Radiotherapy of low-stages seminoma. Results and controversies

From January 1968 to December 1983, 297 low-stage testicular seminoma patients (209 stage I, 80 stage II A-B, and 8 Nx) were treated by means of prophylactic and/or curative radiotherapy. Overall 10-year relapse-free survival rate is 94% (97.3% stage I, 85.8% stage II A-B). Global survival-rate: 95.8% (100% stage I). Saving treatment was always effective in five relapses at stage I (2 lymphnodal recurrences in untreated areas, and 3 distant metastases). Out of twelve relapses at stage II A-B and Nx patients (4 lymphnodal recurrences in treated areas, 2 in untreated areas, and 6 distant metastases) saving treatment was effective in 3 patients, one of whom died for radiation late effect. Nine radiation sequelae were observed, three of which were neoplastic diseases. Referring to analysis of the results, failures and possible options in the management of seminomas, the authors confirm the effectiveness of current treatment schedule.     

The prognostic significance of anaplastic variants in patients with testicular seminoma subjected to exclusive radiotherapy

Three-hundred and sixty-six patients affected with seminoma testis (234 stage I, 85 stage II low, 47 advanced diseases) were treated between January 1968 and December 1985. Overall incidence of anaplastic lesions (43 patients) was 12%, progressively increasing with stage of the disease (9% stage I, 13% stage II low, 21% advanced disease). Only 343 patients submitted to exclusive curative/prophylactic radiotherapy were studied: 35 of them were anaplastic (22 stage I, 11 stage II low, 2 advanced disease). Radiation therapy was always performed regardless of the histologic subtype. Recurrences occurred in 14% of anaplastic tumors (5/35) and in 7.5% of classical seminomas (23/308). There was no statistically-significant difference between global and stage-by-stage failures. After literature review and complete analysis of the patterns of recurrence, the authors stress the lack of evidence suggesting a different radioresponsiveness of anaplastic versus classical seminomas; nonetheless, a more accurate staging is recommended for anaplastic variants, since they tend to appear in the advanced stages of the disease.     

Tumorectomy and radiation therapy in early breast cancer: a report on 392 patients

Three hundred ninety-two breast cancer patients (231 with stage I and 161 with stage II disease) were treated with tumorectomy followed by radiation therapy. The overall actuarial survival rate was 86.5% at 5 years and 78.0% at 10 years. The 5-year disease-free survival rate was 70.2%. Survival rates depended on locoregional tumor extension. Patients with stage I tumors had a survival rate of 92.0% at 5 years and 84.0% at 10 years; patients with stage II tumors had a survival rate of 82.0% at 5 years and 75.0% at 10 years. The percentage of patients with local recurrences was 13.0% for all patients (10.8% for stage I and 16.1% for stage II patients). The percentage of patients with lymph node recurrences was 1.5% for all patients (1.3% for stage I and 1.9% for stage II patients). The percentage of patients with distant metastases was 11.2% for all patients (7.8% for stage I and 16.1% for stage II patients). Locoregional control rates compared favorably with those in the literature. Breast preservation rates at 5 years were 85.0% for stage I and 80.9% for stage II patients. Cosmetic results were judged good by physicians in 80% of patients and by 90% of the patients themselves. Complication rates were very low.     

Postoperative radiotherapy in the treatment of breast tumors. Evaluation of a 5-year case series

Between January 1981 and December 1985, 364 female patients underwent surgical treatment for breast cancer in Mestre General Hospital. The pathological stage of the disease was stage I in 60 patients, stage II in 215 patients, stage III A in 30 patients, stage III B in 44 patients and stage IV in 15 patients. The patients with T1-T2 N0 lesions located in the outer quadrants received no additional treatment after surgery, while the others received adjuvant therapy. The patients with stage-IV disease (M+) were treated with chemo and/or hormonotherapy. All patients were followed for an average of 33 months up to December 1986 (range 1-71 months). Local-regional relapses developed in 17 patients, 15 on the chest wall and 2 in the drainage lymph nodes (only 7 within the previously-treated area). A 5-year actuarial survival rate was observed of about 78%, and 66% of relapse-free survival, in the whole group of patients (100% and 92% in stage I; 92.5% and 76% in stage II; 51% and 33% in stage III A; 32% and 19% in stage III B; 31% in stage IV, respectively). As far as our series of patients is concerned, the massive involvement of axillary lymph nodes seems to be the most adverse prognostic factor in survival rates. Even though the short follow-up does not allow definitive conclusions to be drawn, the authors believe such loco-regional treatments as surgery and radiation therapy to be extremely important in the local control of breast cancers, as well as in the patients' survival in the long run.     

Surgical and radiotherapeutic treatment in stage I endometrial adenocarcinoma. Retrospective analysis of 218 patients

From April 1977 through April 1985, 218 stage I endometrial carcinomas were treated with radiosurgery or radiotherapy alone. Postoperative irradiation was external (60Co) in 131 and curietherapy in 27 patients. Twenty patients underwent preoperative curietherapy and 40 patients radiotherapy alone. Median follow-up was 5.6 years (range 3-11). The overall 5-year actuarial survival (Kaplan-Meier method) was 86.1% +/- 2.5. The 5-year D.F. actuarial survival was 95% +/- 4.9, 93.1% +/- 4.7, 88.4% +/- 2.9, respectively, for preoperative radiotherapy, postoperative curietherapy and postoperative external irradiation groups. The 5-year actuarial survival was 69.8% +/- 7.7 in the radiotherapy alone group. There was difference in survival among patients treated with radiotherapy alone as compared to those radiosurgically treated (P less than 0.001). Local and general recurrence rate was 8.2%; vaginal recurrences 2/218 (0.9%); pelvic recurrences 7/218 (3.3%); distant metastases 9/218 (4.1%). Overall side effects were observed in 20/218 patients (9.1%): grade I and II in 8.6% of cases, grade III in 0.9% of cases. The authors conclude that good results can be achieved with adjuvant radiotherapy both in high risk cases and in low risk cases, with minimal side effects.     

Treatment of subdiaphragmatic lymph node metastases of primary testicular seminoma (stage II)

From January 1968 through December 1985, 123 patients with subdiaphragmatic lymph node metastases from testicular seminoma were observed. Eighty-five patients presented with metastases not bigger than 5 cm (stage II low), and they were all treated with radiotherapy (target dose: 35-45 Gy). Out of 38 patients with advanced retroperitoneal disease (because of metastases bigger than 5 cm: stage II, bulky), 18 were treated with radiotherapy, 14 with chemotherapy, and 6 with combined radiotherapy and chemotherapy; moreover, 14 out of 38 patients underwent surgical treatment (whole/partial lymph node resection). Actuarial relapse-free survival rate has proven higher for "low" patients than for "bulky" ones, both at 5 years (85.4% versus 75.8%) and at 10 years (83.5% versus 75.8%). On the contrary, overall survival has been higher for "low" patients at short-term follow-up only (90.4% vs 83.9% at 5 years), while long-term follow-up (10 years) has proven the same in both groups. Relapses (22 cases) occurred within 2 years in 75% of cases, and within 3 years in 90%. Overall incidence of lymph node recurrence has been 10.6%, higher in "bulky" patients (13.3% if treated with radiotherapy alone and 21.4% if treated with chemotherapy and/or surgery). Distant metastases occurred in 8.1% of cases. Long-term salvage treatment by chemotherapy was performed on 1/13 failures in stage II "low" patients and in 3/9 failures in stage II "bulky" patients. Four patients underwent effective salvage therapy in the "low" group, 3 by radiotherapy and 1 by surgery. The authors stress how curative radiotherapy appears to be the best treatment for retroperitoneal lymph node metastases less than 5 cm diameter, while chemotherapy is still to be demonstrated to yield better results than radiotherapy as first treatment for patients with advanced abdominal disease.     

Postoperative radiotherapy in the treatment of adenocarcinoma of the endometrium in pathological stage I

We report on 49 patients with pathologic stage I endometrial adenocarcinoma who underwent postoperative whole-pelvis irradiation (RT) (45-50 Gy in 5-6 weeks) from November 1981 to December 1988. RT was performed when one or more of the following unfavorable prognostic factors were discovered: myometrial infiltration greater than 1/3 (42 cases, or 85.7%), poorly-differentiated tumor (10, or 20.4%), tubaric angles involvement (4; or 8.2%), pelvic nodal metastases (1, or 2.0%). Five-year actuarial disease-free survival was 91.4%. After an average follow-up of 58 months, we observed recurrent disease in 4 patients (8.2%) (3 cases with distant metastases, 6.1%; 1 case with vaginal relapse, 2.0%). All recurrences were observed within 18 months from treatment and occurred only in patients with both myometrial infiltration greater than 1/3 and poorly or moderately differentiated tumor. The patient with vaginal relapse had a complete response after endocavitary curietherapy, but died later on from lung metastases. None of the treated patients experienced severe complications related to the treatment. Our results are comparable with those of the most recent literature, and confirm the good tolerance and efficacy of postoperative RT to prevent loco-regional relapses in early stage endometrial cancer with unfavorable prognostic factors.     

The effect of radiotherapy treatment changes on sites of relapse in stage I testicular seminoma

AIM: To evaluate relapse patterns in stage I testicular seminoma related to changes in radiotherapy practice.METHOD: Four hundred and six patients with stage I testicular seminoma were treated with adjuvant radiotherapy following orchidectomy: 338 patients received para-aortic radiotherapy only and 68 patients with added risk factors had radiotherapy extended to include the pelvis. Computed tomograms of relapsed patients were reviewed and sites of relapse were documented with correlation to the radiotherapy field. RESULTS: Thirteen relapses were identified; 10 occurring in the para-aortic radiotherapy group (3.0% relapse rate) and three in the extended radiotherapy field group (4.4% relapse rate). Sites of relapse were; five pelvis, three mediastinum, one lung, one scapula, one scrotum, while one patient had multiple relapse sites including the pelvis and one had a tumour marker relapse with no site identified. All the pelvic relapses occurred in the para-aortic radiotherapy group. CONCLUSION: Pelvic relapse only occurred when radiotherapy had been confined to the para-aortic region. Since para-aortic radiotherapy achieves equivalent outcome to wider field radiotherapy with reduced toxicity, it is likely to become standard practice in stage I seminoma and pelvic relapses will therefore increase in frequency. It is therefore important to include pelvic imaging when relapse is suspected.     

Primary non-Hodgkin lymphoma of the small bowel

PURPOSE: To clarify the natural history of primary lymphoma of the small bowel and identify preferred treatments for it. MATERIALS AND METHODS: A retrospective analysis of 61 patients with primary lymphoma of the small bowel was performed. The Ann Arbor stages were I in 20 patients, II in 28, and IV in 13. After resection or biopsy, 15 patients were treated with radiation therapy, 26 with chemotherapy, and 16 with combined-modality therapy. Four patients underwent no adjuvant treatment after resection. RESULTS: The actuarial 10-year overall survival and relapse-free survival for the patients with intermediate- and high-grade lymphoma were 47% and 53%, respectively. For the patients with low-grade lymphoma, these rates were 81% and 62%. For patients who underwent radiation therapy, combined-modality therapy, or chemotherapy, the recurrence rates inside the abdomen or pelvis were one of 12, two of 15, and five of 20, respectively, and those outside the abdomen or pelvis were four of 12, one of 15, and zero of 20, respectively. Four of the five abdominopelvic recurrences of disease in the chemotherapy group were among the nine patients who had Ann Arbor stage II disease. CONCLUSION: Chemotherapy lowered the recurrence rate outside the abdomen or pelvis. Patients with stage II disease may benefit most from radiation therapy.     

Radiation therapy of periaortic node metastases in cancer of the uterine cervix and endometrium

Thirty-eight women with surgically confirmed periaortic lymph node metastases from cervical or endometrial carcinoma received radiation therapy. The 5-year observed actuarial survival and relapse-free rates were 42% and 41%, respectively. Concomitant peritoneal metastases conferred a bleak prognosis. There were no differences in survival as a function of site of origin, histologic characteristics, or bulk of periaortic metastases. Earlier stage disease tended to have a higher probability of cure. Morbidity was acceptable. The results confirmed the importance of radiation therapy in the management of lymph node metastases in uterine cancer.     

The value of lymphography in the management of carcinoma of the cervix

Lymphography has been used to evaluate the pelvic and para-aortic nodes in 205 patients with carcinoma of the cervix treated between 1970 and 1979. The incidence of positive nodes was found to be 17% for Stage I, 24% for Stage II, 52% for Stage III and 100% for Stage IV. Of 73 patients who had lymphograms before Wertheim's hysterectomy, four out of 59 patients (7%) with negative lymphograms had histologically positive nodes; four out of 14 (28%) with positive lymphograms had negative nodes. Within each FIGO stage a positive lymphogram indicated a poor prognosis. The actuarial 5-year survival rates for patients with negative and positive lymphograms were 94% and 55% respectively for Stage I, 72% and 64% for Stage II, and 34% and 17% for Stage III. Of 39 patients with positive lymphograms who died of tumour, 31 out of 39 (80%) had distant metastases, compared with nine out of 29 patients (31%) with negative lymphograms. It is concluded that lymphography is a valuable method of evaluating lymph node status in carcinoma of the cervix.     

The postoperative adjuvant radiation therapy and radiochemotherapy for UICC stage II and III rectal cancer. A retrospective analysis.

AIM: This analysis was undertaken to review the outcome and toxicity of postoperative adjuvant therapy for Stage II and III rectal cancer. PATIENTS AND METHODS: We reviewed 112 patients treated with radiotherapy (44 patients) and radiochemotherapy (68 patients) after potentially curative (R0) surgery for rectal cancer (UICC Stages II and III), between 1983 and 1994 at the University Clinic of Würzburg. Median radiation dose was 56 Gy (range: 45 to 66 Gy). Chemotherapy consisted of 4 to 6 courses of 5-fluorouracil (5-FU) (420 mg/m2/d) and leucovorin (200 mg/m2/d). Median follow-up was 37 months. RESULTS: The overall survival was 84% for patients with UICC Stage II and 45% for patients with UICC Stage III disease (p = 0.0045). There were no statistically significant differences between patients treated with radiochemotherapy vs radiotherapy in terms of 5-year survival (63% after radiochemotherapy vs 53% after radiotherapy, p = 0.16), relapse-free survival (52% vs 50%) and locoregional control (69% vs 67%). UICC Stage III disease was associated with high failure rates (40% pelvic recurrences and 53% distant metastases). There was a statistically significant difference in terms of the incidence of distant metastases between the 2 treatment modalities for patients with Stage III disease (49% 5-year probability for developing distant metastases after radiochemotherapy vs 66% after radiotherapy, p = 0.047). In a multivariate analysis, the addition of chemotherapy, lymph node stage and grading were independent prognostic factors for survival. Severe late toxicity was documented in 5% of treated patients. CONCLUSIONS: Prognosis of patients with UICC Stage III rectal cancer remains poor after "standard" surgery followed by postoperative adjuvant treatment (pelvic radiotherapy and bolus intravenous injection of 5-FU and leucovorin). Major efforts should be made in order to improve prognosis for these patients, including optimization of surgical treatment and systemic treatment. More effective multimodality treatment strategies should be investigated in prospective randomized trials.     

Ovarian carcinoma: results of radiation therapy and chemotherapy in 83 patients

Eighty-three patients with ovarian cancer who had undergone radiation therapy, chemotherapy, or both were evaluated. Eight patients had FIGO stage I, 12 had stage II, 61 had stage III, and two had stage IV disease. In 60 patients, radiation was delivered with open abdominopelvic field (30 Gy over 4 weeks), with or without a pelvic boost dose. Fifty-five patients received a combination of chemotherapeutic agents, and 30 received a single agent as initial therapy. The patients were divided into three groups. The 26 patients in group 1 received primary radiation therapy with or without adjuvant single-agent chemotherapy. The 34 patients in group 2 underwent radiation therapy after chemotherapy failed. The 23 patients in group 3 received combination chemotherapy. Nineteen patients (23%) achieved complete remission--eight from group 1, two from group 2, and nine from group 3. The 5-year actuarial survival for group 1 was 41% but was only 16% for both groups 2 and 3 combined (P = .026). Primary radiation therapy, with or without adjuvant single-agent chemotherapy, was superior to combination chemotherapy in patients with ovarian cancer.     

The surgical and radiotherapy treatment of endometrial adenocarcinoma. A retrospective analysis of 128 patients]

From January 1980 through December 1987, 128 endometrial carcinomas were treated with combined irradiation and surgery (101 cases) or with radiotherapy alone (27 patients). Mean follow-up was 5 years (range: 2-9). Actuarial disease-free (DF) survival (according to the Kaplan and Meyer method) was 86% for T1-T2 patients, 50% for T3 cases and 35% for T4. Recurrence rate was 20% (26 patients): 9 had local recurrences, 9 nodal relapses, and 8 distant metastases. Overall side-effects were observed in only 7/128 patients (5.4%): they were grade I in 6 cases and grade II in 1. The evaluation of the prognostic factors confirms the importance of: stage (disease-free survival at 5 years: 86% for T1-T2 versus 50-35% for T3-T4); uterus size in stage T1 (DF survival at 5 years: 90% for T1A versus 70% for T1B); grading (DF survival at 5 years: 92, 87, 62% for G1, G2, G3, respectively). Myometrial infiltration seems to have no prognostic value.     

Role of radiotherapy in cancer of the ethmoid. Retrospective study of a series of 24 cases]

From april 1978 to december 1988, 24 patients were treated were by radiotherapy at the Bergonié Foundation cases were for ethmoidal cancer cases. Twenty two for initial treatment and two refermed for local recurrence. The mean age was 51.4 years and the sex ratio was 5.2 (21 men/4 women). Histologically there were 15 adenocarcinomas, 3 squamous carcinomas, 4 undifferentiated carcinomas and 2 esthesioneuroblastomas. According to the classification of the University of Florida, they were retrospectively classified as stage I = 9 pts, stage II = 5 and stage III = 10. Twenty one patients had postoperative radiotherapy and 3 had exclusive radiotherapy. The average dose was 55.3 Gy. Local control was obtained in 12 pts. Seven patients have recurred locally (within an average period of 12 months) and 5 patients showed progression of disease after treatment. The overall actuarial survival and the disease free survival at 5 years were respectively 50% and 53%. The actuarial survival by stage at 2 years and 5 years was: stage I (88% and 61%), stage II (100% and 50%), stage III (0%). The prognosis of ethmoidal cancer is strictly correlated to local control. For this reason, radiotherapy (with or without surgery) remains important in the treatment of this disease.     

Radical radiation therapy of carcinoma of the rhinopharynx: analysis of 80 cases

From 1976 to 1987, 98 patients affected with nasopharyngeal carcinoma were observed at the Oncology Center, Trento, Italy. Eighty of them were treated with radical radiation therapy (average total dose: 6432 Gy, range: 5500-7400 Gy) on primary tumor and positive neck nodes. The clinically negative neck received 5000 Gy. Each dose ranged from 180 to 250 Gy. Fifty-nine patients were treated with the split-course technique with an interval of about 15 days after receiving 4000 cGy. The patients were 60 males and 20 females, their age ranging 17-81 years (mean: 57 years). Histology diagnosed squamous cell carcinoma in 15 cases and undifferentiated carcinoma in 65 cases. All patients were staged according to TNM (UICC, 1978) criteria. Ten patients were stage I/II. Complete local control was obtained in 81.3% of cases. Actuarial global survival at 10 years was 52%, actuarial relapse-free survival was 49%. Mean follow-up is 33 months (range: 4-122 months). Squamous cell carcinoma at histology and advanced nodal involvement (N2-N3) were negative prognostic factors. Six patients had a relapse in the nasopharynx and 5 in the neck; the incidence of distant failures was 20%. The most frequent mid-/long-term side-effect was xerostomia.     

Postoperative radiotherapy of salivary gland tumors. Prognostic factors and treatment results]

A retrospective analysis of 63 patients with malignant major salivary gland tumours treated between 1972 and 1988 is presented. In 54 patients the tumour was located in the parotid gland, in the remaining nine patients the tumour was located in the submandibular gland, 31 patients were treated for stage I to II disease, 32 patients for stage III to IV disease. All patients were irradiated postoperatively using 60 Co. 137 Cs photons or electrons of adequate energies. As basic techniques ipsilateral portals, a wedge pair of portals or parallel opposed fields were used. The target doses ranged between 45 and 70 Gy with fractions of three to five times 2 to 3 Gy weekly, dependent on postoperative status and stage. In 25% of the patients a local recurrence was evident after radiotherapy with 13% developing distant metastases. The five-year survival was 95% for stage I, 83% for stage II, 30% for stage III and 7% for stage IV. Additionally, the prognosis varied according to lymph node involvement, grading and microscopic or macroscopic residual disease.     

Tumour size as a prognostic factor in carcinoma of the cervix: assessment by transrectal ultrasound

Transrectal ultrasound (TRUS) was used to measure tumour size in patients with carcinoma of the cervix and to assess its prognostic significance. Clinical staging was conducted and at the time of examination under anaesthesia, TRUS was used to assess maximum transverse diameter of the tumour. Eighty-one patients were studied. FIGO stages were 1B 34 patients, IIA seven patients, IIB 31 patients, IIIA two patients and IIIB seven patients. Mean tumour diameters by stage were IB 37 mm, IIA 37 mm, IIB 49 mm, IIIA 42 mm and IIIB 50 mm. There was a significant correlation between size and stage (p = 0.001). With a median follow-up of 18 months, 16 relapses have occurred. The actuarial relapse rates at median follow-up by stage were IB 10%, IIA 17%, IIB 22%, IIIA 0% and IIIB 35%. The actuarial relapse rates by size grouping at median follow-up were less than 30 mm 0%, greater than 30 and less than 40 mm 11%, greater than 40 and less than 50 mm 22%, and greater than 50 mm 38%. There was a significant difference between the mean recorded size of the tumours in the relapsed group and the relapse-free group (p = 0.02). Despite the small number of patients and short follow-up, tumour size as measured by TRUS appears to predict relapse.     

Die postoperative Strahlentherapie beim Endometriumkarzinom Eine retrospektive Analyse von 541 Patienten

PURPOSE: This retrospective study was designed to evaluate the role of adjuvant radiotherapy for surgically treated endometrial carcinoma. PATIENTS AND METHODS: From 1980 through 1988, 541 patients were treated with either intravaginal cuff irradiation with a high-dose-rate (HDR) Iridium-192 remote afterloading technique (n = 294) or with combined HDR-brachytherapy and additional external pelvic irradiation to 54 Gy (n = 247) after surgery for endometrial cancer. Afterloading irradiation was administered in 4 fractions 4 to 6 weeks after surgery. A dose of 30 Gy was delivered at a depth of 0.5 cm from the vaginal mucosa. RESULTS: Patients with HDR-brachytherapy alone showed a 5-year survival of 94.3% for Stage I and 73.6% for Stage II (p = 0.0007). Patients who received both brachytherapy and additional external pelvic irradiation had a 5-year survival of 94.1% for Stage I, 81.1% for Stage II, 70.4% for Stage III and 46.9% for Stage IV (p = 0.0001). The main predictors for survival in a multivariate analysis were stage and grading. Patients with combined radiotherapy had a local recurrence rate of 3.2%, whereas patients with brachytherapy alone who were better selected and had more favorable prognostic factors showed a recurrence rate of 2%. Low-risk patients (Stage I, Grade 1, low infiltration) in the HDR-brachytherapy group had 6 relapses, mainly caused by insufficient treatment on the basis of papillary histology. High-risk patients with poorly differentiated tumors, which infiltrate more than half the myometrial wall might benefit from additional external radiotherapy in terms of reduction of local recurrence and better survival. Five-year actuarial survival rate was 93.6% after combined radiotherapy vs 86.7% after brachytherapy alone. Complications were graded according to the RTOG scoring system. Severe late complications were fistulas of bladder and/or bowel, which occurred in 2.8% in the combined radiotherapy group, and 0.7% in the HDR brachytherapy group. CONCLUSIONS: Low-risk patients should be generally treated postoperative with HDR-brachytherapy alone. Combined radiotherapy decreased pelvic relapses for high-risk patients with overall low complication rates. We conclude that an individually adjusted postoperative radiotherapy allows a well tolerated treatment with excellent results.     

Analysis of prognostic factors in 106 cases of carcinoma of the rhinopharynx treated with cobalt teletherapy

A series of 106 patients affected with nasopharyngeal carcinomas and treated by definitive external irradiation from January 1975 to December 1986 was retrospectively reviewed. The median follow-up, from the end of the treatment, was 43 months (range 24-90). The nasopharynx received not less than 60 Gy to the midplane: the clinically negative neck (N0) was treated with a total dose of 50 Gy and the patients who had N1-3 disease received not less than 60 Gy. Thirty-eight patients had a recurrence in the irradiated areas (31 in the nasopharynx, and 7 in the neck); 17 patients developed distant metastases. Disease-free survival at 60 months was 42%. The most significant prognostic factor (p less than 0.05) was the presence of advanced neck involvement (N2-3), since most of the lymphatic and distant recurrences were observed in this group of patients. The overall results did not reveal but slight differences in the survival according to histology, even though patients with undifferentiated carcinomas had a local recurrence rate significantly lower than those with squamous cell carcinomas. Our findings suggest that patients with N2-3 neck diseases or with locally advanced involvement (T3-4) be treated by adjuvant chemotherapy in order to decrease the risk of local and distant relapses.