Junichi Horiuchi

Results of brachytherapy for cancer of the tongue with special emphasis on local prognosis

One hundred and sixty-six patients with squamous cell carcinoma of the tongue were treated with radiation. Treatment modalities were mainly interstitial implant with or without external beam irradiation, except for early lesions, which were treated with intraoral electron beam therapy. Analysis was made on the local prognosis of the lesion to clarify the indications for interstitial therapy, especially the combined program with external beam therapy, and the time-dose relationship of the brachytherapy. Local recurrence-free rates (two years) were 94% in T1, 77% in T2 and 32% in T3 lesions, respectively. For T1 and superficial or exophytic T2 lesions, the local recurrence-free rate was excellent with the interstitial therapy alone using either permanent implants of gold grain or radium implants. Therefore, prior external beam therapy seemed to be unnecessary for these lesions. When the treated area was less than 10 cm2, subsequent complications were not likely even if the TDF (time-dose factor) value was high. Most of the patients who received combined external beam and interstitial therapy showed infiltrative T2 and a majority of the T3 lesions. In these patients, it was apparent that most of the total dose should be given from the interstitial implant after a small prior dose with external irradiation, because these lesions could not be cured even if the external dose was increased.

Multiple primary cancer risk in patients with squamous cell carcinoma of the oral cavity

During 6375 patient‐years of observation, 136 new cancers developed in 117 of 1429 patients with squamous cell carcinoma of the oral cavity. The risk of multiple cancers was excessive in the upper digestive or respiratory tract in patients with squamous cell carcinoma of the oral cavity, accounting for 87 (64%) of the 136 later cancers. In addition, multiplicity of cancers was site‐specific, being common in the oral cavity–esophagus–lung axis and uncommon in sites such as the maxillary sinus and epipharynx. In addition, the observed‐to‐expected ratio was different in each site of the oral cavity–esophagus–lung axis, i.e., 57.5 for the oral cavity and pharynx, 12.0 for the esophagus, 7.3 for the larynx, and 2.0 for lung cancers.

Leukoplakia‐associated multiple carcinomas in patients with tongue carcinoma

A series of 522 patients with a diagnosis of squamous cell carcinoma or carcinoma in situ of the tongue were reviewed and followed. Leukoplakia was found in 88 of these patients before and after the diagnosis of tongue carcinoma. A high incidence of multiple carcinomas in the oral cavity and pharynx (116 times greater than expected) was encountered in tongue carcinoma patients. The observed incidence of multiple oral carcinomas in the group with tongue carcinoma with leukoplakia was five times greater than that of the subjects without leukoplakia. The incidence of secondary esophageal carcinomas was also high, 12 times greater than the statistical expection. However, there was no increased occurrence of secondary esophageal carcinomas in the patients with leukoplakia.

Some considerations on radiation therapy of tongue cancer.

In the 9‐year period, 1960 to 1968, 117 patients with cancer of the tongue were treated by radiation therapy. Radiation techniques mainly used were interstitial radon seed or radium therapy to the primary lesion. As for 102 primary cases, the cumulative 5‐year survival rate was 43 ± 5.5% according to the life‐table method. When the primary lesion is relatively small, the radon seed implantation technique has advantages over radium needles in terms of patient comfort and easy applicability. It is highly suggestive that prophylactic lymph node irradiation decreases node metastases and improves the prognosis. Though radionecrotic complications were observed later in about 10% of the cases, successful management was done with the cooperation of oral surgeons.

Maxillary sinus carcinoma: Result of radiation therapy

Four hundred and sixteen patients with carcinoma of the maxillary sinus received primary therapy consisting of external beam irradiation alone or in combination with surgery and/or chemotherapy at the Department of Radiology, Tokyo Medical and Dental University Hospital, between 1953 and 1982. In our institution, methods of treating cancer of the maxillary sinus have been changed from time to time and showed different control rates and clinical courses. An actuarial 10-year survival rate of 21% has been obtained by megavoltage irradiation alone as well as 34% actuarial 10-year survival rate by megavoltage irradiation with surgery. After the introduction of conservative surgery followed by conventional trimodal combination therapy (antrotomy: intraoral partial maxillectomy + radiation + intra-arterial infusion), the local control rate has been improved. The amount of functional, cosmetic, and brain damages have been remarkably decreased by this mode of therapy. The actuarial five year survival rate was 67%. In addition, along with the improvement of the local control rate, the control of nodal and distant organ metastases have been emerging as one of the important contributions to the prognosis of this disease.

Malignant melanomas of the oral cavity: Heterogeneity of pathological and clinical features

Data on 35 patients with oral malignant melanomas were pooled and the pathological features and the clinical course were examined in detail. Of these 35 cases, 27 (77.1%) showed a two-phase growth pattern, with both a vertical and a radial growth phase. Moreover, these 27 cases were classified into three subtypes according to gross features of the vertical growth phase; nodular, flat elevated and ulcerated types. Almost two-thirds of the cases were of the melanotic type. Malignant melanomas without a radial growth phase were found in 8 instances, all of which showed a nodular growth pattern, 1 being of melanotic type and 7 amelanotic. Mean latent insidious periods were evaluated for the cases with different growth phases. Cases with a radial growth phase exhibited the longest mean latent period (35.7 months), and a median survival time of 23.5 months. Cases without a radial growth phase showed a short mean latent period (2.1 months), and a median survival time of 7.5 months. The thickness of invasion ranged from 2 to 9 mm. Although 77.1% of the cases depicted similar pathological patterns to acral lentiginous melanomas of the skin, oral malignant melanomas demonstrated heterogeneity in morphological features, developmental process and biological behaviour. The histogenesis of oral melanomas is briefly discussed.

Reappraisal of trimodal combination therapy for maxillary sinus carcinoma

The introduction of trimodal combination therapy (surgery + radiation + intraarterial infusion) for maxillary carcinoma resulted in a change in the sites of recurrence and no satisfactory improvement in the local control rate. To examine the cause of these phenomena, external carotid angiography was performed on 51 patients prior to the start of the therapy and the results of the treatment were studied. Angiographic findings indicated that maxillary carcinoma is fed not only by the maxillary artery, but also by the internal carotid, facial, transvers facial and other arteries from the external carotid artery. The multiplicity of feeders causes irregular distribution of the intraarterially infused antimetabolites. Irregular and local low distribution of antimetabolites may well bring about the high rate of recurrence. The results of intraarterial transcatheter Tc‐99m‐MAA injection were also in accord with the angiographic findings.

Usefulness of 198Au grain implants in the treatment of oral and oropharyngeal cancer

A series of 177 patients with squamous cell carcinoma of the oral cavity and oropharynx were treated with 198Au grain (gold grain) implants. Sites of the lesion included the tongue, mouth floor, buccal mucosa and oropharynx, especially the soft palate and faucial arch. Three-fourths of the patients were treated in combination with prior external beam irradiation. A permanent implant dose (total decay) of 80-90 Gy was given in the form of gold grains alone and in combination with an external dose of no more than 30 Gy, and 60-70 Gy, total decay, was given after an external dose greater than 30 Gy. The 2-year recurrence-free rate was 86.2% in the case of T1N0, 72.6% in T2N0 and 72.2% in T3N0. The difference in the results of implant therapy alone and combined therapy was not significant. Late complications were minimal after grain implantation alone, and when used in combination, less than 70 mCi of grain activity after a 40 Gy external dose did not seem to be a serious hazard with respect to bone damage except in the case of cancer of the mouth floor. Gold grain implants were useful and easily applied under local anesthesia to early or superficial lesions at sites where a rigid linear source could not be used. Exposure of the radiology staff was only 5-10 mrad in the case of the usual 10-15 (50-75 mCi) implant grains.

Extranodal Non-Hodgkin's Lymphoma in the Head and Neck: Irradiation and clinical course

A retrospective analysis was performed of localized extranodal non-Hodgkins lymphomas in the head and neck region treated with irradiation. Histopathologic reevaluation revealed 94 per cent with a diffuse type. The lesions were as a rule locally cured with doses ranging from 30 to 50 Gy. Relapses in localized stage I and II patients were, however, not seldom observed in distant extranodal sites. Gastrointestinal relapse in cases with lesions originally located in Waldeyers ring was thus frequently observed, and the probability of multiple or systemic involvement should be considered also when the disease is located in the oral cavity or sinus region. The value of systemic examination for staging purposes is discussed.

Carcinomas of the Esophagus with Synchronous or Metachronous Primary Carcinoma in other Organs

Twenty-eight patients with esophageal carcinoma and one or more separate primary carcinomas in other organs were treated from 1960 to 1980, representing 8.3 per cent of the 339 cases of esophageal carcinoma observed during this period. The most frequent sites of the additional tumors were the oral cavity and pharynx (11 patients) and the stomach (12 patients). Awareness of the frequent combination of esophageal carcinoma with other primary neoplasms in the sites mentioned may lead to the detection of small curable malignant tumors.