Scott P. Stringer

Squamous Cell Carcinoma of the Oropharynx Surgery, Radiation Therapy, or Both

The treatment of patients with squamous cell carcinoma (SCC) of the oropharynx remains controversial. No randomized trial has addressed adequately the question of whether surgery (S), radiation therapy (RT), or combined treatment is most effective.

Postoperative irradiation for squamous cell carcinoma of the head and neck: an analysis of treatment results and complications☆

One hundred thirty-four patients with advanced head and neck cancer were treated with radical surgery and postoperative radiation therapy between October 1964 and October 1984. All patients had greater than or equal to 2 years and 84% had greater than or equal to 5 years of follow-up. All patients included in the study were scheduled to receive continuous-course irradiation following a major cancer operation for previously untreated squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx and began radiation treatment less than or equal to 3 months after the surgical procedure. Ninety-six percent had AJCC pathologic Stage III or IV cancer, and all were without evidence of gross disease at the start of irradiation. The majority of recurrences above the clavicles occurred in the primary field (84%) as opposed to the posterior strip (8%) or low neck (8%). Based on multivariate analysis and tabular comparisons, 4 factors were found to be significantly important for predicting disease control above the clavicles: (a) Surgical margin (5-year actuarial control with invasive cancer at the margin, 53%, versus 81% with negative margins, p = .009). Patients with close margins or in situ cancer at the margins had the same rate of control as those with negative margins. (b) Primary site (oral cavity, 64%, versus other sites, 83%; p = .029). (c) Neck Stage (N0-1 versus N2-3). (d) Number of indications for irradiation--for example, bone invasion, multiple positive nodes, perineural invasion (1-3 indications, 85%, versus greater than or equal to 4, 62%; p = .06). The rate of disease control above the clavicles did not correlate well with AJCC pathologic stage: Stage I-II, 67%; Stage III, 81%; Stage IVA (T1-3, N2-3A), 68%; Stage IVB (T4 and/or N3B), 80%. The interval between surgery and the start of irradiation (range 1-10 weeks) also was not prognostically important, even with stratification by tumor dose, surgical margin, and number of indications for irradiation. At 5 years, the actuarial survival rate was 33% for the entire group; for patients with invasive cancer at the margin, the survival rate was approximately half that of those whose margins were free of invasive cancer (17% versus 37%). Based on multivariate analysis, 2 factors were found to significantly increase the probability of death due to cancer: (a) neck Stage (N0-1 versus N2-3); (b) extension of tumor from the primary site into the skin or soft tissues of the neck.(ABSTRACT TRUNCATED AT 400 WORDS)

Diagnostic evaluation of squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site

The purpose of this study was to evaluate the efficacy of the modern diagnostic evaluation for squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site.

Carcinoma of the skin of the head and neck with perineural invasion.

Perineural invasion is observed in a small subset of patients with carcinomas of the skin of the head and neck.

Radiation Therapy for Squamous Cell Carcinoma of the Tonsillar Region: A Preferred Alternative to Surgery?

PURPOSE There are no definitive randomized studies that compare radiotherapy (RT) with surgery for tonsillar cancer. The purpose of this study was to evaluate the results of RT alone and RT combined with a planned neck dissection for carcinoma of the tonsillar area and to compare these data with the results of treatment with primary surgery. PATIENTS AND METHODS Four hundred patients were treated between October 1964 and December 1997 and observed for at least 2 years. One hundred forty-one patients underwent planned neck dissection, and 18 patients received induction (17 patients) or concomitant (one patient) chemotherapy. RESULTS Five-year local control rates, by tumor stage, were as follows: T1, 83%; T2, 81%; T3, 74%; and T4, 60%. Multivariate analysis revealed that local control was significantly influenced by tumor stage (P =.0001), fractionation schedule (P =.0038), and external beam dose (P =.0227). Local control after RT for early-stage cancers was higher for tonsillar fossa/posterior pillar cancers than for those arising from the anterior tonsillar pillar. Five-year cause-specific survival rates, by disease stage, were as follows: I, 100%; II, 86%; III, 82%; IVa, 63%; and IVb, 22%. Multivariate analysis revealed that cause-specific survival was significantly influenced by overall stage (P =.0001), planned neck dissection (P =.0074), and histologic differentiation (P =.0307). The incidence of severe late complications after treatment was 5%. CONCLUSION RT alone or combined with a planned neck dissection provides cure rates that are as good as those after surgery and is associated with a lower rate of severe complications.

Oropharyngeal carcinoma treated with radiotherapy: A 30-year experience

PURPOSE This study was done to determine the outcome in patients with oropharyngeal carcinoma treated at the University of Florida with radiotherapy alone to the primary site, for comparison with reported results of other types of treatment. METHODS AND MATERIALS Of a consecutive cohort of 785 patients with biopsy-proven, previously untreated, invasive squamous cell carcinoma of the oropharynx, this report is based on the 490 patients who had continuous-course irradiation with curative intent at the University of Florida between October 1964 and January 1991. All patients had a minimum 2-year follow-up. Forty-eight percent had Stage T3 or T4 disease, and 64% had clinically apparent neck node metastases. The median radiation dose was 68 Gy for once-a-day treatment and 76.8 Gy for twice-a-day treatment. Patients with advanced neck node disease had planned neck dissection(s) after radiotherapy. RESULTS The overall local control rate after radiotherapy alone was 73%. The ultimate local control rate (including surgical salvage) was 78%. At 5 years, the probability of control of neck disease was 85%; control above the clavicles, 67%; absolute survival, 44%; cause-specific survival, 77%; distant metastasis (as the first or only site of failure), 11%. Thirteen patients (2.6%) experienced severe treatment complications. CONCLUSION Radiotherapy results in tumor control and survival rates comparable with rates achieved with combined irradiation and surgery, with less morbidity.

Synchronous and Metachronous Squamous Cell Carcinomas of the Head and Neck Mucosal Sites

PURPOSE The present study presents the experience at the University of Florida with synchronous and metachronous squamous cell carcinomas of the head and neck mucosal sites. PATIENTS AND METHODS This study included 1,112 patients with squamous cell carcinomas of the oropharynx, hypopharynx, and supraglottic larynx treated with radiation therapy with curative intent from 1964 to 1997. All patients had follow-up for at least 2 years. No patients were lost to follow-up. RESULTS The overall survival rate was 45% and the disease-specific survival rate was 67% at 5 years after initial diagnosis of carcinoma of the head and neck mucosal sites. Seventy-seven patients (7%) presented with synchronous carcinomas of the head and neck mucosal sites and 103 patients (9%) developed metachronous carcinomas of the head and neck mucosal sites at 0.6 to 21.7 years (median, 3.6 years). The overall survival rate was 31%, and the disease-specific survival rate was 50% at 5 years after metachronous carcinomas of the head and neck mucosal sites. Seven patients (1%) developed metachronous carcinomas of the thoracic esophagus at 1 to 11.1 years (median, 2.8 years), 15 patients (1%) presented with synchronous carcinomas of the lung, and 83 patients (7%) developed metachronous carcinomas of the lung at 0.6 to 17.6 years (median, 3.5 years). CONCLUSION Development of synchronous and metachronous squamous cell carcinomas of the head and neck mucosal sites are in part responsible for failure to improve overall survival rates for patients with squamous cell carcinomas of the head and neck mucosal sites, justifying rigorous follow-up and studies on chemoprevention.

Skin cancer of the head and neck with clinical perineural invasion.

PURPOSE To review treatment and outcomes in 62 patients with clinical and/or gross evidence of perineural invasion from skin cancer of the head and neck. METHODS AND MATERIALS Sixty-two patients received radiotherapy at the University of Florida as part or all of their treatment between January 1965 and April 1995. All patients had clinical signs and symptoms of perineural involvement and/or documentation of tumor extending to grossly involve nerve(s). Twenty-one patients underwent therapy for previously untreated lesions, including 12 who received radiotherapy alone and nine who had surgery with postoperative radiotherapy. Forty-one patients underwent therapy for recurrent lesions, including 18 treated with radiotherapy alone and 23 who received preoperative or postoperative radiotherapy. RESULTS Factors on multivariate analysis that predicted local control included patient age, previously untreated vs. recurrent lesions, presence of clinical symptoms, and extent of radiotherapy fields. Recurrence patterns were predominantly local; 26 of 31 patients (84%) who developed local recurrence after treatment had recurrent cancer limited to the primary site. CONCLUSIONS Many patients with skin cancer and symptomatic perineural invasion have disease that is incompletely resectable. Approximately half these patients will be cured with aggressive irradiation alone or combined with surgery. Age, prior treatment, and clinical symptoms influence the likelihood of cure.

Is Radiation Therapy a Preferred Alternative to Surgery for Squamous Cell Carcinoma of the Base of Tongue

PURPOSE To evaluate irradiation alone for treatment of base-of-tongue cancer. PATIENTS AND METHODS Two hundred seventeen patients with squamous cell carcinoma of the base of tongue were treated with radiation alone and had follow-up for >/= 2 years. RESULTS Local control rates at 5 years were as follows: T1, 96%; T2, 91%; T3, 81%; and T4, 38%. Multivariate analysis revealed that T stage (P =.0001) and overall treatment time (P =.0006) significantly influenced local control. The 5-year rates of local-regional control were as follows: I, 100%; II, 100%; III, 83%; IVA, 64%; and IVB, 65%. Multivariate analysis revealed that the following parameters significantly affect the probability of this end point: T stage (P =.0001), overall treatment time (P =.0001), overall stage (P =.0131), and addition of a neck dissection (P =.0021). The rates of absolute and cause-specific survival at 5 years were as follows: I, 50% and 100%; II, 81% and 100%; III, 65% and 76%; IVA, 42% and 56%; and IVB, 44% and 52%. Severe radiation complications developed in eight patients (4%). CONCLUSION The likelihood of cure after external-beam irradiation was related to stage, overall treatment time, and addition of a planned neck dissection. The local-regional control rates and survival rates after radiation therapy were comparable to those after surgery, and the morbidity associated with irradiation was less.

Management of minor salivary gland carcinomas

PURPOSE To assess the role of radiotherapy alone or in combination with surgery in the treatment of patients with malignant minor salivary gland carcinomas. METHODS AND MATERIALS Between October 1964 and November 1992, 95 patients with minor salivary gland carcinomas of the head and neck received radiotherapy with curative intent. Eighty-seven patients were previously untreated, and 8 were treated for postsurgical recurrence. Fifty-one patients were treated with radiotherapy alone, and 44 were treated by surgical resection plus radiotherapy. Patients were staged according to the 1983 American Joint Committee on Cancer (AJCC) staging criteria for squamous cell carcinomas. RESULTS The 20-year actuarial rate of local control was 57% with no significant difference according to histologic type. When tumor stage was taken into consideration, there were no significant differences in local control according to tumor site. The 12-year actuarial probability of distant metastases was 40% (19% as the only site of failure). In multivariate analyses, local control was significantly affected only by tumor stage and treatment type (combined therapy better than radiotherapy alone); tumor stage was a significant predictor of cause-specific survival and freedom from relapse. Freedom-from-relapse rates were higher for patients who received combined treatment (p = 0.068). CONCLUSIONS Treatment of minor salivary gland carcinomas is usually by combined surgery and radiotherapy, but there are situations where surgery alone or radiotherapy alone may be used. The ability to control these tumors with radiotherapy alone is not widely recognized. In the present series, the tumor was locally controlled in 20 patients with previously untreated primary lesions after radiotherapy alone (2.5 to 21 years) and in 4 other patients who were treated by radiotherapy alone for postsurgical recurrent tumor (3.5 to 14 years after radiotherapy). Contrary to the widely held belief that local recurrence after radiotherapy eventually develops in all patients with adenoid cystic carcinoma, local control has been maintained in 13 patients after radiotherapy alone; 5 of the 13 patients have been observed for 10 to 17 years.