Treatment of choice for squamous carcinoma of the tonsillar fossa

The records of 160 patients with squamous cell carcinoma of the tonsillar fossa treated from 1968 through 1979 were reviewed. Biologic behavior, local and regional findings, and other prognostic factors were evaluated. patients were treated by either radiation alone (112 patients), radiation followed by planned neck dissection (31 patients), surgery alone (11 patients), or surgery combined with radiation (6 patients). Analysis of the data supports the recommendation that radiation be used as treatment for T1, T2, and early T3 lesions, whereas surgery alone or combined with radiation is best employed for advanced T3 or T4 tumors. Primary tumor control rates with radiation as the initial modality were 100% for T1 lesions, 89% for T2, 68% for T3, and 24% for T4. In addition, the control of cervical metastases with radiation therapy for patients with neck disease staged N0 through N3b was excellent (95%). In instances where a planned neck dissection was done 5 weeks after radiation, the control of cancer in the neck was 100%. The incidence of distant metastases was 10% and was not affected by the selection of therapy. The 2- and 5-year determinate survival figures for 112 patients treated with radiation therapy alone was 67% and 48% respectively, while 31 patients treated with radiation therapy followed by neck dissection achieved survival rates of 70% (2 year) and 58% (5 year). The criteria for selection of treatment are discussed.     

Distant metastases after definitive radiotherapy for squamous cell carcinoma of the head and neck

PURPOSE: To analyze parameters that influence the risk of distant metastases after definitive radiotherapy. METHODS: Between 1983 and 1997, 873 patients were treated with definitive radiotherapy and had follow-up for 2 years or more. Univariate and multivariate analyses were performed to evaluate risk factors that might influence the risk of distant metastases. RESULTS: The 5-year distant metastasis-free survival rate was 86%. Univariate analyses revealed that the risk of distant metastases was significantly influenced by gender (p =.0092), primary site (p =.0023), T stage (p <.0001), N stage (p <.0001), overall stage (p <.0001), level of nodal metastases in the neck (p <.0001), histologic differentiation (p =.0096), control above the clavicles (p <.0001), and time to locoregional recurrence (p <.0001). Multivariate analysis of freedom from distant metastases revealed that gender (p =.0390), T stage (p <.0001), N stage (p =.0060), nodal level (p <.0001), and locoregional control (p <.0001) significantly influenced this end point. Multivariate analysis revealed that gender (p =.0049), T stage (p <.0001), N stage (p <.0001), and locoregional control (p <.0001) significantly influenced cause-specific survival. CONCLUSIONS: The risk of distant metastases after definitive radiotherapy is 14% at 5 years and is significantly influenced by gender, T stage, N stage, nodal level, and locoregional control.     

Planned neck dissection after definitive radiotherapy for squamous cell carcinoma of the head and neck

BACKGROUND: To define the role of planned neck dissection after definitive radiotherapy for patients with node-positive squamous cell carcinoma of the head and neck. METHODS: Review of the pertinent literature. RESULTS: Radiotherapy alone produces a relatively high likelihood of regional control for patients with early-stage neck disease. Patients with more advanced neck disease have a higher probability of regional control if a planned neck dissection follows radiotherapy. However, for patients who have a complete response to radiotherapy, the likelihood of an isolated recurrence in the neck is low. Radiographic evaluation of the response to radiotherapy may better define the subset of patients who are likely to benefit from a neck dissection. CONCLUSIONS: Neck dissection after definitive radiotherapy improves regional control for patients with advanced neck disease. Patients who have a complete clinical and radiographic regional response to radiotherapy have a low probability of an isolated recurrence in the neck. It is advisable to proceed with a neck dissection for patients who have an equivocal response to radiotherapy, because the likelihood of salvage of an isolated recurrence in the neck is remote.     

Parameters that predict local control after definitive radiotherapy for squamous cell carcinoma of the head and neck

PURPOSE: To analyze parameters that may influence the likelihood of local control after definitive radiotherapy for head and neck cancer. METHODS: Between April 1980 and January 2000, 404 patients were treated with definitive RT alone (358 patients) or combined with adjuvant chemotherapy (46 patients) at our institution and were followed up for 0.25 to 20.25 years (median, 3.5 years.) All living patients were followed up for at least 2 years. All patients had the primary tumor volume calculated on pretreatment CT. End points were local control after RT and local control after RT without a severe late complication. Parameters evaluated in multivariate analyses of these end points included primary site, T stage, primary tumor volume, N stage, histologic differentiation, fractionation schedule, adjuvant chemotherapy, and gender. RESULTS: The rates of local control and local control without a severe late complication after RT were significantly influenced by primary tumor volume for patients with cancer of the supraglottic larynx and true vocal cord. In contrast, the rates of local control and local control without severe complications for patients with tumors of the oropharynx and hypopharynx were less influenced by tumor volume. Multivariate analysis of the overall population revealed that the only parameter that was significantly related to the probability of local control after RT was T stage. Multivariate analyses stratified by primary site revealed that tumor volume significantly influenced local control for patients with cancers of the supraglottis (p =.0220) and glottis (p =.0042) but not for those with lesions of the tonsillar fossa/posterior tonsillar pillar (p =.0892), base of tongue (p =.9493), anterior tonsillar pillar/soft palate (p =.5909), and hypopharynx (p =.2282). CONCLUSIONS: The most important parameter that has an impact on local control after RT is T stage. Primary tumor volume also significantly influences the probability of local control in cancers of the supraglottis and glottis.     

The pattern of nodal recurrence following definitive radiotherapy for nasopharyngeal carcinoma.

BACKGROUND: The pattern of nodal metastasis in previously untreated nasopharyngeal carcinoma (NPC) has been studied and reported. In order to analyse the pattern of recurrent nodal disease in previously treated NPC, a retrospective study on 68 patients who underwent radical neck dissection for regionally recurrent NPC was conducted. METHODS: Seventy-four neck dissections were performed on 68 patients who developed nodal recurrence after a mean disease-free interval of 39.2 months. None of the patients had evidence of local or systemic disease at the time of surgery. Histopathological reports of the 74 neck dissections were analysed with regard to the number of positive nodes as well as the number of involved nodal levels. RESULTS: Of the 65 neck dissection specimens with analysable data, 31 showed metastatic disease at a single nodal level with a mean number of positive nodes of 1.2, while 34 showed metastatic disease at multiple levels with a mean number of positive nodes of 6.6. Nodal recurrence occurred at level II with the greatest frequency (78.5%). Of the 31 specimens with single level nodal involvement, 21 (67.7%) occurred at level II. Isolated involvement at the other levels did occur, but was uncommon (range 3-16%). Of the 34 specimens with multiple level nodal involvement, 30 (88.2%) showed involvement at level II. Once more than one level was involved, the frequency of involvement at any given level was at least 30%. CONCLUSION: The predominant involvement at level II and the high frequencies of involvement at all levels support the use of a classical radical neck dissection in treating recurrent nodal disease in NPC.     

Local radiotherapy in the management of squamous carcinoma of the anus

This paper describes the results of treating 74 patients with squamous cell carcinoma of the anal canal and perianal skin using interstitial radiotherapy as primary treatment. This technique does not involve irradiation of regional lymph nodes. The local control rate for patients with tumours smaller than 5 cm and with negative inguinal nodes was significantly better than for the remaining patients (64 versus 23 per cent). Only 3 of 41 patients with tumours less than 5 cm diameter had clinically significant nodes at presentation, while in 33 patients with tumours larger than 5 cm there were 6 with involved nodes at presentation. Local treatment using interstitial radiotherapy is suggested as useful primary treatment for small, node-negative carcinomas, with surgery held in reserve for failures.     

Resection of advanced cervical metastasis prior to definitive radiotherapy for primary squamous carcinomas of the upper aerodigestive tract.

Thirty-five previously untreated patients with stage IV squamous cell carcinoma of the upper aerodigestive tract with advanced neck disease (mass greater than 3 cm) but with primary lesions thought to be locally controllable with radiotherapy were selected between 1972 and 1988 for treatment by neck dissection followed by radiotherapy; postoperative to the neck and definitive to the primary. Limited neck dissections spared muscles, nerves, and vasculature structures unless clinically involved with cancer. All patients received at least 50 Gy, postoperatively, to the entire neck with doses of up to 75 Gy being delivered to the primary treatment portals. Regional (neck) failure occurred in 11% (4 of 35) patients. Overall, 5-year survival from cancer was 55%. Multiple levels of neck involvement were associated with poorer survival than a single large node; however, the difference was not statistically significant. Delay in the institution of radiotherapy following surgery adversely affected survival (p = 0.01). This study demonstrates that in selected patients it is possible to resect advanced nodal metastasis prior to treating the primary with radiotherapy without compromising cancer control.     

Advanced-staged tonsillar squamous carcinoma: organ preservation versus surgical management of the primary site

BACKGROUND: Our aim was to review our experience in the management of advanced tonsillar squamous cell carcinoma (SCC) and to compare treatment outcomes between patients treated with and without surgery to the primary site. METHODS: The records of 74 patients with advanced-stage tonsillar SCC were reviewed. The median age at diagnosis was 58 years. Thirty-eight patients received definitive surgery to the primary site, and 36 were treated with an organ-preservation approach (OP) using radiotherapy +/- chemotherapy. RESULTS: No significant difference in overall survival (OS) or freedom from relapse (FFR) by treatment was found. T classification and N status were significant independent predictors on multivariate analysis for OS and FFR. Major late toxicity was noted in 10 patients in the surgical group and nine in the OP group. CONCLUSION: Patients treated with OP and primary surgery had comparable OS and FFR. T classification and N status were significant independent predictors for tumor relapse and survival. On the basis of these results, we favor organ-preservation therapy for patients with advanced-stage tonsillar SCC.     

Recurrent orbital squamous cell carcinoma with extension to the middle cranial fossa

Squamous cell carcinoma (SCC) of the orbit may arise from various sources. SCC of the orbit commonly is the result of metastases or invading tumors of the paranasal sinus. Cysts of various etiologies may also give rise to orbital SCC. Last year, perhaps the first case of SCC arising from multiple cutaneous epidermoid cysts was described in the literature. While perineural spread of cutaneous SCC to the orbit has been thoroughly reported; this is not likely to be the etiology of our case. Squamous cell carcinoma arising de novo in the orbit is also exceedingly rare, and to our knowledge not described in the English-language literature. Below, we describe a unique presentation of possibly de novo squamous cell carcinoma of the orbit that was diagnosed and resected in a multidisciplinary fashion by ophthalmology, neurosurgery, and plastic surgery. Level of Evidence: Level V, diagnostic study.     

Expression of Ku86 confers favorable outcome of tonsillar carcinoma treated with radiotherapy

BACKGROUND: To determine possible molecular markers for predicting radiosensitivity in squamous cell carcinoma, we have examined the relationship between pretreatment expression of the DNA damage recognition complex DNA-PK, its in vitro substrates, p53 and MDM2, local tumor control after radiotherapy (RT), and patient survival. METHODS AND MATERIALS: Formalin-fixed tumor biopsy specimens from 79 previously untreated patients with tonsillar carcinoma were analyzed by immunohistochemical methods. RESULTS: Tumors expressing high levels of Ku86 had better locoregional control in contrast to tumors expressing low levels of Ku86 (p =.023). Survival of patients with tumors expressing high levels of DNA-PKcs was significantly better than survival of patients with tumors expressing low levels of DNA-PKcs (p =.0024). p53 and MDM2 status alone did not correlate with survival of patients. However, patients with p53 tumors and high DNA-PKcs expression had significantly better survival than patients with p53+ tumors expressing low levels of DNA-PKcs (p =.0018). Furthermore, survival of patients with high expression of DNA-PKcs or Ku86 and low MDM2 levels was significantly better when compared with survival of patients with low DNA-PKcs or Ku86 and high MDM2 (p =.0017 and p =.0034, respectively). CONCLUSIONS: High expression of DNA-PKcs/Ku86 in combination with p53 negativity in tonsillar carcinoma correlates with better survival of patients. Identifying tumors with a phenotype predicting poor survival may be used to optimize treatment of patients with radioresistant tumors.     

New concepts in radiotherapy for advanced squamous cell carcinoma of the head and neck.

This paper reviews two of the newer concepts - multiple daily fractions of radiotherapy - in improving the treatment of squamous cell carcinoma of the head and neck.     

Sonographic monitoring of prostate cancer after definitive radiotherapy.

Thirty patients who had transrectal ultrasonography before and after definitive radiotherapy were studied retrospectively to determine the effects of radiotherapy on the sonographic appearance of prostate cancer. Before therapy one or more discrete hypoechoic areas characteristic of cancer were present in 29 (97%) of the patients. In 10 patients (34%) the hypoechoic areas disappeared six to twenty-seven months (mean 11.4) after radiotherapy, but in 3 of these the hypoechoic lesion subsequently reappeared. Six months after radiotherapy a hypoechoic lesion could still be seen in the original area in 79 percent of 19 patients studied. Sonography showed persistent lesions in 65 percent of 17 patients at twelve months, in 79 percent of 14 patients at twenty-four months, and in 75 percent of 8 patients at thirty-six months. In 9 of the 29 patients (31%), there was a measurable increase in the size of the lesion, but overall, the size (maximum diameter) of the hypoechoic lesion had decreased by a mean of 41 percent when evaluated twelve months after radiotherapy. Previous studies from our laboratory have shown that persistent prostate cancer after definitive radiotherapy retains its hypoechoic appearance, and this study indicates that these characteristic hypoechoic lesions can be monitored by transrectal ultrasound.