Carcinoma of the tonsil: Results of radical irradiation with surgery reserved for radiation failure

This analysis reviews the treatment results of 58 patients with squa-mous cell carcinoma of the tonsil who were treated by radical irradiation to the primary, with operation reserved for radiation failures. Postirradia-tion radical neck dissection was sometimes added as part of the initial treatment plan. The local control and absolute survival rates for Ti-Ta lesions were quite good, and complications were minimal. On the other hand, the local control and absolute survival for T3-T4 lesions were only fair, and complications generally more severe, although mandibulectomy for osteonecrosis was not required in this small series. There appears to be no justification for combining operation with radiation in the initial attack for Tj-To lesions. Although the T_l-T₂ lesions might as well be cured by operation alone, it would entail the loss of part of the mandible, pharyngeal wall, possibly some tongue and soft palate, and at least one radical neck dissection. At attempt at combining operation and irradiation for some T₃ (T₄) lesions appears justified by the high failure rate of radical irradiation alone. However, therapeutic zeal should be tempered by the realization that many of these patients are elderly or in poor general health, and an aggressive combined treatment approach may be unrealistic     

Failures after irradiation in early vocal cord cancer

Radiation therapy for early laryngeal cancer offers an excellent probability of cure as well as preservation of vocal function. Reported failure rates range from 9 to 21% in patients with T₁ lesions, and from 28 to 44% in those with T₂ lesions, the majority of whom are subsequently salvaged by surgery. Results obtained at the Radiotherapy Center of the University of Wisconsin Hospitals in 44 patients during the period from 1960 to 1972 yielded failure rates of 21% in patients with T₁ tumors and 38% in patients with T₂ tumors at 5 years. Five of the eight recurrences were salvaged with surgery yielding an overall tumor control rate of 93%. The larynx was preserved in 82% of the cases. Determinate 5-year survival was 91% in T₁ cases and 86% in T₂ cases. Failure rates at 3 years were 18% for T₁ tumors and 30% for T₂ lesions. These results are in conflict with those reported by Brandenburg and Rutter as being 46% and 60% respectively. Ultimate success in the treatment of laryngeal cancer rests in the full cooperation between surgeons and radiotherapists.     

Treatment and outcome of middle ear cancer

This study addressed the clinical characteristics, treatment, and outcome of middle ear cancer. A series of 33 patients with middle ear cancer were analyzed with survival, the primary outcome. Altogether, 25 patients underwent surgery with adjuvant radiotherapy, seven patients had surgery alone, and one patient had only radiotherapy. The patients were staged according to the Stell staging system. Among patients with T₁/T₂ cancers, five underwent lateral temporal bone resection (LTBR) and three underwent subtotal temporal bone resection (STBR). Among those with T₃/T_x cancers, 11 underwent LTBR, and 13 had STBR. Of the total 33 patients, 18 died of their disease during follow-up. The overall 5-year survival rate was 37.4 %. The 5-year survival rates for patients with T₁/T₂ disease and T₃/T_x disease were 85.7 and 22.0 %, respectively. There was a statistically significant difference in 5-year survival rates between the two groups using the log-rank test (P < 0.05). The 5-year survival rates after LTBR and STBR for the T₃/T_x group were 15.2 and 30.8 % (P > 0.05), respectively, and those for the T₁/T₂ group were 100 and 66.7 % (P > 0.05), respectively. The 5-year survival rates for patients who underwent preoperative or postoperative radiotherapy were 38.9 and 40.4 %, respectively (P > 0.05). En bloc resection is favored in an effort to produce negative surgical margins for middle ear cancer. Adjunctive radiotherapy is used for advanced lesions.     

Treatment of T3 carcinoma of the larynx by surgery or radiotherapy

T₃ carcinoma of the larynx may be treated by surgery or by irradiation. A large number of oncologists feel that radical surgery offers a better chance of cure than does radiotherapy. We report a series of 147 patients with T₃, N₀ carcinoma of the larynx treated either by irradiation with salvage laryngectomy in the event of a recurrence, or by total laryngectomy. 109 patients had radiotherapy and 38 patients underwent surgery. The groups were well matched with no significant difference between the significant prognostic factors. The 5-year survival rate between the radiotherapy (70%) and surgery (40%) groups was significantly different (x₂= 4.48, d. f. = 1, P0.05). In spite of the well known problems associated with retrospective studies the present series suggests that radiotherapy combined with salvage surgery is an oncologically sound option for treating T₃ laryngeal carcinoma.     

Nasopharyngeal carcinoma: An evaluation of 209 patients

A unique racially balanced North American series of 209 Patients with nasopharyngeal carcinoma will be presented. The patients were 49% Chinese and 51% non-Chinese (predominantly Caucasian). Whereas Chinese born in China had a 117.9 times greater incidence of the disease. North American born Chinese showed only a 7.3 times greater incidence than Caucasians. Five year absolute (NED) survival was 25.6% for Chinese and 32% for non-Chinese. Other racial differences are also discussed. Two four-year-old patients with definite nasopharyngeal carcinoma, the youngest in the literature, are included in the study. Survival and prognosis of nasopharyngeal carcinoma depends on tumor histology, initial stage of disease, dose of radiation and pre-irradiation node biopsy. Five year absolute survivals for different histologies were; lymphoepithelioma 52.4%, non-keratinizing squamous cell 31.5% and keratinizing squamous cell 16.3%. The overall 5 year absolute survival for the series was 29%. When initial primary disease was localized to the nasopharynx (T₀, T₁, T₂) with or without mobile nodes (N₀, N₁, N₂) the survival rose to 41%. Cases treated with 6000 rads or more primarily had the best survival results. Pre-irradiation node biopsy consistently resulted in poorer survival. When the nodes were mobile (N₁, N₂) the survival rate was 46.9% 5 year NED in the non-biopsied group and 25% 5 year NED when nodes were excised prior to primary irradiation therapy.     

T3N0M0 glottic carcinoma—a failure analysis

T₃N₀M₀ glottic carcinoma-a failure analysis There is at present considerable controversy regarding the appropriate management of a patient who presents with a T₃N₀M₀ glottic carcinoma. This paper presents the results for 141 patients presenting clinically with T₃N₀M₀ glottic carcinoma between 1964 and 1981 and treated with primary radiotherapy reserving surgery for residual or recurrent disease. The actuarial survival for the entire group of patients was 50.5% at 5 yr; 28% of the patients died of glottic cancer. The local relapse-free rate achieved with radiotherapy was higher in female patients (68%) than male patients (41%) (P= 0.04); the local relapse-free rate was higher in males 60 yr of age or older (46%) than in males 59 yr of age or younger (31%) (P= 0.02). Involvement of all three laryngeal regions and initial tracheotomy were associated with a high primary failure rate. Fifty-nine per cent of patients alive at 5 yr retained an intact and functioning larynx. The time up until diagnosis of recurrence and the number of endoscopies required to establish recurrent or residual disease were all assessed with respect to their effects on survival and were shown to have no significant impact. Methods of improving the results of treatment for those patients with a high primary failure rate following radiotherapy are discussed.     

Management of T3N0M0 Glottic Carcinoma: Therapeutic Outcomes

Background The best therapeutic approach for the treatment of T₃N₀M₀ (stage III) glottic carcinoma is controversial. Method A retrospective study of Tumor Research Project data were performed using patients with T₃N_OM_O glottic squamous cell carcinoma treated with curative intent by seven different treatment modalities from January 1950 to December 1996 at Washington University School of Medicine/Barnes‐Jewish Hospital. Results Two hundred patients with T₃N_OM_O glottic carcinoma were treated using seven modalities: total laryngectomy (TL, n = 30), TL with neck dissection (TL/ND, n = 40), conservation surgery alone (CS, n = 22), radiation therapy alone (RT, n = 29), TL combined with RT (TL/RT, n = 31), TL and ND combined with RT (TL/ND/RT, n = 36), and CS combined with RT (CS/RT, n = 12). The overall 5‐year observed survival rate (OS) was 54% and the 5‐year disease‐specific survival rate (DSS) was 67%. The 5‐year DSS for the individual treatment modalities included TL, 65.4%; TL/ND, 76.5%; CS, 71.4%; RT, 56.5%, TL/RT, 51.9%; TL/ND/RT, 71.4%; and CS/RT, 80%. There was no significant difference in DSS for any individual treatment modality (P = .375). The overall local and regional control rate was 74% (148 of 200). The overall recurrence rate was 37.5% with recurrence at the primary site and in the neck of 19.5% and 11%, respectively. Recurrence was not related to treatment modality. The 5‐year DSS after treatment of recurrent cancer (salvage rate) was 35.8%. The incidence of distant metastasis was 11% and for second primary cancers it was 19.5%. There was no statistically significant difference in survival between necks initially treated (72%, 5‐y DSS) versus necks observed and later treated if necessary (70%, 5‐y DSS) (P = .797). Conclusions The seven treatment modalities had statistically similar recurrence, complication, and survival rates. Patients with clear surgical margins have a significant survival advantage compared with patients with close and involved margins. Because postoperative radiation therapy in patients with positive margins did not improve survival, formal re‐resection of the site of the positive margin should be considered. In patients whose N0 neck was not treated electively, close follow‐up observation with meticulous examinations combined with appropriate treatment for subsequent neck disease resulted in a similar survival rate compared with those patients whose N0 necks were treated initially. Six‐year minimum follow‐up is recommended for early identification of primary and neck recurrence and for discovering expected second primary cancers. Patients treated with RT and CS had statistically similar rates of survival, maintenance of voice, and acquired permanent tracheal stoma. CS is a valid alternative to RT in treating highly selected patients with T₃N_O glottic carcinoma.     

Optimal treatment for the technically resectable squamous cell carcinoma of the supraglottic larynx.

The charts of 431 patients with squamous cell carcinoma of the supraglottic larynx observed at the M. D. Anderson Hospital between January, 1954, and June, 1971, were analyzed. This study is concerned with those patients who had a technically resectable lesion. Emphasis is directed to the analysis of the effectiveness of primary irradiation instead of partial laryngectomy for those lesions which are technically suitable for a partial resection and to define the groups of patients which are best treated by combining surgery and planned postoperative irradiation. One hundred forty-seven patients with T₁ and T₂ lesions, selected exophytic T₃ lesions of the suprahyoid epiglottis and aryepiglottic folds and some selected exophytic T₄ lesions of the suprahyoid epiglottis received irradiation for their laryngeal lesion. A satisfactory control of the laryngeal disease has been obtained with preservation of a normal voice ranging from 88.5 percent for T¹ lesions to 60 percent for T₄ lesions. Comparing the groups of patients who had surgery alone or postoperative irradiation an NED rate of 63 percent was found in the latter group which is clearly superior to the 37 percent found in the surgery only group. There is no difference for the five-year NED rates, because the patients who had surgery and postoperative irradiation had more advanced neck disease which is a cause for distant metastases. The incidence of recurrences above the clavicles is clearly less in the patients having had surgery and postoperative irradiation than in those who had surgery alone. Correlating in the two groups, surgery only and surgery followed by planned irradiation, the surgical staging of the neck metastases with recurrences above the clavicles within 24 months after treatment, it was found that the planned combined treatment has reduced the recurrence rate from 45 percent to 15 percent in the N₂ and N₃ patients. Postoperative irradiation should be given routinely after resection for all T₄ lesions and for any T₃ lesion which extends to the pharyngeal wall(s), vallecula, base of tongue, and pyriform sinus. Postoperative irradiation should also be given for any patient whose nodal classification is greater than N₁. Irradiation should be given within six weeks (preferably three to four weeks) after the surgical procedure. To achieve this goal, the operation need only remove grossly detectable disease.     

Early glottic carcinoma involving the anterior commissure

Between 1958 and 1990 67 patients with an early glottic carcinoma involving the anterior commissure were treated by radiotherapy. Excluding three with carcinoma in situ, 64 had a T₁N₀M₀ squamous cell carcinoma; in eight of these (12.5%) the tumour was only located in the anterior commissure, in 45 (70.3%) it also involved one vocal cord and in 11 (17.2%) both vocal cords. The overall 5-year survival rate was 85%. For those with only anterior commissure involvement it was 60%, with involvement of one vocal cord and the anterior commissure it was 89% and with involvement of both vocal cords 82%. The 3-year recurrence rate was 58% for patients with involvement of only the anterior commissure, 24% with involvement also of one vocal cord, and 45% for those with involvement of both vocal cords. It was found that in cases of early glottic carcinoma, involving the anterior commissure and treated by radiotherapy, the prognosis for recurrence and survival was poorest when the carcinoma was only located in the anterior commissure, and it was concluded that this group of patients deserves special consideration.     

Prevention of complications of composite resection after high dose preoperative radiotherapy

Recent reports have suggested that carcinoma of the tonsil and adjacent structures (tonsillar pillars, adjacent soft palate and lateral pharyngeal wall) can be treated with improved survival rates by combining definitive surgery with planned preoperative radiotherapy. Experience to date does not clearly demonstrate the ideal dose of preoperative radiotherapy; however, in general it appears that survival rates improve in proportion to increasing dosage of preoperative radiation. The use of preoperative radiation in doses approaching or exceeding tumoricidal levels (6,000-6,500 rads at approximately 1,000 rads/week) has been limited by the unacceptable complication rate to be expected. The rate of major complications reported has ranged from 18 percent to almost 47 percent. For the past three years, all patients seen by the Department of Otolaryngology of the Upstate Medical Center with malignancies involving the tonsil and its adjacent structures have been managed by a combined modality of 5,500 rads preoperative radiotherapy followed by definitive surgical resection, using distant, unirradiated flaps for repair where necessary. There were 33 patients in the group, including three T₂, 20 T₃ and 10 T₄ lesions. Joint evaluation and planning of treatment between radio-therapy and otolaryngology coupled with meticulous attention to various aspects of surgical management has yielded the results reported in the table. The major complication rate has been limited to 3.03 percent. These results indicate that it is possible to undertake extensive resections for carcinoma of the tonsil and adjacent structures after high-dose preoperative radiotherapy without incurring any significant increase in morbidity over surgery alone.     

Radiotherapy or CO2 laser surgery as treatment of T1a glottic carcinoma?

Both radiotherapy and laser surgery give excellent results in the treatment of T_1a glottic carcinoma. In this study, we compared the outcome of these treatment options. Demographic details and continuous follow-up with exact cause of death have been recorded prospectively for 351 patients with T_1a glottic carcinoma at a tertiary referral centre in two consecutive decennia 1986–2005. Patients were treated with radiotherapy (163 patients) until 1996 when laser surgery was adopted as primary treatment (188 patients). The minimum follow-up time was 29 months. Neither the estimated 5-year disease-free survival, the disease-specific survival nor the crude survival differ between the two treatment options. The incidence of mainly local recurrences was equal during the first 3 years, followed by an increase in number of recurrences in the laser-operated patients. The odds ratio for a laryngectomy was 13.5 in patients treated with radiotherapy (P = 0.002), but mortality due to recurrence did not differ between the groups. The incidence of second primaries was equal (11%) but death due to second primaries differed significantly, favouring laser-treated patients (P = 0.003). In conclusion, the relative risk for a laryngectomy when a tumour recurs is 12.7 times higher in patients primarily treated with irradiation for T_1a laryngeal carcinoma, compared with patients treated with laser surgery. Regarding the treatment costs, treatment impact on patients and organ preservation, we consider laser therapy to be the better treatment option for patients with T_1a glottic cancer as no difference in survival could be observed.     

Staging of Oesophageal Carcinoma with High Resolution Endoluminal Ultrasonography

Oesophageal carcinoma is a disease with poor prognosis despite improved treatment and diagnostic methods. The most important prognostic features are the degree of wall invasion and the presence of lymph node metastasis. Endoscopic ultrasonography (EUS) in the region of 7.5-12 MHz has improved the accuracy of tumour staging. In the course of 1 year, 21 patients with oesophageal carcinoma were examined with 20 MHz high resolution intraluminal ultrasonography (HRES). In 11 (52%) patients, both ultrasound catheter and fiber gastroscope could pass the tumour, in 5 (23%) only the ultrasound catheter could pass. In the remaining patients the ultrasound catheter could only partially pass without prior dilatation. One patient was classified as having a stage T₂ tumour, 14 (67%) had T₃ and 4 (19%) had T₄. In 2 patients the tumour could not be fully classified but was at least T₃. When comparing our results with findings at computed tomography (CT), the T stage coincided in 9 patients (42%), in 9 patients (42%) CT could not differentiate between T₂ and T₃ and in 3 investigations HRES showed a higher T stage than CT. In 3 patients (14%) ultrasonography found N₁ stage where CT staged N₀. In one patient, CT found lymph nodes not seen with HRES. Further studies comparing EUS, HRES and surgical findings are planned to assess our view that HRES is a useful method in preoperative staging of oesophageal carcinoma.     

Conservation surgery for epidermoid carcinoma of the marginal area (Aryepiglottic fold extension)

Carcinoma of the marginal areas (aryepiglottic fold extension) behaves differently from supraglottic cancer. The majority are T₃ and T₄ lesions. On a selected basis partial laryngopharyngectomy and neck dissection shows a good survival figure of 62 percent.     

CARCINOMA OF THE SOFT PALATE AND THE POSTERIOR OROPHARYNGEAL WALL

Between 1966 and 1984, 14 patients with carcinoma of the soft palate and eight patients with a posterior oropharyngeal wall carcinoma were treated at the Netherlands Cancer Institute. In the soft palate group, the majority of patients (10) had small tumours T₁-T₂; the median patient delay was 1 month (range 0-5). Eleven patients were treated with radiotherapy and three with surgery, as single treatment modalities. Tumour control was achieved in 10 patients following initial treatment. Five-year results for tumour control and overall survival were 67% and 41%, respectively. In the posterior wall group all patients had advanced tumours (T₃-T₄), after a median patient delay of 4 months (range 0-6). Six patients were treated with radiotherapy, one with surgery only and one with a combination of these. Following the initial treatment, tumour control was achieved in half of the patients. Five-year tumour control was 50%, and overall survival at 5 years was 38%. In conclusion, the tumours in these two sub-sites of the oropharynx differ significantly in the extent of the primary tumour (P < 0.01), posterior wall tumours being more advanced on admission, after a significantly longer history (P < 0.01).     

T3 Laryngeal cancer: a retrospective study of the Dutch Head and Neck Oncology Cooperative Group: study design and general results

511 Patients with T₃ N_0-3M ₀ squamous cell carcinoma of the larynx, treated in the Netherlands from 1975 until 1984, were retrospectively analysed. Four different treatment policies were followed: primary surgery, planned combination of radiotherapy and surgery, primary radical radiotherapy, and selective radiotherapy. General results are presented. Local control rate was 72%. Regional control rate was 90% for clinically N₀ patients and 78% for clinically N₊ patients. Salvage therapy was overall successful in 38%. Surgical salvage for local radiation failures (with regional relapse) was successful in 69%, and for regional failures (without local relapse) in 46%. Ultimate locoregional control was 78% and, due to 8% distant metastases, 5-year actuarial corrected survival was 70%. Prognosis did not improve over the years. Corrected survival was independently correlated with tumour extension, involvement of neck nodes and treatment strategy. Corrected survival was similar for primary radiotherapy and primary surgery, but significantly better for planned combined therapy. Multiple primary tumours occurred significantly more often in male (19.5%) than in female patients (7.3%) (P = 0.05), the bronchus being most commonly affected. Cumulative actuarial risk for metachronous tumour was 15% after 5 years and 30% after 10 years so prevention and early detection of these second tumours may play the most important role in improving overall survival rates in the future.     

Primary radiation therapy for T1 glottic cancer. Factors influencing local control

One hundred and seventy-four patients with early glottic cancer received radiation therapy on the kV250 and cobalt 60 machines. Crude survival rates at 5, 10 and 15 years were 83%, 73% and 60%, respectively. Salvage surgery for locoregional recurrences was successful in 85% of the patients. A significantly higher failure rate was noted in patients with a pre-existing chronic laryngitis, with lesions confined to the left vocal cord and in those treated with KV250 irradiation. The rate of second primaries in this case material was 11%, 70% of which were noted in the respiratory tract. Megavoltage radiotherapy offers excellent chances for cure in T₁ laryngeal carcinoma with preservation of good voice in most patients. Patients with chronic laryngitis carry a high risk of local recurrence and therefore should be considered for primary conservation surgery.     

Free vascularized jejunum interposition for pharyngoesophageal reconstruction after total laryngopharyngectomy

The records of 28 patients who underwent free jejunal graft reconstruction after resection for cancer involving the pharynx were analysed. Seven patients had a T₃ carcinoma, 15 patients T₄ and six patients recurrence after laryngectomy. Ten patients had received radiotherapy in the past. Post-operatively, 15 patients (54%) had complications and two patients (7%) died. No significant difference was observed in the complication rate between the group that received radiotherapy in the past and those who did not. Nineteen patients received post-operative radiotherapy. Nine patients had no radiotherapy on the basis of complete resection or because of serious complications. For the whole group the 2-year recurrence free period and survival were 42% and 51% respectively. The postoperative radiotherapy group had a significantly better survival (73%) and recurrence free period (63%) than the group without post-operative radiotherapy (0%). Thus, post-operative radiotherapy seems indicated irrespective of resection margins.     

T3N0M0 glottic carcinoma—a pathologic analysis of 41 patients treated surgically following radiotherapy

T₃N₀M₀ glottic carcinoma—a pathologic analysis of 41 patients treated surgically following radiotherapy Forty-one patients undergoing surgery for recurrent or residual tumour following radical radiotherapy for T₃N₀M₀ glottic carcinoma had their larynges evaluated pathologically by whole organ laryngeal sectioning. All patients had been staged initially as T₃N₀M₀ glottic carcinoma and treated according to a protocol of radical radiotherapy (50–55 Gy in 4–5 weeks) with surgery reserved for radiation failure. Seventeen of the 41 patients died as a result of locoregional or distant recurrence or complications following surgery. Twenty-four patients were either alive or dead with intercurrent disease. Pathologic staging demonstrated 58% of these tumours to be rpT₄, 29% rpT₃ and the remainder rpT₀₂. The incidence of major cartilage invasion, vascular or perineural invasion, and subglottic extension greater than 15 mm was more frequent in patients with locoregional recurrence than in patients without recurrence. The presence of these pathologic features had a positive predictive value of 0.78 in relation to probability of locoregional failure. In addition, there was a significant difference in the frequency of these pathologic features between patients with and without locoregional recurrence (P < 0.001). The frequency of positive margins (19%) and pattern of involvement are described. The incidence of occult nodes (0%) in patients undergoing neck dissection is presented. The frequency (23%) and pattern of osteo-chondroradionecrosis are also described. The patterns of growth and spread observed were similar to those described previously. The importance of performing wide surgical resections in patients with recurrence following radiotherapy is emphasized.     

The treatment of T3 glottic carcinoma with vertical partial laryngectomy

Total laryngectomy has traditionally been considered the optimal treatment for patients with advanced glottic carcinoma who present with a fixed true vocal cord. However, using whole-organ sectioning techniques, it has been demonstrated that vertical partial laryngectomy is a sound oncologic procedure for selected fixed vocal cord lesions. During the period 1969 to 1984, 27 patients who presented at UCLA with T3 glottic carcinoma were treated using vertical partial laryngectomy. Follow-up for these patients averaged 4.0 years. The absolute two-year disease-free survival rate for this group was 85% (23 of 27 patients), and the local cancer recurrence rate during a two-year postoperative interval was 11% (three of 27 patients). These encouraging results support the continued use of partial laryngeal surgery for a subgroup of patients with T3 glottic cancer. Successful patient selection requires a careful analysis of disease extent based on data obtained from physical examination, magnetic resonance imaging or computed tomographic scanning, and direct laryngoscopy.     

Long-term results of open cordectomy for the treatment of T1a glottic laryngeal carcinoma

Objective

To assess the long-term results and prognostic factors in patients who have undergone open cordectomy (OC) for the treatment of T_1a glottic laryngeal carcinoma.

Methods

One hundred four epidermoid cancer patients operated from January 1989 through December 1999 were included in the study. Clinical parameters, postoperative complications, and postoperative stay were retrospectively evaluated in all cases.

Results

Mean survival for the patients included in the study was 61.5 ± 24.8 months after the date of operation (range: 11–121 months). Ninety-four patients did not have recurrent tumor (90.4%). Local, regional and distant recurrence were linked with a statistical negative impact on survival rates (p < 0.05). Only sero-hematoma was significantly related to local recurrence (p < 0.05), whereas the remainder complications did not. None of the complications was associated with neck recurrence or distant metastasis (p > 0.05).

Conclusions

Open cordectomy is nowadays a valid technique for the surgical treatment of T_1a glottic laryngeal carcinoma. Its results are comparable with those of other more recent techniques.