Interstitial and external radiotherapy in carcinoma of the soft palate and uvula

Function Preservation in Head and Neck Cancers

The treatment of head and neck cancers can have a significant impact on function and appearance, which results in impairment of quality of life. Various long-term sequelae of treatment include speech and swallowing difficulty, oral incompetence, trismus, xerostomia, dental caries and osteoradionecrosis. Management has evolved from single modality treatment of either surgery or radiation to multimodality treatment to attain acceptable functional outcomes. Brachytherapy, also known as interventional radiotherapy, with its ability to deliver high doses centrally to the target, has been shown to improve local control rates. Due to the rapid fall-off of the dose of brachytherapy there is better organ at risk sparing as compared with that of external beam radiotherapy. In the head and neck region, brachytherapy has been practiced in various sites, including the oral cavity, oropharynx, nasopharynx, nasal vestibule and paranasal sinuses. Additionally, brachytherapy has also been considered for reirradiation as a salvage. Brachytherapy can also be considered as a perioperative technique together with surgery. Close multidisciplinary cooperation is required for a successful brachytherapy programme. In oral cavity cancers, depending on the location of the tumour, brachytherapy has been shown to preserve oral competence, maintain tongue mobility, maintain speech, swallowing and the hard palate. Brachytherapy in oropharyngeal cancers has been shown to reduce xerostomia and also reduce dysphagia and aspiration post-radiation therapy. For the nasopharynx, paranasal sinus and nasal vestibule, brachytherapy preserves the respiratory function of the mucosa. Despite such an incomparable impact on function and organ preservation, brachytherapy is an underutilised technique for head and neck cancers. There is a strong need to improve brachytherapy utilisation in head and neck cancers.

Radiation treatment of soft palate squamous cell carcinoma

BACKGROUND

To report our institution's experience treating soft palate squamous cell carcinoma with radiotherapy alone or combined with adjuvant chemotherapy and/or neck dissection for residual disease.

METHODS

We analyzed 159 patients treated curatively between 1963 and 2016. Median follow-up was 4 years.

RESULTS

The 5-year local control rates were T1, 90%; T2, 90%; T3, 70%; and T4, 59%. The 5-year cause-specific survival (CSS) rate was nearly identical for patients with stage I-III disease (88%, 86%, and 88%, respectively) compared to stage IVA/B (58%). Five-year overall survival was similar between patients with stage I-III disease (50%, 57%, and 54%, respectively) and approximately double that of patients with stage IVA/B disease (26%). Thirteen patients (8%) had severe complications related to radiotherapy.

CONCLUSIONS

The likelihood of cure after definitive radiotherapy is relatively high in patients with stage I-III disease with soft palate carcinoma. Patients with stage IVA/B disease have a lower cure rate but with a 5-year CSS exceeding 50%.

Squamous Cell Carcinoma of the Soft Palate in the United States: A Population-Based Study

Objectives To describe the incidence and determinants of survival of patients with squamous cell carcinoma of the soft palate (SCCSP) using the Surveillance, Epidemiology, and End Results (SEER) database. Study Design Retrospective, population-based cohort study of patients. Setting SEER cancer registry. Subjects and Methods Patients from the SEER cancer registry from 1973 to 2015 were used to analyze demographics and survival of SCCSP. Results A total of 4366 cases were identified. The average overall survival (OS) and disease-specific survival (DSS) were 68.7 months and 161.3 months, respectively. Multivariate analysis revealed that male sex, stage, and treatment (hazard ratio [HR] = 0.690, P = .019; HR = 1.73, P < .001; HR = 0.64, P < .001, respectively) were independent determinants of better or worse DSS. Age, stage, and treatment (HR = 1.02, P < .001; HR = 1.49, P < .001; HR = 0.66, P < .001; HR = 0.48, P < .001, respectively) were independent determinants of better or worse OS. For stages I, II, and III, radiation alone and surgery alone have nearly equivalent OS. Patients with stage IV disease who underwent both surgery and radiation had a significantly higher median OS at 50.0 months. Conclusion Radiation alone and surgery alone both have nearly equivalent OS benefit for stages I to III, while surgery and radiation provide the most survival benefit for stage IV disease. The large discrepancy between OS and DSS can be due to significant comorbidities. Future studies should aim to address the determinants of quality-of-life variables that help direct treatment decisions and might indirectly affect survival.

The Role of Brachytherapy in the Management of Oropharyngeal Carcinomas: The Trento Experience

Aims

This study was undertaken to determine the outcome of patients with oropharyngeal cancer treated at the Radiotherapy Department of the Santa Chiara Hospital (Trento, Italy) with brachytherapy alone or combined with external beam radiotherapy (EBRT).

Material and methods

We retrospectively reviewed the medical records of 87 patients with squamous cell carcinoma of the oropharynx treated by radiation therapy between January 1986 and September 1999. The median age was 59 years and all patients had a minimum follow-up of one year. Tumor locations were 46 tonsillar region, 31 soft palate and 10 base of the tongue. The patients were staged as follows: 41 T1, 35 T2, 11 T3 with 70 N0, 9 N1 and 8 N2. They received either brachytherapy alone (14 patients) or a combination of external beam irradiation and brachytherapy (73 patients) using an afterloading iridium technique in a plastic tube.

Results

Overall primary tumor control, including salvage surgery, was 81/87 (93%). Control of metastatic cervical adenopathy was as follows: clinical stage N1, 5/9 patients; N2, 2/8 patients. The estimated five-year cause-specific survival and overall survival rates were 81% and 47%, respectively. After interstitial irradiation severe complications were limited to one case of osteoradionecrosis of the mandible and seven cases of mucosal ulcer.

Conclusion

This study confirms that iridium-192 interstitial implant alone or as a boost after external beam irradiation is a safe and effective therapy in the management of oropharyngeal carcinomas.

Soft palate preservation after tumor resection with transoral laser microsurgery

Background: Management and preservation of the soft palate is dependent on clinical stage and tumor histology. However, available literature is scarce regarding the palate preservation with the use of laser CO2. Objectives: We report the results obtained after management with laser surgery and soft palate preservation in three patients with salivary gland neoplasms. Method: Three patients with minor salivary gland tumors were treated by means of transoral laser microsurgery. All tumors were assessed using magnetic resonance imaging. All tumors were >3 cm. Soft palate function was preserved and reconstruction was performed with primary closure. Patients began oral feeding the same day and were discharged after 24 h. Conclusions: Transoral laser microsurgery is recommended for treatment of soft palate tumors. This treatment can be considered a better option when compared with other modalities such as radio- or chemoradiotherapy which require a longer time of treatment, are more expensive and tend to produce significant toxicity.

Key words:Laser CO2, neoplasms, salivary gland.

Surgical management of squamous cell carcinoma of the soft palate: factors predictive of outcome

BACKGROUND

Squamous cell carcinoma of the soft palate (SCCSP) is uncommon. The aim of this study was to report our experience and identify factors predictive of outcome.

METHODS

Between 1976 and 2005, 186 patients with SCCSP were treated with curative intent. In all, 150 patients had primary surgery, of whom 112 patients (75%) had cT1/T2 tumors and 103 patients (69%) had cN0 necks. Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were determined by the Kaplan-Meier method and factors predictive of outcome were identified.

RESULTS

Five-year OS, DSS, and RFS for surgical patients were, respectively, 52%, 71%, and 56%. DSS for cT1T2N0 and cT1T2N+ were 79% and 56%, respectively. For OS and DSS, multivariate analysis showed cN classification was predictive of outcome. For RFS and distant RFS, margin status was a significant predictor, whereas the cT classification was a significant predictor for local RFS.

CONCLUSIONS

Outcomes of patients with early-stage SCCSP managed by surgery were excellent. These patients may be suitable for transoral robotic or endoscopic surgical procedures.

A retrospective analysis of the use of brachytherapy in relation to early stage squamous cell carcinoma of the oropharynx and its relationship to second primary respiratory and upper digestive tract cancers

The purpose of this study was to retrospectively evaluate brachytherapy for early stage squamous cell carcinoma of the oropharynx (SCO) in relation to second primary respiratory and upper digestive tract cancers (RUDT). Between 1976 and 2001, 111 previously untreated patients with stage I or II SCO were treated with Au-198 seed brachytherapy alone (36 cases) or Au-198 seed brachytherapy plus external irradiation (75 cases). Of the 111 patients, 28 patients had stage I disease and 83 patients had stage II disease. Each patient was evaluated for therapeutic efficacy, post-treatment quality of life (QOL) and a second cancer. The 5-year and 10-year cause-specific actuarial survival rates for stage I and II SCO were 87% and 86%, respectively. We found that the 5-year and 10-year survival rates for all SCOs combined with second primary RUDT cancers were 71% and 45%, respectively. 51 second primary RUDT cancers occurred successively in 41 patients following treatment for early stage oropharyngeal cancer and this was the sole prognostic factor by the multivariate analysis. Au-198 seed brachytherapy with or without ipsilateral external irradiation of up to 30 Gy was associated with fewer late complications in the oral cavity and salivary gland. We concluded that our treatment policy of brachytherapy with or without external irradiation for patients with early stage SCO was effective and acceptable from the standpoint of tumour control and post-treatment QOL.

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.

Site specific dependency of second primary cancer in early stage head and neck squamous cell carcinoma

BACKGROUND

A study was conducted to determine the site specificity of second primary cancer (SPC) following early (Stage I and II) squamous cell carcinoma of the head and neck (SCH) and its impact on prognosis.

METHODS

Between 1956 and 1999, 1,639 early stage SCHs in 1,609 patients were treated by radiotherapy at the authors' institution. The risk of additional respiratory and upper digestive tract (RUDT) carcinoma and the treatment outcome were reviewed for each SCH site. Second primary RUDT carcinomas were the second most common cause of death (113 cases) after death from primary SCH carcinomas (350 cases).

RESULTS

Among the 1,609 early stage SCH patients, 333 second primary cancers were documented in 258 patients, 235 (71%) of which were RUDT carcinomas. The risk of SPCs was 3.2% per year, and the risk of SPCs in the RUDT region was 2.3% per year. The risk of SPCs was almost two times higher in males (3.7% per year) than in females (2.2% per year). The highest risk of SPC was observed in the oro-hypopharynx index cancer group (8.5% per year), and the lowest risks were observed in the epipharynx group (0% per year) and the maxillary sinus group (1.4% per year).

CONCLUSIONS

Different SPC risks according to the SCH site result in a different prognosis for each site of early stage SCH. Long-term follow-up care after the initial treatment for early SCH should be continued according to the site of the initial SCH.

Interstitial brachytherapy with or without external beam irradiation in head and neck cancer: Institute Rotary Cancer Hospital experience

Iridium-192 interstitial brachytherapy is practiced infrequently in developing countries, even where head and neck cancer is a major neoplasm and the technique could provide good results. This report from India is presented as an audit to validate the benefit of brachytherapy. One hundred and six head and neck cancer patients were treated by interstitial brachytherapy alone (n = 29) or combined with external irradiation (n = 77). The oral cavity and the oropharynx together constituted 82% of the sites of implanted tumours; 75% were T(1-2)N0 status. Brachytherapy was carried out using afterloaded plastic catheters and the Paris dose prescription system was followed. External cobalt-60 beam portals covered the primary and the neck. The median duration of follow-up was 22 months. The median dose of brachytherapy used alone was 60 Gy. With combined treatment, the median external radiotherapy and brachytherapy doses were 50 Gy and 25 Gy respectively. The median brachytherapy dose rate was 0.5 Gy/h. Primary and nodal recurrences were recorded in 41/106 (38.7%) and 18/106 (17.0%) patients at median intervals of 15 and 13 months respectively. Implant site failure was more common after combined treatment than with brachytherapy alone (42.8% versus 27.5%), but it did not reach statistical significance in this analysis (P = 0.15). Kaplan-Meier actuarial 5-year estimates showed 52% and 87% disease-free and overall survivals. Iridium-192 interstitial implants in suitably selected head and neck cancer patients can improve the radiotherapeutic results, with the promise of organ conservation in 50%. In India, the practice should be established in more radiotherapy centres and could be utilized in 10,000-25,000 head and neck cancer patients annually.

Squamous cell carcinomas of the soft palate treated with radiation therapy alone or followed by planned neck dissection

PURPOSE

The present study presents the experience at the University of Florida with treatment of unselected patients with carcinomas of the soft palate with radiation therapy (RT) alone or followed by planned neck dissection.

METHODS AND MATERIALS

One hundred seven patients treated with curative intent with RT alone or followed by neck dissection from 1965 to 1996 were included in the study. All patients had follow-up for at least 2 years. No patients were lost to follow-up.

RESULTS

Local control rates at 5 years were 86% for T1, 91% for T2, 67% for T3, and 36% for T4 carcinomas. T-stage and overall treatment time significantly affected local control in multivariate analysis. Nodal control rates at 5 years were 86% for NO, 76% for N1, 61% for N2, and 67% for N3 carcinomas. Overall treatment time and planned neck dissection significantly affected nodal control in multivariate analysis. Ultimate local-regional control rates at 5 years were 90% for Stage I, 92% for Stage II, 84% for Stage III, and 60% for Stage IV disease. Overall treatment time and planned neck dissection significantly affected ultimate local-regional control in multivariate analysis. The overall survival rate at 5 years was 42% for all patients. Overall stage, overall treatment time, and planned neck dissection significantly affected overall survival in multivariate analysis. The cause-specific survival rate at 5 years was 70% for all patients. Overall treatment time and planned neck dissection significantly affected cause-specific survival in multivariate analysis. Three patients sustained severe postoperative complications and 3 patients sustained severe late complications. Sixteen patients had synchronous and 14 patients had metachronous carcinomas of the head and neck mucosal sites.

CONCLUSION

For limited carcinomas of the soft palate, RT (alone or followed by planned neck dissection) results in relatively high local-regional control and survival rates. For advanced carcinomas of the soft palate, local-regional control and survival rates are relatively low and local-regional recurrence rates are substantial. Advanced carcinomas of the soft palate may be better treated with RT and concomitant chemotherapy.

The importance of in situ light dosimetry for photodynamic therapy of oral cavity tumors

BACKGROUND

Photodynamic therapy (PDT) is being evaluated for treatment of localized head and neck cancer. "Light dose" is usually prescribed as incident fluence, which takes no account of reflected and scattered light. This study investigates variations in total tissue fluence for a given incident fluence in the oral cavity.

METHODS

Light dosimetry was performed in 19 patients treated with PDT for cancers in the oral cavity and in 5 volunteers. Illumination was with 652 nm laser light delivered via a microlens. In situ dosimetry was performed with isotropic probes held against the tissue in the illuminated area.

RESULTS

Tissue fluences of 254% to 305% of the incident fluence were measured in the illuminated area in healthy volunteers. In the patient population tissue fluences were 133% to 545% of the incident fluence.

CONCLUSION

The relationship between incident and total tissue fluence depended on the location and pigmentation of the target area and was not predictable. In situ dosimetry during cavity illumination allows for more controlled tissue illumination and should be employed as the basis for light dose prescription in PDT for head and neck cancer.

Feasibility and tolerance of pulsed dose rate interstitial brachytherapy

PURPOSE

Pulsed dose rate (PDR) treatment is a new approach that associates the physical advantages of high-dose-rate (HDR) technology with the potential radiobiological advantages of low-dose-rate (LDR) brachytherapy. This retrospective study analyzes the feasibility, toxicity, and preliminary oncologic results in a series of 43 patients treated with PDR interstitial brachytherapy.

METHODS AND MATERIALS

Twenty-four patients with pelvic, 17 patients with head and neck, and 2 patients with breast cancers were treated. Twenty-eight patients had primary and 15 recurrent tumors; 14 had received prior external irradiation to the same site. The doses per pulse at the prescription isodose were 0.4-1 Gy (median 0.5 Gy), delivered using a single cable-driven 0.3-1.0 Ci 192-iridium source (PDR Nucletron Micro-Selectron).

RESULTS

The median treated volumes (at the prescribed isodose) were 28 cc for pelvic, 8.33 cc for head and neck, and 40 cc for breast malignancies. Of 14,499 source and 14,499 dummy source transfer procedures, 3 technical machine failure events were observed (0.02%). Grade 3 acute toxicities were seen in 5/43 patients (4 oral stomatitis, 1 vaginal mucositis) and grade 4 acute toxicity in one patient (rectovaginal fistula). Grade 3-4 late complications were observed in 4/41 (9.8%) patients: 1 pubic fracture, 1 rectovaginal fistula, 1 vesicovaginal fistula and 1 local necrosis. With a median follow-up of 18 months, 10/41 patients progressed locoregionally (6 pelvic, 4 head and neck), 3 developed local recurrence and distant metastasis (3 pelvic), 3 only distant metastasis (2 pelvic, 1 head and neck). Two patients are lost to follow-up.

CONCLUSION

PDR interstitial brachytherapy for pelvic, head and neck, and breast malignancies is feasible and the acute and late toxicities seem acceptable. Although the physical advantages of PDR are clear, further follow-up is required to determine how results compare with those obtained with standard LDR brachytherapy.

Modern brachytherapy: current state and future prospects

This article reviews the current trends and future developments in brachytherapy. Established techniques including interstitial and high-dose rate brachytherapy are discussed with particular reference to lung, oesophageal, cervical and endometrial cancer. Intra-operative high-dose rate brachytherapy and other new techniques are also mentioned.

Fractionated high-dose-rate and pulsed-dose-rate brachytherapy: first clinical experience in squamous cell carcinoma of the tonsillar fossa and soft palate

PURPOSE

Fractionated high-dose-rate (fr.HDR) and pulsed-dose-rate (PDR) brachytherapy (BT) regimens, which simulate classical continuous low-dose-rate (LDR) interstitial radiation therapy (IRT) schedules, have been developed for clinical use. This article reports the initial results using these novel schedules in squamous cell carcinoma (SCC) of the tonsillar fossa (TF) and/or soft palate (SP).

METHODS AND MATERIALS

Between 1990 and 1994, 38 patients with TF and SP tumors (5 T1, 22 T2, 10 T3, and 1 T4) were treated by fr.HDR or PDR brachytherapy, either alone or in combination with external irradiation (ERT). Half of the patients were treated with fr.HDR, which entailed twice-daily fractions of > or = 3 Gy. The other 19 patients were administered PDR, which consisted of pulses of < or = 2 Gy delivered 4-8 times/day. The median cumulative dose of IRT +/- ERT series was 66 Gy (range 55-73). The results in these patients treated by brachytherapy were compared to 72 patients with similar tumors treated in our institute with curative intent, using ERT alone. The median cumulative dose of ERT-only series was 70 Gy (range 40-77).

RESULTS

Excellent locoregional control was achieved with the use of IRT +/- ERT, with only 13% (5 of 38) developing local failure, and salvage surgery being possible in three of the latter (60%). Neither BT scheme (fr.HDR vs. PDR) nor tumor site (TF vs. SP) significantly influenced local control rates. The type and severity of the side effects observed are comparable to those reported in the literature for LDR-IRT. These results contrast sharply with our ERT-only series, in which 39% of patients (28 of 72) developed local failure, with surgical salvage being possible only in three patients (11%). Taking the data set of 110 patients, in a univariate analysis IRT, T stage, N stage, overall treatment time (OTT), and BEDcor10 (biological effective dose with a correction for the OTT) were significant prognostic factors for local relapse-free survival (LRFS) and overall survival (OS) at 3 years. Using Cox proportional hazard analysis, only T stage and BEDcor10 remained significant for LRFS (p < 0.001 and 0.008, respectively), as well as for OS (p < 0.001 and 0.003, respectively). With regard to the current (IRT) and historical (ERT) series, for the LRFS at 3 years, dose-response relationships were established, significant, however, only for the BEDcor10 (p = 0.03).

CONCLUSION

The 3-year LRFS of approximately 90% for TF and SP tumors reported here is comparable with the best results in the literature, particularly given the fact that 30% of the patients (11 of 38) presented with T3/4 tumors. When compared with our historical (ERT-only) controls, the patients treated with IRT had superior local control. A dose-response relationship was established for the BEDcor10.

Complications following definitive irradiation for cancers of the oral cavity and the oropharynx (in a series of 1134 patients)

PURPOSE

To study the rate and severity of complications in a series of 1134 patients treated by definitive irradiation for tumors of the oral cavity (772 cases) or the oropharynx (361 cases).

METHODS AND MATERIALS

Patients were staged as 29.5% T1, 42% T2, 26% T3, 2.5% T4-Tx, and 74.5% N0 tumors. We treated 364 patients with brachytherapy only (192Ir) for the primary lesion. External irradiation and brachytherapy were combined for 770 patients.

RESULTS

The results included local control and survival. Out of 1134 patients, 330 had 376 complications. Grade 1 complications occurred in 20% of the patients, Grade 2 in 9%; Grade 3 in 4%; and Grade 4 in 0.2%. Of the Grade 1 complications, 78% were soft tissue and only 24% were bone complications. For the more severe grades (2, 3, and 4), there were 56 soft tissue complications and 90 bone complications out of 1340 patients. The statistical analysis included tumor-related factors and treatment-related factors. For the first two factors, only tumor location was significant. The treatment-related factors significant for complications were studied in univariate and multivariate study. This multivariate study confirmed that for soft tissue complications dose rate and volume treated were important (p < 0.001). It also confirmed that for bone complications, total dose > 80 Gy, dose rate > 0.7 Gy/h, and the absence of leaded protection of the mandible were all important factors.

CONCLUSION

This statistical study should allow future reduction of severe complications (Grades 2, 3, 4), if treatment factors inducing them can be taken into account. This is not always possible for very large tumors.

External and interstitial radiotherapy in the treatment of oropharyngeal squamous cell carcinoma

The records of 165 patients with squamous cell carcinoma of the oropharynx treated at our hospital with external and/or interstitial radiotherapy between 1971 and 1990 were reviewed to evaluate the treatment results, focusing on primary control and complications. All cancers were restaged according to the UICC 1987 TNM staging system. Of these 165 patients, 11% were in Stage I, 55% in Stage II, 24% in Stage III and 8.5% in Stage IV. Local control and complications were analysed in 140 patients. The remaining 25 patients died of intercurrent or metastatic disease during the first 2 years following treatment and were excluded from the analysis. 70 patients were treated by interstitial implant using permanent implant seeds (Rn-222 in eight patients, Au-198 in 62 patients) with or without external radiation. 56 other patients received external irradiation alone and another 14 patients received pre-operative external irradiation plus surgery. 2-year recurrence-free rates were 73% (100% for T1, 76% for T2, 36% for T3 tumours) in the patients who received interstitial implant with or without external radiation and 36% (67% for T1, 48% for T2, 13% for T3 tumours) in the patients treated by external irradiation alone. The incidence of soft-tissue or bone complications requiring long-term treatment was 14%. Based on these findings, it is believed that an interstitial implant using Au-198 grains combined with external beam irradiation is a useful treatment modality for small lesions of the oropharynx.

Influence of tumoral, radiobiological, and general factors on local control and survival of a series of 361 tumors of the velotonsillar area treated by exclusive irradiation (external beam irradiation+brachytherapy or brachytherapy alone)

PURPOSE

To evaluate statistically the factors influencing the therapeutic results.

METHODS AND MATERIALS

A statistical study was carried out concerning 361 patients treated from 1977 to 1991 for velotonsillar carcinoma. They received either brachytherapy alone (18) or a combination of external beam irradiation and brachytherapy (343 patients) using an afterloading iridium technique in plastic tubes. The distribution of patients according to the localization was: 128 tonsils, 134 soft palates, 9 posterior pillars, 63 anterior pillars, and 27 glossotonsillar sulcus. The patients were staged as follows: 90 T1, 141 T2, 119 T3, 2 T4, 9 Tx with 230 N0, 93 N1, 9 N2, 20 N3, and 9 Nx.

RESULTS

The results at 5 and 10 years show: local control 80% and 74%, locoregional control 75% and 70%, overall survival 53% and 27%, specific survival 63% and 52%, respectively. The univariate study shows at 5 years a better local control for T1T2 (87%) compared with T3 (67%) with p = 0.00004. The locoregional control is better for N0 (80%) than for N+ (55%) with p = 0.002. This is the same for the overall survival (59% vs. 42%, p = 0.002). Tumors with an extension to the mobile tongue or the base have a poor prognosis (p < 0.002). The radiobiological factors show less recurrences if the total duration of the treatment is < 55 days, the number of days between External Beam Irradiation and brachytherapy is < 20. The security margin seems important also.

CONCLUSIONS

For the combination external irradiation and brachytherapy, the multivariate study for local control shows that ony T, localization, and the total duration of treatment are significant. For complications, classified into four grades, only the dose rate is significant.

Carcinoma of the oropharynx

Carcinoma of the oropharynx poses particular challenges and problems to head and neck clinicians. These include relative anatomic inaccessibility, field cancerization and the need to minimize speech and swallowing dysfunction. The aim of this review is to bring together an appreciation of the issues involved in the management of this disease and the more recent results of its treatment.

Carcinoma of the soft palate and the posterior oropharyngeal wall

Between 1966 and 1984, 14 patients with carcinoma of the soft palate and eight patients with a posterior oropharyngeal wall carcinoma were treated at the Netherlands Cancer Institute. In the soft palate group, the majority of patients (10) had small tumours T1-T2; the median patient delay was 1 month (range 0-5). Eleven patients were treated with radiotherapy and three with surgery, as single treatment modalities. Tumour control was achieved in 10 patients following initial treatment. Five-year results for tumour control and overall survival were 67% and 41%, respectively. In the posterior wall group all patients had advanced tumours (T3-T4), after a median patient delay of 4 months (range 0-6). Six patients were treated with radiotherapy, one with surgery only and one with a combination of these. Following the initial treatment, tumour control was achieved in half of the patients. Five-year tumour control was 50%, and overall survival at 5 years was 38%. In conclusion, the tumours in these two sub-sites of the oropharynx differ significantly in the extent of the primary tumour (P < 0.01), posterior wall tumours being more advanced on admission, after a significantly longer history (P < 0.01).

Place of Iridium 192 implantation in definitive irradiation of faucial arch squamous cell carcinomas

PURPOSE

We have reviewed the results of 165 T1 and T2 squamous cell carcinomas of the faucial arch treated by definitive irradiation including or not Iridium 192 brachytherapy to ascertain whether a significant relationship existed between Iridium implantation, local control, complications, and survival.

METHODS AND MATERIALS

From March 1971 to November 1990, 58 T1 and 107 T2 (NO: 107/165; N1: 30/165; N2: 9/165; N3: 19/165) biopsy proven squamous cell carcinomas of the tonsillar region (104/165) and the soft palate and uvula (61/165) were treated in Henri Mondor Hospital by definitive irradiation with curative intent. From 1971 to 1981 (period 1), only guide gutter technique was available, so that implants were reserved for small tumors: patients were either managed by definitive telecobaltherapy to tumor site and neck node areas (Group 1; n = 48; mean dose: 70 Gy; confidence interval: +/- 5.5; 5 fractions of 1.8 Gy per week) or by exclusive Iridium implant (Group 2; n = 11; all T1NO; 64 Gy +/- 4.8) or by a combination of external beam radiation therapy to tumor site and neck nodes areas and Iridium implant (Group 3; n = 40). In 1981 (Period 2), a new plastic tube technique, which enables implantation of larger areas, was introduced in the department and all patients (Group 4; n = 66) were then managed by external radiation therapy (Group 3 + 4: 47 Gy +/- 4.3) followed by an Iridium implant (31 Gy +/- 10.5). Clinically positive neck nodes either received additional external dose with electrons or were excised.

RESULTS

Overall 5-year survival (Kaplan Meier) was 21%, 50.5%, and 60% in groups 1, 2, and 3 + 4, respectively (p < 0.001, log rank). Five-year local control was 58%, 100%, and 91%, respectively (p < 0.001). Five-year necrosis rate was 4.5%, 20.5% and 18%, respectively (N.S.). Comparison of results between the two periods of the study (Group 1 + 2 + 3 vs. group 4) show that these two groups are statistically comparable according to site and size of tumor and N status and that both local control (77% vs. 94% at 5 years; p < 0.01) and disease-free survival (56% vs. 71%; p = 0.03) were improved after 1980, while there was a trend to an increase in overall survival (42% vs. 53% at 5 years; p = 0.08); nodal control (86% vs. 95% at 5 years), and necrosis rate (11% vs. 20% at 5 years) were not modified. Multivariate analysis showed that both local control (p < 0.0001) and overall survival (p < 0.0001) were improved when tumor was implanted.

CONCLUSION

We recommend then to treat T1 and T2 squamous cell carcinomas of the faucial arch by external radiation therapy to tumor site and neck areas (45 Gy/25 fractions/5 weeks) followed by a 30 Gy Iridium implant and, for patients with clinically positive nodes, either a further 25-30 Gy electron beam irradiation to the nodes or neck node dissection.

Carcinoma of the uvula and midline soft palate: indication for neck treatment

According to common classification and staging systems, tumors of the uvula and soft palate are included in the group of oropharyngeal cancers. As such, the same staging systems apply and therapeutic decisions are made accordingly. Our experience with small tumors of the uvula and midline soft palate has shown that these common rules may not apply in these anatomical sites. A multicenter retrospective study was performed to examine the aspects of presentation and clinical course of tumors of the uvula. Only patients with small tumors, less than 2.0 cm in diameter, were included. Twenty-three cases were reviewed. Eleven (47.8%) patients had clinical or radiologic evidence of neck disease on presentation. Five of 12 (41.7%) patients who presented with negative neck were found eventually to have neck disease. Eight patients had cervical recurrence. Only one patient had local recurrence. We suggest that attention may need to be directed to the treatment of the neck of all tumors of the uvula and midline soft palate, regardless of size.

Second head and neck cancers following radiation therapy of T1 and T2 cancers of the oral cavity and oropharynx

The risk of second cancer in the head and neck region following definitive radiation therapy was evaluated among 600 patients who were treated for T1 and T2 cancers of the oral cavity and oropharynx at the Henri Mondor hospital between January 1970 and March 1987. Seventy-five patients (12.5%) were managed with external irradiation only, 243 (40.5%) with RT and Iridium 192, and 282 (47%) with Iridium 192 alone. One hundred fifteen patients (19%) developed a second cancer from 3 to 183 months after initial therapy (median: 32 months), including 69 patients (11.5%) in whom the second malignancy was diagnosed in the head and neck region. An increased and constant actuarial risk of development of second head and neck cancer was found (2.7%/year of observation). Univariate analysis showed that age, sex, stage, and modality of the initial treatment did not influence the risk of second head and neck cancer; there was a greater risk of second head and neck malignancy for those patients with soft palate carcinoma (p less than 0.05). Multivariate analysis revealed that the only group of patients who developed a second head and neck cancer more frequently were those who were irradiated with Iridium 192 only (p = 0.0076). There was a trend toward a greater risk of second head and neck malignancy for those with soft palate carcinoma (p = 0.059). Radical treatment of the second head and neck malignancy by surgery and/or re-irradiation was performed for 67% of patients. Patients initially treated by Iridium 192 only could undergo salvage treatment more often than those who previously received external beam radiotherapy (79% vs 53%, p = 0.02). The overall 2-year and 5-year survivals after the diagnosis of the second head and neck cancer were 32% and 10%, respectively.

Velotonsillar squamous cell carcinoma: 277 cases treated by combined external irradiation and brachytherapy--results according to extension, localization, and dose rate

From 1977 to 1987, 277 patients with velotonsillar cancer (oropharyngeal cancer excluding base of tongue and valleculae) were treated by brachytherapy either alone (14 patients) or combined with external beam irradiation (263 patients) using a new afterloading Iridium-192 technique. The distribution of patients according to the localisation was as follows: 106 tonsillar region, 98 soft palate, 45 anterior pillar, 8 posterior pillar and 20 pharyngoglossal sulcus. According to the UICC TNM classification of 1979, the patients were staged as follows: 65 T1, 103 T2, 101 T3, 8 TX. 172 patients were NO, 74 N1, 3 N2, 20 N3 et 8 NX. According to the tumor extension, the 5 year actuarial local control, locoregional control, specific survival and overall survival by T stage (T1 [65 pts], T2 [103 pts.], T3 [101 pts]) were respectively: local control: 89%, 86%, 69%; locoregional control: 84%, 80%, 67%; specific survival (excluding patients dead with intercurrent disease or second cancer): 78%, 62%, 46%; overall survival: 62%, 53%, 43%. No local recurrence was detected after 3 years. According to the localization, the tumors arising from the tonsillar region, the soft palate and the posterior pillars (A Group) had a better prognosis than the tumors arising from the anterior pillars and glossotonsillar sulcus (B Group). The complications were classified into four grades according to their extension and duration: Grade 1 (minor) with very small tissue ulcer which healed within 2 months with medical treatment (20%). Grade 2 (moderate) (5%), grade 3 (severe) (1.4%), grade 4 (fatal) (0.4%). The dose rate seemed to be relatively higher in patients with grade 2 and 3 complications (70 cGy per hour on average) versus the dose rate of patients without complications (50 cGy per hour) but the difference was not significant. In conclusion, the brachytherapy boost after external irradiation can be performed under favourable conditions with an acceptable rate of complications. It was set out in order to attempt to improve the local control of the tumor while preserving the salivary function and lessening the muscular fibrosis. It shows how experienced the team is, however only a randomized study would allow to state whether this technique brings about a real improvement especially as for tumors T2 or T3.

Usefulness of 198Au grain implants in the treatment of oral and oropharyngeal cancer

A series of 177 patients with squamous cell carcinoma of the oral cavity and oropharynx were treated with 198Au grain (gold grain) implants. Sites of the lesion included the tongue, mouth floor, buccal mucosa and oropharynx, especially the soft palate and faucial arch. Three-fourths of the patients were treated in combination with prior external beam irradiation. A permanent implant dose (total decay) of 80-90 Gy was given in the form of gold grains alone and in combination with an external dose of no more than 30 Gy, and 60-70 Gy, total decay, was given after an external dose greater than 30 Gy. The 2-year recurrence-free rate was 86.2% in the case of T1N0, 72.6% in T2N0 and 72.2% in T3N0. The difference in the results of implant therapy alone and combined therapy was not significant. Late complications were minimal after grain implantation alone, and when used in combination, less than 70 mCi of grain activity after a 40 Gy external dose did not seem to be a serious hazard with respect to bone damage except in the case of cancer of the mouth floor. Gold grain implants were useful and easily applied under local anesthesia to early or superficial lesions at sites where a rigid linear source could not be used. Exposure of the radiology staff was only 5-10 mrad in the case of the usual 10-15 (50-75 mCi) implant grains.

Interstitial radioactive implants for oral and oropharyngeal cancer: dentistry's role

Five patients with oral or oropharyngeal cancer were treated with external beam radiation therapy and interstitial radioactive implants as part of their tumor management. The radiation oncologists used various radioisotopes and techniques for placement. Local anesthesia, and in most cases conscious sedation, were used instead of general anesthesia to insert the implants. The dental team, working in conjunction with the radiation oncologists, was able to provide this service which resulted in safe, cost-effective care for the patients.