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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).

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. Patlents 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.

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°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.

The results of therapy are reported in 296 patients with histologically proven epidermoid carcinoma of the tonsillar fossa; 127 were treated with irradiation alone (5,500 to 7,000 cGy), 133 with preoperative radiotherapy (2,000 to 3,000 cGy) or were initially planned for preoperative irradiation but treated with radiotherapy alone, and 36 with postoperative irradiation (5,000 to 6,000 cGy). The operation in all but 4 patients consisted of an en bloc radical tonsillectomy with ipsilateral lymph node dissection. Actuarial 5-year no evidence of disease (NED) was as follows: survival rates for patients with T1 tumors, 76%; T2, 54%; T3, 45%; and T4, 20%. Patients with no cervical lymphadenopathy or with a small metastatic lymph node (N1) had better relapse-free survival (60% to 70% at 5 years) than those with large or fixed lymph nodes (30% to 40%). Primary tumor recurrence rate in the T1-T2 groups was about 20% in patients treated with irradiation and surgery and 30% for those treated with irradiation alone (difference not statistically significant), 30% in patients with stage T3 lesions in all treatment groups, and 33% in patients with T4 disease treated with surgery and postoperative irradiation compared to 52% with irradiation alone (p = 0.03). The overall recurrence rate in the neck was about 20% for the N0 patients, 25% for N1, and 30% for those with N2 and N3 cervical lymph nodes in the 4 treatment groups. The incidence of contralateral neck recurrences was about 8% with the various treatment modalities.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

From 1962 to 1984, 13 patients with juvenile nasopharyngeal angiofibroma (JNA) were treated with megavoltage radiation therapy. Follow-up ranged from 40 to 255 months (median, 136 months). Two patients received radiation therapy as the initial treatment; the other 11 patients had undergone unsuccessful previous surgical treatment (median, three resections). Gross tumor was evident at the start of radiation therapy in seven patients, and orbital, sphenoid sinus, or intracranial extension was noted in eight of 13 (62%). Doses ranged from 3,600 to 5,200 cGy (median, 4,800 cGy in daily fractions of 180-200 cGy). Tumor was controlled in 11 patients (85%) after irradiation. Two patients were treated with embolization for residual mass; both remained asymptomatic and without evidence of tumor 134 and 83 months after embolization, respectively. With the exception of xerostomia and caries, no significant chronic morbidity was seen. This review and other studies demonstrate that megavoltage radiation therapy is an effective and appropriate treatment for advanced and recurrent JNA; its routine use for early tumors remains controversial.

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%. This study demonstrates that there is no difference in local recurrence or disease-free survival, or time to recurrence relative to the status of the surgical margins, which may be a benefit of the postoperative radiation therapy. This study also demonstrates that there is an increase in the number of patients with grave signs with increasing nodal stage. The rate of neck recurrence in patients with grave signs was substantially higher (54%) than in patients without grave signs (8%), even though these patients also had positive lymph nodes.more » Interestingly, there was also a higher rate of local recurrence among patients who had grave signs. Patients receiving doses higher than 6000 cGy to the primary site had fewer local failures, although within each group of patients with positive or negative surgical margins the differences in survival were minimal.« less

Untreated neoplasms of the neck (tumors of the oropharynx, supraglottic area, carotid body, and thyroid, in addition to malignant lymphadenopathy) were evaluated in 23 patients with magnetic resonance (MR) imaging. The results were compared with computed tomographic (CT) scans in 20 patients. Contrast between tumor and fat was best on relatively T1-weighted images (500/30-35 [TR msec/TE msec]), whereas separation of tumor and muscle was best with relatively T2-weighted pulse sequences (1,500/90). Balanced images (1,500/30-35) provided best overall image quality and best demonstrated vascular anatomy. MR imaging was usually superior to CT in showing the relationship of tumor mass to muscle. MR imaging and contrast material-enhanced CT were equivalent in most patients in defining vascular anatomy, but MR imaging was superior when intravenous contrast material was not administered. However, CT was more helpful in showing bone and cartilage anatomy, and in some patients CT also was better in showing airway abnormalities. Despite these limitations, MR imaging is a promising imaging technique for studying neoplasms of the neck.

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.

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 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.