Limitations of radiotherapy in the definitive treatment of squamous carcinoma of the tonsillar fossa

Clinical and pathological determinants in tonsillar cancer

BACKGROUND

The purpose of this study was to present the impact of clinicopathological factors on patient survival in tonsillar squamous cell carcinoma (SCC) that needs to be evaluated.

METHOD

This study enrolled 86 patients with tonsillar SCC undergoing surgical resection.

RESULTS

The cumulative 5-year disease-specific survival (DSS) rate for stages I, II, III, and IVa/b tumors was 100%, 91.7%, 100%, and 61.8%, respectively. Unfavorable cumulative 5-year DSS rates were significantly correlated with advanced T classification (p = .029), tumor thickness over 1 cm (p = .007), 3 or more positive neck lymph nodes (p < .001), and extracapsular spread (ECS; p = .002). Cox regression analysis revealed that the presence of 3 or more positive neck lymph nodes (p = .035) and the stage IVa/b (p = .022) were the independent predictors of the 5-year DSS.

CONCLUSION

Patients with tonsillar SCC with stage IVa/b and metastasis to 3 or more lymph nodes have poorer clinical outcomes. Novel therapeutic strategies are necessary for these patients.

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

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

Current management of tonsillar cancer

Traditionally, risk factors for the development of tonsil cancer include the use of alcohol and/or tobacco, however a significant proportion of new cases develop in young patients without these risk factors. Recent investigation suggests that human papilloma virus (HPV) may serve as an etiology in such cases and represent a unique risk factor in a sub-set of patients. Irrespective of the etiology, in the majority of cases early carcinoma of the tonsil can effectively be treated using single modality therapy. While local-regional control and survival are similar following surgery or radiotherapy, primary surgery can be accomplished with minimal functional morbidity while reserving radiation for recurrent disease. In contrast, surgical salvage following external beam radiotherapy can be technically challenging and is often associated with a significant increase in surgical complications and functional morbidity. In contrast to early tonsillar disease, advanced tonsil cancer represents a clinical challenge that requires multimodality therapy. While advanced lesions are often treated with a combination of radiation, chemotherapy, and surgical ablation, management of the neck and distant metastases continues to present a therapeutic dilemma.

Search for prognostic factors in head and neck cancer

Fifteen patients with head and neck carcinoma were treated with irradiation (14-70 Gy telecobalt). Apoptotic and mitotic index, DNA index, ratio of cells in S phase, p53 protein overexpression in untreated tumours as well as the changes of these parameters after the first 2 Gy irradiation except proliferative kinetics parameters were examined in order to determine the prognostic value of these factors. The data show that inducibility of apoptosis is very low in head and neck carcinomas which correlate with the unfavourable prognosis. The decrease in mitotic index after the first 2 Gy irradiation, which occurred in 7 cases--5 of them still alive--indicates a better chance for relatively longer survival. In immunohistochemically p53 positive tumours frequently occurring aneuploidy and elevated S-phase rate were found.

Head and neck cancer

This synthesis of the literature on radiotherapy for head and neck cancer is based on 424 scientific articles, including 3 meta-analyses, 38 randomized studies, 45 prospective studies, and 246 retrospective studies. These studies involve 79174 patients. The literature review shows that radiotherapy, either alone or in combination with surgery, plays an essential role in treating head and neck cancers. When tumors are localized, many tumor patients can be cured by radiotherapy alone and thereby maintain full organ function (1, 2). Current technical advancements in radiotherapy offer the potential for better local tumor control with lower morbidity (3). This, however, will require more sophisticated dose planning resources. To further improve treatment results for advanced tumors, other fractionation schedules, mainly hyperfractionation, should be introduced (5). This mainly increases the demands on staff resources for radiotherapy. The combination of radiotherapy and chemotherapy should be subjected to further controlled studies involving a sufficiently large number of patients (4, 5). Interstitial treatment (in the hands of experienced radiotherapists) yields good results for selected cancers. The method should be more generally accessible in Sweden. Intraoperative radiotherapy should be targeted for further study and development.

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.

Comprehensive treatment strategy for oral and oropharyngeal cancer

This prospective nonrandomized study analyzes the effectiveness of the following treatment protocol for oral and oropharyngeal cancers: (1) radical initial surgery; (2) elective modified or selective neck dissection for NO necks; (3) jaw preservation unless gross invasion is present; (4) radial forearm freeflap reconstruction; (5) elective tracheotomy; (6) postoperative radiotherapy unless previously given; and (7) active oral rehabilitation. Between 1987 and 1992, 75 patients (55 men and 20 women) with a median age of 58 years had this treatment. Fifteen had been previously treated with radiotherapy. Clinical stages of untreated patients were as follows: 4 patients, stage I; 25 patients, stage II; 12 patients, stage III; and 19 patients, stage IV. Ten patients had segmental jaw resection, 26 had a marginal mandibulectomy, and 26 had a jaw swing. There were no operative deaths, and only one flap (1.2%) failed. Median times for oral feeds and hospital stay were 8 and 17 days, respectively. Forty-four patients had postoperative radiotherapy. Median follow-up time is 30 months, and locoregional control is 95% for previously untreated patients and 54% for previously treated patients. Thirteen patients have died of disease, 8 with locoregional recurrence and 5 with distant metastases alone. We conclude that this treatment strategy is highly effective in previously untreated patients but less effective in salvaging patients in whom radiotherapy has failed.