The Role of Irradiation in the Management of Head and Neck Cancer: Analysis of Results and Causes of Failure

The records of patients with squamous cell carcinoma of the oral cavity, oropharynx, supraglottic and glottic larynx, whose primary lesion was treated with radiation therapy from 1964 through 1973, were reviewed. End points of the study are local control rate at the primary site, ultimate control with surgical salvage, and causes of failure. The local control rate at the primary site was 90 % for T1 lesions, 80 % for T2 lesions, and approximately 70 % for selected T3 lesions. The control rates for the advanced T2 and T4 lesions are unsatisfactory; therefore, preoperative or postoperative irradiation is combined with appropriate surgical procedures to improve the local control rates and in some instances survival rates. Analysis of cervical node metastases treatment shows that the incidence of local recurrence in the radically dissected neck can be significantly reduced with either pre- or postoperative irradiation. Elective irradiation of initially clinically uninvolved areas of the neck (both ipsilateral and contralateral) has almost eliminated subsequent nodal metastases.

An analysis of the late effects of radiotherapy in pediatric central nervous system tumors

PURPOSE

The purpose of this study is to assess the long term results of all pediatric patients diagnosed with central nervous system (CNS) tumors treated with external beam radiotherapy either primarily or postoperatively.

MATERIALS

Forty-seven pediatric patients with CNS tumors were treated between 1978 and 1989 with external beam radiotherapy to customized fields using cobalt 60, 4, 6, or 18 MV photons. Daily doses ranged from 1.5 to 2.0 Gray; total doses from 35 to 66 Gray. Ages ranged from one month to 18 years of age, with an average age of 8.2 years. Thirty-nine patients survived more than 12 months (range 36 to 178 months; median 62 months) and were included for analysis. Ten of 39 (25.6%) patients experienced Grade I to II complications and six patients had (15.7%) Grade III to IV complications for an overall incidence of 41%. The influence of field size, radiation dose, chemotherapy, age, and extent of surgical resection upon long-term complications were studied.

CONCLUSION

Radiation therapy for pediatric CNS malignancies is associated with long-term complications. Significant long-term complications can be limited to an acceptable level of approximately 15%.

Retrospective analysis of patients with primary fallopian tube carcinoma treated at the University of Louisville

Medical records of patients diagnosed with primary fallopian tube carcinoma between 1979 and 1989 were reviewed. Twenty-six patients were eligible; 8 patients were excluded after pathologic review, leaving 18 patients included in the study for this analysis. The median and mean age were 61 and 59 years, respectively, with a range of 39-80 years. There were three Stage I, five Stage II, seven Stage III, and three Stage IV patients. The most common presenting symptoms were abdominal/pelvic pain, abdominal distension, and vaginal discharge/bleeding. The primary site of the lesion was determined to be the right tube in 44% of the cases, the left tube in 39% of the patients, bilateral lesions in 11% of the patients, and indeterminate in 6%. Histologic grade was poorly differentiated (Grade III) in 13 patients, moderately differentiated (Grade II) in 4 patients, and well differentiated (Grade I) in one. No patient was correctly diagnosed preoperatively. Survival at 5 years of the entire group was 35% with a 3 year minimum followup. Corresponding disease free survival was 30%. Mean and median survival times were 74 and 37 months, respectively. The range of survival times was from 1 to 120 months. All Stage I patients, 80% (4/5) of Stage II, and 29% (2/7) of Stage III patients are alive without disease. None (0/3) of the Stage IV patients are alive. Treatment regimens consisted of intraperitoneal P-32, external beam radiotherapy, and/or chemotherapy. Radiotherapy was associated with a low incidence of treatment-related complications, the majority being gastrointestinal related. There was one chemotherapy-related death. These patients and their treatment outcomes add to the data base of numerous previous reports on fallopian tube carcinoma. Stage I and II patients fared excellently with primary surgical and adjuvant therapy. While the prognosis of Stage III and IV patients is much worse, significant levels of long term survival can be achieved with aggressive treatment.

Rhabdomyosarcoma in children--a ten year review

PURPOSE

The purpose of this study is to retrospectively analyze all pediatric patients with Rhabdomyosarcoma (RMS) of various anatomic sites, treated in our department over a 10-year period, for treatment results. Anatomical site, group, and gender are individually analyzed as prognostic indicators of overall survival.

MATERIALS AND METHODS

Sixteen rhabdomyosarcoma patients diagnosed by biopsy or surgical resection were reviewed. All patients were treated according to assigned IRS protocols except one. Age ranged from 1 to 19 years with a median age of 4 years. Ten patients were male and 6 were female, 14 were white and 2 black. Anatomic sites included six from the head and neck region, seven in the trunk and three in the extremities. Embryonal RMS was present in all but one which was classified as undifferentiated. All patients had surgery (biopsy-5, partial-1 or complete resection-10) and chemotherapy (VA, VAC, VAC plus Adriamycin, or VAC plus Adriamycin, CIS Platinum and VP-16). Ten patients received irradiation consisting of 3060 cGy to 5850 cGy using shrinking fields with 1.8 to 2.0 Gy/day/5 day/wk.

RESULTS

Patients tolerated the treatment well and there were no late complications. Only one patient had a recurrence in the primary site with a median follow-up of 61 months (range 5-118 months) for the whole group. The 5-year disease free survival and actuarial survival for all patients treated were 73% and 87% respectively, with four patients developing metastasis and three of those dead of disease.

CONCLUSION

This study represents a heterogeneous group of patients with RMS treated over a 10-year-period. The results correlate with those found in the most recent published IRS data for embryonal histology. From experience gained from earlier studies, newer IRS protocols have tailored treatment protocols to specific site with more intense therapy used for difficult treatment sites.

Wilms' tumor in an adult: a case report and review of the literature

Wilms' tumor in an adult is extremely rare, with less than 250 cases reported in the world literature. Treatment guidelines for pediatric Wilms' tumor are well established; those for adults are not. This article presents the case of a 19-year-old male diagnosed with Wilms' tumor after complaints of hematuria. He was categorized as Stage IV after nephrectomy and received post-operative radiotherapy and chemotherapy consisting of Vincristine, Adriamycin, and Actinomycin-D. Two years later he was found to have metastases to brain and lungs. He was treated with radiotherapy and bone marrow transplantation, and died of septic shock. The literature regarding Wilms' tumor in adults is reviewed, and current therapy is discussed.

Chemical modification of normal tissue damage induced by photodynamic therapy

One of the limitations of successful use of photodynamic therapy (PDT) employing porphyrins is the acute and long-term cutaneous photosensitivity. This paper describes results of experiments designed to test the effects of two radiation protective agents (WR-2721, 500 mg kg-1 or WR-3689, 700 mg kg-1) on murine skin damage induced by PDT. C3H mice were shaved and depilated three days prior to injection with the photosensitiser, Photofrin (5 or 10 mg kg-1). Twenty-four hours later, the mice were injected intraperitoneally with a protector 30 min prior to Argon dye laser (630 nm) exposure. The skin response was followed for two weeks post irradiation using an arbitrary response scale. A light dose response as well as a drug dose response was obtained. The results indicate that both protectors reduced the skin response to PDT, however WR-2721 was demonstrated to be the most effective. The effect of the protectors on vascular stasis after PDT was determined using a fluorescein dye exclusion assay. In mice treated with Photofrin (5 mg kg-1), and 630 nm light (180 J cm-2) pretreatment with either WR-2721 or WR-3689 resulted in significant protection of the vascular effects of PDT. These studies document the ability of the phosphorothioate class of radiation protective agents to reduce the effects of light on photosensitized skin. They do so in a drug dose-dependent fashion with maximum protection at the highest drug doses.

Radiation therapy for pituitary adenomas. A retrospective study of the University of Louisville experience

A retrospective analysis of treatment outcome was performed on patients treated with radiation for pituitary adenomas at the University of Louisville from January 1988 to December 1992. The study population included 27 patients. Twenty received radiation as a component of their initial treatment while seven received radiation as part of their treatment for recurrent disease. Nineteen patients were treated with post-operative radiation, and eight were treated with radiation alone. Follow-up interval ranged from 1 month to 109 months, with a median of 28 months. All three patients with stage I disease were controlled with radiation alone (1/3) or combined surgery and postoperative radiation (2/3), whereas six of eight stage II patients had disease control following surgery and postoperative radiation. Both patients with stage III adenomas treated with radiation alone had local control, whereas local control was achieved in six of seven with post-operative radiation. Three of five patients with recurrent disease had local control with radiation alone, whereas both patients undergoing surgery and postoperative radiation had local control. This retrospective analysis supports previous findings that radiation therapy alone or combined with transphenoidal resection is effective in long-term control of pituitary adenomas. It further suggests that immediate radiation therapy may be superior to radiation for surgical or medical failures.

Results of irradiation in patients with high-grade gliomas evaluated by magnetic resonance imaging

Evidence shows that most high-grade gliomas are a diffuse process. Prior studies reported a median survival with surgery and postoperative radiotherapy of 8.6 months for glioblastoma multiforme (GBM) and 36.2 months for anaplastic astrocytoma (AA). Since MRI delineated the glioma better than CT scan, using MRI-based radiotherapy treatment planning allows for more precise treatment volumes. We retrospectively reviewed the records of the first 36 patients with malignant glioma, who had a presurgery MRI-based radiotherapy treatment planning. These patients were diagnosed between January 1986 and February 1991. Minimum follow up was 14 months and median survival was 15.4 months for GBM (7-42 months) and 27.4 months for AA (7-53 months). We feel that the trend for increased median survival in GBM (15.4 vs 8.6 months) is partly due to better definition of the tumor volume by using MRI. Larger studies are needed to confirm this finding.

Radiation therapy for pancreatic cancer: a retrospective study of the University of Louisville experience

Although multiple regimens and approaches have been used in attempts to treat pancreatic cancer, the 5-year disease-free survival is dismal. With an increase in incidence of pancreatic cancer over the past 35 years, researchers continue their efforts to find an effective treatment for this aggressive disease. Between January 1983 and January 1993, we treated 77 patients with radiotherapy for pancreatic cancer. Only 35 of these patients had localized adenocarcinoma and were treated for cure. In this group of 35 patients, 5 received < 4,000 cGy (mean survival of 5.6 months) and 30 received > or = 4,000 cGy (mean survival of 14.7 months). Twenty-four of these 30 received > or = 5,000 cGy, resulting in a mean survival of 15.4 months, and 17 of these 24 received > or = 6,000 cGy, with a mean survival of 15.7 months. Some palliation of symptoms was achieved in 57% of all patients. These results at the University of Louisville Brown Cancer Center are comparable to other published results, but the prognosis for patients with pancreatic cancer remains bleak.

Use of P-32 in stage III epithelial carcinoma of the ovary

From 1982 through 1989, 56 patients with Stage III epithelial carcinoma of the ovary received intraperitoneal chromic phosphate following chemotherapy and second look (52 pts) or as the only postsurgical management (4 pts). Median follow-up was 48 months (range of 24 to 108 months). The 4 patients treated following primary surgery with P-32 without chemotherapy had microscopic abdominal disease (3 pts) or complete reduction of gross abdominal disease (1 pt), and their 5-year survival was 100%. Of the 52 patients treated with P-32 following PAC chemotherapy, 23 were pathologic negative, 15 had microscopic residual, and 14 had gross residual at second look. The 5-year survival following second look was 75% for negative, 48% for microscopic, and 32% for gross residual. There were 4 Grade 3 GI complications (7%). There were no complications in the 38 patients who received the P-32 within 12 hr of surgery. The use of P-32 as an adjuvant for Stage I and II epithelial carcinoma of ovary has been found to be effective in prior GOG trials. We have expanded the selection criteria in patients with Stage III carcinoma to include those who can be surgically reduced to microscopic residual at primary surgery or second look following chemo reduction. Because of multiple prognostic variables affecting survival in Stage III ovarian cancer, a randomized study with control arm would be necessary to draw firm conclusions regarding the effectiveness of P-32. The 5-year survival in this group of patients compares favorably to published reports.

Radioneurosurgery using the LINAC scalpel: technique, indications, and literature review

Two available commercial units for radiosurgery are the modified linear accelerator (LINAC scalpel) and the gamma knife. Advantages of the LINAC scalpel over the gamma knife are its greater accuracy, the availability of a wide range of collimator sizes that allow for a more homogeneous field of radiation for large lesions, state-of-the-art computer software programs, and lower expense. Radiosurgery does not require an incision, is painless, and can be performed on an outpatient basis. It is ideally suited for the treatment of inaccessible, deep intracranial lesions that are radioresistant to conventional forms of radiotherapy, such as arteriovenous malformations, meningiomas, vestibular schwannomas, selected primary brain tumors, and cerebral metastases. Radiosurgery is an attractive treatment alternative to conventional neurosurgery for several intracranial lesions.

Irradiation in the management of anal cancer with literature review

Sixteen patients with a diagnosis of anal cancer were treated from 1981 to 1990 with combination of surgery, irradiation, and chemotherapy. Median age was 56 years (range 42 to 78 years). There were 3 males and 13 females. Fourteen patients were white and 2 were black. The stage of the primary was: T1-4, T2-9, T3-3. Eleven patients had the tumor in anal canal and 5 patients at the anal verge. Twelve patients had squamous cell carcinoma and 4 had cloacogenic carcinoma. Four patients had planned abdomino perineal resection (APR) after pre-operative chemotherapy (mitomycin C-15 mgm/m2 day 1; 5-fluorouracil, 750 mgm/m2, 24 hour infusion, days 1 to 5, repeated q15 days), and irradiation (30 gy in 15 fractions in 3 weeks). One patient had wide excision of the primary site after the pre-op chemotherapy and irradiation. Ten of 11 patients received higher dose of irradiation (45 to 55 Gy in 4 1/2 to 5 1/2 weeks, 5 days/week) in combination with chemotherapy and anal sphincter conservation surgery. One patient refused chemotherapy and was treated with surgery and high dose irradiation. The median follow-up was 28 months (range 3-125 months). Fifteen patients (94%) had local control. Thirteen are NED from 3 to 125 months and 2 died of intercurrent disease without cancer at 3 and 14 months. One patient with local recurrence at 9 months had salvage surgery, but died of disease. Except for moderate diarrhea and perineal reactions, there were no major complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Phase I-II study of multiple daily fractions for palliation of advanced head and neck malignancies

PURPOSE

To assess palliation of advance head and neck malignancies with the use of rapid hyper fractionation studies similar to the RTOG 85-02.

MATERIALS AND METHODS

37 patients with 39 lesions were entered into the non-randomized Phase I-II protocol, between 1984 and 1991. Previously untreated malignancies were present in 24 lesions, primary recurrent diseases in six patients, metastasis to the head and neck in five patients and skin primaries in the remaining two cases. At presentation 15 of 37 patients (or 17 of 39 lesions) were in operable due to poor medical status, eight patients were considered technically in operable due to extent of disease, 10 patients had distant metastasis and four patients refused surgery. The protocol uses twice a day fraction (370 cGy per fraction) for 2 consecutive days totalling 1,480 cGy per course. Three courses were given at 3-week intervals for a final tumor dose of 4,440 cGy in twelve fraction over 8-9 weeks.

RESULTS

Eleven of 39 lesions had complete response; 19 lesions had partial response; 4 lesions had no response; 3 lesions progressed under treatment. Response could not be assessed in two patients. The average survival after completion of therapy was 4.5 months ranging from 2 weeks to 31 months. Palliation was achieved in 33 of 39 lesions. The acute reactions were minimal and no late or long term complications were noted.

CONCLUSION

The absence of significant complications with reasonable response in the high rate of palliation suggests that this rapid hyper fractionation palliation study should be studied for further evaluation.

Imaging of radiation dose for stereotactic radiosurgery

The distributions of radiation dose for stereotactic radiosurgery, using a modified linear accelerator (Philips SL-25 and SRS-200), have been studied by using three different dosimeters: (1) ferrous-agarose-xylenol orange (FAX) gels, (2) TLD, and (3) thick-emulsion GafChromic dye film. These dosimeters were loaded into a small volume of defect in a phantom head. A regular linac stereotactic radiosurgery treatment was then given to the phantom head for each type of dosimeter. The measured radiation dose and its distributions were found to be in good agreement with those calculated by the treatment planning computer.

Phase II trial of combination chemotherapy and irradiation in non-small-cell lung cancer, Radiation Therapy Oncology Group 88-04

Encouraging results of several clinical trials utilizing combination chemotherapy and irradiation in unresectable non-small-cell lung cancer have been reported. A recent report from a cooperative group study suggested that preirradiation vinblastine and cisplatin improved survival over irradiation alone. In an attempt to enhance the possible effectiveness of combination chemotherapy and irradiation, the Radiation Therapy Oncology Group embarked on a Phase II trial utilizing preirradiation vinblastine (5 mg/m2 weekly x 5) and cisplatin (100 mg/m2) on days 1 and 29 prior to irradiation and on days 50, 71, and 92 during irradiation. The irradiation began on day 50 and consisted of 6300 cGy in 7 weeks. Between May 20, 1988 and May 1, 1989, 30 patients were entered on study. Seventy-two percent of patients had Karnofsky status greater than 90, and 76% had weight loss less than 5%. Forty-eight percent of the patients were younger than 60 years of age. Forty-five percent of the patients had Stage IIIA disease. Eighty-three percent of the patients received at least four courses of vinblastine, and 59% received at least four courses of cisplatin. Seventy-eight percent of the patients received at least 95% of the prescribed irradiation. The major toxicity was hematologic, and there were two fatal complications in the study group. The preliminary survival figures are encouraging. This combination of chemotherapy and irradiation appears to be tolerable and may merit further investigation.

Incidence of complications with mini vaginal culpostats in carcinoma of the uterine cervix

Between 1980 and 1987, 298 patients with carcinoma of the uterine cervix were treated at the University of Louisville Department of Radiation Oncology. Of these, 197 (66.1%) were treated for cure by radiotherapy alone: 36 by external beam alone and 161 by external beam and tandem and ovoid applications. The F.I.G.O. staging of the 161 patients was 82 (50.1%) Stage IB, 9 (5.6%) Stage IIA, 40 (24.9%) Stage IIB, and 30 (18.6%) Stage III. The usual treatment was whole pelvis irradiation followed by two intracavitary applications using the Fletcher Suit Applicators of tandem and ovoids in 79/161 patients (49%), a 3-M Mini Applicator (Fletcher Suit Delcos Applicator) in 52/161 patients (32.3%), and a 3-M Mini Applicator with Caps in 30/161 patients (18.6%). The incidence of grade 3-4 gastrointestinal or genitourinary complications as defined by the RTOG was 19.3% (31/161). Various treatment parameters were analyzed to define possible contributing factors. Grade 3-4 complications were seen in 7.6% (6/79) of patients treated with the standard ovoid Fletcher system, 26.9% (14/52) treated with the mini-ovoid system, and 36.6% (11/30) treated with the mini-ovoid system with caps (p = .0006). Although trends were noted, neither the vaginal surface dose (VSD) from the ovoids nor the addition of the external beam dose to the VSD (total vaginal surface dose = TVSD) were significant independent variables (p = 0.19 and = 0.133, respectively). The TVSD was significant when comparisons were made between different ovoid systems (p = 0.05 for less than 12,000 cGy and p = 0.004 for greater than 12,000 cGy). In this study, the 3-M mini applicator was associated with a significant increase in grade 3-4 complications as compared to the Standard Fletcher Suit Applicator.

Glioblastoma multiforme in adults: results of treatment

One hundred and thirty adult patients with brain tumors were treated in the Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine from 1973 to 1980. Forty-one patients (39%) were diagnosed with glioblastoma multiforme. Forty-two percent of the patients were in the age group of 51-60 years. There were 24 males and 27 females. Forty-seven percent of the patients had partial resection, 27% had total excision and 26% had biopsy only. The radiation dose ranged from 4400 to 6600 rad with a median dose of 5500 rad. The median survival was 8.5 months, (range 3 to 120 months), 38% of patients survived one year or more and 10% survived 2 years or more. A detailed review of the current policy of treatment and of the ongoing clinical trials is done in this paper.

GYN implant orthogonal film holder

An orthogonal film holder has been developed for the use of implants in the O.R. This film holder provides both AP and lateral films that are truly 90 degrees apart from each other. Placement of the GYN applicators must be checked before completion of the procedure. Traditionally, orthogonal films have been used for positioning and for the dose calculations. Therefore it is critical to have good quality radiographs. The AP film holder is placed beneath the patient and the lateral film holder slides into the side of the AP film holder, providing accurate placement and reproducibility in relation to each other. After the films have been approved, the lateral film holder bolts on top of the AP film holder. The system then looks like a briefcase and has a carrying handle for easy transportation and storage. This newly designed system has been used successfully and has proved its ease of use and accuracy.

Biteblock-head immobilizer system

To accurately deliver high doses of radiation to the head and neck region one must be able to achieve three primary goals: reproduce the patient set-up or position, immobilize the patient, and most importantly, position the treatment field on the patient in the same exact location on a daily basis. Many patient positioning devices are available commercially but none address the concept of positioning the treatment field on the patient. The system presented in this paper accomplishes all 3 goals. Using a biteblock and a coordinate system, it has decreased the daily set-up time and improved the accuracy of the treatment field placement on the patient. Five hundred port films were reviewed retrospectively from previously treated patients who were treated without this new system (66% of those films were approved, and 34% needed some sort of adjustment). Using the new system the accuracy of 107 port films was determined (91% were approved, while only 9% needed any type of adjustment). This newly developed system provides the extra step, treatment accuracy, that no other device has done.

Medulloblastoma: results of treatment

Fourteen patients with a diagnosis of medulloblastoma were treated in the Department of Radiation Oncology, University of Louisville School of Medicine from 1973 to 1979. The age of these patients ranged from 2 to 47 years with a median of 9 years. Twelve of them were 15 years or younger. All patients received craniospinal radiation after surgery, with a boost to the primary site by reduced field. The median dose to the primary was 4736 rads (range 3600 to 5600 rad). The median follow-up was 29.5 months. Six patients have died, and four of those six patients lived more than two years. Eight patients are alive to the last follow-up with a median survival of 29 months. Eight of 14 patients had local control and one patient developed distant metastasis. A brief review of the literature is done in this paper.

Primary gastric lymphoma and pseudolymphoma

Eighteen patients with primary gastric lymphomas and two with pseudolymphomas treated at the University of Louisville affiliated hospitals were analyzed in order to develop a more precise understanding of these rare diseases. Abdominal pain and weight loss were the most common initial symptoms. Only one patient presented with an abdominal mass. Upper GI series were helpful but failed to show a definite abnormality in two of 18 cases. Endoscopic examinations in all 18 were compatible with malignancy on gross finding, but six out of 15 endoscopic biopsies were not conclusive. All four cases, which proved fatal in less than two years, showed serosal invasion and diffuse histological pattern. On the basis of our analysis, we suggest that in patients with abdominal pain and weight loss of more than two months duration an aggressive course of evaluation should include upper gastrointestinal x ray and repeated endoscopic biopsy. If symptoms persist, laparotomy and biopsy may be warranted even if endoscopic biopsy shows no neoplasm. Curative surgery is the treatment of choice, but radiation therapy should be added in patients with serosal involvement. Very careful histological assessment of pseudolymphomas is necessary, because they may contain malignant lymphoma.

Evaluation of unplanned interruptions in radiotherapy treatment schedules

One of the major radiobiological interests has been to maximize the effectiveness of the time-dose relationship in the clinical setting. Current explorations include altered fractionation schedules, multiple daily fractions and hypofractionation. Patient compliance to standard radiotherapy treatment schedules is taken for granted. To evaluate the true rate of compliance, the charts of all new patients treated from July 1, 1984 through June 30, 1985 were reviewed. The overall incidence of unplanned interruptions was 54% (361/668). The frequency of interruptions is significantly higher in patients treated to the primary site as compared to those treated for metastasis (59.8% and 35.6% respectively). The duration of the interruptions varied: 12.7% of the patients missed only 1 day, 25% missed 2 to 5 days, 38% had interruptions totalling 6-15 days, and in 24% the total exceeded 15 days. The most frequent cause of the unplanned interruptions was a rest resulting from unusually adverse tissue reactions (46.8%-169/361). Although this study has documented that unplanned interruptions are a major problem, the impact on local control and survival cannot be determined from our data. A retrospective review of multi-institutional studies such as those conducted by the Patterns of Care or RTOG might show that one of the major causes of failure is unplanned interruptions.

Rhabdomyosarcoma of the biliary tree in childhood. A report from the Intergroup Rhabdomyosarcoma Study

Ten cases of rhabdomyosarcoma of the biliary tree (RMS/BT) in children are reported in this review of the Intergroup Rhabdomyosarcoma Study (IRS) I and II. RMS/BT constitutes 0.8% of evaluable tumors on IRS I and II. Intermittent obstructive jaundice with or without abdominal distention, fever, and loss of appetite is the typical presentation. Attribution of these symptoms to hepatitis commonly delayed definitive treatment. Demonstration of a mass in the porta hepatitis by ultrasound led quickly to surgical consultation and an exploratory laparotomy. Intraoperative cholangiography was a valuable technique in establishing the level of biliary tree obstruction and verifying a functioning drainage procedure. Resection of the mass with only microscopic or minimal gross residual disease was possible at the initial surgery in six of the ten patients. Included in this group are all four of the surviving patients. The continuity of bile flow was usually maintained by variations of a Roux-en-Y jejunostomy. Histology was embryonal RMS with some botryoid elements. Consultation with a surgical pathologist during the course of the surgery was of invaluable assistance. Multi-drug chemotherapy and radiotherapy consistent with the IRS protocols were given postoperatively. A second-look surgery was useful in evaluating residual or recurrent disease. Four patients are surviving free of disease at 6 months, 3, 6 1/4, and 6 1/2 years from diagnosis, respectively. This review demonstrates that a multidisciplinary approach in RMS/BT can lead to long-term survival.

Perineural invasion in squamous cell skin carcinoma of the head and neck

On review of 520 patients with 967 squamous cell carcinomas of the skin of the face treated at The University of Texas M.D. Anderson Hospital and Tumor Institute at Houston during a 10 year period, 14 percent of the patients were noted to have perineural extension of tumor. Study of the patients with perineural tumor demonstrated an increased incidence of spindle cell and adenosquamous cell types, an increased incidence of cervical lymphadenopathy and distant metastasis, and significantly reduced survival curves compared with those of patients with squamous cell skin carcinoma without perineural invasion. Tabulation confirmed that the maxillary and mandibular branches of the trigeminal nerve and the facial nerve were most commonly involved. For patients with squamous cell skin carcinomas with perineural invasion, aggressive therapy is recommended, specifically, resection of involved tissues and nerves and appropriate regional lymphadenectomy followed by postoperative radiotherapy. This plan affords the best opportunity for tumor control. The indications for exploration of the middle fossa of the intracranial portion of the trigeminal nerve deserve further study.

Ground Water Redox Reactions: An Analysis of Equilibrium State Applied to Eh Measurements and Geochemical Modeling

Computer modeling of 611 high-quality analyses of normal ground waters from diverse geographic areas reveals that aqueous oxidation-reduction reactions are generally not at equilibrium. Multiple redox couples present in individual samples yield computed Nernstian Eh (redox potential) values spanning as much as 1000 millivolts. The computed Eh values do not agree with each other, nor do they agree with the single "master" value measured in the field with a platinum electrode. Because of internal disequilibrium, the use of any measured Eh value as input to equilibrium hydrogeochemical computer models will generally yield misleading results for normal ground waters.

Soft tissue sarcoma of the head and neck in childhood: nonorbital and nonparameningeal sites. A report of the Intergroup Rhabdomyosarcoma Study (IRS)-I

Seventy-two patients with soft tissue sarcoma arising in the oral cavity, oropharynx, larynx, parotid region, cheek, scalp, and neck, were entered on the Intergroup Rhabdomyosarcoma Study (IRS)-I, and could be analyzed for survival. Sixty-three (88%) attained complete remission (CR), of whom 13 subsequently relapsed (78% actuarial 5-year retained CR rate). The patients with primary tumor arising in sites other than the neck had a retained CR rate exceeding 90%. In contrast, 11 relapses occurred in the 26 patients with neck primaries (54% retained CR rate). Females, and infants younger than age 24 months were more likely to relapse. Prognostic factors with little or no influence on relapse included tumor size, histology, regional lymph node status, clinical group, and treatment arm. Five of the 6 patients with failure at the primary site had either no radiotherapy (2 patients) or an insufficient dose (less than 3000 rad). No patient required major organ sacrifice such as laryngectomy or pharyngectomy. Isolated failure in regional nodes did not occur. Children with nonorbital, nonparameningeal head and neck soft tissue sarcoma treated in accordance with the IRS protocol have an excellent rate of local control and survival. Primary tumors arising in the neck are more likely to relapse locally or distantly.

Soft tissue sarcoma of the head and neck in childhood: nonorbital and nonparameningeal sites. A report of the Intergroup Rhabdomyosarcoma Study (IRS)-I

Seventy-two patients with soft tissue sarcoma arising in the oral cavity, oropharynx, larynx, parotid region, cheek, scalp, and neck, were entered on the Intergroup Rhabdomyosarcoma Study (IRS)-I, and could be analyzed for survival. Sixty-three (88%) attained complete remission (CR), of whom 13 subsequently relapsed (78% actuarial 5-year retained CR rate). The patients with primary tumor arising in sites other than the neck had a retained CR rate exceeding 90%. In contrast, 11 relapses occurred in the 26 patients with neck primaries (54% retained CR rate). Females, and infants younger than age 24 months were more likely to relapse. Prognostic factors with little or no influence on relapse included tumor size, histology, regional lymph node status, clinical group, and treatment arm. Five of the 6 patients with failure at the primary site had either no radiotherapy (2 patients) or an insufficient dose (less than 3000 rad). No patient required major organ sacrifice such as laryngectomy or pharyngectomy. Isolated failure in regional nodes did not occur. Children with nonorbital, nonparameningeal head and neck soft tissue sarcoma treated in accordance with the IRS protocol have an excellent rate of local control and survival. Primary tumors arising in the neck are more likely to relapse locally or distantly.

Major complications of radiotherapy in cancer of the oral cavity and oropharynx. A 10 year retrospective study

In an attempt to determine the late effects and associated morbidity of radiotherapy on normal tissue, patients with squamous carcinoma of the oral cavity and oropharynx were retrospectively reviewed. Between 1964 and 1975, 569 patients with cancer of the floor of the mouth, oral tongue, tonsil, and retromolar trigone region of the anterior faucial pillar had their primary lesions treated by radiotherapy alone for cure. One hundred twenty-eight of the patients were evaluable for this study. Bone and soft tissue morbidity were graded according to the late radiation scoring scheme of the radiation therapy oncology group of the European Organization on Research and Treatment of Cancer, tallying only grade 4 changes. Patients were further classified according to site of tumor, age, sex, tumor stage, histologic grade, and dental status--none of which had a positive correlation with complications. Of 31 evaluable patients with cancer of the floor of the mouth (median follow-up 136 months), 71 percent (22 of 31 patients) had at least one complication involving bone (osteonecrosis, pathologic fracture) or mucus membrane (ulcer). Sixty-one percent (25 of 41 patients) with primary cancer of the oral tongue had grade 4 sequelae (median follow-up 112 months). In 26 patients with cancer of the tonsil, 13 (50 percent) had grade 4 sequelae (median follow-up 113 months). This included 11 patients with clinical and radiographic evidence of osteonecrosis, 6 of whom required mandibulectomy. Patients with cancer of the retromolar trigone region of the anterior faucial pillar fared the best (median follow-up 122 months). Late sequelae were noted in 40 percent (12 of 30 patients). The morbidity attendant to cure by radiotherapy included at least one significant complication of bone or soft tissue in 40 to 70 percent of the patients, depending on the location of the primary tumor. There was also a positive correlation with dose of radiation received.

Malignant salivary gland tumors of the paranasal sinuses and nasal cavity

Of a total of 122 patients with minor salivary gland tumors of the nose and paranasal sinuses, 66 patients were identified who had had their therapy at the University of Texas M.D. Anderson Hospital and Tumor Institute, Houston. Adenoid cystic carcinomas and adenocarcinomas were the most frequent tumors. Eighty percent of the patients were treated for relatively advanced (T3 and T4) cancers. Low-grade and high-grade carcinomas could be identified in the two groups studied, and the pathologic grading influenced prognosis in addition to the amount of local extent and degree of invasion of the neoplasm. The adequate preoperative documentation of tumor extension is mandatory, and a team effort in the surgical resection is worthwhile. Radiation therapy remains an important adjuvant in this treatment and occasionally has been used effectively as the only modality of treatment.

Rhabdomyosarcoma of the ear in childhood. A report from the Intergroup Rhabdomyosarcoma Study-I

Twenty-four children with rhabdomyosarcoma of the middle (22 patients) or external ear (two patients) were entered on the Intergroup Rhabdomyosarcoma Study-I protocol from 1972 to 1978. After surgery, treatment consisted of radiotherapy plus vincristine, dactinomycin, and cyclophosphamide, with or without Adriamycin. Nine of 19 patients (47%) who presented with localized sarcoma are free of disease at 2.2 to 6.5 years after diagnosis (median, 3.6 years). One is alive with regional recurrence at 6.7 years; another developed a contralateral cerebellar astrocytoma 4.4 years from diagnosis and died without evidence of rhabdomyosarcoma 2 months later. The other 13 children died of recurrent rhabdomyosarcoma at 5 to 25 months after diagnosis (median duration of survival, 10 months). Outcome was influenced by the presence of diagnosis of signs indicating meningeal extension; death rates were 5 of 5 patients with intracranial tumor, 3 of 4 with petrous bone erosion, 2 of 6 with facial nerve palsy, and 3 of 9 with no initial evidence of meningeal extension.

Rhabdomyosarcoma of the ear in childhood. A report from the Intergroup Rhabdomyosarcoma Study-I

Twenty-four children with rhabdomyosarcoma of the middle (22 patients) or external ear (two patients) were entered on the Intergroup Rhabdomyosarcoma Study-I protocol from 1972 to 1978. After surgery, treatment consisted of radiotherapy plus vincristine, dactinomycin, and cyclophosphamide, with or without Adriamycin. Nine of 19 patients (47%) who presented with localized sarcoma are free of disease at 2.2 to 6.5 years after diagnosis (median, 3.6 years). One is alive with regional recurrence at 6.7 years; another developed a contralateral cerebellar astrocytoma 4.4 years from diagnosis and died without evidence of rhabdomyosarcoma 2 months later. The other 13 children died of recurrent rhabdomyosarcoma at 5 to 25 months after diagnosis (median duration of survival, 10 months). Outcome was influenced by the presence of diagnosis of signs indicating meningeal extension; death rates were 5 of 5 patients with intracranial tumor, 3 of 4 with petrous bone erosion, 2 of 6 with facial nerve palsy, and 3 of 9 with no initial evidence of meningeal extension.

Anatomical coverage in elective irradiation of the neck for squamous cell carcinoma of the oral tongue

From January 1954 through December 1978, 146 patients with squamous cell carcinoma of the oral tongue and clinically negative neck had their primary lesion controlled with irradiation. Metastases to the neck developed later in: 27 of 76 patients (36%) treated by interstitial implantation; nine of 27 patients (33%) who received 2,000 rad in five fractions to the upper neck prior to the implant; eight of 19 (42%) patients who received 5,000 rad through an upper ipsilateral neck field prior to the implant; four of 24 patients (16.6%) who received 5,000 rad through bilateral portals to the upper neck with or without irradiation of the lower neck. In the 43 ipsilateral neck failures, 23 were in the upper jugular chain, (posterior subdigastric nodes), 12 in the mid-jugular, three in the lower jugular, and four in the more anterior part of the subdigastric area. There was one failure in the posterior cervical chain, and five contralateral neck failures. A review of the treatment charts showed that the patients who had an ipsilateral upper neck field only, had smaller portals because the irradiation was tailored to produce shrinkage of the primary tumor prior to needling. To include adequate coverage of the posterior subdigastric nodes (upper jugular), the bodies of the vertebrae must be seen on the simulator films. Also the junction of the subdigastric and the mid-jugular lymphatics must be covered. Although there were only three failures in the lower jugular nodes, it is technically easier to treat the upper mid-jugular nodes through an anterior appositional portal to the lower neck. A dose of 5,000 rad must be given since 2,000 rad, even if delivered in five fractions, gives a failure rate as if there had been no irradiation to the neck.

Soft-tissue sarcoma of the trunk in childhood. Results of the intergroup rhabdomyosarcoma study

Disease-free survival data were obtained on 30 children with soft-tissue sarcoma of the trunk. The children were clinically grouped and treated in accord with the IRS protocol (Cancer 1977; 40:2015) from November 1972 through December 1976. Histologically, 40% of the tumors were alveolar rhabdomyosarcoma (RMS), 20% were embryonal RMS, 20% were extraosseous Ewing's sarcoma, 17% were undifferentiated sarcoma, and 3% were pleomorphic RMS. In 13 patients with primary tumors of the chest wall, the male-to-female (M:F) ratio was 3:11, and the median age was 12.5 yr. Five of the ten patients (50%) with localized tumor (Groups I-III) were disease-free at a median of 4.7 yrs. after diagnosis; two died of locally recurrent tumor, two died of metastases to lungs or bones, and 1 died of intracranial hemorrhage. None of the four with chest wall tumors and distant metastases (Group IV) survived. In ten patients with localized paraspinal primary tumors, the M:F ratio was 8:2, and the median age was 3.5 yrs. None had metastases. Seven of ten (70%) were disease-free at a median of 4.7 yrs. after diagnosis. Two died after regional recurrence developed (one retroperitoneal, one meningeal), and one died of lung metastases. In six patients with primary tumors of the abdominal wall, the M:F ratio was 3:3 and the median age was 9.5 yrs. Three of five with localized tumor (Groups I-III) were disease-free at a median of 5 yr. after diagnosis; one died after regional recurrence, and one died from accidental trauma. The one Group IV patient died of tumor. Overall, 15 of 30 patients (50%) are alive and free of recurrent disease at a median of 5+ yr. after initiation of treatment. The authors conclude that prognosis is most favorable for patients with paraspinal tumors, least favorable for those with chest wall tumors, and intermediate in patients with abdominal wall tumors. Prognostic differences appeared to be influenced by extent of disease at diagnosis and histologic subtype of the sarcoma.

Three-year relapse-free survival rates in childhood rhabdomyosarcoma of the head and neck: report from the Intergroup Rhabdomyosarcoma Study

In 202 patients with rhabdomyosarcoma of the head and neck who registered in the first Intergroup Rhabdomyosarcoma Study, the primary lesions arose about the eye and orbit in 26%, in parameningeal sites in 46%, and in other head and neck areas in 28%. Histopathologically, 78% were embryonal-botryoid, 9% alveolar, 10% undifferentiated, and 3% extraosseous Ewing's types. Actual three-year relapse-free survival rates were calculated from data on 103 of these patients who were free of distant metastases at diagnosis and in whom follow-up had been completed for a three-year period. The actual relapse-free survival rates were 91% (21/23) for those with eye/orbit primaries, 46% (20/44) for those with parameningeal primaries, and 75% (27/36) for those with other head and neck sites affected. Among those with no clinical evidence of tumor activity at two years, 8% (6/75) had subsequent relapses.

Fifteen year radiotherapy experience with chondrosarcoma of bone

A retrospective analysis of 20 patients with chondrosarcoma of bone treated for cure between 1961 and 1976 using supervoltage radiotherapy and/or neutrons is presented. Radiotherapy was used alone or in combination with other modalities. The 20 patients were divided into four groups: 1) 11 patients who received radiotherapy alone, 2) three patients who received postoperative radiotherapy following less than radical local excision, 3) three patients who received radiotherapy with chemotherapy but without surgery, and 4) three patients who received radiotherapy for tumor recurrent after surgery. Typical tumor doses ranged from 4000 to 7000 rad at 1000 rad/week using parallel-opposed fields. Failure of radiotherapy was indicated by progression of symptoms and increasing tumor size. At 53 months, the average follow-up, the survival rate is 65% (13/20), including one patient with distant metastases, and two patients who developed local recurrent disease after radiotherapy and were surgically salvaged. Seven patients died with uncontrolled local disease; six of them also had distant metastases. Five patients developed severe complications. All four patients treated with a combination of neutron and photon beam alone show no evidence of local failure, compared with only one of the seven patients treated with conventional radiotherapy alone.

Carotid artery disease following external cervical irradiation

A retrospective study of 910 patients surviving at least five years after cervical irradiation for Hodgkin's disease, non-Hodgkin's lymphoma, or primary head an neck neoplasms showed the incidence of stroke following cervical irradiation was 63 of 910 patients (6.3%) during a mean period of observation of nine years. This represents a trend toward an increased risk for this population observed over the same period of time (p = 0.39). A prospective study of 118 similar patients currently living five years after cervical radiotherapy was performed to determine the incidence of carotid artery disease occurring as a consequence of neck irradiation. Abnormal carotid phonangiograms (CPA) were found in 25% of the patients and abnormal oculoplethysmographs (OPG) were found in 17%. These studies represent significant carotid lesions that are not expected in such a population. It is concluded that the carotid stenoses demonstrated are most likely a consequence of prior irradiation. Patients that are five-year survivors of cervical irradiation should have noninvasive vascular laboratory studies performed as part of their routine follow-up examinations in order to detect these carotid lesions while they are occult.

Combined laryngeal conservation surgery and irradiation: can we expand the indications for conservation therapy?

Thirty-nine patients (median age of 60 years) with carcinoma of the supraglottic larynx (N = 16), vocal cord (N = 4), and hypopharyngeal wall and pyriform sinus (N = 19) were treated by combined conservation surgery and radiation therapy. Thirty-three patients had postoperative treatment, and the remaining six were given preoperative irradiation. The plan was chosen because of clinical and pathologic features known to be fraught with a high incidence of recurrence above the clavicles. Long-term complications occurred in six patients, two of whom died of aspiration pneumonia. Thirty-eight patients completed their treatment and have been followed for a median of 48 months (1 1/2 to six years). Survival rates are 56% and 63% for absolute and determinant cases, respectively.

Conservative surgery and postoperative radiotherapy in 300 adults with soft-tissue sarcomas

From January 1963 through December 1977, 300 adults with soft-tissue sarcomas were treated by a conservative surgical excision and postoperative radiotherapy. The absolute two- and five-year disease-free survival rates are 74% (222/300) and 61.3% (103/168), respectively. The five-year survival rate varies with: (1) anatomic site, e.g., 69.4% (75/108) for extremity lesions vs. 33% (5/15) for abdominal lesions; (2) histopathologic diagnosis, e.g., 86.4% (19/22) for fibrosarcoma vs. 50% (15/30) for neurofibrosarcoma; and (3) stage of the lesion. The overall local recurrence rate was 22.3% (67/300) and 27% (81/300) of the patients developed distant metastases. The incidence of lymph node metastases as an initial site of spread was only 2.7% (8/300); therefore, elective treatment of the regional lymphatics is not indicated. The 6.5% incidence of significant complications in extremities is low and might be further diminished by careful treatment planning. The combination of conservative surgery and postoperative radiation therapy maintains a functional limb in 84.5% (169/200) of patients with extremity lesions. This rate is comparable to the five-year survival rate attained with radical surgery.

Special considerations related to primary site in rhabdomyosarcoma: experience of the Intergroup Rhabdomyosarcoma Study, 1972--76

Rhabdomyosarcomas (RMS) arising in the head and neck region, retroperitoneum, and perineum were considered together here because the usual surgical approach is incisional biopsy. Thus successful treatment of these neoplasms depends on effective radiation therapy and chemotherapy. From November 1972 through December 1976 the Intergroup Rhabdomyosarcoma Study accrued 127 patients with primary tumors in the head and neck, 34 with orbital tumors, 24 with sarcomas arising in the retroperitoneum-pelvis (no genitourinary), and 11 with perineal lesions. Results of treatment varied among these primary sites. Patients with orbital RMS had the best prognoses; 77% of them were free of disease, compared with a 51% disease-free rate in patients with nonorbital head and neck RMS. In this latter group, disease recurrence was evenly divided among local failure, distant metastases, and direct meningeal extension. Prognoses were similar for retroperitoneal tumors; 46% of such patients are currently free of disease. That the perineum was a rare site for RMS was fortunate because only 3 of 11 such patients (27%) are free of detectable disease now (January 1979). We concluded that the site of the primary tumor is an important prognostic variable in children with RMS.

Radiation therapy combined with systemic chemotherapy of rhabdomyosarcoma in children: local control in patients enrolled in the Intergroup Rhabdomyosarcoma Study

The 524 children enrolled in the Intergroup Rhabdodomyosarcoma Study were the basis for our reviewing the effect on local tumor control by radiation therapy (RT) when combined with systemic chemotherapy. Of those who received RT, 291 were evaluated for dose and 317 for volume. No statistical differences of local control were observed at doses ranging between 3,500 and 6,000 rad, by extent of local disease, nor by adequacy of RT volume as long as the tumor mass and a 5-cm margin were in the RT portal.

Ewing sarcoma: its course and treatment in 50 adult patients

34 patients were treated for Ewing sarcoma with primary presentation. There were 10 females and 24 males with average age of 21 years (range 16-36 years). These patients received radiotherapy (greater than 5,000 R) to the primary site and combination chemotherapy with vincristine, cyclo-hosphamide, doxorubicin and actinomycin D. Of 19 patients with primary presentation in an extremity, 12 remain alive at 29 months without clinical evidence of tumor (63%); 2 patients are alive with relapse. All 10 patients with primary presentation in the pelvis died despite vigorous treatment. 3 patients are alive out of 5 patients with primary presentation in chest or abdominal wall or axilla but only 1 patient remained tumor-free. Of the entire group of 34 patients, 12 remained tumor-free at 27 months (35%). 2 relapsed patients were rendered surgically tumor-free and receive further treatment. 20 patients died or are receiving treatment for advancing disease. 16 patients were treated for locally recurrent (1 patient) or metastatic (15 patients) Ewing sarcoma. There were 6 females and 10 males (average age 24.7 years). These patients received palliative radiotherapy and combination chemotherapy with vincristine, cyclophosphamide, doxorubicin, actinomycin D and dacarbazine. At 36 months, 3 patients are alive tumor-free and 1 patient is alive with stable disease. 12 patients died, 2 after temporarily achieving complete remission.

Parameningeal rhabdomyosarcoma

The records of 27 patients with rhabdomyosarcoma involving the parameningeal area (nasopharynx, paranasal sinus, and middle ear) treated from 1961 to 1976 were reviewed. Due to the location of the primary tumor, radiation and chemotherapy were used but surgery was limited to simple biopsy. In the literature, spread of tumor from these primary sites to the meninges has been as high as 26-35%. In this series, meningeal disease developed in only 2 of the 27 patients (7%).

Solitary plasmacytoma of bone vs. extramedullary plasmacytoma and their relationship to multiple myeloma

Solitary plasmacytoma of bone (SPB) and extramedullary plasmacytoma (EMPC) are unusual solitary tumors of plasma cell origin. The clinical differences between these tumors and multiple myeloma are the subject of continued study. This review examines the radiotherapy experience at M. D. Anderson Hospital. Between 1948 and 1977, 12 patients with SPB and 12 patients with EMPC were treated with radiotherapy. Radiotherapeutic doses were most often (22/24) greater than 4,000 rads, at 200 rads per day. In order to qualify as solitary plasmacytoma a disease-free interval of 3 years was required. In the group of SPB, 5 patients of 9 were alive with no evidence of disease (NED) at 3 years, 4 of 5 at 5 years, and none of 4 at 10 years. In the EMPC group, 8 patients of 11 were NED at 3 and 5 years, and 6 of 9 at 10 years. Six patients with SPB developed multiple myeloma compared with only two with EMPC. The results confirm the better prognosis of EMPC and support the theory that SPB and EMPC are two different entities.

Management and results of localized Ewing's sarcoma

Seventy-six patients with localized Ewing's sarcoma who received primary treatment at M.D. Anderson Hospital from 1948 through December 1975 were reviewed. Patients have been divided into four groups according to the different treatment regimens they received: Group I, moderate dose radiotherapy alone; Group II, high dose radiotherapy alone; Group III, radiotherapy plus vincristine and cytoxan; and Group IV, radiotherapy plus vincristine, Adriamycin, cytoxan and actinomycin. The problem of local recurrence appears to be solved with combined chemotherapy and radiation therapy with only one of 36 patients having a recurrence at the primary site in Groups III and IV. Multimodal therapy is the preferred treatment to obtain control of the primary lesion by radiation therapy while preserving good function. However, the major cause of failure remains distant metastases, 19 of 36 (53%) in Groups III and IV. In addition, 4 of 10 patients who have survived over 5 years have developed osteogenic sarcoma.

An analysis of distant metastases from squamous cell carcinoma of the upper respiratory and digestive tracts

The charts of 5,019 previously untreated patients with squamous cell carcinoma of the upper respiratory and digestive tracts who completed treatment for cure from January 1948 through August 1973, were reviewed. These patients had no evidence of distant metastases when initially evaluated. Five hundred and forty-six patients developed clinical evidence of distant metastases. The overall incidence of distant metastases was 10.9%, varying from 3.1% for vocal cord cancers to 28.1% for cancer of the nasopharynx. The lungs and bones were the most common first sites of metastases, accounting for 52% and 20.3% respectively, whereas metastases to the mediastinum (2.9%) were rare. Forty-eight percent of the metastases were detected within nine months after treatment and 80% were detected within two years. The rate of distant metastases increased with the stage (2% for Stage I to 19.5% for Stage IV). The rate also increased with the T and N classification; however, the N stage had greater influence on the rate of metastases than the T stage. The incidence of distant metastases was significantly higher when there was a recurrence above the clavicles (16.7%) than when there was no recurrence (7.9%, less than 0.001). In patients whose primary lesion was treated by radiotherapy or surgery alone, the incidence was essentialy the same. Patients receiving postoperative irradiation had double the incidence of the preoperative group (20.1% vs 9.9%--p less than .005); however, the sequence of modalities was not randomized.