Gershon J. Spector

Intensity-modulated radiation therapy reduces late salivary toxicity without compromising tumor control in patients with oropharyngeal carcinoma: a comparison with conventional techniques

BACKGROUND AND PURPOSE Intensity-modulated radiation therapy (IMRT) offers superior dosimetric conformity for normal tissue sparing in patients with oropharyngeal cancer. In this study, acute and late toxicity, and tumor control were compared between conventional beam arrangement (CRT) and IMRT. MATERIALS AND METHODS Between January 1970 and December 1999, 430 patients with carcinoma of the oropharynx were treated at the Mallinckrodt Institute of Radiology. There were 260 patients with tonsil primary tumors and 170 patients with tumors arising from the base of the tongue. Twenty-four (6%) patients had stage I disease, 88 (20%) had stage II, 128 (30%) had stage III, and 190 (44%) had stage IV disease. Patients were divided into five treatment groups. Group I consisted of 109 patients who received preoperative CRT. Group II consisted of 142 patients who received postoperative CRT. Group III consisted of 153 patients who received definitive CRT. Inverse planning IMRT (Peacock, NOMOS) was used to treat 14 patients postoperatively (Group IV) and 12 patients definitively without surgery (Group V). Acute and late normal tissue side-effects were scored according to the Radiation Therapy Oncology Group radiation morbidity criteria. The median follow-up was 3.9 years. RESULTS The 2-year local-regional control values for the five studied groups were 78, 76, 68, 100 and 88%, respectively. The 2-year disease-free survival values for the five studied groups were 68, 74, 58, 92 and 80%, respectively. IMRT significantly reduced the incidence of late xerostomia. CONCLUSIONS When IMRT was compared with conventional techniques, the dosimetric advantage of IMRT did translate into a significant reduction of late salivary toxicity in patients with oropharyngeal carcinoma. No adverse impact on tumor control and disease-free survival was observed in patients treated with IMRT.

Free Flap Reconstruction of the Head and Neck: Analysis of 241 Cases

OBJECTIVE: We undertook this study of free flap reconstruction of the head and neck to stratify patients and procedures, to determine how donor site preference changed over time, to assess medical and surgical outcomes, and to identify variables associated with complications. METHODS: We analyzed computerized medical records from 236 patients who underwent a total of 241 reconstructions at a tertiary academic medical center in St. Louis between 1989 and 1998. We created a more detailed retrospective database of 141 of those patients by using 48 perioperative variables and 7 adverse outcome measures. Multivariate statistical models were used to analyze associations between variables and outcomes. RESULTS: The fibula became the preferred donor site for mandibular reconstruction, and the radial forearm became the preferred donor site for pharyngoesophageal reconstruction. For the 241 procedures, the mortality rate was 2.1%, the median length of stay was 11 days, and the flap survival rate was 95%. Administration of more than 7 L of crystalloid during surgery and age over 55 were associated with major medical complications. Blood transfusion, prognostic comorbidity, and number of surgeons correlated with length of stay. Cigarette smoking and receipt of more than 7 L of crystalloid during surgery were associated with overall flap complications, and weight loss of more than 10% before surgery, more than one operating surgeon, and cigarette smoking were associated with major flap complications. CONCLUSIONS: Risk to patients and transferred tissue is low in free flap head and neck reconstruction. Age, smoking history, and weight loss should be considered during patient selection. Fluid balance should be considered during and after surgery. Division of labor for patient care should be carefully delineated among surgeons in a teaching setting.

Adenoid cystic salivary gland carcinoma: A histopathologic review of treatment failure patterns†

Seventy‐one cases of adenoid cystic salivary gland carcinoma were reviewed according to treatment modality and clinical course. Thirty‐six patients (51%) were treated by combined surgery and radiation therapy. The tumors were classified by their histotogic patterns into tubular, cribriform, and solid forms. Distant metastases, in 52%, were the most frequent and ominous sources of failure. In 35% of cases, distant metastases developed despite local control at the primary site. In this group, the disease had a more fulminant course with shorter survival. Histopathologically, the cribriform subtype was associated with multiple local recurrences, greater local aggressiveness, and a poorer salvage rate as compared with the tubular subtype. Late onset of local recurrences and distant metastases was especially assocated with the cribriform subtype. Overall prognosis in terms of distant metastases and survival was worst for the solid subtype. Control of local disease is best achieved with combined surgery and radiation therapy. The high incidence of distant metastases may not be affected by this regimen. The ultimate outcome of therapy is poorly predicted. Survival appears to be based on the pattern in which distant metastases develop. Overly aggressive and mutilating surgical approaches for these tumors are not recommended in many instances. The need for the development of new, more effective forms of therapy is emphasized.

Analysis of Treatment Results for Oral Tongue Cancer

Objective The study reports the results of treatment of oral tongue cancer with five different treatment modalities with long‐term follow‐up.

Glomus Jugulare Tumors II. A Clinicopathologic Analysis of the Effects of Radiotherapy

Radiotherapy is an often used treatment in glomus tumors of the middle ear. Histologic evidence revealing nonuniform radiotherapeutic effect on tumor vessels is shown. The reticular tumor stroma is replaced by collagen. The chief cells demonstrate little change. The results in 19 radiated patients demonstrate that radiation eliminated the tumor in 20% of the cases. Radiation followed by surgery was more successful in tumor eradication than surgery followed by radiation.

Supraglottic laryngeal cancer: analysis of treatment results.

Objective: This study reports the results of treatment for supraglottic laryngeal cancer with nine different treatment modalities with long‐term follow‐up.

Analysis of surgical therapy for epidermoid carcinoma of the laryngeal glottis

Four hundred sixty‐three patients with glottic carcinoma were treated by surgical techniques with or without preoperative irradiation. Two hundred eighty‐one had hemilaryngectomy and 182 total laryngectomy procedures. The overall cure rate for the hemilaryngectomy group was 91 percent and 80 percent for the total laryngectomy group, with an overall cure rate of 87 percent.

Analysis of treatment results for base of tongue cancer

Objective The study reported the results of treatment for base of tongue cancer with five different treatment modalities with long‐term follow‐up.

Reirradiation of recurrent head and neck cancers.

Ninety‐nine patients with recurrent cancers of the head and neck region were treated with surgery, radiation therapy, or combination therapy. The follow‐up period ranged from 18 months to 18 years. An initial overall complete response rate of 67% and a partial response rate of 7% (overall response rate –‐ 74%) were achieved. The eventual tumor control rate was 15%. Although equal initial response rates were achieved in recurrences at the primary site and the cervical nodes, the eventual local control was better for the former (21% vs. 10%). Patients receiving less than 5,000 rad had radiotherapy had a 44% complete response and an 11% eventual tumor control. Patients receiving over 5,000 rad had an 80% complete response and a 25% eventual tumor control.

Conservation surgery for epidermoid carcinoma of the supraglottic larynx

The determinant survivals for supraglottic subtotal laryngectomy and neck dissection in T1, T2, T3 and T4 are 83 percent, 79 percent, 70 percent and 67 percent respectively with an overall success rate for primary surgery of 79 percent. The salvage rate is 47 percent for an overall success rate of 82 percent.