Radiotherapy and radiosurgery for skull base tumors.

Tumors arising in the vicinity of the skull base are relatively uncommon; however, lesions that may be successfully treated by radiotherapy and radiosurgery include temporal bone chemodectomas, schwannomas, juvenile angiofibromas, pituitary adenomas, and meningiomas. This article reviews treatment techniques and results and discusses the pertinent literature.

Planned postradiotherapy bilateral neck dissection for head and neck cancer.

PURPOSE: This is a retrospective analysis of 50 patients with squamous cell carcinoma of the head and neck treated with radiotherapy (RT) to the primary site and bilateral neck followed by a planned bilateral neck dissection approximately 4 to 6 weeks after completion of RT. PATIENTS AND METHODS: Between November 1964 and March 1997, 50 patients underwent bilateral neck dissections after RT, with minimum 2-year follow-up. Forty-eight patients had bilateral positive neck nodes. RESULTS: At 5 years, the rates of neck disease control, local-regional control, and cause-specific survival were 76%, 70%, and 39%, respectively. Five severe complications developed after surgery, and 1 developed after RT. CONCLUSIONS: Radiotherapy followed by a planned bilateral neck dissection resulted in a high rate of local-regional control with acceptable morbidity. The likelihood of severe complications after simultaneous (as opposed to staged) neck dissection was not significantly different (P =.24).

Treatment of paragangliomas with radiation therapy.

Paragangliomas of the head and neck may be treated successfully with surgery, radiation therapy, or stereotactic radiosurgery. The choice of treatment depends on the location and extent of the tumor, the presence of multiple tumors, the age and health of the patient, and the preference of the patient and attending physician. This article reviews the role of radiation therapy in the treatment of patients with paragangliomas of the head and neck.

Squamous cell carcinoma metastatic to the neck from an unknown head and neck primary site.

Squamous cell carcinoma metastatic to the neck from an unknown head and neck primary site is relatively uncommon and presents a challenging diagnostic and therapeutic dilemma. Diagnostic evaluation includes fine-needle aspiration of the neck mass, chest roentgenography, computed tomography, and/or magnetic resonance imaging of the head and neck, followed by panendoscopy and biopsies. The primary tumor will be detected in approximately 40% of patients; approximately 80% of cancers are located in the base of the tongue or tonsillar fossa. Management options include treatment of the neck alone or both sides of the neck and the potential head and neck primary sites. The latter approach is associated with better long-term control above the clavicles. The 5-year survival rate is approximately 50% after treatment and is influenced by the extent of neck disease. In this article, we review the pertinent literature.

Long-term results of radiation therapy for juvenile nasopharyngeal angiofibroma.

PURPOSE: To analyze 15 patients treated with radiation therapy for juvenile nasopharyngeal angiofibroma (JNA) between June 1975 and March 1996. MATERIALS AND METHODS: All patients had a 2.5-year minimum follow-up. All patients had advanced disease (Chandler stage III or stage IV); two thirds of the patients had intracranial extension. RESULTS: Local control after radiotherapy was obtained in 13 of 15 patients (85%). Two patients had local recurrences, and both were salvaged with surgery for an ultimate local control rate of 100%. Late complications included cataracts in 3 patients, delayed transient central nervous system (CNS) syndrome in 1 patient, and a basal cell carcinoma of the skin in 1 patient. Of 15 patients, 13 (85%) had a complete response (CR) on physical examination following radiation therapy. The median time to CR was 13 months (range, 1 to 39 months). Of 6 patients with residual disease in more than 24 months, 2 (33%) had a recurrence, whereas no patient achieving CR in less than 24 months experienced a recurrence. CONCLUSIONS: Radiotherapy is an effective treatment for advanced JNA. Tumor regression usually occurs slowly over several months. JNAs that are slow to regress (greater than 2 years) may have an increased risk of recurrence.

Squamous cell carcinomas of the soft palate treated with radiation therapy alone or followed by planned neck dissection.

PURPOSE: The present study presents the experience at the University of Florida with treatment of unselected patients with carcinomas of the soft palate with radiation therapy (RT) alone or followed by planned neck dissection. METHODS AND MATERIALS: One hundred seven patients treated with curative intent with RT alone or followed by neck dissection from 1965 to 1996 were included in the study. All patients had follow-up for at least 2 years. No patients were lost to follow-up. RESULTS: Local control rates at 5 years were 86% for T1, 91% for T2, 67% for T3, and 36% for T4 carcinomas. T-stage and overall treatment time significantly affected local control in multivariate analysis. Nodal control rates at 5 years were 86% for NO, 76% for N1, 61% for N2, and 67% for N3 carcinomas. Overall treatment time and planned neck dissection significantly affected nodal control in multivariate analysis. Ultimate local-regional control rates at 5 years were 90% for Stage I, 92% for Stage II, 84% for Stage III, and 60% for Stage IV disease. Overall treatment time and planned neck dissection significantly affected ultimate local-regional control in multivariate analysis. The overall survival rate at 5 years was 42% for all patients. Overall stage, overall treatment time, and planned neck dissection significantly affected overall survival in multivariate analysis. The cause-specific survival rate at 5 years was 70% for all patients. Overall treatment time and planned neck dissection significantly affected cause-specific survival in multivariate analysis. Three patients sustained severe postoperative complications and 3 patients sustained severe late complications. Sixteen patients had synchronous and 14 patients had metachronous carcinomas of the head and neck mucosal sites. CONCLUSION: For limited carcinomas of the soft palate, RT (alone or followed by planned neck dissection) results in relatively high local-regional control and survival rates. For advanced carcinomas of the soft palate, local-regional control and survival rates are relatively low and local-regional recurrence rates are substantial. Advanced carcinomas of the soft palate may be better treated with RT and concomitant chemotherapy.

Squamous cell carcinomas metastatic to cervical lymph nodes from an unknown head and neck mucosal site treated with radiation therapy with palliative intent.

Minimal information has been published about the results of palliative irradiation for squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site. Forty patients with this diagnosis were treated at the University of Florida with radiation therapy with palliative intent. The nodal response rate was 65% and the symptomatic response rate was 57% at 1 year. The absolute survival rate was 25% at 1 year, as was the cause-specific survival rate. Radiotherapy successfully palliates more than half of those treated. Approximately one fourth are alive 1 year after irradiation.

Squamous cell carcinomas metastatic to cervical lymph nodes from an unknown head-and-neck mucosal site treated with radiation therapy alone or in combination with neck dissection.

PURPOSE: The present study presents the experience at the University of Florida with treatment of patients with squamous cell carcinomas (SCC) metastatic to cervical lymph nodes from an unknown head-and-neck mucosal (H&NM) site with radiotherapy (RT) alone or in combination with neck dissection (ND). METHODS AND MATERIALS: The study included 126 patients treated with curative intent from 1964 to 1997. All patients had follow-up for at least 2 years. No patients were lost to follow-up. RESULTS: Twelve patients (10%) developed SCC in H&NM sites at 0.5 to 10.9 years (median, 1.8 years). The rate of developing carcinomas in H&NM sites at 5 years was 13%. Histologic differentiation significantly affected the rate of developing carcinomas in H&NM sites in multivariate analysis. Sixteen patients (13%) had persistent nodal disease and 12 patients (10%) developed recurrent nodal disease at 0.5 to 10.9 years (median, 1.1 years). The nodal control rate at 5 years was 78%. Nodal size, N stage, and planned ND significantly affected the rate of nodal control in multivariate analysis. Nineteen patients (15%) developed distant metastasis at 0.2-5.1 years (median, 0.9 years). The distant metastases rate at 5 years was 14%. Extracapsular extension and RT dose significantly affected the risk of distant metastases in multivariate analysis. The overall absolute survival rate at 5 years was 47%. Extracapsular extension, N stage, RT dose for H&NM sites, and planned ND significantly affected absolute survival in multivariate analysis. The rate of cause-specific survival at 5 years was 67%. Extracapsular extension, nodal size, N stage, overall treatment time, and planned ND significantly affected cause-specific survival in multivariate analysis. Eight patients (6%) had severe postoperative complications and 6 patients (5%) had severe late complications. CONCLUSION: The present study supports the effectiveness of RT in lowering the rate of developing carcinomas in the H&NM sites.

Definitive radiotherapy in the management of chemodectomas arising in the temporal bone, carotid body, and glomus vagale.

PURPOSE: To evaluate the results of treatment for 71 patients with 80 chemodectomas of the temporal bone, carotid body, or glomus vagale who were treated with radiation therapy (RT) alone (72 tumors in 71 patients) or subtotal resection and RT (8 tumors) at the University of Florida between 1968 and 1998. METHODS AND MATERIALS: Sixty-six lesions were previously untreated, whereas 14 had undergone prior treatment (surgery, 11 lesions; RT, 1 lesion; or both, 2 lesions) and were treated for locally recurrent disease. All three patients who received prior RT had been treated at other institutions. Patients had minimum follow-up times as follows: 2 years, 66 patients (93%); 5 years, 53 patients (75%); 10 years, 37 patients (52%); 15 years, 29 patients (41%); 20 years, 18 patients (25%); 25 years, 12 patients (17%); and 30 years, 4 patients (6%). RESULTS: There were five local recurrences at 2.6 years, 4.6 years, 5.3 years, 8.3 years, and 18.8 years, respectively. Four were in glomus jugulare tumors and one was a carotid body tumor. Two of the four patients with glomus jugulare failures were salvaged, one with stereotactic radiosurgery and one with surgery and postoperative RT at another institution. Two of the five recurrences had been treated previously at other institutions with RT and/or surgery. Treatment for a third recurrence was discontinued, against medical advice, before receiving the prescribed dose. There were, therefore, only 2 failures in 65 previously untreated lesions receiving the prescribed course of RT. The overall crude local control rate for all 80 lesions was 94%, with an ultimate local control rate of 96% after salvage treatment. The incidence of treatment-related complications was low. CONCLUSIONS: Irradiation offers a high probability of tumor control with relatively minimal risks for patients with chemodectomas of the temporal bone and neck. There were no severe treatment complications.

Organ preservation with radiotherapy for T1-T2 carcinoma of the pyriform sinus.

PURPOSE: To report long-term results using radiotherapy with or without a planned neck dissection for T1-T2 carcinoma of the pyriform sinus. METHODS: An analysis of 101 patients treated at the University of Florida with RT with or without a planned neck dissection for organ preservation. RESULTS: The 5-year local control rates after RT were 90% for T1 cancers and 80% for T2 lesions. The only parameter that significantly influenced local control in univariate analyses was apex involvement for T1 tumors. Multivariate analysis revealed no parameter that significantly affected local control. Cause-specific survival rates at 5 years were as follows: stage I-II, 96%; stage III, 62%; stage IVA, 49%; and stage IVB, 33%. The absolute survival rates were as follows: stage I, 57%; stage II, 61%; stage III, 41%; stage IVA, 29%; and stage IVB, 25%. Moderate to severe long-term complications developed in 12% of patients. CONCLUSIONS: RT alone or combined with a planned neck dissection resulted in local control with larynx preservation in a high proportion of patients. The chance of cure is comparable to that observed after conservation surgery, and the risk of major complications is lower. The addition of adjuvant chemotherapy is unlikely to improve the probability of organ preservation, but might improve locoregional control for patients with advanced nodal disease.

Synchronous and metachronous squamous cell carcinomas of the head and neck mucosal sites.

PURPOSE: The present study presents the experience at the University of Florida with synchronous and metachronous squamous cell carcinomas of the head and neck mucosal sites. PATIENTS AND METHODS: This study included 1,112 patients with squamous cell carcinomas of the oropharynx, hypopharynx, and supraglottic larynx treated with radiation therapy with curative intent from 1964 to 1997. All patients had follow-up for at least 2 years. No patients were lost to follow-up. RESULTS: The overall survival rate was 45% and the disease-specific survival rate was 67% at 5 years after initial diagnosis of carcinoma of the head and neck mucosal sites. Seventy-seven patients (7%) presented with synchronous carcinomas of the head and neck mucosal sites and 103 patients (9%) developed metachronous carcinomas of the head and neck mucosal sites at 0.6 to 21.7 years (median, 3.6 years). The overall survival rate was 31%, and the disease-specific survival rate was 50% at 5 years after metachronous carcinomas of the head and neck mucosal sites. Seven patients (1%) developed metachronous carcinomas of the thoracic esophagus at 1 to 11.1 years (median, 2.8 years), 15 patients (1%) presented with synchronous carcinomas of the lung, and 83 patients (7%) developed metachronous carcinomas of the lung at 0.6 to 17.6 years (median, 3.5 years). CONCLUSION: Development of synchronous and metachronous squamous cell carcinomas of the head and neck mucosal sites are in part responsible for failure to improve overall survival rates for patients with squamous cell carcinomas of the head and neck mucosal sites, justifying rigorous follow-up and studies on chemoprevention.

Radiation therapy for squamous cell carcinoma of the tonsillar region: a preferred alternative to surgery?

PURPOSE: There are no definitive randomized studies that compare radiotherapy (RT) with surgery for tonsillar cancer. The purpose of this study was to evaluate the results of RT alone and RT combined with a planned neck dissection for carcinoma of the tonsillar area and to compare these data with the results of treatment with primary surgery. PATIENTS AND METHODS: Four hundred patients were treated between October 1964 and December 1997 and observed for at least 2 years. One hundred forty-one patients underwent planned neck dissection, and 18 patients received induction (17 patients) or concomitant (one patient) chemotherapy. RESULTS: Five-year local control rates, by tumor stage, were as follows: T1, 83%; T2, 81%; T3, 74%; and T4, 60%. Multivariate analysis revealed that local control was significantly influenced by tumor stage (P =.0001), fractionation schedule (P =.0038), and external beam dose (P =.0227). Local control after RT for early-stage cancers was higher for tonsillar fossa/posterior pillar cancers than for those arising from the anterior tonsillar pillar. Five-year cause-specific survival rates, by disease stage, were as follows: I, 100%; II, 86%; III, 82%; IVa, 63%; and IVb, 22%. Multivariate analysis revealed that cause-specific survival was significantly influenced by overall stage (P =.0001), planned neck dissection (P =.0074), and histologic differentiation (P =.0307). The incidence of severe late complications after treatment was 5%. CONCLUSION: RT alone or combined with a planned neck dissection provides cure rates that are as good as those after surgery and is associated with a lower rate of severe complications.

Radiation therapy in inverted papillomas of the nasal cavity and paranasal sinuses.

PURPOSE: Between December 1969 and September 1989, a total of 10 patients with advanced and/or recurrent inverted or cylindrical cell papillomas were treated with irradiation at the University of Florida in Gainesville. MATERIALS AND METHODS: Nine of 10 patients had 1 or more recurrences before they received radiation therapy. Three patients were treated with irradiation alone, and 7 patients received surgery and irradiation (preoperatively in 1 patient and postoperatively in 6 patients). Eight patients had inverted papillomas (3 with concomitant squamous cell carcinoma), and 2 patients had cylindrical cell papillomas. RESULTS: Local recurrence developed in 4 patients at 1.5, 6.5, 12, and 13 years after treatment. No evidence of recurrence was observed in 6 patients at 7, 8.5, 8.5, 9, 9, and 20.5 years after treatment. Four patients died of intercurrent disease. No patient developed a malignant transformation. Significant complications of treatment included, in 1 patient, an area of bone exposure in the orbit that necessitated debridement. CONCLUSION: Surgery is the primary treatment of this entity. Radiation therapy should be considered in patients with incompletely resectable lesions, multiply recurrent tumors, and tumors associated with malignancy.

Skin cancer of the head and neck with clinical perineural invasion.

PURPOSE: To review treatment and outcomes in 62 patients with clinical and/or gross evidence of perineural invasion from skin cancer of the head and neck. METHODS AND MATERIALS: Sixty-two patients received radiotherapy at the University of Florida as part or all of their treatment between January 1965 and April 1995. All patients had clinical signs and symptoms of perineural involvement and/or documentation of tumor extending to grossly involve nerve(s). Twenty-one patients underwent therapy for previously untreated lesions, including 12 who received radiotherapy alone and nine who had surgery with postoperative radiotherapy. Forty-one patients underwent therapy for recurrent lesions, including 18 treated with radiotherapy alone and 23 who received preoperative or postoperative radiotherapy. RESULTS: Factors on multivariate analysis that predicted local control included patient age, previously untreated vs. recurrent lesions, presence of clinical symptoms, and extent of radiotherapy fields. Recurrence patterns were predominantly local; 26 of 31 patients (84%) who developed local recurrence after treatment had recurrent cancer limited to the primary site. CONCLUSIONS: Many patients with skin cancer and symptomatic perineural invasion have disease that is incompletely resectable. Approximately half these patients will be cured with aggressive irradiation alone or combined with surgery. Age, prior treatment, and clinical symptoms influence the likelihood of cure.

Chronic invasive fungal rhinosinusitis.

Chronic invasive fungal rhinosinusitis is an increasingly recognized, but inadequately characterized, disease entity which is separate and distinct from acute fulminant invasive fungal sinusitis and allergic fungal sinusitis. Chronic invasive fungal rhinosinusitis is divided into granulomatous and nongranulomatous subtypes based on histopathology, but the clinical distinction between the two subtypes is not clear. Current management includes varying degrees of surgical débridement and a prolonged course of antifungal agents. A protracted clinical course with recurrence after treatment is common.

Is radiation therapy a preferred alternative to surgery for squamous cell carcinoma of the base of tongue?

PURPOSE: To evaluate irradiation alone for treatment of base-of-tongue cancer. PATIENTS AND METHODS: Two hundred seventeen patients with squamous cell carcinoma of the base of tongue were treated with radiation alone and had follow-up for >/= 2 years. RESULTS: Local control rates at 5 years were as follows: T1, 96%; T2, 91%; T3, 81%; and T4, 38%. Multivariate analysis revealed that T stage (P =.0001) and overall treatment time (P =.0006) significantly influenced local control. The 5-year rates of local-regional control were as follows: I, 100%; II, 100%; III, 83%; IVA, 64%; and IVB, 65%. Multivariate analysis revealed that the following parameters significantly affect the probability of this end point: T stage (P =.0001), overall treatment time (P =.0001), overall stage (P =.0131), and addition of a neck dissection (P =.0021). The rates of absolute and cause-specific survival at 5 years were as follows: I, 50% and 100%; II, 81% and 100%; III, 65% and 76%; IVA, 42% and 56%; and IVB, 44% and 52%. Severe radiation complications developed in eight patients (4%). CONCLUSION: The likelihood of cure after external-beam irradiation was related to stage, overall treatment time, and addition of a planned neck dissection. The local-regional control rates and survival rates after radiation therapy were comparable to those after surgery, and the morbidity associated with irradiation was less.

Pre- and post-radiotherapy computed tomography in laryngeal cancer: imaging-based prediction of local failure.

PURPOSE: To determine if pre-radiotherapy (RT) and/or post-radiotherapy computed tomography (CT) can predict local failure in patients with laryngeal carcinoma treated with definitive RT. METHODS AND MATERIALS: The pre- and post-RT CT examinations of 59 patients (T3 glottic carcinoma [n = 30] and T1-T4 supraglottic carcinoma [n = 29]) were reviewed. For each patient, the first post-RT CT study between 1 and 6 months after irradiation was used. All patients were treated with definitive hyperfractionated twice-daily continuous-course irradiation to a total dose of 6,720-7,920 cGy, and followed-up clinically for at least 2 years after completion of RT. Local control was defined as absence of primary tumor recurrence and a functioning larynx. On the pre-treatment CT study, each tumor was assigned a high-or low-risk profile for local failure after RT. The post-RT CT examinations were evaluated for post-treatment changes using a three-point post-RT CT-score: 1 = expected post-RT changes; 2 = focal mass with a maximal diameter of < 1 cm and/or asymmetric obliteration of laryngeal tissue planes; 3 = focal mass with a maximal diameter of > 1 cm, or < 50% estimated tumor volume reduction. RESULTS: The local control rates at 2 years post-RT based on pre-treatment CT evaluation were 88% for low pre-treatment risk profile patients (95% CI: 66-96%) and 34% (95% CI: 19-50%) for high pre-treatment risk profile patients (risk ratio 6.583; 95% CI: 2.265-9.129;p = 0.0001). Based on post-treatment CT, the local control rates at 2 years post-RT were 94% for score 1, 67% for score 2, and 10% for score 3 (risk ratio 4.760; 95% CI: 2.278-9.950 p = 0.0001). Post-RT CT scores added significant information to the pre-treatment risk profiles on prognosis. CONCLUSIONS: Pre-treatment CT risk profiles, as well as post-RT CT evaluation can identify patients, irradiated for laryngeal carcinomas, at high risk for developing local failure. When the post-RT CT score is available, it proves to be an even better prognosticator than the pre-treatment CT-risk profile.

Salvage treatment for neck recurrence after irradiation alone for head and neck squamous cell carcinoma with clinically positive neck nodes.

BACKGROUND: To analyze the likelihood of salvage for patients with recurrence in the neck after radiotherapy. METHOD: Recurrent disease developed in the neck of 51 patients after primary irradiation for head and neck carcinoma. Salvage was defined as no recurrence of cancer anywhere for at least 1 year after initial salvage treatment and continuously thereafter. RESULTS: Thirty-three patients (65%) did not undergo a salvage attempt: 18 had unresectable disease; 9 were medically unfit, 4 had distant metastasis; and 2 refused treatment. Eighteen patients (35%) underwent salvage treatment with chemotherapy alone (4 patients), chemotherapy and neck dissection (1 patient), neck dissection alone (11 patients), or surgery with radiotherapy (2 patients). After the initial salvage treatment, recurrent local-regional and/or distant disease developed in all patients. Recurrence was in the neck alone in 10 patients (55%); neck and distant sites in 3 patients (17%); neck, primary site, and distant sites in 2 patients (11%); and with distant metastasis alone in 3 patients (17%). Control of neck disease at 5 years was 9% for the 18 patients who underwent a salvage attempt, as well as for all 51 patients. For the overall group, absolute and cause-specific survival rates were both 10% at 5 years. CONCLUSIONS: The likelihood of successful salvage treatment after a neck recurrence following radiotherapy is remote.

Squamous cell carcinoma of the nasal vestibule.

BACKGROUND AND METHODS: Sixty patients were treated with radiation therapy alone (56 patients) or followed by surgery (4 patients) between 1970 and 1995 for squamous cell carcinoma of the nasal vestibule. RESULTS: Local control rates at five years after irradiation alone in 56 patients were: T1-T2, 94%; T4, 71%; and overall, 85%. Multivariate analysis revealed that tumor size and bone invasion significantly influenced local control. All four patients with extensive T4 tumors treated with radiation therapy plus surgery were cured. Cause-specific survival rates at five years for 56 patients treated with radiation therapy alone were: T1-T2, 94%; T4, 86%; and overall, 91%. Multivariate analysis revealed that bone invasion and tumor size adversely influenced cause-specific survival. No patient treated with irradiation alone experienced a major complication, compared with three of four patients who underwent irradiation and surgery. CONCLUSIONS: Radiation therapy results in a high cure rate with good cosmesis. Patients with extensive T4 cancers have an improved chance of cure with radiation and surgery but more complications.