Douglas A. Fein

T1–T2 squamous cell carcinoma of the glottic larynx treated with radiotherapy: A multivariate analysis of variables potentially influencing local control

PURPOSE To examine various parameters that might influence the probability of local control of T1-T2 glottic carcinoma treated with radiotherapy. METHODS AND MATERIALS Two hundred forty-seven patients with invasive, previously untreated T1-T2 squamous cell carcinoma of the glottic larynx were treated with radiotherapy between May 1977 and December 1989. All patients had a minimum 2-year follow-up. To minimize treatment-related variables, only patients with T1 lesions treated once daily at 225 cGy per fraction and patients with T2 lesions treated once daily at 225 cGy per fraction or twice daily at 120 cGy per fraction were included. Surgical alternative, thickness of the neck at the posterior edge of the lateral fields, vocal cord mobility, anterior commissure involvement, gender, and T stage were evaluated in a multivariate analysis. RESULTS The 5-year local control rates, calculated by the product-limit method, were T1a, 95%; T1b, 96%; T2a, 87%; and T2b, 76%. The 5-year local control rate for patients with T2 lesions treated with once-daily fractionation was 81% compared with 91% for those who received twice-a-day radiotherapy. For the endpoint of local control with irradiation, the surgical alternative (p = .020) and cord mobility (p = .001) were of independent prognostic significance. CONCLUSION Of the variables analyzed, only vocal cord mobility and surgical alternative significantly influenced local control. Specifically, anterior commissure involvement and neck thickness did not affect local control.

Oropharyngeal carcinoma treated with radiotherapy: A 30-year experience

PURPOSE This study was done to determine the outcome in patients with oropharyngeal carcinoma treated at the University of Florida with radiotherapy alone to the primary site, for comparison with reported results of other types of treatment. METHODS AND MATERIALS Of a consecutive cohort of 785 patients with biopsy-proven, previously untreated, invasive squamous cell carcinoma of the oropharynx, this report is based on the 490 patients who had continuous-course irradiation with curative intent at the University of Florida between October 1964 and January 1991. All patients had a minimum 2-year follow-up. Forty-eight percent had Stage T3 or T4 disease, and 64% had clinically apparent neck node metastases. The median radiation dose was 68 Gy for once-a-day treatment and 76.8 Gy for twice-a-day treatment. Patients with advanced neck node disease had planned neck dissection(s) after radiotherapy. RESULTS The overall local control rate after radiotherapy alone was 73%. The ultimate local control rate (including surgical salvage) was 78%. At 5 years, the probability of control of neck disease was 85%; control above the clavicles, 67%; absolute survival, 44%; cause-specific survival, 77%; distant metastasis (as the first or only site of failure), 11%. Thirteen patients (2.6%) experienced severe treatment complications. CONCLUSION Radiotherapy results in tumor control and survival rates comparable with rates achieved with combined irradiation and surgery, with less morbidity.

Lhermitte's sign: Incidence and treatment variables influencing risk after irradiation of the cervical spinal cord

PURPOSE Lhermittes sign is a relatively infrequent sequela of irradiation of the cervical spinal cord. In this study, we sought to determine whether various treatment parameters influenced the likelihood of developing Lhermittes sign. METHODS AND MATERIALS Between October 1964 and December 1987, 2901 patients with malignancies of the upper respiratory tract were treated at the University of Florida. The dose of radiation to the cervical spinal cord was calculated for those patients who had a minimum 1-year follow-up. A total of 1112 patients who received a minimum of 3000 cGy to at least 2 cm of cervical spinal cord were included in this analysis. RESULTS Forty patients (3.6%) developed Lhermittes sign. The mean time to development of Lhermittes sign after irradiation was 3 months, and the mean duration of symptoms was 6 months. No patient with Lhermittes sign developed transverse myelitis. Several variables were examined in a univariate analysis, including total dose to the cervical spinal cord, length of cervical spinal cord irradiated, dose per fraction, continuous-course compared with split-course radiotherapy, and once-daily compared with twice-daily irradiation. Only two variables proved to be significant. Six (8%) of 75 patients who received > or = 5000 cGy to the cervical spinal cord developed Lhermittes sign compared with 34 (3.3%) of 1037 patients who received < 5000 cGy (p = .04). For patients treated with once-daily fractionation, 28 (3.4%) of 821 patients who received < 200 cGy per fraction developed Lhermittes sign compared with 6 (10%) of 58 patients who received > or = 200 cGy (p = .02). CONCLUSION An increased risk of developing Lhermittes sign was demonstrated for patients who received either > or = 200 cGy per fraction (one fraction per day) or > or = 5000 cGy total dose to the cervical spinal cord.

Pharyngeal wall carcinoma treated with radiotherapy : impact of treatment technique and fractionation

PURPOSE To determine whether a modification in treatment technique and the routine use of twice-daily fractionation have influenced the likelihood of local control in carcinomas of the hypopharyngeal and/or oropharyngeal wall. METHODS AND MATERIALS Between October 1964 and July 1990, 99 patients with invasive, previously untreated T1-T4 squamous cell carcinoma of the pharyngeal wall were treated with continuous-course, external-beam radio-therapy with curative intent at the University of Florida. All patients had a minimum 2-year follow-up. RESULTS The 2-year local control rates for patients treated with once-daily vs. twice-daily fractionation were T1, 100% each; T2, 67% vs. 92%; T3, 43% vs. 80%; and T4, 17% vs. 50%. The 2-year local control rates for patients treated with our former technique (posterior border placed at middle of the vertebral body when the portals were reduced off the spinal cord) vs. our current, modified technique (posterior border placed at posterior edge of the vertebral body) were T1, 100% each; T2, 57% vs. 100%; T3, 46% vs. 73%; and T4, 29% vs. 75%. The parameters of T stage, fractionation schedule, primary site, (oropharynx vs. hypopharynx) treatment technique, and lateral vs. posterior pharyngeal wall location were evaluated in a multivariate analysis for the end point of local control. T stage (p = .003), fractionation schedule (p = .001), and primary site (p = .028) were of independent prognostic significance. CONCLUSION Twice-daily fractionation was the most important treatment-related variable in this patient population.

Carcinoma in situ of the glottic larynx: The role of radiotherapy

PURPOSE To examine the University of Florida experience with radiotherapy of carcinoma in situ of the true vocal cord and compare our results with those reported in other series using various treatment modalities. METHODS AND MATERIALS Nineteen patients with carcinoma in situ of the true vocal cord were treated with curative intent with radiation therapy at the University of Florida between October 1964 and September 1990. All patients had a minimum 2-year follow-up. Before the radiotherapy, four patients had undergone a biopsy only, 11 patients had undergone one stripping procedure, and four patients had undergone 2 to 5 strippings. Radiation doses were between 5625 cGy and 6300 cGY (median, 5625 cGy). RESULTS The 5-year rates of local control, ultimate local control, and local control with voice preservation were 93%, 100%, and 93%, respectively. A literature review revealed that local control rates after primary treatment with radiotherapy, laser resection, and vocal cord stripping were 84%, 68%, and 66%, respectively. CONCLUSION Primary treatment with radiotherapy should be strongly considered for patients with carcinoma in situ of the true-vocal cord who have a recurrence after vocal cord stripping or who cannot have close follow-up after treatment.

Stage III ovarian carcinoma: An analysis of treatment results and complications following hyperfractionated abdominopelvic irradiation for salvage

PURPOSE Patients with persistent disease found at laparotomy following platinum-based chemotherapy for Stage III ovarian carcinoma have a remote chance of cure with second-line chemotherapy or conventional radiotherapy. To decrease relapse rates and improve tolerance, we have used twice-daily radiotherapy in 28 such patients. METHODS AND MATERIALS Twenty-eight patients with Stage III epithelial ovarian carcinoma were treated with curative intent at the University of Florida with hyperfractionated, continuous-course radiotherapy for persistent disease at laparotomy after administration of platinum-based chemotherapy. All patients received .8 Gy per fraction, twice daily, to a mean total dose of 30.2 Gy to the whole abdomen and pelvis; 20 patients had additional radiotherapy to the pelvis (mean, 14.54 Gy). All patients had undergone two to four (mean, 2.6) laparotomies for ovarian carcinoma and had received 6-28 (mean, 12) cycles of chemotherapy before irradiation. RESULTS With a 2-year minimum follow-up, survival rates at 1, 2, and 5 years were as follows: absolute survival, 79%, 50%, 21%; relapse-free survival, 52%, 36%, 19%. For the 11 patients with no evidence of gross residual disease after the second-look laparotomy, the absolute survival rates were 100%, 73%, and 27%. This was superior to the rates of 65%, 34%, and 18% for the 17 patients who had gross residual disease. Only two patients required treatment breaks. Four patients required surgical intervention for small-bowel obstruction, which in two cases revealed recurrent disease. Two patients died of treatment-related complications. Twenty-two of 23 failures occurred in the abdomen and/or pelvis. CONCLUSION Although most patients eventually relapse, a small percentage have had a prolonged disease-free interval. Since treatment was relatively well tolerated, escalation of the dose of hyperfractionated abdominopelvic irradiation is being investigated.

40 Pretreatment hemoglobin level influences local control and survival of T1-T2 squamous cell carcinomas of the glottic larynx

PURPOSE A number of reports have documented the relationship between pretreatment hemoglobin level and local control and/or survival in the treatment of cervix, bladder, and advanced head and neck tumors. Consideration of correcting anemia before initiation of radiation therapy may prove increasingly important as clinical trials use intensive induction chemotherapy in the treatment of head and neck carcinomas. Neoadjuvant chemotherapy may produce anemia, which in turn may reduce the effectiveness of subsequent irradiation. MATERIALS AND METHODS One hundred nine patients with T1-2N0 squamous cell carcinoma of the glottic larynx were treated with definitive radiotherapy at the Fox Chase Cancer Center between June 1980 and November 1990. Follow-up times ranged from 26 to 165 months (median, 82). RESULTS The 2-year local control rate for patients who presented with a hemoglobin level < or = 13 g/dL was 66%, compared with 95% for patients with a hemoglobin level more than 13 g/dL (P = .0018). The 2-year survival rate for patients with a hemoglobin level < or = 13 g/dL was 46%, compared with 88% for patients with a hemoglobin level more than 13 g/dL (P < .001). Cox proportional hazards regression analysis showed that hemoglobin level (P = .0016) was the only variable that significantly influenced local control (P = .0016) and survival (P < .0001). CONCLUSION Patients who presented with hemoglobin levels more than 13 g/dL had significantly higher local control and survival rates. The strong apparent correlation between hemoglobin level, local control, and survival supports consideration of correcting anemia before initiation of radiation therapy.