V.R. Devineni

Carcinoma of the nasopharynx: factors affecting prognosis

This is a retrospective analysis of 143 patients with histologically confirmed epidermoid carcinoma of the nasopharynx treated with definitive irradiation. Patients were treated with a combination of Cobalt-60, 4 to 6 MV X rays, and 18 to 25 MV X rays to the primary tumor and the upper necks, excluding the spinal cord at 4000 to 4500 cGy to total doses of 6000 to 7000 cGy. At 10 years the actuarial primary tumor failure rate was 15% in T1, 25% in T2, 33% in T3, and 60% in T4 lesions. The corresponding failure rate in the neck was 18% for N0, 14% for N1, and 33% for N2 and N3 lymphadenopathy. The incidence of distant metastasis was related to the stage of the cervical lymphadenopathy: 16% in patients with N0-N1 nodes compared with 40% in the N2-3 node group. The actuarial 10-year disease-free survival rate was 55% to 60% for T1-3N0-1 tumors, 45% for T1-3N2-3 tumors, 35% for T4N0-1, and 20% for T4N2-3 lesions. The overall 10-year survival rate was about 40% for patients with T1-2N0-1 tumors, 30% for those with T3 any N stage tumors, and only 10% for the patients with T4 lesions. Multivariate analysis showed that tumor stage and histological type, cranial nerve involvement, patient age, and doses of irradiation to the nasopharynx were significant prognostic factors for local/regional tumor control. Increasing doses of irradiation resulted in nasopharynx tumor control in 80% of the patients receiving 6600 to 7000 cGy and 100% of those receiving over 7000 cGy in the T1, T2, and T3 tumors. However, the tumor control rate did not rise above 55% even for doses over 7000 cGy in the T4 lesions. Local tumor control was higher in patients who had simulation (55/78 = 71%) compared with those on whom simulation was not performed (34/61 = 56%) (p = 0.10). Moreover, patients with more than 75% of the reviewed films judged as adequate had 69% primary tumor control (66/96) compared with 53% (23/43) for those with fewer than 75% adequate portal films (p = 0.07).

Reirradiation of recurrent head and neck cancers.

Ninety‐nine patients with recurrent cancers of the head and neck region were treated with surgery, radiation therapy, or combination therapy. The follow‐up period ranged from 18 months to 18 years. An initial overall complete response rate of 67% and a partial response rate of 7% (overall response rate –‐ 74%) were achieved. The eventual tumor control rate was 15%. Although equal initial response rates were achieved in recurrences at the primary site and the cervical nodes, the eventual local control was better for the former (21% vs. 10%). Patients receiving less than 5,000 rad had radiotherapy had a 44% complete response and an 11% eventual tumor control. Patients receiving over 5,000 rad had an 80% complete response and a 25% eventual tumor control.

Cervical metastases from unknown primaries: Radiotherapeutic management and appearance of subsequent primaries

Between 1964 and 1986, 72 patients who presented with squamous or undifferentiated metastatic carcinoma to neck nodes, where the primary tumor could not be found by standard clinical procedures, were treated at the Mallinckrodt Institute of Radiology. These cases were managed in the following manner: biopsy and radiotherapy in 46 out of 72 patients, radiotherapy (RT) and a planned neck dissection in 14 out of 72, and neck dissection after failure to achieve a complete response (CR) with RT in 12 out of 72. Minimum follow-up was 2 years. The initial CR rates for stages N1, N2a, N2b, N3a, and N3b were 83%, 93%, 61%, 50%, and 33%, respectively. The long-term neck tumor control for the same stages was 83%, 71%, 67%, 44%, and 50%, respectively. One patient had soft tissue necrosis and two had carotid artery ruptures, one of which left no symptomatic sequelae. Twenty-one out of 72 patients developed subsequent primary tumor. Only one of these patients survived. This incidence was not affected significantly by prophylactic treatment of the mucosal areas except in patients with bilateral neck nodes, undifferentiated or poorly differentiated histologies, and/or posterior cervical node involvement. A multivariate analysis showed that prognosticators of an improved disease-free survival were: a complete clearance of tumor by the end of radiotherapy (p less than 0.0009) and no appearance of a subsequent primary tumor (p = 0.035). The only factor that correlated with an increased loco-regional control was having a complete response by the end of radiotherapy (p less than 0.00009). The recommended management and possible ways of preventing the appearance of subsequent primaries will be discussed.

The Risk of Contralateral Lymphatic Metastases for Cancers of the Larynx and Pharynx

PURPOSE This study was undertaken to determine the risk of cervical metastases to the contralateral side in patients treated for carcinoma of the larynx and pharynx. PATIENTS AND METHOD Retrospective evaluation of 846 patients treated between 1962 and 1981 with carcinoma of the supraglottis, transglottis, and pyriform sinus were reviewed. Lesions were classified as either transglottic with fixed vocal cord (TG-F), transglottic with mobile vocal cords (TG-M), central supraglottic (SG-C), marginal supraglottic (SG-M), glossoepiglottic cancers of the suprahyoid epiglottic, vallecula, and tongue base (SG-GE), and cancers of the pyriform sinus (PS). RESULTS Contralateral lymph node metastases were identified at presentation or later developed in SG-GE 26%, SG-M 14%, PS 13%, SG-C 7%, TG 4%. Contralateral metastases were significantly higher in patients with ipsilateral metastasis. The risk of contralateral metastasis was unrelated to the primary tumor size. CONCLUSIONS All but 79 patients received variable doses of irradiation to the contralateral neck. Therefore, the risk of metastatic disease is probably higher than reported. Parotid-sparing radiation technique is suggested for centrally located cancers of the supraglottis and transglottis when ipsilateral nodes are not involved because the risk of contralateral neck involvement is sufficiently low that opposite neck irradiation may be safely avoided.

Combined hyperthermia and irradiation in the treatment of superficial tumors: results of a prospective randomized trial of hyperthermia fractionation (1/wk vs 2/wk)☆

From December 1984 to December 1989, 240 superficially located recurrent/metastatic malignant lesions (173 patients) were enrolled in a prospective randomized study of one versus two hyperthermia fractions per week. In the majority of patients, the dose of radiation therapy was less than 4000 cGy over 4 to 5 weeks. Stratification was by tumor size, site, and histology. The goal of the hyperthermia sessions were 42.5 degrees C for 45-60 min minimum intra-tumor measured temperature. Hyperthermia was given after radiation within 30-60 min. External applicators, both microwave (over 90% of treatments) and ultrasound, were used. Overall, complete response rate in 222 evaluable lesions was 56.3% (125/222) with a minimum follow-up of 6 months and a maximum follow-up of 52 months. The complete response rate for once a week versus twice a week hyperthermia group was 54.7% and 57.8%, respectively. The severe complication rate was 18% (41/222). There was no difference between the two treatment arms. Cox regression analyses were performed to study the prognostic significance of patient characteristics, tumor characteristics, and treatment parameters. Detailed analysis and results are presented.

Supraglottic carcinoma: impact of radiation therapy on outcome of patients with positive margins and extracapsular nodal disease.

Seventy‐nine patients with supraglottic carcinoma treated between 1966 and 1985 are reviewed. All patients were treated with surgery and postoperative radiation therapy. Thirty‐five percent of the patients had positive margins at the site of resection of the primary tumor. Of the 25 patients who had positive nodal disease, 13 patients (52%) had either extracapsular extension or soft‐tissue or adjacent organ invasion, referred to in composite as “grave signs.” The median follow‐up of the patients was 4.9 years and all patients were followed for a minimum of 3 years. The disease‐free survival for all patients was 76% at 2 years and 71% at 3 years. The locoregional control rate for all patients was 70%.

Malignant tumors of the middle ear and external auditory canal: a 20-year review.

Twenty-four patients with malignant tumors of the external auditory canal and middle ear, originally seen between 1960 and 1980, were reviewed retrospectively. Seventeen patients had epidermoid carcinoma, one had adenocarcinoma, three had rhabdomyosarcoma, and one had osteosarcoma. At presentation, four had disease confined to the external auditory canal, three had superficial invasion of the bony canal, four had deeply invasive disease, and thirteen had disease that extended beyond the temporal bone. Treatment consisted of radiation, surgery, and combination therapy. Four patients with osteosarcoma or rhabdomyosarcoma received adjuvant chemotherapy. Five years after therapy, one of four patients with external auditory canal tumor died of disease, and two died of intercurrent disorders. One of three patients with superficial temporal bone invasion and two of four patients with deeply invasive tumor died of their disease; another died of intercurrent disorder. Twelve of 13 patients with tumor beyond the temporal bone died.