Marco Krengli

Voice quality after treatment for T1a glottic carcinoma--radiotherapy versus laser cordectomy.

The purpose of this study was to assess the anatomic and functional outcomes and compare the voice quality in patients affected by T1a glottic carcinoma treated with curative intent with radiotherapy or laser cordectomy. Fifty-seven cases were analysed: 27 after curative radiotherapy and 30 after laser cordectomy. All patients were studied with videolaryngostroboscopy, voice analysis by narrow spectrogram, and vocal parameters (Jitter, Shimmer, noise/harmonic ratio, and diplophonia). Videolaryngostroboscopy showed severe glottic inadequacy in 25% of cases treated with radiation and insufficient compensation ‘ventricular band’ or ‘with arytenoid hyperadduction’ in 65% of cases after surgery. Severe dysphonia on the electro-acoustic analysis of voice was observed in 25% of cases after radiation and 70% after laser (p<0.001). Fundamental frequency and vocal parameters showed more favourable results in the radiation group (p<0.001). Voice assessment showed better results after radiotherapy compared with laser cordectomy. Voice outcome should be carefully considered in the treatment decision for T1 glottic carcinoma.

Renal carcinoma metastasis to the parotid gland

Metastatic tumours in major salivary glands are uncommon with a higher incidence of primary sites from the head and neck. The lungs and breast are the common primary sites, while metastases from the kidney are very rarely found. The authors describe a case of renal clear-cell carcinoma with metastasis to the parotid gland. The incidence of a metastasis in the parotid gland from a primary renal carcinoma, even if rare, should not be overlooked in making a correct differential diagnosis with acinic cell carcinoma and monomorphic clear cell adenoma.

Metastases to parotid gland from cancers of the upper airway and digestive tract

Forty-four cases of parotid metastases were diagnosed and treated in the period 1968-1994. In 10 patients (23%), the primary tumour was sited in the mucosal layer of the upper airway or digestive tract: oropharynx (n=3), larynx (n=3), nasopharynx (n=2), hypopharynx (n=1) and the maxillary sinus (n=1). Histologically, the primary tumour was squamous cell carcinoma in 9 cases and adenocarcinoma in one. One patient received surgical treatment only, two patients surgery and postoperative radiotherapy, one radiotherapy only, four chemotherapy and two symptomatic treatment only. Only one patient is alive, disease-free, 5 years after treatment. The other patients died: six within 1 year, two within 2 years and one within 3 years of diagnosis.

REVIEW OF CURRENT PROTOCOLS FOR PROTONTHERAPY IN USA

The basis for interest in proton beams by clinical radiation oncologists lies in reduction in treatment volume. The yields from employing a smaller treatment volume are the increase of tumor control probability and the reduction of normal tissues complication probability. The clinical use of proton therapy began in 1954 at Uppsala University in Sweden and in 1961 at Harvard Cyclotron Laboratory in Boston, USA. So far, the total number of worldwide patients treated by protons is about 20,000. In this paper attention will be given to the treatment of patients at the Massachusetts General Hospital-Massachusetts Eye and Ear Infirmary-Harvard Cyclotron Laboratory, and at the Loma Linda University Medical Center. In particular, a review of the literature about the techniques and the results of treatment of skull base and cervical spine chordoma and low-grade chondrosarcoma, skull base meningioma, pituitary tumors, paranasal sinus carcinoma, glioblastoma multiforme, artero-venous malformations, uveal melanoma, macular degeneration, retinoblastoma, thoracic spine-sacrum tumors, and prostate carcinoma is presented. In order to verify and improve the clinical results, the conduct of prospective trials on an inter-institutional basis is essential. To facilitate the conduct of such studies the US National Cancer Institute and the American College of Radiology have established the Proton Therapy Oncology Group (PROG). Several phase III and some phase I-II trials are active at the Massachusetts General Hospital, Harvard Cyclotron Laboratory, and at the Loma Linda University Medical Center.

Number of potential patients to be treated with proton therapy in Italy

In radiotherapy, the use of proton beams is one of the most promising approaches in order to reduce the treatment volume and, consenquently, increase the total dose avoiding severe complications to the normal tissues surrounding the target. Among the new hospital-based facilities that are planned for the next future, the italian project is in an advanced stage of study. Because of the complexity and high cost of the italian centre, one of the most important information in order to establish the cost/benefit balance, is represented by the number of potential patients to be treated for the various pathologies. For this reason it is useful to define a priority scale of clinical indications and, on this basis, to estimate the yearly patient afflux to the center, taking into account the incidence and the expected new cases to be treated with protons. Indications have been divided into two categories, according to decreasing priority. Category A includes all the tumors in which the use of proton therapy has clearly demonstrated to be advantageous, being the only way to give a curative dose to the target. In Italy, the extimated number of this category of patients is 825 each year. Category B comprises a great variety of tumors characterized mainly by a local evolution, with a limited likelihood of distant spread, and therefore potentially cured if the local control can be obtained. The total number of potential patients in this category is more than 10,000.

Angiosarcoma of the hypopharynx

Angiosarcoma is a tumour of endothelial origin rarely found in the head and neck. A case of angiosarcoma of the pyriform sinus, treated by surgery and post-operative radiotherapy, is reported, providing a cue for discussion of the diagnostic, clinical and pathological peculiarities of the tumour in the light of personal experience and the published data.

Phase II Trial of Vinorelbine, Cisplatin and Continuous Infusion of 5-Fluorouracil Followed by Hyperfractionated Radiotherapy in Locally Advanced Head and Neck Cancer

Objective: We undertook a prospective phase II study to assess the feasibility and activity of a new induction chemotherapy regimen followed by hyperfractionated irradiation in locally advanced squamous cell head and neck cancer. Methods: 25 patients with locally advanced head and neck cancer were treated with 4 cycles of vinorelbine (20 mg i.v. day 1, 3), cisplatin (60 mg/m2 i.v. day 1) and 5-fluorouracil (200 mg/m2 continuous i.v. infusion day 1–21) (ViFuP regimen) followed by bifractionated radiotherapy (bidRT) up to 74.4 Gy in 62 fractions of 1.2 Gy twice daily. Results: Chemotherapy was well tolerated, 6 patients developed grade 3 and one patient grade 4 neutropenia. Response to chemotherapy was observed in 19 patients (76%) including three complete responses and 16 partial responses. Planned bidRT was completed in 25 patients and all but one received planned bidRT dose without interruptions. Radiotherapy was well tolerated, mucositis was the most common side effect (grade 3–12 patients, grade 4–1 patient). At evaluation after the completion of bidRT, 13 patients had complete response (52%), 7 partial response (28%), 2 stable disease and 3 tumor progression. At the median follow-up of 18.2 months, 11 patients were alive and free of disease, and 14 patients had died (12 of tumor). Late xerostomy was observed in all but one 3-month survivors. Late mandibular necrosis was seen in 1 patient. Conclusions: bidRT preceded by ViFuP seems a feasible and active combination in locally advanced head and neck cancer. Good patient compliance did not compromise the delivery of planned dose of bidRT. However, short median duration of response (14.6 months) and moderate median overall survival (18.7 months) indicate the need for more intensive therapeutic strategies. On the basis of these results, modifications of our treatment schedule (shortening the overall treatment time by reduction of chemotherapy cycles and the use of chemotherapy concomitantly with irradiation) are planned for the future study.