therapy.

METHODS

From 1971 to 1991 239 patients with oral pharyngeal cancer were treated at Roswell Park Cancer Institute. Of these patients 90 had tonsillar carcinoma. Seventy-six of these patients received either surgery (SA) (n = 56) or radiation therapy (RA) (n = 20) as single-modality therapy and are the subject of this review. All patients in the radiation arm of this review were surgical candidates who declined primary surgical therapy.

RESULTS

Sixty-three percent of the SA and 80% of the RA treatment groups presented with either stage III or stage IV disease (P < or = .05). Forty-seven percent of the SA group and 52% of the RA patients had clinically positive regional disease at initial presentation. There was a predictable pattern of nodal presentation, with level II the most frequently involved region. The rate of occult metastasis was 27% and was evenly distributed between T1 and T4 disease. The overall local control rate in the SA group was 75%, compared with 60% in the RA group (P value was not significant). The disease-specific survival (all stages) was 61% in the SA group and 37% in the RA group (P < or = .05). The disease-free survival for stage III and stage IV disease in the SA group was 47% and in the RA group 27% (P < or = .05). Survival measured against clinical response to radiation therapy, in complete responders (all stages) was 83%; by contrast there were no survivors past 24 months in the partial response group (P < or = .001).

CONCLUSION

The results from this study suggest that for early disease (stage I/II), surgery or radiation therapy as single-modality treatment is equally effective. For advanced disease radiation therapy is inferior to surgery as a single-modality treatment, as measured by ultimate survival and the local control of disease. There is, however, a subset of patients with advanced disease who respond to radiation therapy and whose survival is equivalent to our surgical cohort of patients.

Quantitative glycohistochemistry defines new prognostic markers for cancers of the oral cavity

BACKGROUND

Histopathologic grading and clinical staging cannot provide a precise prognosis of oral cavity cancer patients. The use of glycohistochemical markers may improve the level of prognostic accuracy of such conventional classification systems.

METHODS

Computer-assisted microscopy was employed in a series of 40 oral cavity cancers to determine quantitatively the percentage of positive cells, the staining intensity, and the level of staining heterogeneity for 3 glycohistochemical markers, including peanut agglutinin (PNA), Thomsen-Friedenreich antigen (T antigen) as part of a neoglycoprotein, and sarcolectin. Data were evaluated by discriminant analysis.

RESULTS

Although the level of differentiation (P < 0.01 to P < 0.001) and the T variable of the TNM staging system (P < 0.05 to P < 0.01) related mainly to the level of expression of the acceptor sites for PNA and the T antigen, the patient survival period (P < 0.05) was largely a fraction of the level of expression of the acceptor sites for the carrier-immobilized T antigen and for sarcolectin.

CONCLUSIONS

In oral cavity cancer, determining the level of acceptor sites for PNA, T antigen, and sarcolectin provides useful information on histopathologic differentiation, clinical staging, and survival. Because these processes of determination were carried out quantitatively, a discriminant model was set up, which enabled the level of oral cavity cancer aggressiveness to be characterized precisely. The current methodology described in this article should therefore afford pathologists original and quantitative (and thus objective) prognostic markers for oral cavity cancers.

Concomitant boost radiotherapy for squamous carcinoma of the tonsillar fossa

PURPOSE

To assess the efficacy of a concomitant boost fractionation schedule of radiotherapy for treating patients with squamous carcinoma of the tonsillar fossa.

PATIENTS AND METHODS

Between December 1983 and November 1992, 83 patients with squamous carcinoma of the tonsil were treated with concomitant boost fractionation. The distribution of American Joint Committee on Cancer T stages was TX-4, T1-5, T2-29, T3-41, T4-4; N stages were NX-1, N0-26, N1-13, N2-31, N3-12. Patients were treated with standard large fields to 54 Gy in 6 weeks. The boost treatment consisted of a second daily 1.5 Gy fraction for 10-12 fractions, usually delivered during the final phase of treatment. The tumor dose was 69-72 Gy, given over 6 weeks. Twenty-one patients, who all had N2 or N3 regional disease, underwent neck dissections, either before (13 patients) or 6 weeks after radiotherapy (8 patients); the other patients were treated with radiotherapy alone.

RESULTS

The 5-year actuarial disease-specific survival and overall survival rates were 71 and 60%, respectively. Patients with T2 and T3 primary tumors had 5-year actuarial local control rates of 96 and 78%, respectively. Patients with T3 disease who received the final-phase boost had a 5-year actuarial local control rate of 82%. Actuarial 5-year regional disease control rates were N0, 92%; N1, 76%; N2, 89%; and N3, 89%. The 21 patients who had neck dissections all had their disease regionally controlled. Patients presenting with nodal disease or after a node excision who were treated with radiation alone had a 5-year actuarial regional disease control rate of 79%. All but five patients had confluent Grade 4 mucositis during treatment. Severe late complications attributable to radiation included mandibular necrosis [1], in-field osteosarcoma [1], and chronic dysphagia for solid foods [5].

CONCLUSIONS

High rates of local and regional disease control were achieved with the concomitant boost fractionation schedule, with few cases of severe late morbidity. Patients with N2 and N3 neck disease were effectively treated with radiation and the selective use of neck dissections. The concomitant boost schedule is our preferred fractionation approach for treating patients with intermediate stage tonsil cancer who are not participating in our current research protocols.