Roy B. Sessions

Critical assessment of supraomohyoid neck dissection

During a recent 5-year period, 115 patients had 131 supraomohyoid neck dissections. Eighty-one percent of these procedures were performed for squamous carcinoma. Seventy-nine percent of the primary tumors were located in the oral cavity and 16 percent arose in the oropharynx. Almost 80 percent of the necks dissected for primary squamous carcinoma were clinically N0, and occult nodal disease was discovered in 31 percent of these neck specimens. When the supraomohyoid neck dissection specimen showed no involvement, the overall incidence of treatment failure in the neck at 2-year follow-up was 5 percent. Almost all patients with occult squamous carcinoma in the supraomohyoid neck dissection specimen received postoperative radiotherapy, and the failure rate in the neck was 15 percent. When neck nodes were both clinically and pathologically involved, neck recurrence developed in 29 percent of the patients despite the addition of adequate postoperative radiotherapy. Among those patients with nonsquamous primary tumors and a pathologically negative supraomohyoid neck dissection specimen, there was only one subsequent treatment failure in the neck. Supraomohyoid neck dissection appears to be a valid staging procedure for clinically N0 patients with primary squamous carcinomas located in the oral cavity or oropharynx, with an appropriate yield of occult nodal disease, and infrequent treatment failure in the dissected neck when the supraomohyoid neck dissection specimen is pathologically uninvolved. When nodal disease is clinically obvious, treatment failure is more frequent, even with the addition of postoperative radiotherapy. The role of supraomohyoid neck dissection in this setting deserves further study.

Ototoxicity of high-dose cisplatin by bolus administration in patients with advanced cancers and normal hearing.

Our institution undertook a phase I trial to define the toxicity of high‐dose (150 to 225 mg) bolus administration (every 3 to 4 weeks) of cisplatin in patients with advanced cancers. All patients reported had baseline normal hearing. Hearing levels were measured prior to each course of chemotherapy. Audiological monitoring included conventional assessment of pure tone sensitivity at 500 to 8,000 Hz and assessment of ultra high frequencies (9,000 to 20,000 Hz). After one to two doses, 100% of patients failed to respond at 9,000 Hz and above. In the 2,000 to 8,000 Hz range, repeated administration of the drug effected successively lower frequencies with progressive loss, until a maximum threshold shift or plateau was reached at each frequency between 3,000 and 8,000 Hz. The plateau for cisplatin ototoxicity appears to fall within the moderate hearing loss range (40 to 60 dB HL) in the high frequencies. All patients complained of tinnitus and difficulty understanding speech in the presence of background noise. The pattern of pure tone audiometric alteration is consistent in all patients, all dosages, and each method of administration. The ultra high frequency alteration is prompt and dramatic.

Mandibulotomy approach to oropharyngeal tumors

We have reviewed our experience with 120 selected patients who had pharyngeal tumors resected through a median mandibulotomy approach with paralingual extension (mandibular swing). Clinical findings, technique, and complications are discussed. Results were gratifying in terms of salvage, patient appearance, and function. We believe that this surgical approach, in combination with postoperative radiotherapy when appropriate, offers an attractive alternative to high dose radiotherapy alone in patients with oropharyngeal carcinoma.

Concomitant chemotherapy-radiation therapy followed by hyperfractionated radiation therapy for advanced unresectable head and neck cancer

In January 1988, we initiated a prospective study evaluating a new treatment approach with chemotherapy and radiotherapy for unresectable head and neck cancer. Weeks 1-4 were the initial debulking phase. Radiotherapy was delivered using 1.8 Gy/day to large portals including gross disease and all areas at risk. Cisplatinum, 100mg/m2, was given concomitant with radiotherapy on days 1 and 22. Weeks 5 and 6 were the boosting phase. This involved twice-a-day irradiation. The AM fraction of 1.8 Gy was given to the entire area at risk, whereas the PM dose of 1.6 Gy was limited to the gross disease alone. Thus a total of 70 Gy/6 weeks was delivered. A total of 24 patients were treated, 22 of whom have completed this protocol and are evaluable. All patients had massive disease, with 15 having gross involvement of brain, orbit, skull base, or carotid artery. Follow-up ranged from 3-22 months (median 12 months). Major responses were achieved in 96%, with 64% complete responses and 32% partial responses. Two patients with PR were able to undergo complete surgical resection, making the overall rate of complete response, including surgery, 73%. At 1 year, actuarial survival was 69%, and local progression-free survival was 56%. Distant metastases developed in 5 (23%). This approach appears both safe and effective in producing excellent regression and local control for far advanced head and neck cancer. More time is needed to see if these results are sustained. Efforts to build upon this experience appear warranted.

The problem of neck relapse in early stage supraglottic larynx cancer

We reviewed the records of 104 patients with Stage T1NO or Stage T2NO epidermoid carcinoma of the supraglottic larynx treated between 1965 and 1979. In 79 patients, surgery was the only type of initial treatment. These 79 patients are the subjects of this report. Forty‐eight (61%) of these patients were treated by total laryngectomy, whereas 31 (39%) had a partial laryngectomy. An elective unilateral radical neck dissection was performed on 31 patients considered at high risk, butt metastatic disease was found in the dissected side of the neck histologically in only 32% (ten of 31) of these patients. The minimum follow‐up period was 5 years and the maximum was 20 years. Twenty‐nine percent of the patients (23 of 79) experienced a neck relapse. The neck relapse rate was the same whether the patients did or did not have an elective radical neck dissection. Among the patients who experienced a neck relapse, 65% (15 of 32) have died of the cancer. Among those who did not experience a neck relapse, none (zero of 56) have died of the cancer (P < 0.01). These results indicate that in surgically treated patients with early stage supraglottic larynx cancer, neck relapse was the major cause of failure associated with death from cancer. Strategies for decreasing the relapse rate are discussed.

Brachytherapy as part of the definitive management of squamous cancer of the base of tongue

Between 1981 and 1986, 17 patients were treated at the Department of Radiation Oncology at the Memorial Sloan-Kettering Cancer Center with squamous cancer of the base of the tongue whose definitive treatment included brachytherapy. The patient sample consisted of 14 men and 3 women with age range of 35 to 71 years (median = 58). There were four patients with T1 lesions, six with T2, six with T3, and one with T4. In general, treatment consisted of 5000-5400 cGy with external beam radiation and 2000-3000 cGy boost to the base of tongue via an Ir-192 implant using afterloading catheters. Necks were managed with elective radiation alone in the N0 group (n = 5) or with radiation plus neck dissection in the N+ group (n = 12). Five patients who would have required laryngectomy had they undergone primary surgery received neoadjuvant chemotherapy followed by external beam and implant as part of a larynx preservation study that was being done at our institution (4-T3, 1-T2). The range of follow-up is 8 to 59 months, with median follow-up of 24 months. No patients have been lost to follow-up. Crude local control by T-Stage are as follows: T1-4/4, T2-5/6, T3-5/6, T4-1/1. Actuarial local control at 24 months is 87%. There have been no neck failures. There have been five patients who had soft tissue ulceration (STU) and one patient who had osteoradionecrosis (ORN). All soft tissue ulceration patients have been successfully managed conservatively. The patient with osteoradionecrosis is currently being managed. In 4 of these 6 cases, the implant was the initial therapeutic intervention and the entire tumor bed was implanted. On the other hand, when external beam was the initial treatment, the boost was administered to the smaller volume of residual disease. Overall, 4 of 7 patients who had implant first developed either soft tissue ulceration or osteoradionecrosis, as opposed to 2 of 10 patients who had implant after external beam and/or chemotherapy. The numbers are too small to be statistically significant, but our current policy is to perform brachytherapy after the external beam. In addition, all those with either soft tissue ulceration or osteoradionecrosis were implanted with a non-looping technique. Overall, 6 of 12 patients treated with a non-looping technique developed an injury, whereas none of the five treated with a looping technique has developed one.(ABSTRACT TRUNCATED AT 400 WORDS)

Intraoperative radiotherapy in patients with recurrent head and neck cancer.

Patients with head and neck cancer who have a relapse of the disease above the clavicles can sometimes be salvaged by additional surgery. However, if all gross tumor cannot be removed during surgery or if the resection margins are unsatisfactory, the likelihood of salvage is remote, especially when postoperative radiotherapy is not feasible due to previous radiotherapy. Between 1979 and 1983, we employed intraoperative brachytherapy for 21 such patients. Sixteen patients had a recurrence after previous surgery and radiotherapy, and 5 after radical radiotherapy. All gross tumor could not be removed in 15 patients, whereas satisfactory margins could not be obtained in 6. In 11 patients, we delivered radiotherapy by a temporary implant of iridium-192 (median dose 4,800 rads in 6 days). In 10 patients, radiotherapy was delivered by a permanent implant of iodine-125 (median activity 13 mCi). Three patients (14 percent) had a relapse within the surgical field, whereas six others (28 percent) had a relapse elsewhere or had development of metastases. Complications developed in four patients (19 percent) and were fatal in one patient. The actuarial disease-free survival rate at 2 years was 55 percent, whereas the rate of local disease control was 81 percent. Our experience suggests that intraoperative brachytherapy can salvage certain high-risk patients with head and neck cancer.

Prospective computer-assisted voice analysis for patients with early stage glottic cancer: A preliminary report of the functional result of laryngeal irradiation

In January 1987 we began a prospective study aimed at evaluating objective parameters of vocal function for all patients treated with RT for early glottic cancer. All patients underwent vocal analysis using a voice analyzer interfaced with a computer. This allowed for the determination of percent voicing (%V) (normal = presence of phonation = 90-100%V). Other parameters such as breathiness (air turbulence or hoarseness) and strain (vocal cord tension) were also measured. Patients were recorded before RT, weekly during RT, and at set intervals after RT. There have been 25 patients studied. Eighteen (18) are evaluable at 9 months after treatment. All patients were male and ranged from 45-84 years old. Fourteen (14) and T1 lesions and received 66 GY/33 fractions to their larynx and 4 had T2 tumors and received 66-70 Gy/33-35 fractions. To date, all patients are locally controlled. Three distinct patterns of %V changes have been encountered. However, all patients demonstrated normal phonation pattern by 3 months after RT, and this is sustained at 9 months follow-up. In addition, 94% of patients have had significant decrease in breathiness after RT, which objectively documents diminished hoarseness. In 83%, breathiness is normal after RT. Most patients have had increased strain after RT, which documents increased vocal cord tension. However, strain remained within normal limits in 89%. Our preliminary analysis suggests that the majority of patients irradiated for early glottic cancer demonstrate a decrease in breathiness and an increase in strain after RT, and enjoy a resultant voice that has normal phonation maintained at 9 months after RT. Our data also demonstrate three distinct phonation patterns. Further follow-up will allow us to determine the prognostic significance, if any, of these patterns, and to continue to follow objective vocal parameters on larger numbers of patient.

A non-looping afterloading technique for base of tongue implants: Results in the first 20 patients

The results of treatment in the first 20 patients treated by a non-looping afterloading technique for base of tongue implant are described. Ten patients had carcinoma recurrent in the base of tongue after previous treatment and they were treated by implant alone. The other 10 patients had previously untreated carcinoma of the base of tongue and they were treated with a combination of interstitial implant, external radiation therapy and surgery. The minimum follow-up is 1 year and maximum 5 years. No local or regional failures have occurred in the previously untreated patients. No local failures have occurred in the previously treated patients who had lesions up to 4 cm in diameter, but three out of four patients with recurrent lesions larger than 4 cm have failed locally. Two patients developed necrosis related to the implant; the factors responsible for this are discussed.

Vocal changes in patients undergoing radiation therapy for glottic carcinoma

A prospective evaluation of vocal changes in patients receiving radiation therapy for T1 and T2 (AJC) glottic carcinoma was undertaken in January 1987. Vocal analysis was performed prior to radiotherapy and at specific intervals throughout the radiation treatment program. The voicing ratio was extrapolated from a sustained vowel /a / phona‐tion using the Visipitch interfaced with the IBM‐PC. Preliminary observations suggested three distinct patterns of vocal behavior: 1. reduced voicing ratio with precipitous improvement within the course of treatment, 2. high initial voicing ratio with reduction secondary to radiation induced edema, with rapid improvement in the voicing component after the edema subsided, and 3. fluctuating voicing ratio during and following treatment. Enrollment of new patients and a 2‐year follow‐up of current patients was undertaken.