Preoperative irradiation and surgery for carcinoma of the base of the tongue

Treatment of Squamous Cell Carcinoma of the Tongue Base: Irradiation, Surgery, or Palliation?

Objectives:

Squamous cell carcinoma of the tongue base has a poor prognosis, and treatment is accompanied by a number of major problems. In view of this, it is important to recognize which patients will benefit from treatment with curative intent and which treatment method to use.

Methods:

One hundred sixty-five patients with squamous cell carcinoma of the tongue base were identified on our database. Eighty-two patients were treated by radical irradiation, and 41 by surgery. A further 42 patients were considered unsuitable for curative treatment.

Results:

The 5-year cause-specific survival rate was 41% for those treated by irradiation, 58% for those treated by surgery, and 9% for untreated patients. There was no difference in the efficacy of treatment methods (p = .5362), but a highly significant difference was seen in survival rate between treated and untreated patients (p = .0028). The decision regarding administration of curative treatment was based on the extent of locoregional involvement at the primary site (p = .0139; odds ratio, 0.43) and in the neck (p = .0078; odds ratio, 0.23). No factors affected the decision to treat by irradiation or surgery. When the observed survival rate was calculated, there was no significant difference in 5-year survival rate between treated and untreated patients (p = .2762). Those with early (T1-2) disease at the primary site had an improved survival rate from 0.5 to 4 years compared with those who were untreated (T3-4; p = .0081; odds ratio, 2.2). In addition, those with early (T1-2) disease had a better survival rate than those with advanced cancers (p = .0139; odds ratio, 2.09). There was, however, no difference in survival rate at 5 years. Those with early disease compared with those with advanced disease were twice as likely to be alive at 2 years; however, all survival advantages had disappeared by 5 years.

Conclusions:

In terms of observed survival, treating tongue base squamous cell carcinoma that is locally advanced (T3-4) at presentation offers no survival advantage over palliation alone. Treating early disease (T1-2) doubles the survival rate for up to 4 years, but by 5 years this survival advantage is lost. The present study finds radiotherapy and surgery to be equivalent at controlling this disease.

Chemoradiotherapy for locoregionally advanced squamous cell carcinoma of the base of tongue

BACKGROUND

Our aim was to report the outcomes of base of tongue cancers treated with chemoradiotherapy.

METHODS

Between 1990 and 2004, 127 patients with stage III or IV base of tongue cancer were treated with chemoradiotherapy on protocol. Indications included nodal involvement, T3/T4 tumors, positive margins, those patients refusing surgery, or were medically inoperable. The most common regimen was paclitaxel (100 mg/m2 on day 1), infusional 5-fluorouracil (600 mg/m2/day × 5 days), hydroxyurea (500 mg prescribed orally [PO] 2 × daily [BID]), and 1.5 Gy twice daily irradiation followed by a 9-day break without treatment.

RESULTS

Median follow-up was 51 months. The median dose to gross tumor was 72.5 Gy (range, 40-75.5 Gy). Five-year locoregional progression-free survival, overall survival, and disease-free survival was 87.0%, 58.2%, and 46.0%, respectively.

CONCLUSION

Concurrent chemoradiotherapy results in promising locoregional control for base of tongue cancer. As distant relapse was common, further investigation of systemic therapy with novel agents may be warranted.

Cancer of the tonsil presenting as central nervous system metastasis: A case report

BACKGROUND

Metastases from tonsilar cancers are uncommon, usually found in the lung and less commonly in the bone, liver, and mediastinal sites. Only approximately 20% of patients die from distant metastasis. Central nervous system (CNS) metastases usually appear later in the course of the disease, with only 1% to 2% of patients developing metastasis involving the CNS in the course of their disease. Patients seen with symptomatic CNS lesions are rare.

METHODS AND RESULTS

A case report is presented of a patient seen with signs and symptoms of CNS disease from an isolated CNS metastasis. The primary site was ultimately determined to be of tonsilar origin. The patient's treatment and outcome are discussed.

CONCLUSIONS

Tonsilar cancers seen with signs and symptoms of CNS disease is a rare event. The benefit of aggressive treatment of isolated CNS metastasis from head and neck cancers will likely be gained from case reports because the incidence is quite low.

Concurrent platinum-based chemotherapy and simultaneous modulated accelerated radiation therapy for locally advanced squamous cell carcinoma of the tongue base

BACKGROUND

Randomized data support use of chemotherapy concurrently with radiation in treatment of advanced squamous cell carcinoma (SCC) of the oropharynx. Intensity modulated radiation therapy (IMRT) is increasingly being used to deliver such radiotherapy; no published reports specifically describe results of chemotherapy with IMRT for SCC of the base of tongue (BOT). We present outcomes data using simultaneous modulated accelerated radiation therapy (SMART) combined with platinum-based chemotherapy in treatment of locally advanced SCC of the BOT METHODS: The records of the Otolaryngology/Head and Neck Surgery Department of Emory University were screened for patients undergoing definitive chemoradiotherapy for SCC of the BOT. Radiation Oncology records were reviewed for dosimetry and prescription data. Hospital and clinic records were reviewed for control and toxicity data. All patients were treated definitively with platinum-based chemotherapy and once-daily RT. Median dose and dose per fraction to sites of gross primary or nodal disease, clinically involved neck, and clinically uninvolved neck were 70.29 Gy (2.13 Gy/fx), 63.03 Gy (1.91 Gy/fx), and 57.75 Gy (1.75 Gy/fx), respectively.

RESULTS

Between January 2003 and August 2005, 34 patients underwent definitive therapy for SCC of the BOT using SMART and chemotherapy. Follow-up was documented in all cases (median, 20.1 months). There have been 3 distant failures and 3 locoregional failures.

CONCLUSION

With moderate follow-up, chemotherapy and SMART contributes to excellent results, with 24-month actuarial overall survival and local control of 90% and 92%, respectively. Toxicity may be increased, however, with 15% of patients developing esophageal stricture or stenosis. .

Definitive radiotherapy for squamous cell carcinoma of the base of tongue

OBJECTIVE

To evaluate definitive radiotherapy (RT) for treatment of base of tongue cancer.

METHODS

There were 333 patients with squamous cell carcinoma of the base of tongue treated with definitive RT and had follow-up from 0.2 to 26.2 years. Follow-up on living patients ranged from 1.2 to 26.2 years (median, 6.6 years).

RESULTS

Local control rates at 5 years were: T1, 98%; T2, 92%; T3, 82%; and T4, 53%. The 5-year rates of local-regional control rates were: I-II, 100%; III, 82%; IVA, 87%; and IVB, 58%. The rates of absolute and cause-specific survival at 5 years were as follows: I-II, 67% and 91%; III, 66% and 77%; IVA, 67% and 84%; and IVB, 33% and 45%. Severe complications developed in 52 patients (16%).

CONCLUSION

Our data and review of the pertinent literature reveal that the local-regional control rates and survival rates after RT were comparable to those after surgery, and the morbidity associated with RT was less.

Phase II Study of Tolerance and Efficacy of Hyperfractionated Radiation Therapy and 5-Fluorouracil, Cisplatin, and Paclitaxel (Taxol) and Amifostine (Ethyol) in Head and Neck Squamous Cell Carcinomas

The objective of this study was to determine the toxicity and efficacy of the current phase II chemoradiation protocol. Stage III or IV locally advanced head and neck squamous cell carcinomas arising from the oral cavity, hypopharynx, oropharynx, nasopharynx, paranasal sinuses, or larynx were treated using hyperfractionated radiation (74.4 Gy at twice-daily fractions of 1.2 Gy) in combination with a 5-fluorouracil, cisplatin, paclitaxel regimen, and an amifostine infusion. Thirty-five of 36 eligible patients were evaluable. The overall survival (OVS) was 88%, 82%, and 66% at 1, 2, and 3 years respectively. Twenty-five patients (71%) had a complete response, which was maintained in 20 (57%) patients until last follow up or death. Disease-free survival (DFS) of the complete responders was 92% at 1 year and 77% at 2 years and 3 years, respectively. Percutaneous endoscopic gastrostomy dependency lasted for a median of 7 months. Grade 3 and 4 mucositis occurred in 23 and 3 patients, respectively. Comparison with a similar study (A-2) that did not include amifostine showed no significant benefit to the addition of amifostine in these patients. A locoregional control benefit should be confirmed in a prospective, randomized trial. Alternative amifostine delivery methods should be investigated.

Quality-of-Life Assessment After Hyperfractionated Radiation Therapy and 5-Fluorouracil, Cisplatin, and Paclitaxel (Taxol) in Inoperable and/or Unresectable Head and Neck Squamous Cell Carcinoma

PURPOSE

To determine quality of life (QOL) after hyperfractionated radiation and chemotherapy.

MATERIALS AND METHODS

Functional Assessment of Cancer Therapy (FACT) and the Functional Assessment of Cancer Therapy-Head and Neck (FACT H-N) questionnaires were administered to protocol patients at baseline study entry, during and at the completion of therapy, and during subsequent follow-up.

RESULTS

Twenty-four patients completed baseline QOL questionnaires. Six subsequent assessments were given to patients who were available for follow-up. Social/family well-being and relationship with doctor subscores were not significantly different from baseline. Emotional well-being was not different from baseline initially, but actually showed a significant increase 6 months after completion of radiation, seen on assessments 5 and 6 (P < 0.01). Physical and functional well-being subscores, total FACT-G score, head and neck subscores, and total FACT H-N score all showed initial decreases during, at the completion of radiation, or, in some subscores, up to 3 months postradiation. However, all these scores recovered to baseline levels. These scores subsequently showed a significant increase after 6 months to 1 year in all but the physical well-being and head and neck subscores, which remained at baseline.

CONCLUSION

QOL scores returned to baseline levels or increased at 6 to 12 months postradiation in long-term survivors who completed QOL questionnaires.

A comparison of treatments of squamous cell carcinoma of the base of tongue: surgical resection combined with external radiation therapy, external radiation therapy alone, and external radiation therapy combined with interstitial radiation

PURPOSE

The outcomes of patients treated at a single institution over a specific time frame using three different therapeutic approaches for cancer of the base of tongue were reviewed.

METHODS AND MATERIALS

Between 1992 and 1998, 53 patients were treated with curative intent for base of tongue cancer. Seventeen patients underwent surgical resection with postoperative radiation therapy, 16 patients received definitive external radiation therapy only, and 20 patients were treated with external and interstitial radiation, with neck dissection in 16 of those patients. Local control, survival, and functional status were assessed with each approach.

RESULTS

The 5-year actuarial local control and survival for the surgically treated patients were 74% and 44%, respectively. The patients treated with external radiation therapy alone had local control of 28% and 5-year survival of 24%. The patients treated with external and interstitial radiation with neck dissection as indicated had 5-year actuarial local control of 87% and survival of 33%. Survival was not statistically different between the three treatment approaches (p=0.0995) but local control was worse in the definitive external radiation group (p < 0.0001). Speech and swallowing function among the long-term survivors was superior in the definitively irradiated patients compared with the operated patients.

CONCLUSION

In this retrospective analysis, survival and local control was lowest in the patients treated with external radiation alone, however, patient selection likely played an important role. Local control was far better with surgical treatment and with external combined with interstitial radiation but survival remains less than 50% with each approach. Surgical treatment was superior for patients with T4 disease. Functional status was higher in the long-term survivors treated nonsurgically.

Brachytherapy in the treatment of Stage IV carcinoma of the base of tongue

PURPOSE

Survival in patients with Stage IV carcinoma of the base of tongue (BOT) treated by surgery and radiotherapy remains poor. External beam radiotherapy (EBRT) and brachytherapy (BT) have been used as an alternative treatment.

METHODS AND MATERIALS

Eighteen patients with Stage IV carcinoma of the BOT were treated by EBRT and BT.

RESULTS

Local control is 89%. The 5-year overall (OS) and disease specific survival (DSS) rates are 52% and 67%. No neck node positive patient implanted in the neck developed cervical metastases. Two patients (11%) developed complications.

CONCLUSIONS

Local regional control, survival, and complications in patients with Stage IV carcinoma of the BOT treated by EBRT and BT have been satisfactory. The use of brachytherapy for nodal metastases has eliminated the need for neck dissection. We recommend this approach in the treatment of Stage IV carcinoma of the BOT.

Radical radiotherapy compared with surgery for advanced squamous cell carcinoma of the base of tongue

PURPOSE

This study reports on T3/T4 base of tongue (BOT) tumors treated at the Erasmus MC (Rotterdam) with external beam radiotherapy (EBRT) and brachytherapy (BT). Local control, survival, and functional outcome are compared to results obtained in similar patients treated at the Vrije University Medical Center (VUMC, Amsterdam) by surgery and postoperative RT (PORT).

METHODS AND MATERIALS

At Rotterdam 46/2 Gy was given to the primary and bilateral neck, followed by an implant using low-dose-rate (LDR 24-35 Gy; median 27 Gy), or fractionated high-dose-rate (fr. HDR 20-28 Gy; median 24 Gy). A neck dissection (ND) was performed in case of N+ disease. 67% of BOT tumors had a T4 cancer. At Amsterdam surgery (S) followed by PORT 40-70 Gy (median 60 Gy) was performed; 26% BOT tumors were T4. Sex, age and nodal distribution were similar. Actuarial local control and survival were computed. Performance Status Scale (PSS) scores were established. Xerostomis was determined on visual analog scales (VAS).

RESULTS

Local failure at 5-years was 37% (Rotterdam) vs. 9% (Amsterdam) (p < 0.01). The overall survival was not significantly different (median 2.5 years vs. 2.9 years, respectively [p = 0.47]). The PSS favored brachytherapy. Both groups were equally affected by xerostomia.

CONCLUSIONS

The 5-year local control was 65% with EBRT and BT. This result is strongly affected by 4 patients with residual disease after implantation. The Rotterdam patients had more advanced BOT tumors (67% vs. 26% T4), explaining the higher local failure rate. Given the organ preservation properties of radiotherapy-only and the better PSS scores, the jury is still out on the optimal treatment for BOT tumors.

Current philosophy on the management of cancer of the base of the tongue

Cancer of the base of the tongue is a challenging disease for the head and neck surgeon, radiation oncologist and medical oncologist. However, over the last 10-15 years, improved treatment strategies have evolved which offer patients high probability of loco-regional control, survival, and good quality of life. The ability to offer patients good oncologic and functional outcomes serves as a paradigm for the successful application of multidisciplinary care, and the emphasis on quality of life in head and neck cancer treatment. This review provides an overview of the treatment options that exist, their advantages and disadvantages, and hopefully provides proper guidelines for the current management of this challenging disease.

Organ preservation with interstitial radiation for base of tongue cancer

Management options for squamous cell carcinoma of the base of tongue include surgical resection (often with adjuvant radiation), definitive external radiation and external combined with interstitial radiation. The reported series is a single institution experience with interstitial radiation for base of tongue cancer. Twenty patients were treated definitively with interstitial radiation as a boost to external radiation, and four patients were treated palliatively with interstitial radiation alone for recurrent base of tongue cancers or disease arising in a previously irradiated base of tongue. Patient, tumor, and treatment details were analyzed relative to disease control and posttreatment patient function. The 5-year actuarial local control, locoregional control, distant metastasis-free survival, overall disease-free survival, and actuarial overall survival of the definitively treated patients were 86%, 84%, 57%, 41%, and 30%, respectively. The 5-year actuarial rate of tolerating a normal diet was 86%, and all long-term survivors had normal speech function. Of the four patients treated palliatively with interstitial implant alone for recurrent disease (three patients), or a second primary cancer in a previously irradiated site (one patient), local control was obtained in three and long-term disease-free survival was obtained in one. Interstitial implantation combined with external radiation is associated with a high rate of disease eradication with preservation of speech and swallow function. Interstitial radiation alone can achieve effective palliation.

Phase II study of tolerance and efficacy of hyperfractionated radiotherapy and 5-fluorouracil, cisplatin, and paclitaxel (Taxol) in stage III and IV inoperable and/or unresectable head-and-neck squamous cell carcinoma: A-2 protocol

PURPOSE

To determine the toxicity and efficacy of concurrent 5-fluorouracil (5-FU), cisplatin, and paclitaxel (Taxol) and hyperfractionated radiotherapy in locally advanced squamous cell carcinoma of the head and neck.

METHODS AND MATERIALS

Twenty-seven patients were entered into this Phase II trial. Eligible patients had Stage III or IV head-and-neck squamous cell carcinoma arising from the oral cavity, hypopharynx, oropharynx, nasopharynx, or larynx. The plan of treatment consisted of hyperfractionated radiotherapy (74.4 Gy at twice daily fractions of 1.2 Gy). Chemotherapy was given on Weeks 1, 5, and 8 as follows: 5-FU at 750 mg/m2 as a constant infusion for 24 h for 3 days; cisplatin at 50 mg/m2 in 250-500 mL D5 0.5 NS or NS infusion during 2-4 h, and paclitaxel at 70 mg/m2 infused in 500 mL NS during 3 h.

RESULTS

The overall survival rate of the entire group was 81.5%, 66.7%, and 63% at 1, 2, and 3 years, respectively. The median follow-up was 40.2 months (range 30-62). Of the 27 patients, 19 (70%) had a complete response and an overall survival rate of 100% at 1 year and 94% at 2 and 3 years. The disease-free survival rate of the latter group was 95% at 1 year and 84% at 2 and 3 years. Of the 27 patients, 18 (67%) maintained the complete response until the last follow-up visit or death. Percutaneous endoscopic gastrostomy dependency occurred for a median of 7.1 months. Grade 3 and 4 mucositis occurred in 20 and 3 patients, respectively. Six patients were hospitalized for leukopenic fever. Late toxicities included L'Hermitte syndrome (n = 3), osteoradionecrosis (n =1), hypothyroidism (n = 4), paresthesias (n = 1), aspiration pneumonia (n = 3), and esophageal strictures (8 patients underwent dilation).

CONCLUSION

Combining hyperfractionated radiotherapy concurrently with 5-FU, cisplatin, and paclitaxel results in acceptable efficacy and toxicity. However, although a locoregional control benefit is suggested by the preliminary results of this trial, it needs to be confirmed in a prospective randomized trial.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Is radiation therapy a preferred alternative to surgery for squamous cell carcinoma of the base of tongue?

PURPOSE

To evaluate irradiation alone for treatment of base-of-tongue cancer.

PATIENTS AND METHODS

Two hundred seventeen patients with squamous cell carcinoma of the base of tongue were treated with radiation alone and had follow-up for >/= 2 years.

RESULTS

Local control rates at 5 years were as follows: T1, 96%; T2, 91%; T3, 81%; and T4, 38%. Multivariate analysis revealed that T stage (P =.0001) and overall treatment time (P =.0006) significantly influenced local control. The 5-year rates of local-regional control were as follows: I, 100%; II, 100%; III, 83%; IVA, 64%; and IVB, 65%. Multivariate analysis revealed that the following parameters significantly affect the probability of this end point: T stage (P =.0001), overall treatment time (P =.0001), overall stage (P =.0131), and addition of a neck dissection (P =.0021). The rates of absolute and cause-specific survival at 5 years were as follows: I, 50% and 100%; II, 81% and 100%; III, 65% and 76%; IVA, 42% and 56%; and IVB, 44% and 52%. Severe radiation complications developed in eight patients (4%).

CONCLUSION

The likelihood of cure after external-beam irradiation was related to stage, overall treatment time, and addition of a planned neck dissection. The local-regional control rates and survival rates after radiation therapy were comparable to those after surgery, and the morbidity associated with irradiation was less.

Adjuvant radiotherapy for squamous cell carcinoma of the tongue base: improved local-regional disease control compared with surgery alone

PURPOSE

The purpose of this retrospective study is to present the results of postoperative adjuvant radiotherapy after primary surgery for squamous cell carcinoma of the tongue base and to compare these results to those obtained with surgery alone.

METHODS

Between 1974 and 1993, continuous-course postoperative radiotherapy was delivered to 24 patients (Adjuvant Radiotherapy Group). Results were compared to those from a group of 55 patients treated with surgery alone (Surgery Group).

RESULTS

Characteristics of the two groups were similar, except that a larger proportion of patients in the Adjuvant Radiotherapy Group had higher pathologic TNM stages. Ipsilateral neck control (87% vs. 68%, p = 0.04), contralateral neck control (100% vs. 76%,p = 0.002), relapse-free survival (64% vs. 46%,p = 0.04), and control above the clavicles (80% vs. 48%, p = 0.007) were significantly higher in the Adjuvant Radiotherapy Group compared to those in the Surgery Group (5-year figures shown).

CONCLUSION

The use of adjuvant radiotherapy after surgical resection of tongue base squamous cell carcinoma significantly decreased the rate of local-regional recurrence and improved relapse-free survival compared with surgery alone but did not alter cause-specific or overall survival.

A retrospective comparison of treatment outcome in the posterior and anterior tongue

BACKGROUND

The perceived poor survival for tongue base cancer compared with the anterior tongue influences selection of treatment.

METHODS

Treatment outcome is compared in patients with epidermoid carcinoma of the tongue base (n = 112) and anterior tongue (n = 188). A multivariate Cox's proportional hazard model is used to assess the independent effect of tumor location on survival.

RESULTS

Seventy-one percent of patients with tongue base tumors had advanced stages of disease (Stages III & IV) at presentation compared with 32% for the anterior tongue (P = .000). Disease-specific survival at 5 years for the tongue base was 26%, and for the anterior tongue was 64%. Significant risk factors for disease relapse included age > 50 years, advanced stages of disease, and radiotherapy as a single treatment modality. The adjusted hazard ratio for disease relapse for the tongue base compared with the oral tongue was 1.2 (95% CI = 0.83, 1.74; P = .332).

CONCLUSIONS

Treatment response for tongue base and anterior tongue tumors is similar. The pessimism that besets the management of cancer of the tongue base may not be justified in all patients.

Complications of supraglottic laryngectomy for carcinomas of the supraglottis and the base of the tongue

The medical records of patients with either a supraglottic carcinoma (n = 193) or a base of tongue carcinoma (n = 56) who underwent a supraglottic laryngectomy were studied. Because of aspiration total laryngectomy was required in 9.8% and 21.4% of patients with supraglottic and base of tongue carcinomas, respectively, being related to locally advanced stage of disease in the base of tongue and to an age older than 65 years in the case of supraglottic carcinomas. The non-decannulation rates were 23.8% and 50% in supraglottic and base of tongue tumours respectively. Post-operative radiotherapy did not influence the decannulation rate, but advanced local disease and age did. Post-operative mortality in the first month after the operation was 2.6% in supraglottic tumours and 3.6% in base of tongue tumours.

Extended supraglottic laryngectomy for primary base of tongue carcinomas

A retrospective review of 56 patients with a primary base of tongue carcinoma was undertaken to determine the value of supraglottic laryngectomy. All the patients had a supraglottic laryngectomy and a total of 77 neck dissections. Forty-three (76.8%) patients received post-operative radiotherapy. The incidence of local recurrence was 23.2%, neck relapse being seen in 16.1% of patients. The 3 year survival was 47%. The overall survival of the whole series and by stage was not improved by combined therapy compared with surgery alone.

Oropharyngeal carcinoma treated with radiotherapy: a 30-year experience

PURPOSE

This study was done to determine the outcome in patients with oropharyngeal carcinoma treated at the University of Florida with radiotherapy alone to the primary site, for comparison with reported results of other types of treatment.

METHODS AND MATERIALS

Of a consecutive cohort of 785 patients with biopsy-proven, previously untreated, invasive squamous cell carcinoma of the oropharynx, this report is based on the 490 patients who had continuous-course irradiation with curative intent at the University of Florida between October 1964 and January 1991. All patients had a minimum 2-year follow-up. Forty-eight percent had Stage T3 or T4 disease, and 64% had clinically apparent neck node metastases. The median radiation dose was 68 Gy for once-a-day treatment and 76.8 Gy for twice-a-day treatment. Patients with advanced neck node disease had planned neck dissection(s) after radiotherapy.

RESULTS

The overall local control rate after radiotherapy alone was 73%. The ultimate local control rate (including surgical salvage) was 78%. At 5 years, the probability of control of neck disease was 85%; control above the clavicles, 67%; absolute survival, 44%; cause-specific survival, 77%; distant metastasis (as the first or only site of failure), 11%. Thirteen patients (2.6%) experienced severe treatment complications.

CONCLUSION

Radiotherapy results in tumor control and survival rates comparable with rates achieved with combined irradiation and surgery, with less morbidity.

Local control of oropharyngeal carcinoma by irradiation alone

The authors of this study reviewed the management of 402 patients with squamous cell carcinomas of the faucial tonsil and the base of the tongue. These patients received radiation therapy at Massachusetts General Hospital and the Massachusetts Eye and Ear Infirmary from 1970 through 1993. Radiation therapy remains the treatment of choice for these lesions. Although the data from this review were not randomized, the accelerated hyperfractionated radiation therapy twice-daily program was shown to achieve significantly higher 5-year local tumor control rates and disease-specific survival rates than the conventional once-daily radiation therapy program (historical control). In patients with early tumors of the faucial tonsil (cancer stages T1 and T2), the 5-year actuarial local tumor control and disease-specific survival rates following the twice-daily radiation therapy program were 91% and 77%, respectively. In patients with advanced tumors (T3), the corresponding rates following twice-daily radiation therapy showed marked improvement and were 80% and 68%. While the treatment results for carcinoma of the base of the tongue generally were inferior to those for carcinoma of the faucial tonsil, they were still much better after the twice-daily program than after conventional once-daily irradiation. For patients with carcinoma of the base of the tongue, the local tumor control and disease-specific survival rates for T1 and T2 lesions were 85% and 76%, respectively. For T3 lesions, the corresponding rates were 54% and 53%. Extensive T4 tumors are better managed by combined surgery and postoperative irradiation. Residual metastatic nodal disease is managed by neck dissection.

Transhyoid resection of tongue base and tonsil tumors

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

Surgical management of squamous cell carcinoma of the base of the tongue

An 11-year experience with 100 patients who had surgery as definitive treatment for squamous cell carcinoma of the base of the tongue between 1979 and 1989 has been retrospectively reviewed. Although 81% of the patients had stage III or stage IV disease, mandible continuity was maintained in 86%, and the larynx was preserved in 80%. Lymphadenectomy was performed in conjunction with the primary resection in a total of 89 patients, including 62 patients who had clinically evident metastases. Postoperative radiation was administered to 63 patients because of positive resection margins (17), positive cervical lymph nodes (34), or high tumor stage (12). Overall and disease-specific 5-year survival rates for the entire group were 55% and 65%, respectively. The 5-year disease-specific survival rates for stages I/II, III, and IV were 77%, 64%, and 59%, respectively. Local control was achieved in all but 18 patients. Our results indicate that surgery remains a viable treatment option for patients with advanced base-of-tongue cancer. Prospective trials are necessary to compare surgery versus definitive radiotherapy with respect to patients' survival and quality of life.

Base of tongue carcinoma: patterns of failure and predictors of recurrence after surgery alone

Between January 1971 and December 1986, 55 patients with squamous cell carcinoma of the tongue base underwent complete surgical resection with curative intent. No preoperative or postoperative adjuvant therapy was administered. The study group consisted of 41 men and 14 women (median age 61 years). All patients were followed until death (39 patients) or for a median of 9.4 years. Local control at 5 years was 74%. No predictors of local recurrence were discovered. Control in the dissected neck at 5 years was 68%. Control of cancer above the clavicles at 5 years was 48%. Distant metastases developed in 14% of the patients by 5 years. Cause-specific survival at 5 years was 65%. A Cox multivariate regression analysis revealed that pathologic N stage was the only significant independent predictor of recurrence in the dissected neck, recurrence above the clavicles, and cause-specific survival. The 5-year overall survival was 55%. Surgical mortality was 4%.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Combined therapy in advanced head and neck cancers

The results of single modality treatment using surgery or radiotherapy alone in advanced head and neck cancers are known to be unsatisfactory. The present study analyses 252 cases with stage III and IV resectable cancers of the head and neck region selected to be treated by a combined regime of pre- or post-operative radiation and radical surgery. Only 193 patients completed the treatment protocol. There were 58 cases (33.5 per cent) who failed either at primary or regional sites or both. Nine cases (five per cent) developed distant metastasis. Absolute and determinate four year disease-free survival was 55 per cent and 61 per cent respectively. Early lesions (stage I and II) have been excluded from the study. The study indicates that a reduction in primary and regional failures correlates well with a combined therapy, though prolonged treatment may affect patients' compliance to some extent.

Staging and prognostic factors in carcinoma of the base of the tongue

During the period 1966-1985, 66 patients were submitted for curative treatment of a carcinoma of the base of the tongue in the Netherlands Cancer Institute. Treatment consisted of radiotherapy (59 patients), surgery and post-operative radiotherapy (4 patients) and surgery alone (3 patients). Patients were staged according to the UICC (1982) and UICC (1987)/AJCC (1988) criteria. Regrouping by the latter system caused enlargement of the N2-group and of stage IV. The crude 5-year survival was 22%, the 5-year tumour control was 36% and the locoregional control was 47%. The most important prognostic factors for the tumour-free interval are the T-category (P = 0.01) and stage grouping (UICC 1982) (P = 0.022). The same factors predict the locoregional control (P = 0.005 and 0.02 respectively). Crude survival is lower in smokers, and in patients in poor general condition (P = 0.04 and 0.007 respectively).

Results of radiation therapy in carcinoma of the base of the tongue. The Curie Institute experience with about 166 cases

Between 1960 and 1980, 166 patients with squamous cell carcinoma of the base of the tongue were treated with primary irradiation at the Curie Institute (Paris, France). Distribution according to the TNM system 1978 International Union Against Cancer (UICC) was the following: 22 T1 lesions, 47 T2 lesions, 64 T3 lesions, and 33 T4 lesions. Regional nodes were not palpable in 50 cases, 35 had N1 nodes, 12 had N2 nodes, and 69 had N3 nodes. All patients received external beam radiation. The 2-year, 3-year, and 5-year overall survival rates for all patients were, respectively, 45%, 37%, and 27%. Local control was significantly related to the initial status of the primary, to the tumor regression at the end of the radiation therapy, and to the histologic differentiation. The 2-year local control was 96% for T1 lesions, 57% for T2 lesions, 45% for T3 lesions, and 23% for T4 lesions. Local control was 70% if the tumor regression was complete at the end of the treatment and 27% if the tumor regression was partial. No significant differences were found in primary local control with respect to degree of infiltration, age, and dose of radiation therapy over a dose of 60 Gy in 6 weeks. The 3-year regional control was 86% for N0, 78% for N1, and 60% for N2 and N3. Among the tumor characteristics analyzed, the most useful ones for predicting local control and survival were clinical tumor staging parameters and tumor radiation-induced regression. A new therapeutic approach based on the evaluation of the tumor regression at 50/55 Gy is under discussion.

Radical surgery for lingual cancer

The survival rates of 58 patients treated for squamous carcinoma of the tongue between 1972 and 1985 were evaluated. The overall 5-year survival rate was 41.6%; for stage I it was 61.8%; stage II 59.5%; and stage III, 27.7%. No patient survived for more than 2 years when their tumour was stage IV on presentation. A composite pull-through resection with radical neck dissection gave a 5-year survival rate of 50.7%, which was significantly (P less than 0.01) higher than the 13.8% achieved by other treatments, mainly local tumour excision combined with radiation therapy. The same trend in favour of radical surgery was also seen stage by stage. In 45% of the patients regional neck metastases (palpable in 35% and occult in 10%) were present and predicted a poor prognosis. Among T1-T2 cases the 5-year survival of 58.5% in the N0 group was significantly (P less than 0.01) higher than the 15.1% among those with nodal involvement. The location of the primary tumour did not affect the survival rates.

External irradiation plus curietherapy boost in 108 base of tongue carcinomas

From 1960 to 1983, 108 patients underwent an association cobaltherapy plus curietherapy boost for a base of tongue carcinoma. This group included 18 T1 tumors, 39 T2, and 51 T3. Cobaltherapy was delivered to a dose of 45 Gy/4.5 weeks to the primary site and the neck. It was completed by an electron boost or a nodal surgery in case of initial nodal disease. Two techniques of Curietherapy were used: plastic tubes and guide-gutters. As most of these implants have been done before 1975, all the doses have been recalculated on the 85% isodose according to the Paris system. They varied from 22 to 88 Gy. The tolerance of the implantation was excellent. Five-year survival of the whole group is 26%. The local control rate is 85% for T1 tumors, 50% for T2, and 69% for T3. Despite the importance of cumulated doses, a few necrosis were observed. Considering the poor outlook of this cancer, its treatment by exclusive radiotherapy requires very high doses which can only be delivered without major sequellae or complication by a combination of cobaltherapy and curietherapy boost.

Brachytherapy as part of the definitive management of squamous cancer of the base of tongue

Between 1981 and 1986, 17 patients were treated at the Department of Radiation Oncology at the Memorial Sloan-Kettering Cancer Center with squamous cancer of the base of the tongue whose definitive treatment included brachytherapy. The patient sample consisted of 14 men and 3 women with age range of 35 to 71 years (median = 58). There were four patients with T1 lesions, six with T2, six with T3, and one with T4. In general, treatment consisted of 5000-5400 cGy with external beam radiation and 2000-3000 cGy boost to the base of tongue via an Ir-192 implant using afterloading catheters. Necks were managed with elective radiation alone in the N0 group (n = 5) or with radiation plus neck dissection in the N+ group (n = 12). Five patients who would have required laryngectomy had they undergone primary surgery received neoadjuvant chemotherapy followed by external beam and implant as part of a larynx preservation study that was being done at our institution (4-T3, 1-T2). The range of follow-up is 8 to 59 months, with median follow-up of 24 months. No patients have been lost to follow-up. Crude local control by T-Stage are as follows: T1-4/4, T2-5/6, T3-5/6, T4-1/1. Actuarial local control at 24 months is 87%. There have been no neck failures. There have been five patients who had soft tissue ulceration (STU) and one patient who had osteoradionecrosis (ORN). All soft tissue ulceration patients have been successfully managed conservatively. The patient with osteoradionecrosis is currently being managed. In 4 of these 6 cases, the implant was the initial therapeutic intervention and the entire tumor bed was implanted. On the other hand, when external beam was the initial treatment, the boost was administered to the smaller volume of residual disease. Overall, 4 of 7 patients who had implant first developed either soft tissue ulceration or osteoradionecrosis, as opposed to 2 of 10 patients who had implant after external beam and/or chemotherapy. The numbers are too small to be statistically significant, but our current policy is to perform brachytherapy after the external beam. In addition, all those with either soft tissue ulceration or osteoradionecrosis were implanted with a non-looping technique. Overall, 6 of 12 patients treated with a non-looping technique developed an injury, whereas none of the five treated with a looping technique has developed one.(ABSTRACT TRUNCATED AT 400 WORDS)

Squamous cell carcinoma of the base of the tongue: results of treatment in 115 cases

Between 1976 and 1986, we treated 115 patients (mean age 53.8 years) with base of tongue carcinomas. The staging system used was the UICC TNM classification of 1979. Seventy per cent of the tumours were T3 or T4 and 42% had N2 or N3 lymph node. Locoregional treatment was irradiation alone (98/115) or surgery and post-operative radiotherapy (17/115). Sixty-seven patients received induction chemotherapy. Actuarial survival of the entire group at 3 and 5 years was 25 and 23%, respectively, and 3-year actuarial survival rates for T1, T2, T3 and T4 lesions were 42, 48, 20 and 17%, respectively. The local control rate at the primary site was 55% and 78% in the neck. Distant metastases occurred in 10% of patients and 8% had a second primary. Nodal status was the only other prognostic factor. The local control rate obtained with irradiation alone was not good. For limited T1 and T2 tumours, interstitial therapy or surgery should improve the local control rate.

Limited external beam and interstitial 192iridium irradiation in the treatment of carcinoma of the base of the tongue: a ten year experience

A total of 70 patients with histologically proven diagnosis of carcinoma of the base of the tongue were treated with primary irradiation between May 1974 through April 1984. Fifty-eight (83%) of these patients had locally advanced tumors (Stage T3, T4, N2, N3). Fifty-one of the 70 (73%) patients had clinically palpable neck nodes at first presentation. All patients received a combination of external and interstitial irradiation. The dose of external irradiation was limited to 45-50 Gy over 4 1/2-5 1/2 weeks. Interstitial volume implants were performed 2-3 weeks after completion of external irradiation. The primary site as well as the vallecula, epsilateral pharyngeal wall, glossopalatine sulcus, tonsillar bed, and pillars were routinely implanted to encompass contiguous spread of the disease. The doses of implant varied according to the stage of disease, that is, 2000-2500 cGy for T1 and T2 lesions, 3000-4000 cGy for T3 and T4 lesions, with typical dose rates of 50-60 cGy per hour. The neck nodes were also separately implanted to deliver additional doses of 2000-4000 cGy in 50-80 hours. Overall, local tumor control was observed in 58 of 70 (83%) patients at minimum follow-up of 2 years. An absolute 3-year disease-free survival of the entire group was 67.0%. Treatment related complications such as soft tissue necrosis and/or osteoradionecrosis occurred in 8 of the 70 (11.4%) patients. The salvage of neck failures and the local failures was feasible in 74% and 46% of the patients, respectively either by surgery or by re-irradiation using interstitial 192iridium implant alone. This treatment region is well tolerated and it preserves the functional and asthetic integrity in most patients.

Functional restoration after subtotal glossectomy and laryngectomy

Extensive resection of carcinoma that involves the tongue base and supraglottic larynx is accompanied by significant potential morbidity and mortality. This is often indicated by poor rates of cure and the limited palliation afforded by radiotherapy alone. Removal of a significant portion of the posterior tongue frequently results in intractable aspiration. Techniques in reconstruction of the oropharyngeal defect and tongue base have included primary closure, random flaps, and myocutaneous flaps. Each of these techniques has been successful, to some degree, in resurfacing pharyngeal defects. However, the functional results in regard to deglutition are less than satisfactory as a result of aspiration. Frequently, simultaneous or delayed total laryngectomy is performed to deal with the pulmonary complications. Various types of laryngoplasty do not uniformly correct the problems of aspiration and deglutition associated with subtotal glossectomy. Our experience includes eight patients who had advanced squamous cell carcinoma of the tongue base, vallecula, and the supraglottic larynx. All patients underwent partial or subtotal glossectomy and laryngectomy. The mucosal defect was reconstructed with pectoralis myocutaneous flap. In order to reestablish voice, a primary tracheopharyngeal shunt was created with the use of a portion of cricoid and upper trachea. The majority of these patients have had successful rehabilitation of deglutition, mastication, and speech.