Planned Neck Dissection after Definitive Radiotherapy or Chemoradiation for Base of Tongue Cancers

Clinical outcomes associated with evolving treatment modalities and radiation techniques for base-of-tongue carcinoma: thirty years of institutional experience

Curative treatment for base-of-tongue squamous cell carcinoma (BOT SCC) has evolved over time; however, comparative outcomes analysis for various treatment strategies is lacking. The authors reviewed the evolution of treatment modality and radiotherapy (RT) technique for 231 consecutive BOT SCC patients at our institution between 1981 and 2011. Treatment modalities included definitive chemoradiotherapy (chemoRT) (42%), definitive RT (33%), surgery followed by RT (20%), and surgery alone (5%). RT techniques included external beam plus interstitial brachytherapy (EBRT + IB) (37%), conventional EBRT (29%), intensity-modulated radiation therapy ± simultaneous integrated boost (IMRT ± SIB) (34%). Clinical characteristics and outcomes were stratified by modality or RT technique. Treatment modality evolved from definitive RT (1980s–1990s) to definitive chemoRT (1990s–2000s). RT technique evolved from EBRT + IB (1980s–1990s) to conventional EBRT (1990s–2000s) to IMRT + SIB (2000s). With median alive follow-up of 6 years (0.3–28 years), the 5-year LC, LRC, and OS rates were 80%, 73%, and 51%. There was no difference in distribution of gender, age, stage among treatment modalities. Definitive chemoRT had improved LRC (HR 1.6) and OS (HR 1.7) compared to definitive RT. IMRT + SIB had improved LRC (HR 3.2), DFS (HR 3.4), and OS (HR 3.0) compared to conventional EBRT. Over the past 30 years, BOT SCC treatment has undergone major paradigm shifts that incorporate nonsurgical functional preservation, concurrent chemotherapy, and advanced RT techniques. Excellent locoregional control and survival outcomes are associated with accelerated IMRT with chemotherapy.

Photodynamic therapy: The minimally invasive surgical intervention for advanced and/or recurrent tongue base carcinoma

INTRODUCTION

The management of tongue base carcinoma continues to be a major challenge in head and neck oncology. Our aim in this prospective study was to evaluate the outcome following ultrasound-guided interstitial photodynamic therapy (US-iPDT) of stage IV tongue base carcinoma patients. Patients' reports on quality of life with clinical and radiological evaluation were the main end point parameters used to assess the outcome.

MATERIAL AND METHODS

Twenty-one consecutive patients referred to the UCLH Head and Neck Centre for treatment of advanced and/or recurrent tongue base cancer were included in this study. Two-thirds of the referred patients had not been offered further conventional therapeutic options apart from palliative treatment. It was decided, by the multidisciplinary team, that the only available option was to offer US-iPDT under general anesthesia, using mTHPC (Foscan®) as the photosensitizing agent. Following treatment, patients were followed-up for a mean of 36 months (min. 21, max. 45).

RESULTS

Nine of the 11 patients who presented with breathing problems reported improvement after treatment. Also, 19 of the 21 patients reported improvement of swallowing. Improvement of speech was reported by 11 of 13 patients. Clinical assessment showed that more than half of the patients had "good response" to the treatment and about a third reported "moderate response." Radiological assessment comparing imaging 6-week post-PDT to the baseline showed stable pathology with no change in size in four patients, minimal response in seven patients, moderate response in six patients, and significant response in two patients. Eight patients died; four of which due to loco-regional disease; and two from distant tumor spread. Kaplan-Meir survival curve was generated from the survival and follow-up data.

CONCLUSIONS

Photodynamic therapy is a successful palliative modality in the treatment of advanced and/or recurrent tongue base carcinoma.

Survival patterns in patients with carcinoma base of tongue treated with external beam irradiation and salvage surgery

OBJECTIVE

The current study was designed to assess the treatment results and survival in the patients with carcinoma of base of tongue that were treated with primary radiotherapy, radiotherapy with chemotherapy and salvage surgery when indicated.

DESIGN

A prospective study was carried out in 78 cases of carcinoma of the base of tongue between 1995 and 1999.

METHODS

The majority of cases belonged to stage IV 60/78 (76.92%) as per AJCC staging. Radiotherapy in the dose of 60 Gy was given primarily to the patients with stage III tongue base cancer. Patients with early stage IV cancer were given split course radiotherapy followed by assessment for surgery. For the patients with advanced stage IV disease with poor general condition, palliative radiotherapy of 24 Gy with or without palliative chemotherapy was given. 15 patients were subjected to salvage surgery in the form of radical neck dissection alone (8 cases), extended total laryngectomy with neck dissection (3 cases), extended total laryngectomy (2 cases) and extended supraglottic laryngectomy with RND in 2 cases.

RESULTS

Two and 5 years Kaplan - Meier actuarial survival rates were 45% and 10% respectively with local control rates equivalent to survival rates. All surviving patients maintained good function and quality-of-life with few tolerable side effects.

CONCLUSIONS

External beam radiotherapy with salvage surgery results in satisfactory local and regional control in stage III and IV carcinoma base of tongue.

Poor radiotherapy compliance predicts persistent regional disease in advanced head/neck cancer

OBJECTIVE

To determine if poor compliance to chemoradiation results in an increased rate of persistent neck disease.

STUDY DESIGN

Retrospective, cohort study in an urban, tertiary-care medical center.

METHODS

The study included patients with N+ stage III/IV squamous cell carcinoma of the upper aerodigestive tract treated with curative-intent chemoradiation, who underwent subsequent planned neck dissection. Main outcome measure was persistent regional disease evidenced by identifiable carcinoma in neck dissection specimens. Variables including age, gender, race, primary site, initial T, N staging, imaging results, and treatment compliance were assessed and correlated to positive neck dissection pathology.

RESULTS

Of 40 patients, 18 (45%) had persistent carcinoma in neck dissection specimens while 22 (55%) demonstrated complete response in the neck. There were 14 patients (35%) who were poorly compliant to radiotherapy (>or=14 days treatment interruption) and the remaining 26 patients (65%) were considered compliant (<14 missed days). Only 23% of compliant patients had positive pathology while 79% of noncompliant patients had positive pathology (hazard ratio: 9.9). Noncompliance was the only variable that had a statistically significant correlation to positive pathology results (P = .002). Multivariate logistic regression showed all other variables to be insignificant in predicting pathology.

CONCLUSIONS

This study found that poorly compliant patients are at significantly higher risk of persistent neck disease. Poor compliance may help identify patients who will most benefit from neck dissection after chemoradiation. This variable was more predictive than pretreatment variables and posttreatment CT scan. Further studies investigating patterns of failure after chemoradiotherapy in the poorly compliant patient population are warranted.