Robert D. Lindberg

Conservative surgery and postoperative radiotherapy in 300 adults with soft‐tissue sarcomas

From January 1963 through December 1977, 300 adults with soft‐tissue sarcomas were treated by a conservative surgical excision and postoperative radiotherapy. The absolute two‐ and five‐year disease‐free survival rates are 74% (222/300) and 61.3% (103/168), respectively. The five‐year survival rate varies with: (1) anatomic site, e.g., 69.4% (75/108) for extremity lesions vs. 33% (5/15) for abdominal lesions; (2) histopathologic diagnosis, e.g., 86.4% (19/22) for fibrosarcoma vs. 50% (15/30) for neurofibrosarcoma; and (3) stage of the lesion. The overall local recurrence rate was 22.3% (67/300) and 27% (81/300) of the patients developed distant metastases. The incidence of lymph node metastases as an initial site of spread was only 2.7% (8/300); therefore, elective treatment of the regional lymphatics is not indicated. The 6.5% incidence of significant complications in extremities is low and might be further diminished by careful treatment planning. The combination of conservative surgery and postoperative radiation therapy maintains a functional limb in 84.5% (169/200) of patients with extremity lesions. This rate is comparable to the five‐year survival rate attained with radical surgery.

Perineural invasion in squamous cell skin carcinoma of the head and neck

On review of 520 patients with 967 squamous cell carcinomas of the skin of the face treated at The University of Texas M.D. Anderson Hospital and Tumor Institute at Houston during a 10 year period, 14 percent of the patients were noted to have perineural extension of tumor. Study of the patients with perineural tumor demonstrated an increased incidence of spindle cell and adenosquamous cell types, an increased incidence of cervical lymphadenopathy and distant metastasis, and significantly reduced survival curves compared with those of patients with squamous cell skin carcinoma without perineural invasion. Tabulation confirmed that the maxillary and mandibular branches of the trigeminal nerve and the facial nerve were most commonly involved. For patients with squamous cell skin carcinomas with perineural invasion, aggressive therapy is recommended, specifically, resection of involved tissues and nerves and appropriate regional lymphadenectomy followed by postoperative radiotherapy. This plan affords the best opportunity for tumor control. The indications for exploration of the middle fossa of the intracranial portion of the trigeminal nerve deserve further study.

Management of cervical lymph node metastases in squamous cell carcinoma of the tonsillar fossa, base of tongue, supraglottic larynx, and hypopharynx

Abstract 1. 1. The records of 596 patients with previously untreated squamous cell carcinoma of the tonsillar fossa, base of the tongue, supraglottic larynx, and hypopharynx were reviewed to evaluate the efficacy of three modalities of initial treatment of cervical lymph nodes. 2. 2. Elective irradiation of the neck is indicated in patients with tumors of the tonsillar fossa and base of the tongue. For patients with lesions of the supraglottic larynx and hypopharynx and a clinically negative neck, elective irradiation of only the subdigastric and midjugular node areas is adequate if the primary lesion is treated with irradiation. 3. 3. In patients with clinically positive nodes, combined treatment is clearly superior to either radiation or surgery alone in preventing cervical recurrence in the initially involved side of the neck. Pre- and postoperative irradiation is equally effective. 4. 4. As the treatment policies have evolved, combined therapy has been used with increasing frequency, the order dictated by the treatment of the primary lesion.

Treatment of soft tissue sarcomas by preoperative irradiation and conservative surgical resection

From 1970-1984, 114 patients with soft-tissue sarcomas received preoperative irradiation at U.T.M.D. Anderson Hospital. Two patients refused surgery and two had progressing disease and therefore did not proceed to surgery; in the remaining 110 patients, conservative surgical resections were performed 3-6 weeks following irradiation. Analysis of survival by histologic type, age, primary size, and histologic grade revealed a significant negative correlation with grade 3 and to a lesser extent to primary size greater than 15 cm. Eleven patients failed within the radiation portal for the primary, four in conjunction with distant metastases. Of the remaining seven, four were salvaged by further surgery for an ultimate primary-only failure rate of three. Distant metastasis occurred in 35 patients and was the major mechanism of treatment failure in this experience. Adjunctive chemotherapy was not used for the majority of patients and it remains to be seen if its routine employment in large, high-grade, lesions will diminish the deaths caused by distant metastases.

Three-year relapse-free survival rates in childhood rhabdomyosarcoma of the head and neck: Report from the intergroup rhabdomyosarcoma study

In 202 patients with rhabdomyosarcoma of the head and neck who registered in the first Intergroup Rhabdomyosarcoma Study, the primary lesions arose about the eye and orbit in 26%, in parameningeal sites in 46%, and in other head and neck areas in 28%. Histopathologically, 78% were embryonalbotryoid, 9% alveolar, 10% undifferentiated, and 3% extraosseous Ewings types. Actual three‐year relapse‐free survival rates were calculated from data on 103 of these patients who were free of distant metastases at diagnosis and in whom follow‐up had been completed for a three‐year period. The actual relapse‐free survival rates were 91% (21/23) for those with eye/orbit primaries, 46% (20/44) for those with parameningeal primaries, and 75% (27/36) for those with other head and neck sites affected. Among those with no clinical evidence of tumor activity at two years, 8% (6/75) had subsequent relapses.

Major complications of radiotherapy in cancer of the oral cavity and oropharynx: A 10 year retrospective study☆

In an attempt to determine the late effects and associated morbidity of radiotherapy on normal tissue, patients with squamous carcinoma of the oral cavity and oropharynx were retrospectively reviewed. Between 1964 and 1975, 569 patients with cancer of the floor of the mouth, oral tongue, tonsil, and retromolar trigone region of the anterior faucial pillar had their primary lesions treated by radiotherapy alone for cure. One hundred twenty-eight of the patients were evaluable for this study. Bone and soft tissue morbidity were graded according to the late radiation scoring scheme of the radiation therapy oncology group of the European Organization on Research and Treatment of Cancer, tallying only grade 4 changes. Patients were further classified according to site of tumor, age, sex, tumor stage, histologic grade, and dental status--none of which had a positive correlation with complications. Of 31 evaluable patients with cancer of the floor of the mouth (median follow-up 136 months), 71 percent (22 of 31 patients) had at least one complication involving bone (osteonecrosis, pathologic fracture) or mucus membrane (ulcer). Sixty-one percent (25 of 41 patients) with primary cancer of the oral tongue had grade 4 sequelae (median follow-up 112 months). In 26 patients with cancer of the tonsil, 13 (50 percent) had grade 4 sequelae (median follow-up 113 months). This included 11 patients with clinical and radiographic evidence of osteonecrosis, 6 of whom required mandibulectomy. Patients with cancer of the retromolar trigone region of the anterior faucial pillar fared the best (median follow-up 122 months). Late sequelae were noted in 40 percent (12 of 30 patients). The morbidity attendant to cure by radiotherapy included at least one significant complication of bone or soft tissue in 40 to 70 percent of the patients, depending on the location of the primary tumor. There was also a positive correlation with dose of radiation received.

The efficacy of combining radiation therapy with a surgical procedure in patients with cervical metastasis from squamous cancer of the oropharynx and hypopharynx.

To determine whether combining radiation therapy and a surgical procedure was superior to either modality alone, the authors reviewed the records of 345 patients who had primary cancers of the base of the tongue, tonsillar fossa, or pyriform sinus associated with clinically positive nodes at the time of their first observation. Combining the two modalities of therapy produced a local and regional control of the disease in twice as many patients as did one modality alone. The absolute 5‐year survival did not reflect this same trend, however, since as local and regional control increased, more patients lived longer but died before five years from distant metastases. Immunochemotherapy is suggested as a possible adjunct therapy to prevent distant metastases.

Localized ewing's sarcoma—treatment and results

The experience at M. D. Anderson Hospital in the management of 59 patients with apparently localized Ewings sarcoma from 1948 to May, 1972 is presented. Necropsy examination was performed in 18 cases. Disease‐free survival times are compared between 19 patients treated by the combination of high‐dose irradiation and intensive chemotherapy, and 40 patients treated by radiation therapy alone (25) or in combination with relatively less intensive drug therapy (15). Results favor the former group: local recurrence in 1 case of 19 compared to 19 of 40; and median time to first metastasis of >15 months compared to 8 months.

Analysis of Failures in Early Vocal-Cord Cancer

The percentage of local failures in radiation therapy of early vocal cord tumors increases with the extent of the disease. Involvement of the anterior commissure does not affect the prognosis. The surgical salvage rate is excellent in T1 lesions, with a very low ultimate failure rate. An increase in dose is necessary with an increase in size or extension of the lesion. Complications may be eliminated by minor adjustments in the dose-time relationship.

Management and results of localized Ewing's sarcoma.

Seventy‐six patients with localized Ewings sarcoma who received primary treatment at M. D. Anderson Hospital from 1948 through December 1975 were reviewed. Patients have been divided into four groups according to the different treatment regimens they received: Group I, moderate dose radiotherapy alone; Group II, high dose radiotherapy alone; Group III, radiotherapy plus vincristine and cytoxan; and Group IV, radiotherapy plus vincristine, Adriamycin, cytoxan and actinomycin. The problem of local recurrence appears to be solved with combined chemotherapy and radiation therapy with only one of 36 patients having a recurrence at the primary site in Groups III and IV. Multimodal therapy is the preferred treatment to obtain control of the primary lesion by radiation therapy while preserving good function. However, the major cause of failure remains distant metastases, 19 of 36 (53%) in Groups III and IV. In addition, 4 of 10 patients who have survived over 5 years have developed osteogenic sarcoma. Cancer 43:1001–1006, 1979.