Stage I (T1 N0 M0) squamous cell carcinoma of the laryngeal glottis: therapeutic results and voice preservation

BACKGROUND: The therapeutic outcomes for voice preservation in Stage I (T1 N0 M0) glottic carcinoma, treated with conservation surgery, radiation therapy, and endoscopic resection, are controversial. METHODS: A retrospective tumor registry retrieval of data on patients treated with curative intent at Washington University Medical Center-Barnes Hospital between January 1971 and December 1990 for the surgical group, January 1971 to December 1985 for the low-dose radiation group, and January 1986 to January 1995 for the high-dose radiation group, was performed. RESULTS: The 659 patients with Stage I (T1 N0 M0) glottic carcinoma treated with curative intent were subdivided into four groups: (1) 90 patients received low-dose radiation (mean dose 58 Gy, range 55-65 Gy, daily fractionation 1.5-1.8 Gy); (2) 104 patients received high-dose radiation (mean dose 66.5 Gy, range 65-70 Gy, daily fractionation 2-2.25 Gy); (3) 404 patients underwent conservation surgery; and (4) 61 patients had endoscopic resection. T1A (85%) and T1B (15%) disease was equally distributed among the groups. The anterior commissure was involved in 38 patients in the radiation therapy groups and 56 patients in the surgical groups. The overall local control was 89%. The overall local salvage was 84%. The overall unaided laryngeal voice preservation was 90%. The overall 5-year disease specific and actuarial survival rates were 95% and 81%, respectively. Prevalence of 2% regional metastases, 1.2% distant metastases, and 14% second primary malignancies were documented. The cure rate was 69% for regional metastases, 13% for distant metastases, and 44% for second primary malignancies. There were 5 complication deaths (0.1%), and 38 (6%) patients died of intercurrent disease. The use and dose of tobacco products was significantly increased in patients who died of intercurrent disease (p = 0.004) or developed second primary malignancies (p = 0.024). No significant difference was observed among the four therapeutic groups in the 5-year cause-specific survival rate (p, 0.68). Actuarial survival was significantly decreased in the low-dose radiation therapy group as compared with the other three therapeutic groups (p = 0.04). Initial local control was poorer for the endoscopic (77%) and low-dose radiation (78%) groups as compared with the high-dose radiation (89%) and conservation surgery (92%) groups (p = 0.02) but significant differences were not found for ultimate local control following salvage treatment. Unaided laryngeal voice preservation was similar for high-dose radiation (89%), conservation surgery (93%) and endoscopic resection (90%), but significantly poorer for low-dose radiation (80%; p = 0.02). T1B disease (N = 94) had similar local control and voice preservation with conservation surgery (87%) and high-dose radiation (88%) but lower results with low-dose radiation and endoscopic resections (67% unaided laryngeal voice preservation; p = 0.02). CONCLUSION: (1)The four therapeutic groups achieved similar rates of disease specific survival and ultimate local control. (2) Low-dose radiation was associated with significantly lower overall actuarial survival and unaided laryngeal voice preservation. (3) Endoscopic resection was associated with a significantly lower initial local control rate, but following salvage therapy achieved equivalent results to the other treatment methods. (4) Patients with (T1 N0 M0) glottic carcinoma had similar survival, local control, and unaided laryngeal voice preservation rates with high-dose radiation, conservation surgery, and endoscopic resections, but not with low-dose radiation therapy. (c) 1999 John Wiley & Sons, Inc. Head Neck 21: 707-717, 1999.     

"FAR" chemoradiotherapy improves laryngeal preservation rates in patients with T2N0 glottic carcinoma

BACKGROUND: The appropriate treatment approach for patients with T2N0 laryngeal cancer remains highly controversial. Because radiotherapy alone is associated with a high risk of local recurrence, we have developed a triple combination treatment approach consisting of 5-fluorouracil (250 mg/day, i.v.), vitamin A (50,000 unit/day, i.m.) and external radiation (2.0 Gy/day), which we have termed "FAR therapy." METHODS: Patients with T2N0 glottic carcinoma were initially treated with 15 days of FAR therapy, which included a cumulative radiation dose of 30Gy (i.e., "30 Gy of FAR therapy"). Those patients who demonstrated a complete response either clinically or pathologically continued to receive further FAR therapy, with up to 60-70 Gy. All other patients received laryngectomy without any additional treatment. RESULTS: Ninety-five patients were treated according to this program, and most of the patients (98%) were able to complete this treatment course. Eighty-eight patients (93%) were treated with FAR therapy alone. The local control and ultimate local control rates were 91% (85 of 93), and 99% (92 of 93), respectively. The cumulative 5-year voice preservation and complete laryngeal preservation rates were 91% and 87%, respectively. The cumulative 5-year disease-specific survival rate was 97%. CONCLUSIONS: Because a high rate of laryngeal preservation was achieved without compromising disease-specific survival, our treatment approach based on FAR therapy may be promising for the treatment of patients with T2N0 glottic carcinoma.     

Management of advanced glottic carcinomas

One hundred twenty-eight patients with T3 or T4 glottic cancers were treated by initial surgery; 59 had a total laryngectomy and 69 had total laryngectomy with regional node dissection. Fifty-eight percent of the total laryngectomy group and forty-nine percent of the total laryngectomy with neck dissection group remained free of disease for 5 or more years. Forty-seven percent (60 of 128 patients) treated surgically developed regional recurrences requiring further treatment. Nine patients had evidence of widespread metastases, leaving 51 suitable for salvage radiotherapy. Twenty-three percent (12 of 51 patients) were salvaged with radiotherapy given for postoperative recurrences. Twenty-five patients received an initial 6,600 rads to larynx and neck with curative intent, 28 percent of whom remained free of disease for 5 or more years. Seventeen percent of patients were salvaged with one laryngectomy for persistent or recurring tumors. Initial total laryngectomy gave better survival figures for advanced glottic carcinoma.     

Planned neck dissection for advanced primary head and neck malignancy treated with organ preservation therapy: disease control and survival outcomes

BACKGROUND: The role of planned neck dissection after organ preservation therapy with radiotherapy or chemotherapy/radiotherapy for advanced head and neck cancers presenting with clinically positive neck disease is still being elucidated. The aim of this study is to review the outcomes of such patients treated by organ preservation therapy at our institution. METHODS: A retrospective chart review of 33 patients who underwent planned neck dissections after organ preservation therapy for advanced primary head and neck malignancy. Endpoints measured were disease-free survival and local, regional, and distant control. SETTING: Tertiary metropolitan medical center. RESULTS: Two-year actuarial disease-free survival was 61%, and neck control was 92%, with only two failures in the neck. The use of neoadjuvant chemotherapy and total dose of radiotherapy did not correlate with neck control or disease-free survival. The presence of pathologically positive nodal disease at the time of neck dissection did not correlate with recurrent neck disease, but was a predictor of local recurrence (p = .0086). CONCLUSIONS: Our data suggest that for patients undergoing planned neck dissection after organ preservation therapy, neck control is obtained in almost all cases. The presence of pathologically positive nodal disease at the time of surgery may have implications for the incidence of local recurrence.     

Squamous cell carcinoma of the maxillary sinus: Analysis of 66 cases

A retrospective review was performed of 66 patients with squamous cell carcinoma of the maxillary sinus. The majority of patients presented with tumors classified as T₃ (31.8%) and T₄ (54.5%). Seven (10.6%) patients presented initially with neck metastases and 13 (19.7%) patients subsequently developed regional disease. For the 66 patients studied, the observed 5 and 10 year actuarial survival rate was 27.3% and 20.7% respectively. The presence of cervical metastases, particularly when they developed subsequent to initial therapy, was associated with a poorer survival rate. Five year survival rate for patients without cervical metastases was 32.6% in contrast to 28.6% for patients initially presenting with nodal disease and 7.7% for patients who subsequently developed regional metastases. Overall, 5-year survival rate for all patients with cervical metastases was 15.0%. A combined treatment regimen (surgery and radiation therapy) appeared to be superior to single modality therapy. A 58.0% observed 5-year actuarial survival rate was achieved with combined therapy. Surgery or radiation therapy when used alone as a single modality resulted in a 5-year survival rate of 20.0% and 15.7% respectively.     

Adjuvant postoperative radiation therapy for colonic carcinoma.

One hundred thirty-three patients with Stage B2, B3, and C colonic carcinoma had resection for curative intent followed by adjuvant postoperative radiotherapy to the tumor bed. The 5-year actuarial local control and disease-free survival rates for these 133 patients were 82% and 61%, respectively. Stage for stage, the development of local regional failure was reduced for patients receiving postoperative radiotherapy compared with a historic control series. Local recurrence occurred in 8%, 21%, and 31% of patients with Stage B3, C2, and C3 tumors who had radiation therapy, respectively, whereas the local failure rates were 31%, 36%, and 53% in patients treated with surgery alone. There was a 13% and 12% improvement in the 5-year disease-free survival rate in the patients with Stage B3 and C3 lesions who had radiotherapy compared with the historic controls. For patients with Stage C disease, local control and disease-free survival rates decreased progressively with increasing nodal involvement; however, local control and disease-free survival rates were higher in the patients who had radiotherapy than in those who had surgery alone. Failure patterns in the patients who had radiotherapy did not show any notable changes compared with those for patients who had surgery alone. Postoperative radiation therapy for Stage B3, C2, and C3 colonic carcinoma is a promising treatment approach that deserves further investigation.     

The treatment of early laryngeal cancers (T1–T2 N0): surgery or irradiation?

BACKGROUND: Carcinoma of the larynx is the most common cancer affecting the head and neck region. In Northern Europe, early laryngeal cancer is almost universally treated by irradiation, but elsewhere it is treated by surgery. The main aim of this study was to determine whether there was any difference in survival between the two main therapeutic options. The secondary aim was to assess speech and voice quality in a small, randomized sample of patients from each treatment group. METHODS: The subjects investigated were 488 patients with T1-2, N0 squamous cell carcinoma of the larynx. The patients form an unselected sequential group of our institution's experience with treating this disease over three decades. Four hundred nineteen patients were treated by irradiation, and 69 were treated with surgery. Most surgical patients were treated earlier in the series, whereas radiotherapy later became the treatment of choice. The primary outcome measures were recurrence at the primary site, recurrence in the neck, and tumor-specific survival. The secondary outcome measure was speech and voice quality. Statistical analysis was by univariate and multivariate analysis of association and survival. Surgery included horizontal or vertical partial laryngectomy and various minor procedures on the glottis, including cordectomy. Over a 30-year period, radiotherapy was administered to a dose of 60-66 Gy given over 30-33 daily fractions. RESULTS: Surgery tended to be performed early on in the series and radiotherapy thereafter. Surgery was more likely to be carried out for supraglottic disease. These differences apart, the radiotherapy and surgery groups of patients were well matched. The 5-year tumor-specific survival for those treated by irradiation was 87% and for surgery it was 77% (p=.1022). Glottic cancer and T1 disease were associated with high 5-year survivals: 90% and 91%, respectively. Supraglottic site and T2 disease both had a poorer prognoses: 79% and 69%, respectively. The differences for both sets of data were significant. There was no significant difference in primary site recurrence rates for the two treatment modalities, but regional recurrence was higher in the surgery group. Further analysis demonstrated that this was not a function of surgery per se but rather of the unit's policy toward the N0 neck at the time surgery was carried out. Regarding speech and voice quality, radiotherapy was far superior to surgery. All patients in the radiotherapy group but only 3 of 10 in the surgery group were judged to have a good or normal voice (p=.0017). CONCLUSIONS: Both surgery and irradiation are equally effective at treating early laryngeal carcinoma. Speech and voice were highly significantly better in patients treated by irradiation than in those treated by surgery.     

Malignant tumors of the nasal cavity and paranasal sinuses

PURPOSE: To evaluate the role of radiation therapy in patients with nasal cavity and paranasal sinus tumors. MATERIALS AND METHODS: Between October 1964 and July 1998, 78 patients with malignant tumors of the nasal cavity (48 patients), ethmoid sinus (24 patients), sphenoid sinus (5 patients), or frontal sinus (1 patient) were treated with curative intent by radiation therapy alone or in the adjuvant setting. There were 25 squamous cell carcinomas, 14 undifferentiated carcinomas, 31 minor salivary gland tumors (adenocarcinoma, adenoid cystic carcinoma, and mucoepidermoid carcinoma), 8 esthesioneuroblastomas, and 1 transitional cell carcinoma. Forty-seven patients were treated with irradiation alone, 25 with surgery and postoperative irradiation, 2 with preoperative irradiation and surgery, and 4 with chemotherapy in combination with irradiation with or without surgery. RESULTS: The 5-year actuarial local control rate for stage I (limited to the site of origin; 22 patients) was 86%; for stage II (extension to adjacent sites (eg, adjacent sinuses, orbit, pterygomaxillary fossa, nasopharynx; 21 patients) was 65%; and for stage III (destruction of skull base or pterygoid plates, or intracranial extension; 35 patients) was 34%. The 5-year actuarial local control rate for patients receiving postoperative irradiation was 79% and for patients receiving irradiation alone was 49% (p =.05). The 5-, 10-, 15-, and 20-year ultimate local control rates for all 78 patients were 60%, 56%, 48%, and 48%, respectively. The 5-, 10-, 15-, and 20-year cause-specific survival rates for all 78 patients were 56%, 45%, 39%, and 39%, respectively. The 5-, 10-, 15-, and 20-year absolute survival rates for all 78 patients were 50%, 31%, 21%, and 16%, respectively. Of the 67 (86%) patients who were initially seen with node-negative disease, 39 (58%) received no elective neck treatment, and 28 (42%) received elective neck irradiation. Of the 39 patients who received no elective neck treatment, 33 (85%) did not experience recurrence in the neck compared with 25 (89%) of 28 patients who received elective neck irradiation. Most patients who received elective neck irradiation (57%) had stage III disease. Twenty-one (27%) of 78 patients had unilateral blindness develop secondary to radiation retinopathy or optic neuropathy; the complication was anticipated in most of these patients, because the ipsilateral eye was irradiated to a high dose. Four patients (5%) unexpectedly had bilateral blindness develop because of optic neuropathy. All four of these patients received irradiation alone. CONCLUSION: Surgery and postoperative radiation therapy may result in improved local control, absolute survival, and complications when compared with radiation therapy alone. Elective neck irradiation is probably unnecessary for patients with early-stage disease.     

A Critical Assessment of Adjuvant Radiotherapy for Inguinal Lymph Node Metastases from Melanoma

Background: Although patients with inguinal or pelvic lymph node (LN) metastases from melanoma may develop regional recurrence after dissection, the role of adjuvant radiotherapy remains controversial.Methods: The medical records of 40 patients with inguinal and/or pelvic lymph node metastases from melanoma were reviewed retrospectively. Indications for adjuvant radiotherapy included the following nodal characteristics: extracapsular extension, LNs 3 cm in diameter, 4 involved LNs, and LN recurrence after prior nodal surgery. Thirty-seven of 40 patients underwent formal LN dissection. Three patients had only local excision of gross disease for recurrence after prior dissection. All patients received radiation to a median dose of 30 Gy at six Gy/fraction delivered twice weekly.Results: With a median follow-up time of 22.5 months, the 3-year actuarial distant metastasis–free and overall survival rates were 35% and 38%, respectively. The 3-year regional control rate was 74%. Univariate analyses of patient, tumor, and treatment characteristics failed to reveal any association with distant metastasis–free survival, overall survival, or regional control. Regional failures occurred in nine patients; seven of these were isolated dermal failures within the field of irradiation. Only two patients (5%) had LN basin recurrences; one of these patients also developed dermal recurrence. Fifteen of 40 patients developed lymphedema; in seven of these, lymphedema was present before initiation of radiation therapy.Conclusions: Radiation may prevent recurrence of nodal disease in patients at high risk for regional failure, but in-field dermal recurrences may sometimes occur (8 of 40, 20%). Treatment-related lymphedema and death from metastatic melanoma were common.     

Planned neck dissection as an adjunct to the management of patients with advanced neck disease treated with definitive radiotherapy: for some or for all?

BACKGROUND: Management of patients with head and neck carcinoma and advanced nodal disease is controversial. The purpose of this analysis was to evaluate the efficacy and toxicity of definitive radiotherapy followed by planned neck dissection in patients with bulky neck disease. MATERIALS AND METHODS: The records of 52 patients who were treated between 1989 and 1995 at the Peter MacCallum Cancer Institute with a planned neck dissection after radical radiotherapy were reviewed. All had advanced neck disease with one or more nodes >/=3 cm in maximum diameter, 94% being staged N2-3. The most common primary site was the oropharynx (56%). Sixty percent of patients had either T2 or T3 primaries and all were AJCC stage IV. Treatment consisted of high-dose radiotherapy to the primary and involved neck sites using various fractionation protocols followed by radical or modified radical neck dissection after confirmation of a complete response at the primary site. The median follow-up for living patients was 58 months (range 32-97). RESULTS: There were nine regional failures, of which three were outside the dissected neck, yielding a 5-year actuarial overall neck control rate of 83% and an in-field control rate of 88%. In-field control rates by neck stage were N1 3/3; N2 31/35; N3 11/13 and NX 1/1. There was only one in-field failure among 28 patients who had pathologically negative neck specimens compared with five in 24 patients with morphologic evidence of residual disease. Of the 24 patients with pathologically positive necks, 5 were long-term survivors and were probably cured by their surgery. Another 4 died of intercurrent disease without documented recurrence of their head and neck cancer. Ten patients recurred at their primary sites (5-year actuarial control 79%) and 8 developed distant metastases (5-year actuarial rate 20%). A total of 21 patients failed at one or more sites and none was salvaged. Five-year actuarial disease-free survival was 57% and overall survival 38%. Nine patients (17%) sustained significant complications following neck dissection. CONCLUSIONS: In patients with advanced neck disease who are treated primarily with radical radiotherapy, planned neck dissection provides excellent regional control and appears to cure a subset of patients. However, routine neck dissection adds significant morbidity to treatment and should ideally be avoided in those patients in whom surgery is either unnecessary (no residual tumor) or futile (unsalvageable disease recurrence outside the dissected neck). Based on our analysis and other recently reported series, we now recommend observing patients who have a complete response to high-dose radiotherapy (+/- chemotherapy). The ability of PET imaging to detect residual viable tumor in the head and neck or at distant sites is under investigation.     

Results of hemilaryngectomy in primary surgical treatment of laryngeal carcinoma

Hemilaryngectomy is the resection of a true anatomic half of the larynx with preservation of the cricoid cartilage. We present a retrospective study of 438 patients with glottic carcinoma, treated with hemilaryngectomy, at the Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia between 1988 and 1997. The patients with positive margins (19.4% of all) were postoperatively irradiated. Local recurrences of carcinoma were found in 17.3% of subjects, and regional recurrences in 16.4% of subjects. Those patients were treated with total laryngectomy or radical neck dissection, and with radiotherapy. 5-years survival rate in our patients was 79%. Hemilaryngectomy provided acceptable percent of local and regional recurrences, and good functional results: respiration, swallowing and voice quality. Therefore it could be the first choice surgery technique in treatment of T2 laryngeal carcinoma.     

BREAST CONSERVATION: LONG-TERM RESULTS FROM WESTMEAD HOSPITAL

Background : Breast conservation has been shown to be a safe and effective alternative to mastectomy in early-stage breast cancer. The present study reviews the long-term outcome and toxicity after treatment of early breast cancer by conservative surgery and radiation. Methods : Between November 1979 and December 1989, 438 patients with Union Internationale Contre le Cancer (UICC) stage I or II breast cancer were treated with conservative surgery and radiation therapy (CS + RT) at Westmead Hospital. Surgery to the breast varied from a local excision to a quadrantectomy, depending on the preference of the referring surgeon. The axilla was surgically dissected in 299 patients (68%). All patients received postoperative breast irradiation. The whole breast was irradiated to 46–54 Gy (median dose, 50 Gy) using 6 Mev photons for 5–6.5 weeks. Boosts were given at the primary tumour site in 336 patients (78%), by electron therapy (88 patients), iridium-192 (247 patients) or photons (one patient). A total of 44 patients (10%) received adjuvant chemotherapy. Results : The median follow-up period for surviving patients was 84 months (range: 56–172 months). The 5-year actuarial rate of local recurrence was 6% (312 patients at risk), and the 10-year rate was 10% (52 patients at risk). Very young patients (aged 34 years at diagnosis) had a 5-year actuarial rate of local recurrence of 13% compared to 5% for older patients (P= 0.04). Neither the total dose to the primary site nor the boost technique influenced local recurrence. The 5-year freedom from distant relapse was 83%. The side effects included rib fractures (2%), symptomatic pneumonitis (3%), fatty necrosis or fibrosis requiring surgery (4%), and moderate-severe oedema of the arm (7%). Conclusions : The long-term data show that CS + RT for UICC stage I or II breast cancer results in low rates of local recurrence which are influenced by age at diagnosis, but not by radiation dose or boost technique. These results confirm those of other international series that CS + RT is a safe alternative to mastectomy for most women with operable breast cancer.     

Neck dissection followed by chemoradiotherapy for stage IV (N+) oropharynx cancer.

PURPOSE: This study evaluated the strategy of performing neck dissection (ND) without primary tumor resection prior to definitive chemoradiotherapy (CRT) for N2+ oropharynx cancer. METHODS: We analyzed records of 25 patients who underwent ND before concurrent CRT with weekly low-dose concurrent paclitaxel and a platinum compound. The extent of ND was highly customized (1 to 39 nodes) and median radiotherapy dose was 70 Gy. RESULTS: Median follow-up was 36 months. Two-year and 3-year actuarial locoregional control rates were 95% and 88%. No patient had regional neck nodal failure. Two-year rate of freedom from distant metastases was 91%. The 2- and 3-year event-free survival rates were 88% and 75%. Fifteen percent had Grade 3+ late toxicity; none had permanent gastrostomy tube dependence. CONCLUSIONS: Neck dissection without primary tumor resection before definitive chemoradiotherapy for oropharynx cancer is a safe and effective management program and warrants further exploration.     

The effect of surgery and radiotherapy on outcome of anaplastic thyroid carcinoma

BACKGROUND: Anaplastic thyroid carcinoma (ATC) is an aggressive rare tumor. We analyzed our experience for prognosis and the effect of surgery and radiotherapy on patients with ATC. METHODS: We conducted a retrospective review of all patients (n = 67) with ATC treated at a tertiary care center from 1969 to 1999. Survivor median follow-up was 51 months. Tumor and patient characteristics and therapy were assessed for effect on survival by multivariate analysis. RESULTS: Patients presented with a neck mass (99%), change of voice (51%), dysphagia (33%), and dyspnea (28%). Surgery was performed in 44 of 67 patients, with 12 complete resections. The 6-month and 1- and 3-year survival rates were 92%, 92%, and 83% after complete resection; 53%, 35%, and 0% after debulking; and 22%, 4%, and 0% after no resection, respectively (P < .0001). A radiation dose of >45 Gy improved survival as compared with a lower dose (P = .02). Multivariate analysis showed that age < or = 70 years, absence of dyspnea or dysphagia at presentation, a tumor size < or = 5 cm, and any surgical resection improved survival (P < .05). CONCLUSIONS: Candidates for surgery with curative intent for ATC are patients < or = 70 years, tumors < or = 5 cm, and no distant disease. Radiotherapy >45 Gy improves outcome.     

Complications of postoperative radiation therapy after partial laryngectomy in supraglottic cancer: A long-term evaluation.

This retrospective study, based on a series of 90 patients with invasive squamous cell carcinoma of the supraglottis, was designed to document the functional outcome and complications after postoperative radiation therapy following partial laryngeal surgery. The surgical procedure was a standard supraglottic laryngectomy in 62 patients and a supracricoid partial laryngectomy in 28 patients. All of the patients had an unremarkable postoperative course and achieved locoregional control. The average dose delivered to the remaining larynx was 51.2 Gy (range 25-71 Gy). The average dose delivered to the neck was 50.6 Gy (range 22-70 Gy). The patients were treated at 180-cGy per fractions in a continuous course technique with a cobalt 60 beam. In 5 patients (5.5%) complications led to cessation of postoperative radiation therapy, and the total dose delivered to the remaining larynx and neck was less than 40 Gy. All patients were followed up for a minimum of 10 years or until death. The 5-, 10-, and 15-year actuarial survival estimates were 71. 5%, 44.3%, and 36.3%, respectively. The 5-, 10-, and 15-year actuarial severe complication estimates were all 11.2%. Overall, severe complications occurred in 15 patients. Severe complications led to death in 3 patients (3.3%), permanent gastrostomy in 3 (3.3%), and permanent tracheostomy in 1 (1.1%). A severe complication never resulted in completion of total laryngectomy. In univariate analysis, the mean dose delivered to the larynx was the only variable statistically related to the incidence of a severe complication. The mean dose delivered to the larynx was statistically higher (P = 0.014) in patients who had severe complications (60 Gy) than in patients who did not (50 Gy).     

Radiation therapy for angiosarcoma

BACKGROUND: Between 1964 and 1998, 19 patients with histologically proven angiosarcoma were treated with curative intent with radiation therapy. METHODS: Median follow-up was 37 months (range, 8-234 months). RESULTS: The actuarial 5-year absolute survival and local control rates were 51% and 50%, respectively. Of 12 patients who relapsed, 8 had isolated local recurrence as the first site of treatment failure, 2 had local (1 patient) or regional recurrence in conjunction with distant metastases, and 2 had distant metastases alone. Two of four patients who underwent further therapy for recurrent disease were successfully salvaged. CONCLUSIONS: Only the location of the primary tumor was a predictor of local control and absolute survival at 5 years. Angiosarcomas located on the scalp imply a dismal prognosis compared with those in other locations with the predominant pattern of failure being local recurrence. Patients should be treated aggressively with surgical resection and preoperative or postoperative radiation therapy.     

Treatment of early stage squamous-cell carcinoma of the glottic larynx: endoscopic surgery or cricohyoidoepiglottopexy versus radiotherapy

BACKGROUND: Both surgery and radiotherapy are recognized treatments of T1-T2 squamous cell carcinoma of the larynx. We retrospectively analyze and compare the oncological outcome of patients treated in a single institution, either by endoscopic surgery or partial supracricoid laryngectomy versus radiation therapy. METHODS: The medical records of 156 patients treated between 1983 and 1996 with either surgery (n = 75) or radiotherapy (n = 81) were reviewed. Male to female ratio, median age, and T-stage distribution were comparable. RESULTS: With a median follow-up time of 59 months, the 5-year cause-specific survival rate of 93% was identical for both groups. The actuarial incidence of metachronous second primaries was 7% at 5 years. Local control at 5 years remained 84% after surgery and 77% after radiotherapy. Anterior commissure infiltration was shown to represent a negative predictive factor of local control for radiotherapy (p =.01). Salvage treatment brought ultimate local control to 96% of patients after surgery and 94% after radiation therapy with long-term laryngeal preservation rate altered significantly (p =.05) in the group of patients who received radiotherapy (90.1% vs 97.4%). CONCLUSION: The treatment of laryngeal cancer is always a compromise between oncological efficiency and preservation of function. Our data suggest that, assuming proper selection of patients, radiation therapy and surgery yield similar local control and survival rates. The functional disadvantages after surgery are moderate and clearly counterbalanced by a significant decrease in long-term laryngeal preservation rate after radiotherapeutic treatment.     

Results of Surgical Salvage after Failed Chemoradiation Therapy for Epidermoid Carcinoma of the Anal Canal

Background The standard treatment for epidermoid carcinoma of the anal canal consists of combined radiation and chemotherapy. For patients who present with persistent or locally recurrent disease, salvage abdominoperineal resection is the treatment of choice. The purpose of this study is to review our experience with salvage surgery in this group of patients. Methods From 1990–2002, 31 patients underwent radical salvage surgery with curative intent after failure of initial sphincter-conserving therapy, and the medical records of these patients were retrospectively reviewed. Clinicopathologic variables were determined and comparisons performed with the Cox proportional hazards model. Survival was calculated by the Kaplan–Meier method. Results Eleven patients underwent radical salvage surgery for persistent disease and 20 patients for recurrent disease. The median follow-up time was 29 months. The actuarial 5-year overall survival was 64%. Twelve patients developed recurrent disease after radical salvage surgery. Patients who received an initial radiation dose of less than 55 Gy had a significantly worse survival than those who received at least 55 Gy as part of their initial treatment (5-year overall survival 37.5% vs. 75%; age-adjusted hazard ratio 8.2 [95% CI: 1.1–59.8], P = .037). The presence of positive lymph nodes at presentation also adversely affected survival (P < .05). Factors that were not found to have an impact on survival included the presence of persistent versus recurrent disease, tumor (T) stage, and margin status of resection. Conclusions Long-term survival following salvage surgery for persistent or locally recurrent epidermoid carcinoma of the anal canal can be achieved in the majority of patients. However, patients who initially present with node-positive disease and patients who receive a radiation dose of less than 55 Gy as part of their initial chemoradiation therapy regimen have a worse prognosis after radical salvage surgery.     

Primary site management following induction chemotherapy with cis-platinum, 5-fluorouracil,and leucovorin

A phase II clinical trial was initiated in 1987 to evaluate a new induction regimen of cis-platinum, 5-fluorouracil, and leucovorin (PFL) for patients with stages III–IV squamous cell carcinoma of the head and neck. Ninety patients were treated and followed for a median duration of 18 months. The median age was 55 and 87% of the patients had stage IV disease. The rates of complete and overall clinical response following three cycles of PFL were 57% and 80%, respectively; the rate of complete response at the primary site was 72%. Eighty-four percent of patients were treated to the primary site with radiation alone (median dose 68 Gy in daily 1.8-Gy fractions) irrespective of the location of the primary site or initial T-stage. The acute tolerance to full-course radiation following PFL was acceptable. The actuarial rate of primary site control for patients treated, with radiation was 67% at 36 months. An important prognostic indicator for primary site control was a complete clinical response to induction PFL. For patients who achieved a complete response, radiation or surgery followed by radiation controlled primary site disease equally well at 70%. Patients with a partial response did less well. For these patients, surgery and radiation appeared slightly better than radiation alone.