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.

Intensity-modulated radiation therapy reduces late salivary toxicity without compromising tumor control in patients with oropharyngeal carcinoma: a comparison with conventional techniques

BACKGROUND AND PURPOSE

Intensity-modulated radiation therapy (IMRT) offers superior dosimetric conformity for normal tissue sparing in patients with oropharyngeal cancer. In this study, acute and late toxicity, and tumor control were compared between conventional beam arrangement (CRT) and IMRT.

MATERIALS AND METHODS

Between January 1970 and December 1999, 430 patients with carcinoma of the oropharynx were treated at the Mallinckrodt Institute of Radiology. There were 260 patients with tonsil primary tumors and 170 patients with tumors arising from the base of the tongue. Twenty-four (6%) patients had stage I disease, 88 (20%) had stage II, 128 (30%) had stage III, and 190 (44%) had stage IV disease. Patients were divided into five treatment groups. Group I consisted of 109 patients who received preoperative CRT. Group II consisted of 142 patients who received postoperative CRT. Group III consisted of 153 patients who received definitive CRT. Inverse planning IMRT (Peacock, NOMOS) was used to treat 14 patients postoperatively (Group IV) and 12 patients definitively without surgery (Group V). Acute and late normal tissue side-effects were scored according to the Radiation Therapy Oncology Group radiation morbidity criteria. The median follow-up was 3.9 years.

RESULTS

The 2-year local-regional control values for the five studied groups were 78, 76, 68, 100 and 88%, respectively. The 2-year disease-free survival values for the five studied groups were 68, 74, 58, 92 and 80%, respectively. IMRT significantly reduced the incidence of late xerostomia.

CONCLUSIONS

When IMRT was compared with conventional techniques, the dosimetric advantage of IMRT did translate into a significant reduction of late salivary toxicity in patients with oropharyngeal carcinoma. No adverse impact on tumor control and disease-free survival was observed in patients treated with IMRT.

Natural course of distant metastases following radiotherapy or chemoradiotherapy in HPV-related oropharyngeal cancer

OBJECTIVES

To describe the natural course of distant metastases (DMs) following radiotherapy (RT) or chemoradiotherapy (CRT) in HPV(+) oropharyngeal carcinoma (OPC).

METHODS

OPC treated with RT/CRT from 1/1/2000 to 5/31/2010 were reviewed. The natural course of DM were compared between HPV(+) and HPV(-) cohorts.

RESULTS

Median follow-up was 3.9 years. The DM rate were similar (11% vs. 15% at 3-years, p=0.25) between the HPV(+) (n=457) vs. the HPV(-) (n=167) cases. While almost all (24/25) HPV(-) DM occurred within 2-years following RT (1 was at 2.1 years), 7/54 (13%) of HPV(+) DM were detected beyond 3 years (up to 5.3 years). Disseminating to >2 organs occurred in 18 (33%) HPV(+) vs. none in HPV(-). Post-DM survival rates were 11% vs. 4% at 2-years (p=0.02) for the HPV(+) vs. HPV(-) cases respectively. 5/6 HPV(+) with lung oligo-metastasis were still alive with stable disease beyond 2-years after salvage procedures for DM (chemotherapy: 3; surgical resection: 2; radiotherapy: 1).

CONCLUSIONS

Although DM rates are similar, the natural course of HPV(+) DM differs from that of HPV(-) patients: it may occur after a longer interval, often with a "disseminating" phenotype, and a small number may have prolonged survival after salvage for DM.

Primary chemotherapy in resectable oral cavity squamous cell cancer: a randomized controlled trial

PURPOSE

Prognosis of patients with advanced oral cavity cancer is worth improving. Chemotherapy has been reported to be especially active in oral cavity tumors. Here we repeat the results of a randomized, multicenter trial enrolling patients with a resectable, stage T2-T4 (> 3 cm), N0-N2, M0 untreated, squamous cell carcinoma of the oral cavity.

PATIENTS AND METHODS

Patients were randomly assigned to three cycles of cisplatin and fluorouracil followed by surgery (chemotherapy arm) or surgery alone (control arm). In both arms, postoperative radiotherapy was reserved to high-risk patients, and surgery was modulated depending on the tumor's closeness to the mandible. Patients' accrual was opened in 1989 and closed in 1999. It included 195 patients.

RESULTS

In the chemotherapy arm, three toxic deaths were recorded. No significant difference in overall survival was found. Five-year overall survival was, for both arms, 55%. Postoperative radiotherapy was administered in 33% of patients in the chemotherapy arm, versus 46% in the control arm. A mandible resection was performed in 52% of patients in the control arm, versus 31% in the chemotherapy arm.

CONCLUSION

The addition of primary chemotherapy to standard surgery was unable to improve survival. However, in this study, primary chemotherapy seemed to play a role in reducing the number of patients who needed to undergo mandibulectomy and/or radiation therapy. Variations in the criteria used to select patients for these treatment options may make it difficult to generalize these results, but there appears to be room for using preoperative chemotherapy to spare destructive surgery or radiation therapy in patients with advanced, resectable oral cavity cancer.

Intensity-modulated radiation therapy for oropharyngeal carcinoma: impact of tumor volume

PURPOSE

To assess the therapeutic outcomes in oropharyngeal cancer patients treated with intensity-modulated radiotherapy (IMRT) and analyze the impact of primary gross tumor volume (GTV) and nodal GTV (nGTV) on survival and locoregional control rates.

METHODS AND MATERIALS

Between February 1997 and September 2001, 74 patients with squamous cell carcinoma of the oropharynx were treated with IMRT. Thirty-one patients received definitive IMRT; 17 also received platinum-based chemotherapy. Forty-three patients received combined surgery and postoperative IMRT. The median follow-up for all patients was 33 months (range, 9-60 months). Fifty-two patients (70.3%) had Stage IV disease, 17 patients (23%) had Stage III, 3 patients (4.1%) had Stage II, and 2 patients (2.7%) had Stage I tumors. The mean prescription dose was 70 and 66 Gy, respectively, for the definitive and postoperative cohorts. The daily fraction dose was either 1.9 or 2 Gy, five times weekly. The GTV and/or nGTV were determined and derived using the Computational Environment for Radiotherapy Research, a free software package developed at Washington University. The mean GTV was 30.5 +/- 22.3 cm(3), and the mean nGTV was 23.2 +/- 20.6 cm(3).

RESULTS

Ten locoregional failures were observed. Six patients died of disease and three died of concurrent disease. Distant metastasis developed in 6 patients. The 4-year estimate of overall survival was 87%, and the 4-year estimate of disease-free survival was 81% (66% in the definitive vs. 92% in the postoperative RT group). The 4-year estimate of locoregional control was 87% (78% in the definitive vs. 95% in the postoperative RT group); the 4-year estimate of distant metastasis-free survival was 90% (84% in the definitive vs. 94% in the postoperative group). Multivariate analysis showed that GTV and nGTV were independent risk factors determining locoregional control and disease-free survival for definitive oropharyngeal IMRT patients. The worst late toxicities documented were as follows: 32 patients with Grade 1 and 9 with Grade 2 xerostomia; 2 with Grade 1 and 1 with Grade 2 skin toxicity; 3 with Grade 1 late mucositis; and 3 with Grade 1 trismus. Seventeen patients required gastrostomy tube placement.

CONCLUSION

IMRT is an effective treatment modality for locally advanced oropharyngeal carcinoma. The GTV and nGTV are the most important factors predictive of therapeutic outcome.

Extent of extracapsular spread: a critical prognosticator in oral tongue cancer

BACKGROUND

Extracapsular spread (ECS) of metastatic squamous cell carcinoma of the head and neck to regional lymph nodes is the most reliable predictor of poor treatment outcomes. Recently, the authors have shown that ECS is significantly associated with higher rates of locoregional recurrence, distant metastasis, and decreased survival in patients with squamous cell carcinoma of the oral tongue (SCCOT). The purpose of this review was to determine if the degree of ECS impacts distant metastasis rates and survival.

METHODS

Two hundred sixty-six patients treated for SCCOT with surgery +/- adjuvant radiotherapy from 1980-1995 were reviewed. The setting was a tertiary referral center. The extent of ECS on histopathologic review of involved lymph nodes was measured from the capsular margin to the farthest perinodal extension in mm. Extent of ECS and the number of pathologic lymph nodes with or without ECS were analyzed for disease-free interval, survival rates, and distant metastases.

RESULTS

No differences in the survival of patients with ECS of </= 2 mm or > 2 mm was found (P = 0.92). Patients with both ECS and multiple positive lymph nodes had decreased overall survival (P = 0.0003), disease-specific survival (P = 0.0005), and a shorter disease-free interval (P = 0.019) when compared with those with a single positive lymph node with ECS. Those with multiple ECS+ lymph nodes had the worst prognosis (P = 0.001).

CONCLUSIONS

Based on these findings, the authors recommended that all patients with SCCOT with ECS or multiple positive lymph nodes with or without ECS on pathologic review be considered for clinical trials that intensify regional and systemic adjuvant therapy.

Detailed quality of life assessment in patients treated with primary radiotherapy for squamous cell cancer of the base of the tongue

BACKGROUND

This study was conducted to evaluate quality of life in patients treated with primary radiotherapy (RT) for cancer of the base of tongue.

METHODS

From 1981 to 1990, 36 patients with primary squamous cell cancer of the base of tongue were managed with primary radiotherapy. Ages ranged from 35 to 71 years (median, 58 years), T Stage was: T1, n = 11; T2, n = 14; T3, n = 10; T4, n = 1. Thirty-one patients (86%) had palpable cervical lymph node metastases at initial examination (N1, n = 16; N2, n = 11; N3, n = 4). Patients received external beam RT to their primary site and necks, followed by a brachytherapy boost to the tongue. Those with neck nodes also had a neck dissection. The median follow-up is 5 years (minimum, 3 years). Actuarial 5-year local control was 85%; regional control was 96%; distant metastases-free survival was 87.5%; and overall survival, 85%. Twenty-nine of the 30 long-term survivors completed (1) Memorial Symptom Assessment Scale (MSAS), (2) Functional Assessment of Cancer Therapy (FACT), (3) Performance Status Scale for Head and Neck Cancer (PSS), and (4) a sociodemographic and economic questionnaire. At the time of cancer diagnosis, 62% were employed full-time, and 21% were employed part-time; 83% were earning > $20,000/year, and 59% were earning > $60,000/year.

RESULTS

At follow-up, annual incomes were similar to those at initial examination. Of those who had been working full-time, 72% were still in full-time work, and of those who had been working part-time, 83% were still in part-time work. Average PSS scores were 90 for eating in public, 96 for understandability of speech, and 68 for normalcy of diet. On the MSAS, the following symptoms had prevalence: > 30% xerostomia, difficulty swallowing, decreased energy, pain, worrying, insomnia, cough, drowsy, change in taste, and irritability. Scores on the FACT exceeded published values collected for a mixed cancer population.

CONCLUSIONS

The overwhelming majority of patients achieved excellent functional status and quality of life and could maintain their prediagnosis earning potential and employment status after primary radiation for advanced base of tongue cancer.

Tumour thickness predicts cervical nodal metastases and survival in early oral tongue cancer

Squamous cell carcinoma (SCC) of the oral tongue is characterized by a high propensity for cervical nodal metastasis, which affects the probability of regional control and survival. Until now, elective treatment of the clinically negative neck in early lesions (T(1-2)) of the oral tongue cancer remains controversial. This study attempted to identify predictive factor(s) for cervical nodal metastasis and treatment outcomes in patients with early stage SCC of the oral tongue treated primarily by surgery. Fifty patients with previously untreated Stage I/II primary tongue carcinomas with available archival specimens treated at the Royal Marsden Hospital between 1981 and 1998 were reviewed. Clinico-pathological features including age, gender, alcohol and tobacco consumption, tumour location, histological grade, tumour-stromal border, growth pattern, tumour thickness, and clinical stage were evaluated and the correlations with cervical metastases and outcome analysis were determined. The overall occult nodal metastatic rate was 40% (20/50). Tumour thickness exceeding 5 mm was statistically significantly correlated with cervical metastases (P = 0.003; relative risk = 2.429). No statistical correlation was observed between other clinico-pathological parameters and nodal metastasis. With a median follow-up of 98 months, 5-year actuarial overall, disease-specific (DSS), and relapse-free survival were 65.71, 67.77, and 68.18%, respectively. Univariate analysis for DSS showed poorer outcomes for patients with age > 60 years (P = 0.0423) and tumour thickness > 5 mm (P = 0.0067). The effect of tumour thickness was maintained (P = 0.005) on multivariate analysis. The present study indicates that the thickness of primary tumour has a strong predictive value for occult cervical metastasis and poor outcomes in patients with Stage I/II oral tongue SCC. Thus, elective neck treatment (surgery or irradiation) is indicated for tumours exceeding 5 mm thickness.

Development of distant metastasis after treatment of advanced-stage head and neck cancer

BACKGROUND

The recognition of risk factors for the development of distant metastasis is necessary for identifying high-risk patients who may benefit from systemic therapy. Previous investigations studying possible risk factors have been heterogeneous, with patients having varied forms of therapy. This study is designed to evaluate the clinical and histologic risk factors for the development of distant metastasis (DM) in patients with only advanced-stage head and neck squamous cell carcinoma after surgery and radiotherapy.

METHODS

Retrospective analysis of a cohort of potentials with-surgically treated stage III and IV squamous cell carcinoma of the hypopharynx, tongue, and supraglottic larynx between 1988-1992. The cohort consisted of 130 patients of which 30 patients developed DM as the initial site of failure. All patients underwent surgical resection of the primary. Neck dissection was performed in 26 of 30 (87%0 patients who developed distant metastasis. Almost all patients received radiation therapy. Patients who initially developed DM (DM group) were compared with patients who did not initially develop DM (no DM group) with respect to certain clinical and histo-pathological factors.

RESULTS

The majority of patients in the DM group had advanced T stage and clinically palpable cervical lymph nodes (73% and 93% respectively). In the no DM group, most patients had advanced T stage (85%) but 42% of the patients had stage NO necks (p < .05). Eighty-eight percent of patients in the DM group and 60% of patients in the no DM group had histological evidence of extracapsular spread of tumor from cervical lymph nodes (p < .05). Three or more positive lymph nodes were found in 69% of patients who developed DM and in only 35% of patients in the no DM group (p < .05). Age, gender, primary site, history of radiation therapy, perineural invasion and tumor grade were not associated with a higher risk for DM (p > .05).

CONCLUSION

Patients wit clinically palpable neck disease (N1-3), histological evidence of metastatic nodal disease, extracapsular spread, and three or more positive lymph nodes are at greater risk of developing failure at distant sites. This subset of patients should have an extensive evaluation for distant metastatic disease and should be considered for systemic therapy.

The incidence of occult metastases for cancer of the oral tongue and floor of the mouth: treatment rationale

One hundred thirty-six surgical cases of squamous cell carcinoma of the oral tongue and floor of the mouth at the Emory University Hospitals were reviewed for the incidence of occult metastases. Thirty-five percent of the T1 T2 lesions of the anterior tongue had occult metastases. The figure was 31.5% for similarly staged lesions of the floor of the mouth. The presence of regional metastases resulted in a 2-year determinate survival rate of 37% and 32% for patients with oral tongue and floor of the mouth lesions, respectively. The poor prognosis in the study for delayed cervical metastases and the high incidence of occult cervical metastases have led the authors to propose a more aggressive therapy for the clinically negative necks in these two sites of squamous cell carcinoma of the oral cavity.

Analysis of treatment results for oral tongue cancer

OBJECTIVE

The study reports the results of treatment of oral tongue cancer with five different treatment modalities with long-term follow-up.

STUDY DESIGN

Retrospective study of 332 patients with oral tongue cancer treated in the Departments of Otolaryngology-Head and Neck Surgery and Radiation Therapy at Washington University School of Medicine (St. Louis, MO) from 1957 to 1996.

METHODS

Patients with biopsy-proven squamous cell carcinoma of the oral tongue who were previously untreated and were treated with curative intent by one of five modalities and who were eligible for 5-year follow-up were included. The treatment modalities included local resection alone, composite resection alone (with neck dissection), radiation therapy alone, local resection with radiation therapy, and composite resection with radiation therapy. Multiple diagnostic, treatment, and follow-up parameters were studied using standard statistical analysis to determine statistical significance.

RESULTS

The overall 5-year disease-specific survival rate (DSS) was 57% with death due to tumor in 43%. The 5-year cumulative disease-specific survival probability (CDSS) was 0.61 (Kaplan-Meier) with a mean of 17.5 years and a median of 30.1 years. The DSS by treatment modality included local resection (73%), composite resection (61%), radiation therapy (46%), local resection and radiation therapy (65%), and composite resection with radiation therapy (CR/RT) (44%). Overall, local resection had a significantly improved DSS and CR/RT had a decreased DSS that was related to the stage of disease being treated. In treating stage IV disease, CR/RT produced a more significantly improved CDSS than the other treatment modalities. Recurrence at the primary site was as common as recurrence in the neck. Eighty-nine percent of recurrences occurred within the first 60 months. Recurrence significantly decreased survival. DSS was significantly improved in patients with clear margins of resection. Metastasis to a distant site occurred in 9.6% of patients. Twenty-one percent of patients had second primary cancers, and 54% of these patients died of their second primary cancer.

CONCLUSIONS

Significant improvement in DSS was seen in patients with clear margins, early stage grouping and clinical (pretreatment) tumor stage, and negative nodes. Significant decrease in DSS was seen in patients with close or involved margins, advanced stage grouping and clinical (pretreatment) tumor staging, positive clinical (pretreatment) node staging, and tumor recurrence. Obtaining clear margins of resection is crucial because it significantly affects survival. A minimum of 5 years of close monitoring is recommended because of the high incidence of second primary cancers.

Final results of local-regional control and late toxicity of RTOG 9003: a randomized trial of altered fractionation radiation for locally advanced head and neck cancer

PURPOSE

To test whether altered radiation fractionation schemes (hyperfractionation [HFX], accelerated fractionation, continuous [AFX-C], and accelerated fractionation with split [AFX-S]) improved local-regional control (LRC) rates for patients with squamous cell cancers (SCC) of the head and neck when compared with standard fractionation (SFX) of 70 Gy.

METHODS AND MATERIALS

Patients with stage III or IV (or stage II base of tongue) SCC (n=1076) were randomized to 4 treatment arms: (1) SFX, 70 Gy/35 daily fractions/7 weeks; (2) HFX, 81.6 Gy/68 twice-daily fractions/7 weeks; (3) AFX-S, 67.2 Gy/42 fractions/6 weeks with a 2-week rest after 38.4 Gy; and (4) AFX-C, 72 Gy/42 fractions/6 weeks. The 3 experimental arms were to be compared with SFX.

RESULTS

With patients censored for LRC at 5 years, only the comparison of HFX with SFX was significantly different: HFX, hazard ratio (HR) 0.79 (95% confidence interval 0.62-1.00), P=.05; AFX-C, 0.82 (95% confidence interval 0.65-1.05), P=.11. With patients censored at 5 years, HFX improved overall survival (HR 0.81, P=.05). Prevalence of any grade 3, 4, or 5 toxicity at 5 years; any feeding tube use after 180 days; or feeding tube use at 1 year did not differ significantly when the experimental arms were compared with SFX. When 7-week treatments were compared with 6-week treatments, accelerated fractionation appeared to increase grade 3, 4 or 5 toxicity at 5 years (P=.06). When the worst toxicity per patient was considered by treatment only, the AFX-C arm seemed to trend worse than the SFX arm when grade 0-2 was compared with grade 3-5 toxicity (P=.09).

CONCLUSIONS

At 5 years, only HFX improved LRC and overall survival for patients with locally advanced SCC without increasing late toxicity.

Early stage carcinoma of oral tongue: prognostic factors for local control and survival

The purpose of this study was to assess prognostic factors, treatment outcomes and patterns of relapse in patients with early stage (T1-2 N0) squamous cell carcinoma of oral tongue treated primarily by surgery. The medical records of all patients with early stage (T1-2 N0) oral tongue cancer, radically treated at King Faisal Specialist Hospital and Research Center between January 1980 and December 1997, were reviewed. Eighty-five patients were identified for analysis, 38 male and 47 female. With a median follow-up for surviving patients of 64 months, 5-year actuarial overall, disease-specific (DSS), and relapse-free survival (RFS) were 71, 75, and 63%, respectively. Univariate analysis for DSS showed survival advantage for patients with tumor thickness (TT) of < or =10 mm (P=0.0002) and distance from resection margin (DFRM) of > 5 mm (P=0.005). The effect of TT of < or =10 mm was maintained (P=0.001) on multivariate analysis. Higher RFS was observed with TT of < or =10 mm (P=0.0002), DFRM of > 5 mm (P=0.0002) and DFRM of >10 mm (P=0.007). On multivariate analysis higher RFS was also found for TT < or =10 mm (P=0.01) and DFRM >5 mm (P=0.01). Salvage of local tongue recurrence was higher than neck node failure, with 5-year DSS of 71 and 19%, respectively (P=0.007). Time interval for recurrence showed no significant impact on outcome. In T1-2 N0 oral tongue cancer, TT, and DFRM are significant prognostic factors for both local control and survival. Neck node recurrence is associated with poor prognosis and low salvage rate.

A treatment planning comparison of 3D conformal therapy, intensity modulated photon therapy and proton therapy for treatment of advanced head and neck tumours

BACKGROUND AND PURPOSE

In this work, the potential benefits and limitations of different treatment techniques, based on mixed photon-electron beams, 3D conformal therapy, intensity modulated photons (IM) and protons (passively scattered and spot scanned), have been assessed using comparative treatment planning methods in a cohort of patients presenting with advanced head and neck tumours.

MATERIAL AND METHODS

Plans for five patients were computed for all modalities using CT scans to delineate target volume (PTV) and organs at risk (OAR) and to predict dose distributions. The prescribed dose to the PTV was 54 Gy, whilst the spinal cord was constrained to a maximum dose of 40.5 Gy for all techniques. Dose volume histograms were used for physical and biological evaluation, which included equivalent uniform dose (EUD) calculations.

RESULTS

Excluding the mixed photon-electron technique, PTV coverage was within the defined limits for all techniques, with protons providing significantly improved dose homogeneity, resulting in correspondingly higher EUD results. For the spinal cord, protons also provided the best sparing with maximum doses as low as 17 Gy. Whilst the IM plans were demonstrated to be significantly superior to non-modulated photon plans, they were found to be inferior to protons for both criteria. A similar result was found for the parotid glands. Although they are partially included in the treated volume there is a clear indication that protons, and to a lesser extent IM photons, could play an important role in preserving organ functionality with a consequent improvement of the patient's quality of life.

CONCLUSIONS

For advanced head and neck tumours, we have demonstrated that the use of IM photons or protons both have the potential to reduce the possibility of spinal cord toxicity. In addition, a substantial reduction of dose to the parotid glands through the use of protons enhances the interest for such a treatment modality in cases of advanced head and neck tumours. However, in terms of target coverage, the use of 3D conformal therapy, although somewhat inferior in quality to protons or IM photons, has been shown to be a reasonable alternative to the more advanced techniques. In contrast, the conventional technique of mixed photon and electron fields has been shown to be inferior to all other techniques for both target coverage and OAR involvement.

Local control of oropharyngeal carcinoma after two accelerated hyperfractionation radiation therapy schemes

In October 1979 we started an accelerated hyperfractionation program consisting of 1.6 Gy/fraction, 2 fractions/day for 12 days or 38.4 Gy. Due to acute toxicity, the patients were then given a 2-week break and resumed once daily radiation therapy with 1.8 Gy/fraction up to 65 Gy, designated as the b.i.d.-q.d. program. In August 1982, the program was changed and the latter part of the treatment was continued on the twice daily program with 1.6 Gy/fraction for a total of 64 Gy, designated as the b.i.d.-b.i.d. program. We evaluated the local control rates of 140 patients with squamous cell carcinomas arising from the oropharynx, that is faucial tonsil and base of tongue. After these treatment regimens, the 36 month actuarial local rates for the T1-4 lesions were 56% for b.i.d.-q.d. (52 patients) and 85% for b.i.d.-b.i.d. (88 patients) with a p value of 0.0013. For the T1-2 lesions the corresponding rates were 81% (13 patients) and 97% (44 patients) with a p value of 0.53. The difference was marked for the T3-4 lesions, that is 47% vs 77% respectively with a p value of 0.017, and those patients without nodal metastases, that is 46% vs 93% with a p value of 0.00043. The improvement was probably due to marked shortening of the overall treatment course following b.i.d.-b.i.d. accelerated program--in this case 1 1/2 weeks. Our preliminary data suggests that the b.i.d.-b.i.d. program is superior to the b.i.d.-q.d. program. The seemingly improved local control rates for the treatment of oropharyngeal carcinomas requires a clinical prospectively randomized trial for confirmation, that is b.i.d.-b.i.d. versus b.i.d.-q.d. versus standard fractionation (q.d.) program.

Performance status after treatment for squamous cell cancer of the base of tongue--a comparison of primary radiation therapy versus primary surgery

PURPOSE

To compare the quality of life and functional outcome in patients with squamous cell cancer of the base of tongue treated with primary radiation vs. primary surgery.

METHODS AND MATERIALS

At our institution, patients with base of tongue cancer are primarily treated either by radiation or surgery depending upon the philosophy of their primary physician. Primary radiation consists of 45-54 Gy external beam radiation followed by an 192Ir implant delivering an additional 20-30 Gy over 2-3 days. A neck dissection is done at the same time as the implant for those with involved nodes. Primary surgery consists of resection of the base of tongue lesion, neck dissection and postoperative radiation therapy. Because both groups have similar local control in our experience (80-90%), we used a subjective performance status scale for head and neck cancer patients to assess the quality of life in these patients (0-100, 0 = worst function, 100 = normal function). This scale measures ability to eat in public, understandability of speech, and normalcy of diet. There were 30 radiation patients (21: T1-T2; nine: T3-T4) and ten surgery patients (five: T1-T2; five: T3-T4) available for long-term quality of life assessment.

RESULTS

Patients treated with radiation had consistently better performance status scores and quality of life according to our study. This was true for those with early (T1-2) as well as more advanced (T3-4) disease. For eating in public, T1-2 patients had scores of 85 vs. 75 (p = .31) and T3-4 patients had scores of 82 vs. 35 (p < .0001) for radiation vs. surgery, respectively. For understandability of speech, T1-2 patients had scores of 92 vs. 65 (p = .0021), and T3-4 patients had scores of 95 vs. 35 (p < .0001) for radiation vs. surgery, respectively. For normalcy of diet, T1-2 patients had scores of 74 vs. 50 (p = .047), and T3-4 patients had scores of 78 vs. 32 (p = .0012) for radiation vs. surgery, respectively. In addition, we compared scores for early vs. advanced disease treated by the same modality. For radiation, there was no difference in all three functional categories for T1-2 vs. T3-4 (p = .84), showing that quality of life scores remain high for all stages. For surgery, functional status deteriorated significantly when comparing T1-2 vs. T3-4 (p = .0014), consistent with the fact that larger tumors require more extensive operations.

CONCLUSION

Radiation therapy provides a better performance status than surgery for base of tongue cancer. This is true for both early and advanced disease. Because radiation also provides similar local control and survival, our data suggests that radiation may be the preferred strategy. Functional scores remain high for all T stages treated with radiation, but deteriorate with more advanced T stages for patients treated with surgery. Similar studies using objective criteria are needed to further compare these treatments.

On biologically conformal boost dose optimization

A method is described that allows the inclusion of biological imaging data in the optimization of intensity-modulated radiotherapy to produce dose boosts that conform with target subvolumes of potentially reduced radiosensitivity. The biological image (e.g. PET, fMRI, etc) is transformed into a dose efficiency distribution using a piecewise linear calibration function with a prescribed maximum boost factor. Instead of dose alone, the cost function of the optimization algorithm depends on the product of the physical dose times dose efficiency. An example case of a base-of-tongue tumour which was imaged with the hypoxia tracer fluoro-misonidazole is presented, showing the excellent capability of IMRT to produce dose distributions that conform to spatially variable dose prescriptions.

Squamous cell carcinoma of the oral tongue in patients less than thirty years of age

Eleven patients less than thirty years of age who had squamous cell carcinoma of the oral tongue were treated at the M. D. Anderson Hospital from 1956 to 1973. The overall survival was 45 per cent. Many of the usual concomitant factors, such as heavy smoking, drinking, and poor dental hygiene were absent. Poorly differentiated, or grade III, squamous cell carcinoma was present in 48 per cent of the patients and indicated a poor prognosis regardless of the type of treatment. The primary lesion of the tongue was controlled in nine of the eleven patients. Recurrent cancer of the neck was observed in four patients. The selection of treatment in each case must be based on the various factors such as the size of the primary lesion, its histologic aspects, and the presence of nodal disease, and not on any emotional or subjective factors.

Non-Hodgkin's lymphomas of head and neck extranodal sites

The initial staging, therapy and course of 156 patients with non-Hodgkin's lymphomas of head and neck extranodal sites were analyzed to determine whether they have a natural history which differs from primary nodal disease. The sites involved were: Waldeyer's ring-103 patients (tonsil-60, nasopharynx-25, base of tongue-18), and extralymphatic sites-53 patients (salivary gland-20, paranasal sinus-20, oral cavity-10, and larynx-3). Seventy-six percent had unfavorable histologies and 24% had favorable histologies. Fifty-three percent had pathologic Stages I-II and 47% had Stages III-IV. The 5-year survival was influenced by primary sites: salivary gland-61%, oral cavity-57%, tonsil-49%, base of tongue-47%, nasopharynx-36% and paranasal sinus-12%. The 5-year survival was also influenced by histology: unfavorable histologies-39%, favorable histologies-69%. The Ann Arbor staging system was more useful than TNM for determining outcome. For patients with Stage I-II unfavorable histologies treated with radiation alone, the 5-year survival was: involved field-24%, extended field-42%, total lymphoid irradiation-52%. The majority of patients who failed did so in extranodal sites. Forty-one patients with advanced disease received a variety of chemotherapy regimens as the sole treatment. There was a high percentage of CNS recurrence with paranasal sinus lymphoma, and CNS prophylaxis may be necessary. For head and neck extranodal lymphomas, limited radiation is inadequate, and combined modality programs should be considered.

Multifield optimization intensity modulated proton therapy for head and neck tumors: a translation to practice

BACKGROUND

We report the first clinical experience and toxicity of multifield optimization (MFO) intensity modulated proton therapy (IMPT) for patients with head and neck tumors.

METHODS AND MATERIALS

Fifteen consecutive patients with head and neck cancer underwent MFO-IMPT with active scanning beam proton therapy. Patients with squamous cell carcinoma (SCC) had comprehensive treatment extending from the base of the skull to the clavicle. The doses for chemoradiation therapy and radiation therapy alone were 70 Gy and 66 Gy, respectively. The robustness of each treatment plan was also analyzed to evaluate sensitivity to uncertainties associated with variations in patient setup and the effect of uncertainties with proton beam range in patients. Proton beam energies during treatment ranged from 72.5 to 221.8 MeV. Spot sizes varied depending on the beam energy and depth of the target, and the scanning nozzle delivered the spot scanning treatment "spot by spot" and "layer by layer."

RESULTS

Ten patients presented with SCC and 5 with adenoid cystic carcinoma. All 15 patients were able to complete treatment with MFO-IMPT, with no need for treatment breaks and no hospitalizations. There were no treatment-related deaths, and with a median follow-up time of 28 months (range, 20-35 months), the overall clinical complete response rate was 93.3% (95% confidence interval, 68.1%-99.8%). Xerostomia occurred in all 15 patients as follows: grade 1 in 10 patients, grade 2 in 4 patients, and grade 3 in 1 patient. Mucositis within the planning target volumes was seen during the treatment of all patients: grade 1 in 1 patient, grade 2 in 8 patients, and grade 3 in 6 patients. No patient experienced grade 2 or higher anterior oral mucositis.

CONCLUSIONS

To our knowledge, this is the first clinical report of MFO-IMPT for head and neck tumors. Early clinical outcomes are encouraging and warrant further investigation of proton therapy in prospective clinical trials.

Effect of dose rate on local control and complications in definitive irradiation of T1-2 squamous cell carcinomas of mobile tongue and floor of mouth with interstitial iridium-192

From 1971 to 1988, 134 T1 and 145 T2 biopsy-proven squamous cell carcinomas of mobile tongue and floor of mouth were definitively managed by iridium-192. Implantations were performed using either guide gutters or afterloading plastic catheters. The prescribed dose at the reference isodose (85% of the basal dose rate, Paris system) was 60-70 Gy. Total dose was not adjusted to dose rate or tumor volume. Results of the 279 implants have been analysed to look for a possible influence of dose rate on local control and necrosis. Follow-up patients free of local recurrence is 1-180 months with average of 51 months. The 279 tumors were divided in four groups according to dose and dose rate: greater than or equal to 62.5 Gy and greater than or equal to 0.5 Gy/h (n = 130), greater than or equal to 62.5 Gy and less than 0.5 Gy/h (n = 36), less than 62.5 Gy and greater than or equal to 0.5 Gy/h (n = 81), less than 62.5 Gy and less than 0.5 Gy/h (n = 32). The four groups were comparable according to age, sex, tumor diameter and macroscopic aspect. At 5 years, the estimated local control (Kaplan Meier) was 93, 87, 79 and 52%, respectively (dose adjusted to dose rate: p less than 0.001, dose rate adjusted to dose: p less than 0.01, Log-rank); the necrosis rate was 44, 24, 37 and 5%, respectively (dose adjusted to dose rate: p = 0.08, dose rate adjusted to dose: p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)