Elective postoperative radiation therapy in stages III and IV epidermoid carcinoma of the head and neck

Systematic Implementation of Effective Quality Assurance Processes for the Assessment of Radiation Target Volumes in Head and Neck Cancer

PURPOSE

Significant heterogeneity exists in clinical quality assurance (QA) practices within radiation oncology departments, with most chart rounds lacking prospective peer-reviewed contour evaluation. This has the potential to significantly affect patient outcomes, particularly for head and neck cancers (HNC) given the large variance in target volume delineation. With this understanding, we incorporated a prospective systematic peer contour-review process into our workflow for all patients with HNC. This study aims to assess the effectiveness of implementing prospective peer review into practice for our National Cancer Institute Designated Cancer Center and to report factors associated with contour modifications.

METHODS AND MATERIALS

Starting in November 2020, our department adopted a systematic QA process with real-time metrics, in which contours for all patients with HNC treated with radiation therapy were prospectively peer reviewed and graded. Contours were graded with green (unnecessary), yellow (minor), or red (major) colors based on the degree of peer-recommended modifications. Contours from November 2020 through September 2021 were included for analysis.

RESULTS

Three hundred sixty contours were included. Contour grades were made up of 89.7% green, 8.9% yellow, and 1.4% red grades. Physicians with >12 months of clinical experience were less likely to have contour changes requested than those with <12 months (8.3% vs 40.9%; P < .001). Contour grades were significantly associated with physician case load, with physicians presenting more than the median number of 50 cases having significantly less modifications requested than those presenting <50 (6.7% vs 13.3%; P = .013). Physicians working with a resident or fellow were less likely to have contour changes requested than those without a trainee (5.2% vs 12.6%; P = .039). Frequency of major modification requests significantly decreased over time after adoption of prospective peer contour review, with no red grades occurring >6 months after adoption.

CONCLUSIONS

This study highlights the importance of prospective peer contour-review implementation into systematic clinical QA processes for HNC. Physician experience proved to be the highest predictor of approved contours. A growth curve was demonstrated, with major modifications declining after prospective contour review implementation. Even within a high-volume academic practice with subspecialist attendings, >10% of patients had contour changes made as a direct result of prospective peer review.

Latin American Consensus on the Treatment of Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.

Quality improvement intervention to reduce time to postoperative radiation in head and neck free flap patients

BACKGROUND

Best-practice guidelines for head and neck cancer patients advise postoperative radiation therapy (PORT) initiation within 6 weeks of surgery. We report our institutional experience improving timeliness of adjuvant radiation in free-flap patients.

METHODS

Thirty-nine patients met inclusion criteria in the 2017-2019 study period. We divided into "Early" (n = 19) and "Late" (n = 20) time-period groups to compare performance over time. The primary endpoint was time to PORT initiation, with success defined as <6 weeks.

RESULTS

The number of patients achieving timely PORT improved from 10.5% in the Early group to 50.0% in the Late group (p = 0.014). Patients undergoing concurrent adjuvant chemoradiation were more likely to meet the PORT target in the Late group (p = 0.012).

CONCLUSIONS

We ascribe this quality improvement in free-flap patients to increased communication among multidisciplinary care teams, proactive consultation referrals, and a targeted patient-navigator intervention. Though work is needed to further improve performance, insight gained from our experience may benefit other teams.

Current Indications for Transoral Robotic Surgery in Oropharyngeal Cancer

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is increasing dramatically and is conclusively linked to increasing rates of human papillomavirus (HPV) infection. HPV-related oropharyngeal cancers have been shown to occur in a unique demographic group and show favorable oncologic outcomes compared with HPV-negative OPSCC. There has been a paradigm shift in the treatment of early-stage OPSCC, with most patients now undergoing primary surgery in the United States. Transoral robotic surgery is associated with excellent oncologic and functional outcomes in the treatment of OPSCC and is increasingly being used for a broader range of oropharyngeal indications.

Surgical outcomes in patients with endoscopic versus transcranial approach for skull base malignancies: a 10-year institutional experience

Object: The authors performed an extensive comparison between patients treated with open versus an endoscopic approach for skull base malignancy with emphasis on surgical outcomes.Methods: A single-institution retrospective review of 60 patients who underwent surgery for skull base malignancy between 2009 and 2018 was performed. Disease features, surgical resection, post-operative morbidities, adjuvant treatment, recurrence, and survival rates were compared between 30 patients who received purely open surgery and 30 patients who underwent purely endoscopic resection for a skull base malignancy.Results: Of the 60 patients with skull base malignancy, 30 underwent open resection and 30 underwent endoscopic resection. The most common hisotype for endoscopic resection was squamous cell carcinoma (26.7%), olfactory neuroblastoma (16.7%), and sarcoma (10.0%), and 43.3%, 13.3%, and 10.0% for the open resection cohort, respectively. There were no statistical differences in gross total resection, surgical-associated cranial neuropathy, or ability to achieve negative margins between the groups (p > 0.1, all comparisons). Patients who underwent endoscopic resection had shorter surgeries (320.3 ± 158.5 minutes vs. 495.3 ± 187.6 minutes (p = 0.0003), less intraoperative blood loss (282.2 ± 333.6 ml vs. 696.7 ± 500.2 ml (p < 0.0001), and shorter length of stay (3.5 ± 3.7 days vs. 8.8 ± 6.0 days (p < 0.0001). Additionally, patients treated endoscopically initiated adjuvant radiation treatment more quickly (48.0 ± 20.3 days vs. 72.0 ± 20.5 days (p = 0.01).Conclusions: An endoscopic endonasal approach facilitates a clinically meaningful improvement in surgical outcomes for skull base malignancies.

Time abides long enough for those who make use of it

Increased treatment package time is an independent poor prognostic factor for outcomes in head and neck squamous cell carcinoma (HNSCC). Similarly the timeliness of treatment initiation is a risk factor for disease recurrence. Despite these well-known issues, the timeliness of treatment initiation is actually worsening in the United States and the expeditious completion of radiation treatments continues to be difficult secondary to a number of patients and treatment related issues. This analysis evaluates the current data on treatment intervals in the management of head and neck cancer. Rapid staging/diagnosis of head and neck cancer, appropriate referrals to providers qualified to treat said cancer, and expeditious treatment completion remains the most cost-effective, widely applicable method to improve outcomes in head and neck cancer.

Oral Cancer Treatment Through the Ages: Part 2

PURPOSE

Understanding how oral cancer treatment evolved can pave the way for future management. The literature holds an expansive collection of historical findings regarding oral cancer, yet the authors were unable to find a comprehensive review of oral cancer treatment throughout the ages.

MATERIALS

A thorough literature review was carried out using multiple scientific databases and languages, as well as examination of historical archives. Articles were included for their relevance and their findings were assimilated.

RESULTS

Part two of this article considers the development of specific surgical concepts relating to head and neck cancer over the previous two centuries, including neck dissection and reconstruction, as well as exploration of non-surgical cancer therapies.

CONCLUSION

This paper demonstrates historical landmarks made in oral cancer treatment and the prominent figures who pioneered them, confirming that head and neck cancer surgeons of today have valuable lessons to learn from their previous counterparts.

Postoperative Radiotherapy in Locally Advanced Head and Neck Cancer

This retrospective study was conducted on 255 consecutive patients with locally advanced squamous-cell carcinoma of the oral cavity, oropharynx, larynx or hypopharynx, treated at the Radiotherapy Department of Pordenone General Hospital between January 1975 and December 1985. All patients underwent radical surgery followed, after an interval ranging from 10 days to 2.9 months, by radiotherapy given either through a 6 MeV linear accelerator or a cobalt-60 unit. Field extension and dose delivered were comparable in relation to stage and involvement of the surgical resection margins. The aims of the study were to evaluate the survival rate and to analyze the clinical parameters which can influence the disease-free survival. The adjusted overall 5-year survival rate was 71%; stage, performance status at diagnosis, and site of the primary tumor were significant factors in determining patient prognosis, whereas Infiltration of resection margins was not significant in determining locoregional control of disease. Seventy-five patients relapsed and 67 died of cancer-related diseases whereas death in 52 patients was not related to the head and neck cancer. The combined modality treatment consisting of surgery followed by radiotherapy was well tolerated and proved to be effective in the treatment of locally advanced head and neck tumors.

Testing the Timing: Time Factor in Radiation Treatment for Head and Neck Cancers

OPINION STATEMENT

Overall radiation treatment time has long been recognized as an important factor in head and neck tumor control. The concern of tumor growth in waiting time either before starting radiotherapy or during treatment is substantial given its negative impact on clinical outcome. There is an overwhelming evidence that increasing the time to initiate treatment increases the tumor burden and worsens the prognosis. This effect is more pronounced especially in patients with an early stage cancer disease. Delay in treatment initiation is contributed by both health care- and patient-related factors. Health care-related factors include advancement in diagnostic modalities and transfer of patient to academic health care centers accompanied by delayed referrals and long-awaited appointments. Patient-related factors include delayed reporting time and socioeconomic factors. An efficient transition of care along with access of cancer care modalities to community health care centers will not only improve the quality of care in secondary health care centers but also help decrease the patient burden in tertiary centers. A quick and well-structured multidisciplinary appointment program is fundamental in shortening the time required for patient referrals, thus increasing the optimal survival time for Head and Neck cancer patients with early initiation of treatment.

The influence of intraoperative frozen section analysis in patients with total or extended maxillectomy

BACKGROUND

Intraoperative frozen sections and final pathology may influence treatment with regards to intraoperative and postoperative treatments, respectively.

STUDY DESIGN

A retrospective study comparing intraoperative frozen section analysis with final pathologic analysis in patients who had total or extended maxillectomies for malignant disease between 2008 and 2013.

RESULTS

Twenty-five patients met the inclusion criteria. The mean age was 67.8 years. The majority of patients (76%) had stage IV disease (American Joint Committee on Cancer [AJCC] staging). Intraoperative frozen sections were positive in 24% (n = 6) compared with 60% (n = 15) on final pathologic analysis. Frozen section analysis had a sensitivity of 40%. Positive margins were resected where possible, unless limited by proximity to vital structures. Patients were statistically more likely to follow a recommendation for adjuvant therapy (P < .05) compared with adjuvant chemotherapy (P > .05).

CONCLUSIONS

Intraoperative frozen section analyses are unreliable in predicting positive margins in patients with late-stage maxillary malignancies. Patients were more likely to accept adjuvant radiation than adjuvant chemotherapy.

Emerging insights into head and neck cancer metastasis

The purpose of this review was to provide biological concepts of head and neck cancer metastasis. To attain this goal, we analyzed peer-reviewed articles related to head and neck cancer metastasis obtained though PubMed and archived articles. Articles related to the biologic principles of head and neck cancer metastasis were reviewed and summarized. As locoregional control has improved for patients with head and neck cancer, rates of distant metastasis have not decreased. As patients live longer, many will die of complications related to the development of disease at sites below the clavicles. Emerging evidence now suggests a more complicated framework of metastatic behavior for head and neck cancer. Here, we review the role of regional lymph nodes in containing advanced head and neck cancer, evidence for active as opposed to passive tumor cell metastasis, and clinical implications these concepts have on both treatment of head and neck cancer and future research.

Postoperative strategies after primary surgery for squamous cell carcinoma of the head and neck

This review discusses the role of adjuvant treatment after curative surgery for patients with head and neck squamous cell carcinoma (HNSCC). In general, patients with unfavourable prognostic factors have a high-risk of loco-regional recurrence and subsequent worse survival after surgery alone and are therefore considered proper candidates for adjuvant treatment by either postoperative radiotherapy alone or postoperative chemoradiation. Selection of the most optimal adjuvant treatment strategy should be based on the most important prognostic factors. In this review, the different treatment strategies will be discussed in general. More specifically, we will discuss the role of the interval between surgery and radiotherapy, the overall treatment time of radiation, the selection of target volumes for radiation and the value of adding concomitant chemotherapy to postoperative radiation.

The Danish national guidelines for treatment of oral squamous cell carcinoma

The treatment strategy for oral squamous cell carcinoma in Denmark has traditionally varied between the different head and neck oncology centres. A study group within the Danish Society for Head and Neck Oncology (DSHHO) was formed with the aim of optimising and standardising the treatment strategy. The approach was to use single modality treatment for stage I, stage II and some stage III and combined modality treatment for stage III and IV. Surgery was the preferred treatment when it was considered possible to perform a radical excision of the tumour and possible lymph node metastases with acceptable aesthetic and functional outcome. The implementation of a recognised national guideline facilitates prospective studies on a large well-characterised cohort. This increases the possibility of obtaining valid data on parameters such as morbidity, loco-regional control and survival. In addition the establishment of a reference program facilitates national monitoring of the treatment using defined indicators and standards.

An outline of the history of head and neck oncology

This review analyzes the development of head and neck oncology as outlined in medical history articles. A systematic literature survey was conducted with the search engines "Google Scholar" and "PubMed" and the retrieved publications were cross-referenced. In addition, books and, when possible, original sources were consulted. While most of the material was obtained from publications from the modern era reviewing historical data, some of the information was derived from original source material. The obtained articles on the history of cancer were then analyzed for details on head and neck oncology. The cradle of oncology was located in ancient Egypt and Greece. The search showed that the first tumors treated in the head and neck were either cutaneous malignancies or cancers on the mucosal surfaces of the oral cavity. The origin, diagnosis and treatment of more deeply situated tumors of the larynx and hypopharynx remained obscure for many centuries. The medieval age brought little progress to medicine in general, and in head and neck oncology in particular, due to religious concerns. Renaissance medicine was characterized by advances in medicine and oncology made by systematic dissection studies of normal and pathologic anatomy. The 19th and 20th century reflect the development of head and neck oncology in the era of science based medicine. Almost all of our current understanding of head and neck oncology, our diagnostic methods and treatment strategies have been developed in these two centuries. The analysis showed that many oncologic problems, which occupy our minds today, were also concerns of our medical ancestors.

Clinical aspects of metastases

In the short term the major hope for reducing cancer mortality is to effect a reduction in the number of patients who develop malignant disease and in the proportion of cancer patients who present with metastases. Hitherto the major emphasis of clinical research on metastases has been directed at detection and elimination rather than prevention or early diagnosis. Extensive data relating histological class and tumour stage to risk of metastasis and metastatic pattern have been compiled from studies of relapse and from invasive and non-invasive staging procedures. However, the biological events involved in the metastatic process and the factors which influence it in relation to the natural history of primary human tumours are poorly understood. Information describing metastatic heterogeneity in individual patients, in terms of therapeutic response or intrinsic sensitivity to cytotoxic agents, is scanty. Similarly, the characteristics of human metastases in relation to the clonal heterogeneity of primary tumours are poorly defined. The clinical application of molecular biological techniques, which has led to the association of gene amplification with tumour behaviour in a range of sites, offers the prospects of improved tumour localization and therapy and, in the longer term, of tumour control by interventions based on a knowledge of the mechanisms that regulate cell growth and differentiation.

Examining time intervals between diagnosis and treatment in the management of patients with limited stage small cell lung cancer

OBJECTIVE

To examine time intervals between diagnosis and treatment of limited stage small cell lung cancer (L-SCLC) and to evaluate its effect on clinical outcomes.

MATERIALS AND METHODS

Data on 166 patients with L-SCLC referred to a regional cancer center between January 1991 and December 1999 were analyzed. The time intervals studied were defined as: interval A, first abnormal chest x-ray to pathologic diagnosis: interval B, diagnosis to first oncology consultation; interval C, oncology consultation to first day of thoracic radiotherapy (RT); interval D, oncology consultation to first day of chemotherapy; and interval E, first day of chemo to first day of RT. Cox proportional hazards models were used to examine associations between the time intervals and thoracic relapse (TR) and overall survival (OS) outcomes. Logistic regression analysis was used to model associations between time and complete response (CR) rates.

RESULTS

The median time duration of intervals A to E were 20, 12, 63.5, 15, and 48 days, respectively. When time was analyzed as a continuous variable, no statistically significant association between the interval lengths and outcomes studied was observed. Dichotomizing each interval using the median value as cut-off revealed that interval A >20 days was significantly associated with improved CR (odds ratio = 3.573; P = 0.027) whereas interval B >12 days was associated with a trend toward lower CR (odds ratio = 0.348; P = 0.073).

CONCLUSIONS

Short median times from first abnormal chest x-ray to diagnosis and from diagnosis to oncology consultation indicate that L-SCLC patients were diagnosed and referred promptly in the community setting. OS and TR appeared independent of the time intervals analyzed. Individual variations in disease presentation and tumor biology may explain the observed associations between early pathologic diagnosis and inferior CR rates.

Squamous cell carcinoma of the buccal mucosa: An aggressive cancer requiring multimodality treatment

BACKGROUND

In our clinical practice, we have observed a high incidence of locoregional failure in squamous cell carcinoma (SCC) of the buccal mucosa. We analyze our treatment results of this cancer and compare these results with those in the literature. We intend to define the pattern and incidence of failure of buccal cancer and provide information for the design of a better multimodality treatment.

METHODS

During the period from 1983 through 2003, 121 previously untreated patients with M0 stage SCC of the buccal mucosa were treated with a curative intent at our hospital. Twenty-seven patients received surgery alone, 36 had radiotherapy alone, and 58 underwent surgery plus postoperative radiotherapy.

RESULTS

The 5-year locoregional control, overall survival, and cause-specific survival rates for all patients were 36.3%, 34.3%, and 36.9%, respectively. The locoregional recurrence rate was 57% for all patients, with 80% occurring in the primary site alone. Patients with T1-2N0 disease who received surgery alone still had a high local recurrence incidence of 41%. For patients with locally advanced disease, surgery plus postoperative radiotherapy achieved better overall survival and locoregional control rates than surgery alone or radiotherapy alone. T classification was the only prognostic factor affecting locoregional control and survival in the surgery alone group, whereas N classification and skin invasion predicted a poorer survival for the surgery plus postoperative radiotherapy group.

CONCLUSIONS

SCC of the buccal mucosa is an aggressive cancer with a high locoregional failure rate even in patients with T1-2N0 disease. Possible reasons include inadequate treatment and an intrinsically aggressive nature. Postoperative radiotherapy has resulted in a better locoregional control rate for patients with T3-4 or N+ disease and should also be considered for patients with T1-2N0 disease for whom adjuvant therapy after radical surgery currently is not recommended by most guidelines.

Head and neck squamous cell carcinoma: the role of post-operative adjuvant radiotherapy

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) is one of the leading cancers in India. Since a large majority present in loco-regionally advanced stages, surgery followed by adjuvant post-operative radiotherapy (PORT) has been the mainstay of treatment for resectable HNSCC.

AIM

To identify clinico-pathologic factors that could have an impact on outcome in HNSCC in the postoperative setting.

MATERIALS AND METHODS

A retrospective review of 348 previously untreated patients with HNSCC who received PORT following curative surgery. The outcome measures were local control, loco-regional control, and disease free survival (DFS).

RESULTS

With a median follow-up of 36 months (range: 2-127 months) for surviving patients, the 5-year local control, loco-regional control, and DFS was 79%, 63%, and 56%, respectively for all patients. On univariate analysis, site of primary was an independent prognostic factor for all the outcome measures (P = 0.005, 0.02, and 0.04, respectively) with oral cavity lesions faring the worst. Peri-nodal extension (PNE) affected loco-regional control (P = 0.002) and DFS (P = 0.0005), but was not predictive for local control (P = 0.9852). Cut margin positivity predicted for inferior local control alone (P = 0.03), the significance of which was lost on multivariate analysis. Cox regression analysis however confirmed the significance of primary site and PNE as independent prognostic factors.

CONCLUSION

Primary site and PNE are independent factors predicting outcome in the postoperative radiotherapeutic management of HNSCC.

Does delay in starting treatment affect the outcomes of radiotherapy? A systematic review

PURPOSE

The objective of this study was to synthesize what is known about the relationship between delay in radiotherapy (RT) and the outcomes of RT.

METHODS

A systematic review of the world literature was conducted to identify studies that described the association between delay in RT and the probability of local control, metastasis, and/or survival. Studies were classified by clinical and methodologic criteria and their results were combined using a random-effects model.

RESULTS

A total of 46 relevant studies involving 15,782 patients met our minimum methodologic criteria of validity; most (42) were retrospective observational studies. Thirty-nine studies described rates of local recurrence, 21 studies described rates of distant metastasis, and 19 studies described survival. The relationship between delay and the outcomes of RT had been studied in diverse situations, but most frequently in breast cancer (21 studies) and head and neck cancer (12 studies). Combined analysis showed that the 5-year local recurrence rate (LRR) was significantly higher in patients treated with adjuvant RT for breast cancer more than 8 weeks after surgery than in those treated within 8 weeks of surgery (odds ratio [OR] = 1.62, 95% confidence interval [CI], 1.21 to 2.16). Combined analysis also showed that the LRR was significantly higher among patients who received postoperative RT for head and neck cancer more than 6 weeks after surgery than among those treated within 6 weeks of surgery (OR = 2.89; 95% CI, 1.60 to 5.21). There was little evidence about the impact of delay in RT on the risk of metastases or the probability of long-term survival in any situation.

CONCLUSION

Delay in the initiation of RT is associated with an increase [corrected] in LRR in breast cancer and head and neck cancer. Delays in starting RT should be as short as reasonably achievable.

Effect of treatment delay on outcome of patients with early-stage head-and-neck carcinoma receiving radical radiotherapy

PURPOSE

Access to radiotherapy (RT) has been considerably reduced in Quebec since the late 1980s. The aim of the present study was to analyze the impact of delaying treatment on the outcome of patients with early head-and-neck squamous cell carcinomas.

MATERIALS AND METHODS

This retrospective analysis examined the outcome for all 623 patients with early-stage disease (T1-2, N0-1) who received radical RT between 1988 and 1997 at the Hotel Dieu of Quebec Hospital. Delay was defined as the time from initial evaluation by a radiation oncologist to the beginning of RT. Delay intervals were divided as follows: <30 days, 31-40 days, and >40 days.

RESULTS

A delay of >40 days was significantly associated with an increased risk of local and neck failure and poorer survival relative to patients treated in <30 days or between 31 and 40 days. The adjusted hazard ratio and (in parentheses) the 95% confidence interval was 2.6 (1.07-6.4), 2.73 (1.38-5.4), and 1.7 (1.1-2.6), respectively, for local failure, neck failure, and survival. In the subgroup of patients with T2N0 disease, delaying RT for >30 days was associated with a poor outcome, as measured by the same end points.

CONCLUSION

Delaying RT had a deleterious effect on these patients. RT should be started as soon as possible in patients with squamous cell carcinoma of the head and neck, preferably within 20-30 days after evaluation by a radiation oncologist.

[Factors affecting local and regional control and survival of carcinomas of the tongue and floor of mouth]

A retrospective study of 142 patients that had previous surgery for carcinoma of the tongue or floor of mouth looking into the factors that affect significantly the evolution of our patients and in which circumstances we could benefit from new therapeutic techniques. Cause specific survival at 3 and 5 years was 63.4% and 56.9% respectively. Recurrences were found locally in 32 patients (22.5%), regional in 32 (22.5%) and metastasis in 11 (7.4%). T staging had no did impact on local recurrence, but the presence of positive margins (p = 0.0323). Regional control for N0/N1 was 85% (90/106) versus 55.5% (20/36) for N2/N3 (p = 0.001). Regional control by N staging was 84.5% (73/86) for N0, 85% (17/20) for N1, 57% (30/35) for N2 and 0% for N3 (0/1). Both, N staging and number of positive nodes had a significant impact in specific survival. Positive margins and the presence of positive nodes have the greatest impact on survival and regional control. Adjuvant postoperative radiotherapy did not increase survival, but not prospective random selection was performed. To evaluate this.

A pilot study of postoperative CHART and CHARTWEL in head and neck cancer

A Phase II pilot study of continuous hyperfractionated accelerated radiotherapy (CHART)/CHART weekend less (CHARTWEL) was carried out in the postoperative treatment of patients with squamous cell carcinoma of the head and neck. Twenty-four patients (17 male, seven female) with a median age of 64 years (range 34-80) were treated with postoperative radiotherapy between 1991 and 1999. All patients presented with primary squamous cell carcinoma, which, at surgery, had shown adverse pathological factors for recurrence. Intermediate risk was determined by the presence of two of the following factors: margins 5 mm, Stage T3/T4, perineural or vascular invasion, poor differentiation, oral primary, multicentric primary, and more than four positive lymph nodes. High-risk factors included the presence of extracapsular spread and/or incomplete resection margins, or the presence of four of the factors defining intermediate risk. The patients were treated using a CHART (n = 11) or a CHARTWEL (n = 13) schedule, administering a dose between 49.5 Gy and 54 Gy. High-risk factors were present in 18/24 patients. Treatment was commenced from a median time of 6.9 weeks (range 4.4-16.6) after radical surgery. All patients completed treatment. A confluent radiation mucositis occurred in 20/23 evaluable patients, which settled in 4-10 weeks after commencing radiotherapy. Moderate dysphagia was observed in 13 patients. Mild subcutaneus oedema was noted in 11 patients from 12 weeks after treatment. No significant late toxicity has been observed. Over a median follow up-period of 17 months, local control has been maintained in 17 patients (71%). Seven patients have relapsed and died of disease. A mean survival of 24 months (range 1-84) has been observed. This pilot study demonstrates acceptable morbidity for CHART/CHARTWEL in the postoperative setting. A prospective multicentre randomized trial using an accelerated schedule of radiotherapy versus conventional fractionation for the radical postoperative treatment of primary head and neck cancer is currently in preparation.

Three-dimensional radiotherapy of head and neck and esophageal carcinomas: a monoisocentric treatment technique to achieve improved dose distributions

The specific aim of three-dimensional conformal radiotherapy is to deliver adequate therapeutic radiation dose to the target volume while concomitantly keeping the dose to surrounding and intervening normal tissues to a minimum. The objective of this study is to examine dose distributions produced by various radiotherapy techniques used in managing head and neck tumors when the upper part of the esophagus is also involved. Treatment planning was performed with a three-dimensional (3-D) treatment planning system. Computerized tomographic (CT) scans used by this system to generate isodose distributions and dose-volume histograms were obtained directly from the CT scanner, which is connected via ethernet cabling to the 3-D planning system. These are useful clinical tools for evaluating the dose distribution to the treatment volume, clinical target volume, gross tumor volume, and certain critical organs. Using 6 and 18 MV photon beams, different configurations of standard treatment techniques for head and neck and esophageal carcinoma were studied and the resulting dose distributions were analyzed. Film validation dosimetry in solid-water phantom was performed to assess the magnitude of dose inhomogeneity at the field junction. Real-time dose measurements on patients using diode dosimetry were made and compared with computed dose values. With regard to minimizing radiation dose to surrounding structures (i.e., lung, spinal cord, etc.), the monoisocentric technique gave the best isodose distributions in terms of dose uniformity. The mini-mantle anterior-posterior/posterior-anterior (AP/PA) technique produced grossly non-uniform dose distribution with excessive hot spots. The dose measured on the patient during the treatment agrees to within +/- 5 % with the computed dose. The protocols presented in this work for simulation, immobilization and treatment planning of patients with head and neck and esophageal tumors provide the optimum dose distributions in the target volume with reduced irradiation of surrounding non-target tissues, and can be routinely implemented in a radiation oncology department. The presence of a real-time dose-measuring system plays an important role in verifying the actual delivery of radiation dose.

Influence of the delay of adjuvant postoperative radiation therapy on relapse and survival in oropharyngeal and hypopharyngeal cancers

PURPOSE

To determine whether the delay between surgery and the beginning of radiation therapy influences survival or the risk of local-regional relapse in oropharyngeal or hypopharyngeal squamous cell carcinomas.

METHODS AND MATERIALS

From 2052 patients referred to the Henri Becquerel Center for the radiation therapy of an oropharyngeal or hypopharyngeal cancer between January 1, 1981 and December 31, 1992, 420 were included in a retrospective study. Exclusion criteria were another cancer, metastasis, incomplete resection, lack of homolateral lymph node resection, or previous chemotherapy. Radiation therapy delivered 45 to 75 Gy on initial location and lymph node. Follow-up was performed until December 31, 1997. A Cox proportional hazard regression analysis was used to evaluate the prognostic factors.

RESULTS

The delay between surgery and radiation therapy was not found to be a significant prognostic factor for survival or risk of local-regional relapse. The only parameters found to influence local-regional and survival control were margins' pathologic state (respectively p < 0.0001 and p = 0.015) and T (p < 0.0001) and N (respectively p < 0.0001 and p = 0.0004) stages. In terms of local-regional relapse only, age was a prognostic factor (p = 0.048), and a trend was noted for tumor emboli in vessels or nerves (p = 0.061).

CONCLUSION

In patients with oropharyngeal or hypopharyngeal squamous cell carcinoma, the delay between surgical procedure and radiation therapy does not influence survival or risk of local-regional relapse. Radiation therapy might be subjected to complete healing in these patients.

Outcome of squamous cell carcinoma of the gingiva: a follow-up study of 83 cases

BACKGROUND

Squamous cell carcinomas of the gingiva are relatively rare tumours. Standard treatment is based on surgery and radiotherapy. The extent of bone involvement affects mandibulectary indications.

PURPOSE

A retrospective review of squamous cell carcinomas of the gingiva was performed to evaluate the incidence of mandibular or maxillary bone involvement. Indications for marginal and segmental bone resections are specified.

MATERIAL

From 1985 to 1996, 83 patients with squamous cell carcinoma of the gingiva were treated at the Department of Surgery (Institut Bergonié, Bordeaux, France) and at the Department of Maxillofacial and Plastic Surgery (Centre Hospitalier Universitaire, Bordeaux, France). Forty-three underwent surgery plus postoperative radiotherapy. Twenty-two had flap reconstructions. Clinical evaluation and panorex roentgenography were the means used to evaluate bony invasion and to decide on the extent of bone resection.

METHODS

A retrospective review of 83 consecutive patients was performed. This series is unusual in its homogeneity: surgery was performed by only two individuals and the radiotherapy was the responsibility of just two physicians. Outcome was calculated using the Kaplan-Meier method.

RESULTS

Primary local control was achieved in 72 patients (87%). Overall survival and rate of recurrence were comparable to those of other squamous cell carcinomas of the oral cavity and oropharynx.

CONCLUSION

Surgical resection continues to be the mainstay of treatment and this study tends to confirm the validity of modified neck dissection and marginal bone resection in suitably selected patients.

The effect of waiting for radiotherapy for grade III/IV gliomas

AIM

To determine the effect of waiting time for radiotherapy on the overall survival of patients with high-grade gliomas.

METHODS

We examined records of patients with grade III/IV gliomas who were referred to radiotherapy after surgery or biopsy - ECOG <3, any age, radical intent or palliative intent with dose >50 Gy, no interstitial or radiosurgery boost. Waiting time was defined in two ways, time from biopsy to radiotherapy and time from presentation to radiotherapy department to start of radiotherapy.

RESULTS

There were 182 patients in the study having a median survival of 8.5 months, with a median follow up of 10.5 months. The group comprised of 63 (35%) grade III and 119 (65%) grade IV gliomas. Median times and ranges from biopsy and presentation to treatment were 26 days (4-78 days) and 15 days (1-62 days), respectively. The median dose was 60 Gy in a median of 30 fractions over a median of 46 days. Tumour progression before and during radiotherapy occurred in seven patients (4%) and 19 patients (11%), respectively. One hundred and seventy-nine patients died of disease. The seven patients whose tumour progressed before radiotherapy were excluded from the analysis of prognostic variables. In a multivariate analysis the variables that were significantly associated with worse survival were older age, reduced dose and prolonged waiting time from presentation. The risk of death increased by 2% for each day of waiting for radiotherapy.

CONCLUSION

The study showed longer waiting time from presentation at radiotherapy department to treatment to be a significant predictor of overall survival for patients with high-grade glioma.

Postoperative radiotherapy in patients with positive nodes after functional neck dissection

A study was designed to assess the usefulness of postoperative radiotherapy (RT) in patients with surgically treated laryngeal and hypopharyngeal cancer with histologically proven positive neck nodes. Patients underwent operation between 1984 and 1995, with functional neck dissection (FND) being part of the treatment in all cases. The selection criteria included squamous cell carcinoma, negative margins for the primary tumor, and no previous treatment. For evaluation purposes, patients were divided into 2 groups: surgery alone versus surgery with postoperative RT. Eighty-three patients fulfilled the inclusion criteria and entered the study. All but 1 of the patients were men. The mean age was 58 years (range, 35 to 77 years). A multivariate analysis was used to analyze the prognostic parameters selected by univariate analysis, eg, age, alcohol, tumor location, T and N stages, and presence or absence of extracapsular spread and a desmoplastic pattern. Postoperative RT was not selected by univariate analysis as a prognostic factor, but was included in the multivariate analysis in order to assess its impact on survival and recurrence rates. Using the statistical method of multivariate analysis, we could not find evidence of a benefit to survival or local recurrence rates with postoperative RT in this series. Patients younger than 55 years and those with extracapsular spread had a decreased survival rate and a higher neck recurrence rate, irrespective of the treatment method.

Squamous cell carcinoma of maxillary sinus

BACKGROUND

Medical records of 43 patients with histologically proved diagnosis of squamous cell carcinoma who were treated between the years 1975 and 1994 at the department of Otolaryngology Head Neck Surgery, VU Amsterdam were examined.

METHODS

Tumors were restaged according to UICC classification 1997. Thirty-eight patients were treated for cure, nine were treated with chemotherapy followed by external beam radiotherapy, and 28 patients were treated with surgery followed by postoperative radiotherapy. No patient was lost to follow-up. Data with respect to survival were analyzed.

RESULTS

Eighty-three percent of the tumours were in stage III or stage IV at the time of first presentation. Five-year survival after surgery and postoperative radiotherapy for all patients was 64%. For stages II, III, and IV it was 83%, 49%, and 37%, respectively. Cervical nodal metastases were present in 4.1% at the time of presentation. Thirty-seven percent of the patients survived 2 years after chemotherapy followed by radiotherapy.

CONCLUSIONS

Squamous cell carcinoma continues to be diagnosed late. Surgery followed by radiotherapy remains the treatment of choice. Mandibulotomy should be considered for better clearance of retromaxillary space in T3 -T4 tumors. The eye should be preserved whenever it is oncologically safe to do so.

Radiation with concurrent late chemotherapy intensification ('chemoboost') for locally advanced head and neck cancer

The aim of this study was to review our experience with a treatment regimen that combined conventionally fractionated radiation therapy (70 Gy over 7 weeks) with chemotherapy (cisplatin and fluorouracil), given concurrently in the last 2 weeks of radiation therapy in patients with previously untreated advanced squamous cell cancer of the head and neck region.Twenty-eight patients, all but two having UICC stage IV disease, were treated at the Peter MacCallum Cancer Institute between November 1995 and April 1998. Planned chemotherapy consisted initially of continuous infusion at 10 mg/m(2) per day of cisplatin and 400 mg/m(2) per day of fluorouracil on days 1-5 of weeks 6 and 7 of a conventionally fractionated course of radiotherapy. After the first 14 patients, the dose of fluorouracil was reduced to 360 mg/m(2) per day because of acute toxicity.36.8 months), with an estimated 50% surviving at 2 years (CI, 29-71%). Sixteen patients (57%) developed confluent mucositis and 11 (39%) developed patchy mucositis. The median duration of mucositis for these 27 patients was 1.5 months. Seventeen patients (61%) required nutritional support for a median duration of 1.4 months. Fourteen patients (50%) had grade three skin reactions, and 12 (43%) had one or more other significant (Grade 3) toxicities, predominantly infective. Grade 3 late toxicity has been observed in three patients to date (three xerostomia, including one with severe depression), and one patient had chronic ulceration of the oral tongue (grade 4). This chemoradiation regimen achieved an excellent complete response rate and good locoregional control at 2 years in patients with a poor initial prognosis. Acute toxicity was significant but manageable. The regimen offers an alternative to surgery and postoperative radiation therapy in locally advanced head and neck cancer.

Surgery versus surgery and postoperative radiotherapy in squamous cell carcinoma of the buccal mucosa: a comparative study

BACKGROUND

The efficacy of postoperative radiotherapy for squamous cell carcinoma of the buccal mucosa was evaluated.

METHODS

One hundred seventy-six patients treated between 1989 and 1993 were analyzed. One hundred fifteen patients were treated with surgery alone (Group 1), and 61 patients were treated with a combination of surgery and postoperative radiotherapy (Group 2).

RESULTS

Actuarial 3-year locoregional control in Groups 1 and 2 was 11% and 48% for patients with stage III + IV cancer (P = .001) and 71% and 75% for patients with stage I + II cancer (P = .74), respectively. On multivariate analysis for locoregional failure, surgical margin, bone invasion, high grade, and node involvement were significant factors in Group 1, whereas in Group 2 only tumor thickness was a significant factor. For local failure, margin, bone invasion, and stage in Group 1 and tumor thickness in Group 2 appeared as significant factors. For nodal failure, clinical nodal (cl N0 vs. N+) stage and grade in Group 1 and pathologic nodal stage (pN0 + 1 vs. pN2) in Group 2 were observed as significant factors. On subset analysis, postoperative radiotherapy was observed to have a significant advantage for surgical margins of 2 mm or less in both early pT (T1 + T2) (P = .019) and late pT (T3 + T4) (P = .016) stages. The local failure rate was higher if the time between surgery and radiotherapy was greater than 30 days.

CONCLUSIONS

Postoperative radiotherapy was effective in decreasing locoregional failure in patients with close surgical margins, tumor thicker than 10 mm, high-grade tumors, positive node, and bone invasion. The effect of interval between surgery and postoperative radiotherapy on local failure was margin-dependent.

Early closure of a randomized trial: surgery and postoperative radiotherapy versus radiotherapy in the management of intra-oral tumours

Tumours of the oral cavity/oropharynx occur relatively infrequently in the UK. The management of such lesions, especially the squamous cell carcinomas, is still a little controversial. Some centres advocate radiotherapy while others adopt surgery and radiotherapy. In an attempt to resolve the question of which approach gives the better results, a multicentre randomized trial was established to compare surgery plus postoperative radiotherapy with radical radiotherapy alone. It was anticipated that 350 patients would be required to give a statistically significant result, but, after 35 patients had been entered, the trial was closed prematurely with a marked difference in overall survival in favour of the combination arm (P = 0.0006). At this analysis, carried out 23 months after trial closure, the survival difference between the two arms remains statistically significant for all causes of mortality (P = 0.001; relative death rate = 0.24; 95% CI 0.10-0.59).

Metastatic tumours of the parotid gland

Twenty patients (12 men and 8 women, median age 69 years) with metastatic tumours in the parotid gland who presented over a 12-year period were evaluated retrospectively. Preoperative investigations included fine needle aspiration cytology (n = 11) and computed tomography or magnetic resonance imaging (MRI) (n = 14). Most tumours originated from the head and neck region, the two main types being squamous cell carcinoma (n = 10) and malignant melanoma (n = 7). All 20 presented with a parotid mass and 11/20 (55%) had associated lymphadenopathy. Eleven patients (55%) underwent superficial, five total, and four radical, parotidectomy. Neck dissection was required in 16 patients (80%), and all 11 patients with clinically palpable lymph nodes had evidence of tumour in the neck dissection specimens. Half of all patients (n = 10) received adjuvant postoperative radiotherapy. Three-quarters of the patients (n = 15) were alive after a mean follow-up of 31 months and only one developed a marginal recurrence. The cumulative 5-year survival rate was 51%, and there was no significant difference (P = 0.48) in the 3-year survival rates of patients who had radical compared with those who had modified neck dissections. Patients who had superficial parotidectomy had a longer overall survival compared with those who had total or radical parotidectomy (P = 0.04) perhaps reflecting the advanced nature of tumours that required total or radical excision of the gland. We conclude that superficial parotidectomy is usually an adequate treatment for secondary parotid tumours (when disease is clinically limited to the superficial lobe), and we suggest that patients in whom metastatic disease of the parotid gland is suspected do not require neck dissection if they have no palpable lymph nodes and MRI shows no evidence of spread. There seems to be no survival advantage in radical over modified neck dissection.

Bioreductive alkylating agent porfiromycin in combination with radiation therapy for the management of squamous cell carcinoma of the head and neck

Porfiromycin (methyl mitomycin C) has been shown in laboratory studies to have increased preferential cytotoxicity to hypoxic cells and therefore may provide enhanced therapeutic efficacy over mitomycin C when used in combination with radiation therapy (RT). The purpose of the two clinical studies reported here is to evaluate the concomitant use of porfiromycin with RT in the management of squamous cell carcinoma of the head and neck. Between October 1989 and July 1992, 21 patients presenting with locally advanced stage III/IV squamous cell carcinoma of the head and neck were entered into a phase I toxicity trial evaluating porfiromycin as an adjunct to RT. Patients were eligible if they had biopsy documented squamous cell carcinoma of the head and neck with a low probability of cure by conventional means. Patients were treated with standard fractionated daily RT to a total median dose of 63 Gy, with porfiromycin administered on days 5 and 47 of the course of RT. Upon completion of this phase I trial, a phase III trial was initiated in November 1992 randomizing patients with squamous cell carcinoma of the head and neck to RT with mitomycin C vs. RT with porfiromycin. There is no radiation only arm in this current trial. To date, 75 patients have been entered on this trial and acute toxicity data are available on 67 patients (34 porfiromycin, 31 mitomycin C) who have completed their entire course of treatment. Median follow-up of the 21 patients enrolled in the phase I porfiromycin trial is 58.5 months. Of the 21 patients, 5 were treated at a dose of 50 mg/M2, 4 at 45 mg/M2, and the final 12 at 40 mg/M2, which appeared to result in acceptable acute hematological and nonhematological toxicities. As of December 1995, 14 of the 21 patients have died with disease and 7 remain alive and free of disease, resulting in a 5-year actuarial survival of 32%. Of the patients enrolled to date in the phase III randomized trial of mitomycin C vs. porfiromycin, there have been no statistically significant differences between the two arms with respect to white blood cell count (WBC), platelet, or hemoglobin nadirs. Acute nonhematological toxicities including mucositis, epidermitis, odynophagia, and nausea have also been comparable. Two patients in this current randomized trial died during treatment, apparently of nondrug-related causes. We conclude that the bioreductive alkylating agent porfiromycin has demonstrated an acceptable toxicity profile to date. Final analysis of the phase I trial, which revealed a 5-year no evidence of disease survival rate of 32% in patients with locally advanced disease and a low probability of cure, appears encouraging. We anticipate completion of the current ongoing trial comparing mitomycin C to porfiromycin in the next 2 years. Further investigations, including large-scale multiinstitutional trials employing bioreductive alkylating agents or other hypoxic cell cytotoxins as adjuncts to RT, are warranted.

Recurrence patterns with concurrent platinum-based chemotherapy and accelerated hyperfractionated radiotherapy in stage III and IV head and neck cancer patients

BACKGROUND

Stage III and IV squamous cell cancers of the head and neck are often unresectable at presentation and are associated with poor disease-free and overall survival rates. A phase II study using concurrent cisplatin and radiotherapy in advanced head and neck cancer indicated impressive local-regional control and survival with organ preservation.

METHODS

A multicentered phase II study was undertaken consisting of 1.8 Gy fraction radiotherapy for 2 weeks followed by 1.2 Gy BID hyperfractionation to 46.8 Gy. Continuous infusion cisplatin 20 mg/m2 was given on days 1 through 4 and 22 through 25. Biopsy of the primary tumor was done at this point, and patients with clinical and pathologic complete response continued with hyperfractionated radiotherapy to 75.6 Gy plus simultaneous carboplatin 25 mg/m2 BID for 12 consecutive days. Residual disease at 46.8 Gy required curative surgery.

RESULTS

Seventy-four patients entered the study, and 73 completed their treatment. Twenty were stage III and 54 were stage IV. Fifty patients had involved regional lymph nodes. Treatment was well tolerated with only one grade IV hematologic toxicity. At 46.8 Gy, biopsy revealed a complete response in 75% of the primary sites and 47% of the nodes. Only 12 patients required resection of the primary lesion. At 4 years (median follow-up is 26 months), 29 patients have recurred.

CONCLUSIONS

Accelerated hyperfractionated radiotherapy with concurrent chemotherapy in stage III and IV head and neck cancer yields excellent local-regional control with organ preservation. This protocol is intensive, and some patients have distant failures.

Concurrent platinum-based chemotherapy and hyperfractionated radiotherapy with late intensification in advanced head and neck cancer

PURPOSE

To determine whether a course of hyperfractionated radiation therapy concomitant with escalated radiosensitizing platinum compounds can be administered with acceptable morbidity and achieve a high rate of loco-regional control for Stage III and IV head and neck cancer and whether the patients can be tumor free at the primary site after initial therapy and cured by the additional chemoradiation without radical resection of the primary tumor.

METHODS AND MATERIALS

Patients with Stage III/IV head and neck cancer were treated in this multicenter Phase II Study with 1.8 Gy fraction radiotherapy for 2 weeks, with escalation to 1.2 Gy b.i.d. hyperfractionation to 46.8 Gy. Concomitant continuous infusion cisplantinum (CDDP) 20 mg per meter square on day 1 to 4 and 22 to 25 was given. Reassessment by biopsy of primary and nodes was done. Patients with a complete response continued with hyperfractionated radiotherapy to 75.6 Gy with simultaneous carboplatinum (Carbo), 25 mg per meter square b.i.d. for 12 consecutive treatment days. Patients with residual disease at 46.8 Gy required curative surgery. Seventy-four patients were treated at the three institutions; 20 were Stage III and 54 were Stage IV. All patients had daily mouth care, nutritional, and psychosocial support.

RESULTS

This regime was well tolerated. Eighty-five percent of toxicities were Grade 1 or 2 and there was only one Grade 4 hematologic toxicity. Late toxicities included xerostomia in 25 patients, dysphasia in 18, and mild speech impediment in 11. Biopsies of primary site were done after the first course of treatment in 59 patients. Neck dissections were performed in 35 patients. Forty-four of 59 (75%) primary sites and 16 of 35 (46%) lymph nodes had pathologically complete response (CR). Of the 74 patients, only 12 required surgical resection of the primary site. Thirty-five of the 50 node positive patients had neck dissections, 16 of these were CRs at surgery. At 4 years (median follow-up of 26 months), disease-specific survival is 63%. The actuarial survival for all patients is 51%. Patients with pathological CR after initial treatment have disease specific survival of 73% at 4 years vs. 48% of patients with partial response (PR) only.

CONCLUSION

This study, developed on the basis of radiobiological and cell kinetic precepts, produced results that compare favorably with other reports of management of patients with advanced head and neck cancer. In comparison with our previous study, these results are comparable, not impressively better. The associated morbidity was somewhat worse.

Does waiting time affect the outcome of larynx cancer treated by radiotherapy?

AIM

To determine the impact of waiting for radiotherapy on local control in early larynx cancer treated by radiotherapy alone.

METHODS

Records of patients with T1 and T2, N0-2 larynx cancer were examined at three radiotherapy centres. Waiting time was defined in three ways, (1) time from biopsy to radiotherapy, (2) time from presentation to radiation department to start of radiotherapy and (3) the minimum of (1) and (2). Time to relapse was the major end point.

RESULTS

There were 581 patients with a median follow-up of 6.8 years. Stage distribution was as follows: T1, 370; T2a, 106; T2b, 94; T2 unspecified, 11; N0, 563; N+, 18. Median times from biopsy, presentation and minimum time to treatment were 24, 16 and 15 days, respectively. Ninety percent of minimum waiting times were < or = 31 days. The median dose was 61 Gy in a median of 30 fractions over a median 46 days. Local recurrence occurred in 126 patients. The actuarial recurrence free rate at 5 years was 77% (SE 2%). In a multivariate analysis the significant predictors of relapse were higher T stage, longer treatment duration and increasing field area. Waiting time was not significantly associated with local relapse.

CONCLUSION

This study did not show longer waiting time to be a significant predictor of relapse in early larynx cancer. Other end-points which are relevant, such as quality of life, have not been examined. Longer treatment times were significantly associated with relapse.

An analysis of factors influencing the outcome of postoperative irradiation for squamous cell carcinoma of the oral cavity

PURPOSE

To analyze factors influencing outcome in patients who received postoperative irradiation for advanced squamous cell carcinoma of the oral cavity.

METHODS AND MATERIALS

Between October 1964 and November 1993, 134 patients with 135 previously untreated primary invasive squamous cell carcinomas of the oral cavity (excluding the lip) were treated postoperatively with continuous courses of external-beam irradiation at the University of Florida. All patients had a minimum follow-up of 2 years (analysis, December 1995). No patient was lost to follow-up.

RESULTS

The 10-year actuarial rates of primary site, neck, and local-regional control were 79%, 88%, and 71%, respectively. Recurrence of cancer above the clavicles developed in 35 patients. Ninety-four percent of the recurrences were within the primary field of irradiation (anterior to the plane of the spinal cord); there were 24 recurrences at the primary site and nine in the upper neck alone. There were no failures in the neck area behind the plane of the spinal cord (i.e., the "posterior strip"). Two failures occurred in the low neck below the level of the thyroid notch. In univariate analyses, factors that affected local-regional control included pathologic stage (I-II vs. III-IV, p = 0.04), margin status (invasive cancer at the margin vs. other, p = 0.0007), multifocal tumor (p = 0.05), perineural invasion (p = 0.04), and number of indications for postoperative irradiation (p = 0.05). Extracapsular nodal extension was marginally significant (p = 0.07). In multivariate analysis, positive margins and number of indications remained significant. These factors were used to define relatively favorable (< 4 indications, margins not positive) and unfavorable (> or = 4 indications and/or margins positive for invasive cancer) groups. For both favorable and unfavorable groups, there were nonsignificant trends toward improved local-regional control for patients who began irradiation within 45-50 days, compared with those whose irradiation began later. There were also nonsignificant trends toward improved control for patients treated with shorter overall irradiation treatment courses. An analysis was also performed on the effects of duration of the overall "treatment package" (from the date of surgery until the last day of irradiation). For patients with unfavorable tumors, there was a significantly higher probability of local-regional control for patients whose overall "treatment package" was < or = 100 days (60% vs. 14%, p = 0.04). The 5-year rate of distant metastasis as the sole site of failure was 8% and was predicted by pathologic N stage (N0-N1, 3%; N2-N3, 16%, p = 0.02), as well as the presence (20%) or absence (6%) of extracapsular nodal extension (p = 0.06). The 5-year freedom-from-relapse rate was 63%. The 5-year survival and cause-specific survival rates were 50% and 67%, respectively. Four severe radiation injuries occurred (3%).

CONCLUSION

This paper provides data that define relatively favorable and unfavorable groups of patients in the postoperative setting. Patients with four or more indications for irradiation and/or invasive cancer at the surgical margins have a worse outcome than patients who do not have these negative factors; this is true in spite of the fact that the unfavorable group received higher doses of radiation. Attention should be focused on not only the interval between surgery and irradiation, but also time-dose parameters and the overall duration of the treatment "package."

Accuracy of frozen sections in assessing margins in oral cancer resection

PURPOSE

This study examined the accuracy of frozen section diagnosis of tissue samples from surgical margins compared with the final histologic diagnosis of the same tissue. The total resection specimen was also examined to see whether frozen sections were helpful in predicting negative margins for the entire cancer. The nature of positive and negative margins and their implications for the surgeon are discussed.

PATIENTS AND METHODS

The records of 49 consecutive patients with previously untreated squamous carcinoma of the mouth were reviewed. All frozen and permanent sections were evaluated by one pathologist. Margins involved by carcinoma, carcinoma in situ, dysplasia, or with carcinoma within 5 mm were defined as positive. Histologic findings were compared with the patient's clinical course to define the relationship between positive margins and local recurrence. Patients were followed for 17 to 45 months or until death.

RESULTS

Three hundred four of 307 frozen sections showed concordance with the permanent section of the same tissue sample (two false negative and one false positive), an accuracy rate of 99%. When the final margins of the resected surgical specimen were compared with the frozen section diagnoses, ten patients had positive final margins. In three patients, these were diagnosed by frozen section. Seven patients had final margins that were positive when the surgical resection specimen was examined but were not diagnosed by frozen section. A greater local recurrence note was found in patients with invasive carcinoma at the margin, dysplastic margins, and margins within 5 mm of the cancer.

CONCLUSIONS

Although frozen sections are extremely accurate, they are not as reliable in eliminating positive margins in the final specimen as the surgeon might hope.

Post-operative brachytherapy: a prognostic factor for local control in epidermoid carcinomas of the mouth floor

The aim of this study was to analyse the role of post-operative brachytherapy (BT) in a group of patients with a high risk of local relapse (positive or narrow surgical margins) for squamous cell carcinoma of the mouth floor (SCCFM). A comparison with post-operative external beam irradiation (EBI) in a group of patients with standard risk of local relapse for SCCFM with free margins is performed to estimate the benefit of BT. From 1979 to 1992, an initial group of 32 patients with SCCFM (12, T1-2; 20, T3-4x) received an Ir 192 low dose rate BT using plastic tubes (+EBI for 20 patients) after surgery with positive or close margins. BT was applied in one or two planes to the surgical scar. The mean dose of BT was 57 Gy (range: 50-60) for exclusive BT and 22 Gy (range: 15-30) when a boost was applied (mean EBI dose = 50 Gy). During the same period, 36 patients had post-operative external irradiation alone after satisfactory surgical resection. Excluding the post-operative margin, these two groups were comparable for other prognostic factors. The mean follow-up was 46 months (range: 5-145) with a minimum follow-up of 2 years. For BT and EBI groups, the 5-year results (Kaplan-Meier) were, respectively, overall survival 62% and 43%, local control 81% and 60% (P = 0.09) (log-rank) and severe complications 4/32 and 1/36. Post-operative BT achieves good local control for patients with narrow or positive margins by increasing the dose to the surgical scar, with good tolerance. Given these encouraging results, we confirm this treatment for these patients.

Post-operative radiotherapy in carcinoma of buccal mucosa, a prospective randomized trial

Squamous cell carcinoma of the buccal mucosa is a common cancer in India. We are referred a large number of locally advanced lesions where curative surgery is still possible. The objective of this study is to determine the role of post-operative radiotherapy in enhancing disease-free survival. Patients with stages III and IV cancer of the buccal mucosa potentially curable by surgery were randomized to surgery only or post-operative radiotherapy. Patients were followed up for 3 years. The clinico-pathological features in both arms were comparable. Disease-free survival at the end of the study was found to be 38% and 68% (P<0.005) respectively. Post-operative radiotherapy was thus seen to improve disease-free survival in squamous cell carcinoma of the buccal mucosa.

Metastatic cutaneous squamous cell carcinoma of the head and neck region

Cutaneous squamous cell carcinoma has a relatively low metastatic rate (0.5% to 16%), but patients with the disease should always be evaluated for possible regional nodal involvement. We reviewed the records of 37 patients with metastatic disease among the 388 patients with head and neck cutaneous squamous cell carcinoma who were treated at New York University Medical Center between 1961 and 1992. In this group of patients the most common primary sit was the cheek or preauricular region and the most common metastatic site was the level I neck lymph nodes. Seven patients (18%) had metastases at initial presentation. Among the remaining patients the average time to the development of metastases was 19 months. Nineteen patients (51%) had recurrence at the primary site before metastasis; 11 (30%) developed metastases with control of the primary tumor. Analysis of the records of 31 patients treated for cure revealed that 13 were treated by surgery, 2 by radiation therapy, and 16 by a combination of surgery and radiation therapy. During the mean follow-up period of 49 months, 11 (35%) of these 31 patients died of their disease. Recurrence of the primary tumor appeared to increase the risk for nodal and distant metastases.