Pre-treatment and treatment related risk factors for severe late toxicity after chemo-RT for head and neck cancer: An RTOG analysis

5500

Background: Concurrent chemoradiotherapy (CCRT) for squamous cell carcinoma of the head and neck (SCCHN) improves tumor control, but its toxicity is formidable. This study evaluates factors that might predict for severe late toxicity following CCRT. Methods: Patients treated with CCRT were analyzed from three RTOG trials of locally advanced SCCHN: 91–11 arm #2 (XRT + high dose cisplatin for larynx cancer); 97–03 (phase II study of various doublets of chemotherapy with XRT); and 99–14 (phase II study of accelerated XRT + high dose cisplatin). Severe late toxicity was defined in this secondary analysis as late (>180 days from the start of XRT) Grade 3–4 pharyngeal/laryngeal toxicity (RTOG/EORTC late toxicity scoring system); requirement for a feeding tube ≥2 years after registration; or potential treatment-related death (e.g. pneumonia) within 3 years. Case-control analysis was performed to determine factors predictive of severe late toxicity, with a multivariate logistic regression model that included pre-treatment and treatment potential factors. Results: The total sample size of patients treated with CCRT from these three studies was 479; 226 were evaluable (119 patients had severe pre-treatment laryngopharynx dysfunction and 134 had persistent/recurrent cancer). There were 98 cases (patients with severe late toxicity) and 128 controls. In the multivariate model, significant predictors of severe late toxicity were older age (odds ratio 1.05 per year, p = 0.002); advanced T-stage (odds ratio 2.21; p = 0.014); larynx/hypopharynx tumor site (odds ratio 3.20; p = 0.011); and neck dissection (ND) after XRT (odds ratio 2.22; p = 0.029). Radiotherapy dose intensity and chemotherapy dose intensity were not predictive. Among 47 patients who underwent post-XRT ND, the crude rate of severe late toxicity was 55%, compared with 40% for the subgroup of 179 patients who did not undergo post-XRT ND (p = 0.05). Conclusions: Severe late toxicity following CCRT is common. Older age, advanced T-stage, and larynx/hypopharynx primary site were independent risk factors. Neck dissection after CCRT may be associated with an increased risk of these complications. This work was supported in part by the Commonwealth of Pennsylvania (Tobacco Settlement Grant).

No significant financial relationships to disclose.

Induction chemotherapy (CT) with weekly paclitaxel, carboplatin, and cetuximab for squamous cell carcinoma of the head and neck (HN)

5520

Background: To further determine the potential efficacy of combining cetuximab with chemotherapy, we conducted a phase II trial with induction CT consisting of 6 weekly cycles of paclitaxel 135 mg/m2, carboplatin auc 2 and cetuximab 400 mg/m2 week 1 then 250 mg/m2 weekly. Methods: Patients (pts) were treatment-naïve with staging T0–4, N2b/c/3, M0; PS 0/1; with any HN primary site; and evaluated for clinico-radiographic complete response (CR). Pathway signaling biomarkers and genomic profiling are planned. Following CT, patients underwent “risk-based” local therapy. Choice of surgery ± postoperative radiotherapy (RT), RT, or concomitant chemoRT was based upon tumor stage and site at diagnosis. Results: Patient entry (2/05–11/05) has concluded with 47 patients (33 m, 14 f), median age 53 years and range 21–78. Two patients are too early for response analysis. Oropharynx was the dominant primary site, N = 42, with staging: Tx N2b - 4, Tx N3 - 1; T1 N2b - 5, T1 N2c - 6, T1 N3 - 3; T2 Nx - 1, T2 N2b - 10, T2 N3 - 3; T3 N2b - 5, T3 N2c - 3, T3 N3 - 1; T4 N2b - 2 and T4 N2c - 3. Toxicity was acceptable. Sixteen (34%) pts had grade 3/4 leukopenia; 22 (47%) grade 3 folliculitis (median 5 cycles of cetuximab administered); and 2 (4%) serious hypersensitivity. All 41 evaluable pts achieved a response in the primary site, 7 (17%) PR and 34 (83%) CR. Forty-three of 44 evaluable patients achieved a nodal response, 31 (70%) PR and 12 (27%) CR. Overall, 11 of 45 (24%) pts were disease-free after CT. At this early point, 3 pts have had 4 tumor recurrences, 2 local and 2 distant. Conclusions: CT administered over 6 wks, with cetuximab, was feasible and highly active with all patients achieving a tumor response. Severe skin rash affected nearly 50% of pts. Preliminary survival data, and correlation of surrogate biomarkers with tumor response are to be presented. Supported by: Bristol Myers Squibb Oncology and Imclone Systems Grant #CS 2004–00011435 WC.

[Table: see text]

Radiotherapy for Head and Neck Cancer

The length and quality of head and neck cancer survivorship continues to improve. Radiotherapy has been central to this process through advances in treatment technology, fractionation schemas, radiosensitizing chemotherapy, and surgical technique. The future of head and neck radiotherapy looks brighter still with progress in radiosensitizing biologic therapy, molecular characterization, functional imaging, and rehabilitative strategies fast approaching. Head and neck cancer, a disease once fraught with nihilism and failure, is evolving into a major success story of multidisciplinary solid tumor management. Continued dedication and work on the part of provider and patient alike will be required to make this promise a reality.

Preliminary results of Radiation Therapy Oncology Group 97-03: a randomized phase ii trial of concurrent radiation and chemotherapy for advanced squamous cell carcinomas of the head and neck

PURPOSE

To define further the role of concurrent chemoradiotherapy for patients with advanced squamous carcinoma of the head and neck.

PATIENTS AND METHODS

The Radiation Therapy Oncology Group developed this three-arm randomized phase II trial. Patients with stage III or IV squamous carcinoma of the oral cavity, oropharynx, or hypopharynx were eligible. Each of three arms proposed a radiation schedule of 70 Gy in 35 fractions. Patients on arm 1 were to receive cisplatin 10 mg/m(2) daily and fluorouracil (FU) 400 mg/m(2) continuous infusion (CI) daily for the final 10 days of treatment. Treatment on arm 2 consisted of hydroxyurea 1 g every 12 hours and FU 800 mg/m(2)/d CI delivered with each fraction of radiation. Arm 3 patients were to receive weekly paclitaxel 30 mg/m(2) and cisplatin 20 mg/m(2). Patients randomly assigned to arms 1 and 3 were to receive their treatments every week; patients on arm 2 were to receive their therapy every other week.

RESULTS

Between 1997 and 1999, 241 patients were entered onto study; 231 were analyzable. Ninety-two percent, 79%, and 83% of patients on arms 1, 2, and 3, respectively, were able to complete their radiation as planned or with an acceptable variation. Fewer than 10% of patients had unacceptable deviations or incomplete chemotherapy in the three arms. Estimated 2-year disease-free and overall survival rates were 38.2% and 57.4% for arm 1, 48.6% and 69.4% for arm 2, and 51.3% and 66.6% for arm 3.

CONCLUSION

We have demonstrated that three different approaches of concurrent multiagent chemotherapy and radiation were feasible and could be delivered to patients in a multi-institutional setting with high compliance rates.

Postoperative radiotherapy for malignant tumors of the submandibular gland

PURPOSE

This retrospective study assessed the outcome and patterns of failure for patients with malignant submandibular tumors treated with surgery and postoperative radiation.

METHODS AND MATERIALS

Between 1965 and 1995, 83 patients aged 11-83 years old received postoperative radiotherapy after resection of submandibular gland carcinomas. The most common radiation technique was an appositional field to the submandibular gland bed using electrons either alone or mixed with photons. Primary tumor bed doses ranged from 50 to 69 Gy (median, 60 Gy). Regional lymph nodes (ipsilateral Levels I-IV) were irradiated in 66 patients to a median dose of 50 Gy. Follow-up time ranged from 5 to 321 months (median, 82 months).

RESULTS

Actuarial locoregional control rates were 90%, 88%, and 88% at 2, 5, and 10 years, respectively. The corresponding disease-free survival rates were 76%, 60%, and 53%, because 27 of 74 patients (36%) who attained locoregional control developed distant metastases. Adenocarcinoma, high-grade histology, and treatment during the earlier years of the study were associated with worse locoregional control and disease-free survival. The median survival times for patients with and without locoregional control were 183 months and 19 months, respectively. Actuarial 2-, 5-, and 10-year survival rates were 84%, 71%, and 55%, respectively. Late complications occurred in 8 patients (osteoradionecrosis, 5 patients).

CONCLUSIONS

High-risk cancers of the submandibular gland have a historic control rate of approximately 50% when treated with surgery alone. In the current series, locoregional control rates for high-risk patients with submandibular gland cancers treated with surgery and postoperative radiotherapy were excellent, with an actuarial locoregional control rate of 88% at 10 years.

Randomized trial addressing risk features and time factors of surgery plus radiotherapy in advanced head-and-neck cancer

PURPOSE

A multi-institutional, prospective, randomized trial was undertaken in patients with advanced head-and-neck squamous cell carcinoma to address (1) the validity of using pathologic risk features, established from a previous study, to determine the need for, and dose of, postoperative radiotherapy (PORT); (2) the impact of accelerating PORT using a concomitant boost schedule; and (3) the importance of the overall combined treatment duration on the treatment outcome.

METHODS AND MATERIALS

Of 288 consecutive patients with advanced disease registered preoperatively, 213 fulfilled the trial criteria and went on to receive therapy predicated on a set of pathologic risk features: no PORT for the low-risk group (n = 31); 57.6 Gy during 6.5 weeks for the intermediate-risk group (n = 31); and, by random assignment, 63 Gy during 5 weeks (n = 76) or 7 weeks (n = 75) for the high-risk group. Patients were irradiated with standard techniques appropriate to the site of disease and likely areas of spread. The study end points were locoregional control (LRC), survival, and morbidity.

RESULTS

Patients with low or intermediate risks had significantly higher LRC and survival rates than those with high-risk features (p = 0.003 and p = 0.0001, respectively), despite receiving no PORT or lower dose PORT, respectively. For high-risk patients, a trend toward higher LRC and survival rates was noted when PORT was delivered in 5 rather than 7 weeks. A prolonged interval between surgery and PORT in the 7-week schedule was associated with significantly lower LRC (p = 0.03) and survival (p = 0.01) rates. Consequently, the cumulative duration of combined therapy had a significant impact on the LRC (p = 0.005) and survival (p = 0.03) rates. A 2-week reduction in the PORT duration by using the concomitant boost technique did not increase the late treatment toxicity.

CONCLUSIONS

This Phase III trial established the power of risk assessment using pathologic features in determining the need for, and dose of, PORT in patients with advanced head-and-neck squamous cell cancer in a prospective, multi-institutional setting. It also revealed the impact of the overall treatment time in the combination of surgery and PORT on the outcome in high-risk patients and showed that PORT acceleration without a reduction in dose by a concomitant boost regimen did not increase the late complication rate. These findings emphasize the importance of coordinated interdisciplinary care in the delivery of combined surgery and RT.

Altered fractionation for head and neck cancer

A conventional course of radiation for squamous cell carcinoma in the United States is generally 70 Gy in 7 weeks, with a once-daily dose of 1.8 to 2 Gy. This schedule has a modest success rate in curing head and neck cancer. The past several decades have seen numerous investigations into altering this schedule to optimize the results of radiation. Two approaches, founded on radiobiologic principles and clinical observations, have been tested with overlap between both concepts. Hyperfractionation is based on the ability to deliver radiotherapy in small fractions and increased total doses, while not adding to late toxicity. Accelerated fractionation is based on the observations that radiation injury causes accelerated tumor clonogen repopulation and that shortening the overall treatment time helps overcome this phenomenon. Both approaches have been shown to result in modest gains when tested in randomized trials, culminating with the completion of a Radiation Therapy Oncology Group trial (RTOG 9003). This randomized trial of more than 1,000 patients addressed various fractionation schedules proposed to improve results for head and neck cancer patients treated with radiation.

Can positron emission tomography improve the quality of care for head-and-neck cancer patients?

PURPOSE

Fluoro-2-deoxy-d-glucose-positron emission tomography (FDG-PET) is a functional imaging modality that measures the relative uptake of 18FDG with PET. The purpose of this review is to assess the potential contribution of FDG-PET scans to the treatment of head-and-neck cancer patients.

METHODS AND MATERIALS

Data were assessed from the literature with attention to what additional information may be gained from the use of FDG-PET in four clinical settings: (1) detection of occult metastatic disease in the neck, (2) detection of occult primaries in patients with neck metastases, (3) detection of synchronous primaries or metastatic disease in the chest, and (4) detection of residual/recurrent locoregional disease.

RESULTS

Although the data are somewhat conflicting, FDG-PET appears to add little additional value to the physical examination and conventional imaging studies (supplemented by biopsy when appropriate) for the detection of subclinical nodal metastases, unknown primaries, or disease in the chest. However, FDG-PET scans are quite useful in differentiating residual/recurrent disease from treatment-induced normal tissue changes. A positive FDG-PET scan at 1 month after radiotherapy is highly indicative of the presence of residual disease, and a negative scan at 4 months after treatment is highly predictive of tumor eradication.

CONCLUSIONS

Large-scale studies using newer generation equipment and more defined methods are needed to more rigorously assess the potential of FDG-PET in the detection of subclinical primary or simultaneous secondary tumors and of nodal or systemic spread. Currently, however, FDG-PET can contribute to the detection of residual/early recurrent tumors, leading to the timely institution of salvage therapy or the prevention of unnecessary biopsies of irradiated tissues, which may aggravate injury.

Combined interferon-alfa, 13-cis-retinoic acid, and alpha-tocopherol in locally advanced head and neck squamous cell carcinoma: novel bioadjuvant phase II trial

PURPOSE

Retinoids and interferons (IFNs) have single-agent and synergistic combined effects in modulating cell proliferation, differentiation, and apoptosis in vitro and clinical activity in vivo in the head and neck and other sites. Alpha-tocopherol has chemopreventive activity in the head and neck and may decrease 13-cis-retinoic acid (13-cRA) toxicity. We designed the present phase II adjuvant trial to prevent recurrence or second primary tumors (SPTs) using 13-cRA, IFN-alpha, and alpha-tocopherol in locally advanced-stage head and neck cancer.

PATIENTS AND METHODS

After definitive local treatment with surgery, radiotherapy, or both, patients with locally advanced SCCHN were treated with 13-cRA (50 mg/m(2)/d, orally, daily), IFN-alpha (3 x 10(6) IU/m(2), subcutaneous injection, three times a week), and alpha-tocopherol (1,200 IU/d, orally, daily) for 12 months, with a dose modification. Screening for recurrence or SPTs was performed every 3 months.

RESULTS

Tumors of 11 (24%) of the 45 treated patients were stage III, and 34 (76%) were stage IV. Thirty-eight (86%) of 44 patients completed the full 12-month treatment (doses modified as needed). Toxicity generally was consistent with previous IFN and 13-cRA reports and included mild to moderate mucocutaneous and flu-like symptoms; occasional significant fatigue (grade 3 in 7% of patients), mild to moderate hypertriglyceridemia in 30% of patients who continued treatment along with antilipid therapy, and mild hematologic side effects. Six patients did not complete the planned treatment because of intolerable toxicity or social problems. At a median 24-months of follow-up, our clinical end point rates were 9% for local/regional recurrence (four patients), 5% for local/regional recurrence and distant metastases (two patients), and 2% for SPT (one patient), which was acute promyelocytic leukemia (ie, not of the upper aerodigestive tract). Median 1- and 2-year rates of overall survival were 98% and 91%, respectively, and of disease-free survival were 91% and 84%, respectively.

CONCLUSION

The novel biologic agent combination of IFN-alpha, 13-cRA, and alpha-tocopherol was generally well tolerated and promising as adjuvant therapy for locally advanced squamous cell carcinoma of the head and neck. We are currently conducting a phase III randomized study of this combination (v no treatment) to confirm these phase II study results.

ORGAN PRESERVATION FOR CARCINOMA OF THE LARYNX AND HYPOPHARYNX

Treatment of laryngeal and hypopharyngeal cancers often necessitates total laryngectomy. This article reviews approaches of curing patients with these diseases while preserving their larynx. Strategies include radiation alone, neoadjuvant chemotherapy with radiation for responders, or concurrent chemotherapy and radiation. Both retrospective experiences and randomized trials evaluating differing therapies in an effort to achieve voice preservation are reported and analyzed.

A Radiation Therapy Oncology Group (RTOG) phase III randomized study to compare hyperfractionation and two variants of accelerated fractionation to standard fractionation radiotherapy for head and neck squamous cell carcinomas: first report of RTOG 9003

PURPOSE

The optimal fractionation schedule for radiotherapy of head and neck cancer has been controversial. The objective of this randomized trial was to test the efficacy of hyperfractionation and two types of accelerated fractionation individually against standard fractionation.

METHODS AND MATERIALS

Patients with locally advanced head and neck cancer were randomly assigned to receive radiotherapy delivered with: 1) standard fractionation at 2 Gy/fraction/day, 5 days/week, to 70 Gy/35 fractions/7 weeks; 2) hyperfractionation at 1. 2 Gy/fraction, twice daily, 5 days/week to 81.6 Gy/68 fractions/7 weeks; 3) accelerated fractionation with split at 1.6 Gy/fraction, twice daily, 5 days/week, to 67.2 Gy/42 fractions/6 weeks including a 2-week rest after 38.4 Gy; or 4) accelerated fractionation with concomitant boost at 1.8 Gy/fraction/day, 5 days/week and 1.5 Gy/fraction/day to a boost field as a second daily treatment for the last 12 treatment days to 72 Gy/42 fractions/6 weeks. Of the 1113 patients entered, 1073 patients were analyzable for outcome. The median follow-up was 23 months for all analyzable patients and 41.2 months for patients alive.

RESULTS

Patients treated with hyperfractionation and accelerated fractionation with concomitant boost had significantly better local-regional control (p = 0.045 and p = 0.050 respectively) than those treated with standard fractionation. There was also a trend toward improved disease-free survival (p = 0.067 and p = 0.054 respectively) although the difference in overall survival was not significant. Patients treated with accelerated fractionation with split had similar outcome to those treated with standard fractionation. All three altered fractionation groups had significantly greater acute side effects compared to standard fractionation. However, there was no significant increase of late effects.

CONCLUSIONS

Hyperfractionation and accelerated fractionation with concomitant boost are more efficacious than standard fractionation for locally advanced head and neck cancer. Acute but not late effects are also increased.

Phase I/II trial of radiation with chemotherapy "boost" for advanced squamous cell carcinomas of the head and neck: toxicities and responses

PURPOSE

Extrapolating from our experience delivering a "boost" field of radiation concurrently with fields treating both gross and subclinical disease at the end of a course of radiation therapy, we developed a regimen to deliver concurrent chemotherapy during the last 2 weeks of a conventionally fractionated course of radiation.

PATIENTS AND METHODS

Patients had stage III or IV biopsy-proven squamous cell carcinoma originating from a head and neck mucosal site. The regimen was 70 Gy delivered over 7 weeks with concurrent fluorouracil (5-FU) and cisplatin given daily with each radiation dose during the last 2 weeks. A phase I study was performed to determine the maximum-tolerated dose (MTD) before a phase II study was conducted.

RESULTS

The MTD was 400 mg/m(2) per day for 5-FU and 10 mg/m(2) per day for cisplatin. Mucositis persisting more than 6 weeks after therapy was the dose-limiting toxicity. A total of 60 patients were treated on the two phases of the study. Eighteen patients (35%) treated at the MTD developed prolonged mucositis. There were two cases of neutropenic sepsis, including one fatality. The actuarial 2-year rates for overall survival, freedom from relapse, and local control were 62%, 59%, and 80%, respectively.

CONCLUSION

Preliminary locoregional control rates seem to be higher than those reported for treatment with radiation alone. Toxicity was also greater than that seen with radiation alone, but the regimen was designed to deliver an intense treatment schedule, which could be completed without significant interruptions, and to obtain high control rates above the clavicles. These end points were achieved.

Postoperative radiation for squamous cell carcinoma metastatic to cervical lymph nodes from an unknown primary site: outcomes and patterns of failure

BACKGROUND

This retrospective study assesses the outcomes and patterns of failure in patients with squamous cell carcinoma metastatic to cervical lymph nodes from an unknown primary site treated with combined surgery and postoperative radiotherapy.

METHODS

One hundred thirty-six patients with squamous cell carcinoma metastatic to cervical lymph nodes from an unknown primary source were treated postoperatively with radiotherapy at the University of Texas M. D. Anderson Cancer Center between the years 1968 and 1992. Stage distribution was: N1, 31 patients; N2a, 49; N2b, 25; N2c, 3; N3, 18; and Nx, 10. Thirty-nine patients had excisional biopsies only, 64 patients underwent modified neck dissections, and 33 had radical neck dissections. Extracapsular extension was present in 87 cases. Fifty-nine patients had multiple nodes involved. The median duration of follow-up for surviving patients was 8.7 years.

RESULTS

Twelve patients, all with extracapsular nodal disease, developed regional relapse. The 5-year actuarial rates of regional relapse in patients with and without extracapsular nodal disease were 16% and 0%, respectively (p = .004). Nine patients (22%) with extracapsular disease and multiple nodes relapsed compared with three patients (7%) with extracapsular disease and a solitary node (p = .02). None of the patients treated with excisional biopsy and radiotherapy relapsed regionally. No statistically significant relationship between dose, treatment duration, time interval between surgery, and the start of radiotherapy and relapse was detected. The 2-, 5-, and 10-year actuarial disease-specific survival rates were 82%, 74%, and 68%, respectively. Fourteen patients developed cancers in head and neck mucosal sites; six of these cancers were located in unirradiated tissues.

CONCLUSIONS

Relapse occurred infrequently in patients treated with excisional biopsies and postoperative radiotherapy. Extracapsular extension and multiple nodes were associated with worse regional control and disease-specific survival. These results appear consistent with those expected for patients with advanced neck disease and a known primary site, and the absence of a primary site should not exclude patients from studies aiming to improve outcomes in patients with extensive neck disease from a head and neck squamous cell cancer. We continue to recommend radiation to the necks and pharyngeal axis for patients suspected of having residual microscopic disease following surgery for squamous cell carcinoma metastatic to the neck from an unknown primary site.

Ethmoid sinus carcinomas: natural history and treatment results

PURPOSE

This retrospective study was undertaken to assess the clinical features and results of treatment of carcinomas of the ethmoid sinus.

MATERIALS AND METHODS

The records of 34 patients with ethmoid sinus carcinomas treated with curative intent at the U.T.M.D. Anderson Cancer Center (UTMDACC) between January 1969 and December 1993 were reviewed. The age of the patients ranged from 28 to 73 years with a median of 57 years. There were 28 Whites, four Hispanics, one Black and one Asian. A simple staging based on anatomical criteria was used to describe the extent of the disease. Six patients had T1, 13 patients had T2 and 15 patients had T3 disease. Twenty-one patients were treated with surgery plus radiation and 13 patients were treated with radiotherapy alone; nine patients received adjuvant chemotherapy. Radiation was given at approximately 2 Gy per fraction to total doses of 50 Gy preoperatively, 52-66 Gy (median 60 Gy) postoperatively and 50-70 Gy (median 63 Gy) when no surgery was performed.

RESULTS

The actuarial 5-year overall, disease-free and disease-specific survival rates were 55%, 58% and 63%, respectively. The actuarial 5-year local control rate was 71% for the whole group (74% for surgery plus radiation and 64% for radiation alone). Local recurrence occurred in nine patients, nodal relapse occurred in three patients and distant metastases occurred in four patients. Histologically proven dura mater invasion was associated with a poorer local control rate in patients undergoing surgery and radiation. The simple T-staging system used in this study was a good discriminator for local control. Of nine patients receiving chemotherapy, three had complete responses and four had partial responses; six of the seven responders had undifferentiated carcinoma. Severe complications of therapy occurred in patients treated between 1969 and 1984 and consisted mainly of visual impairment and brain necrosis.

CONCLUSIONS

This retrospective review of a large single institutional experience showed that ethmoid sinus carcinomas have a tendency for extensive local invasion but a low propensity for lymphatic and hematogenous spread. Hence, local recurrence was the main cause of cancer-related death. Combined treatment with surgery and postoperative irradiation yielded the highest local control rate. However, radiotherapy alone eradicated two-thirds of primary tumors and, consequently, is a reasonable alternative treatment for patients with medical contraindications to surgery. For patients who underwent surgery and radiotherapy, the presence of histologically proven dura mater invasion was associated with a higher local recurrence rate. Severe radiation complications have been rare with the contemporary radiotherapy technique. Chemotherapy induced excellent responses in undifferentiated carcinoma but its impact on overall disease control is unclear in this small series of patients.

Radiation therapy for early stage (T1-T2) sarcomatoid carcinoma of true vocal cords: outcomes and patterns of failure

Sarcomatoid carcinoma of head and neck mucosal sites is a rare high-grade malignancy that may cause diagnostic and therapeutic controversies. A characteristic of this entity consistently reported but not entirely validated is its relative radioresistance and the general belief is that surgery is the treatment of choice. The objective of this retrospective study was to determine if patients treated with radiation for early glottic sarcomatoid carcinoma had worse outcomes than those achieved with irradiation for the more typical squamous cell carcinoma. Twenty-eight cases of early stage (T1-T2) sarcomatoid carcinoma of the larynx treated with definitive doses of megavoltage irradiation between 1969 and 1995 at The University of Texas M. D. Anderson Cancer Center form the cohort for this analysis. All pathologic material was reviewed to confirm the diagnosis. All tumors manifested spindle cell features with marked cytomorphologic abnormalities characteristic of this entity. Sixteen tumors (57%) had the more typical polypoid gross morphology of sarcomatoid carcinoma. Twenty-one patients (75%) were staged T1 and seven patients (25%) had stage T2 disease. All patients were treated with small laryngeal fields, median size 20 cm2, and to a median dose of 65 Gy. Follow-up ranged from 1.5 to 24 years (median, 10 years). Four patients (14%) had local disease recurrence, and all had salvage total laryngectomies and remained free of local disease. The 5-year actuarial local control rates for patients with T1 and T2 lesions were 94% and 54%, respectively. Only one patient developed regional and distant disease. The 10-year actuarial disease-specific and overall survival rates were 92% and 63%, respectively. Patients with early stage sarcomatoid carcinoma of the glottis treated with radiation had similar control rates to irradiated patients with similar volume disease with the more typical squamous cell carcinoma. The authors contend that the histologic diagnosis of sarcomatoid carcinoma by itself should not influence the decision to treat a patient with early stage glottic disease with irradiation.

Fetal and fetal brain volume estimation in the third trimester of human pregnancy using gradient echo MR imaging

The Cavalieri method has been applied in combination with gradient echo magnetic resonance imaging (MRI) to investigate the increase in the volume of the fetus and fetal brain in the third trimester of pregnancy. Eighteen women with singleton pregnancies were recruited. Birthweights for the fetuses all lay within the 10-90th centile based on Liverpool data. A regression analysis, weighted using values derived from the coefficient of error predicted for each volume estimate, revealed a linear relationship between total fetal volume and gestational age (R2 = 0.88) and between fetal brain volume and gestational age (R2 = 0.71) during the third trimester. Fetal volume increased by an average of 25.2 ml per day and fetal brain volume increased by an average of 2.3 mL per day. Fetal brain volume is on average a constant proportion (10%, SD = 2%) of total fetal volume throughout the third trimester. Volume data were also obtained for eight fetuses diagnosed as abnormal. The volume of seven of the eight abnormal fetuses fell outside the 95% confidence interval established from the data obtained for the normal fetuses. However, for only three of the eight abnormal fetuses did brain volume fall outside the 95% confidence interval established for normals, possibly due to brain sparing occurring in asymmetrical growth retardation. The volume of the fetus and fetal brain may be readily estimated directly using the Cavalieri method and magnetic resonance imaging. These parameters represent potentially useful information for assessing fetal growth.

Paediatric gynaecology: an overview of current practice

Paediatric gynaecology problems can be divided into those which are common and annoying but not life-threatening; those which are serious and require urgent assessment; and those which are rare, potentially serious and require specialist management.

Radiation therapy for nonmelanoma skin carcinomas

Radiotherapy plays an important role in the management of appropriately selected skin carcinomas. Tumors of the eyelid, nose, and ear can be treated successfully with preservation of adjacent normal tissues. Tumors located in the embryologic fusion planes of the face can be irradiated with wide margins, either as primary or postoperative therapy. Radiotherapy has a significant role in the postoperative setting for patients with high-risk features in their pathologic specimens. Patients with NECS (Merkel cell carcinoma) have a high recurrence rate after surgical excision; these patients should undergo radiotherapy after resection of the clinically evident disease.

Concomitant boost radiotherapy for squamous carcinoma of the tonsillar fossa

PURPOSE

To assess the efficacy of a concomitant boost fractionation schedule of radiotherapy for treating patients with squamous carcinoma of the tonsillar fossa.

PATIENTS AND METHODS

Between December 1983 and November 1992, 83 patients with squamous carcinoma of the tonsil were treated with concomitant boost fractionation. The distribution of American Joint Committee on Cancer T stages was TX-4, T1-5, T2-29, T3-41, T4-4; N stages were NX-1, N0-26, N1-13, N2-31, N3-12. Patients were treated with standard large fields to 54 Gy in 6 weeks. The boost treatment consisted of a second daily 1.5 Gy fraction for 10-12 fractions, usually delivered during the final phase of treatment. The tumor dose was 69-72 Gy, given over 6 weeks. Twenty-one patients, who all had N2 or N3 regional disease, underwent neck dissections, either before (13 patients) or 6 weeks after radiotherapy (8 patients); the other patients were treated with radiotherapy alone.

RESULTS

The 5-year actuarial disease-specific survival and overall survival rates were 71 and 60%, respectively. Patients with T2 and T3 primary tumors had 5-year actuarial local control rates of 96 and 78%, respectively. Patients with T3 disease who received the final-phase boost had a 5-year actuarial local control rate of 82%. Actuarial 5-year regional disease control rates were N0, 92%; N1, 76%; N2, 89%; and N3, 89%. The 21 patients who had neck dissections all had their disease regionally controlled. Patients presenting with nodal disease or after a node excision who were treated with radiation alone had a 5-year actuarial regional disease control rate of 79%. All but five patients had confluent Grade 4 mucositis during treatment. Severe late complications attributable to radiation included mandibular necrosis [1], in-field osteosarcoma [1], and chronic dysphagia for solid foods [5].

CONCLUSIONS

High rates of local and regional disease control were achieved with the concomitant boost fractionation schedule, with few cases of severe late morbidity. Patients with N2 and N3 neck disease were effectively treated with radiation and the selective use of neck dissections. The concomitant boost schedule is our preferred fractionation approach for treating patients with intermediate stage tonsil cancer who are not participating in our current research protocols.

Induction chemotherapy followed by radiotherapy versus radiotherapy alone in patients with advanced nasopharyngeal carcinoma: results of a matched cohort study

BACKGROUND

Prospective randomized and retrospective studies on adjunctive chemotherapy in patients with advanced locoregional nasopharyngeal carcinoma have yielded conflicting results and the role of chemotherapy in this disease had not been clearly defined. The authors report the results of a single institution, matched cohort study comparing a group of 61 patients with advanced stage nasopharyngeal carcinoma treated with induction chemotherapy followed by radiation therapy with a matched group treated with radiotherapy alone.

METHODS

Between 1985 and 1992, 61 patients with advanced locoregional nasopharyngeal carcinoma received induction chemotherapy (cisplatin, 100 mg/m2 on Day 1 and 5-fluorouracil [5-FU], 1000 mg/m2, on Days 1-5) for 3 cycles followed by definitive radiation therapy (CT/RT group). This group was matched with a group of 61 patients from a population of 378 patients who received radiation therapy alone (RT group). Matching characteristics were T classification, N classification, histology, and level of cervical lymph node metastases. These characteristics were found to be significant determinants of distant metastasis (DM) and/or survival in a multivariate analysis that was performed in the entire radiotherapy group. Radiation therapy consisted of 66-72 gray in 6.5 to 7 weeks in both groups. Fifty-nine patients (97%) in both groups had Stage IV disease. Fifteen patients (25%) in both groups had lower cervical lymph node metastases. The tumor histologic types also had similar distribution in both groups. Median follow-up time among surviving patients of the CT/RT group was 4.9 years (range, 1.3-9.8 years).

RESULTS

The 5-year cumulative incidence of DM was 19 +/- 5% for the CT/RT group and 34 +/- 6% for the RT alone group (P = 0.019; log rank test). This reduction in distant failure was more prominent in patients with intermediate (N2-N3 disease; upper or midcervical lymph nodes), or high risk (N2-N3 disease; lower cervical lymph nodes) of DM. This reduction in DM translated into improvement in disease free survival (DFS) and overall survival (OS). The 5-year actuarial DFS rates were 64 +/- 6% for the CT/RT group compared with 42 +/- 7% for the RT group (P = 0.015). The 5-year actuarial OS rates were 69 +/- 6% (CT/RT group) and 48 +/- 7% (RT group), respectively (P = 0.012). The incidence of locoregional failure was slightly lower in the CT/RT group, but this difference did not reach statistical significance. There was no significant difference in the incidence and severity of acute mucositis between the two groups during radiotherapy. The 5-year cumulative incidence of Grade 3 or higher late complications was also similar in both groups (5 +/- 3% in the CT/RT group and 8 +/- 3% in the RT group; P = 0.721).

CONCLUSIONS

This matched cohort study provides additional evidence that induction cisplatin-5-FU chemotherapy prior to definitive radiation improves freedom from distant metastasis, DFS, and OS for patients with locoregional Stage IV nasopharyngeal carcinoma without increasing treatment-related morbidity.