Intrafractional gastric motion and interfractional stomach deformity using CT images.

To evaluate the intra- and interfractional gastric motion using repeated CT scans, six consecutive patients with gastric lymphoma treated at our institution between 2006 and 2008 were included in this study. We performed a simulation and delivered RT before lunch after an overnight fast to minimize the stomach volume. These patients underwent repeated CT scanning at mild inhale and exhale before their course of treatment. The repeated CT scans were matched on bony anatomy to the planning scan. The center of stomach was determined in the X (lateral), Y (superior-inferior), and Z (ventro-dorsal) coordinate system to evaluate the intra- and interfractional motion of the stomach on each CT scan. We then calculated the treatment margins. Each patient was evaluated four to five times before their course of RT. The average intrafractional motions were -12.1, 2.4 and 4.6 mm for the superior-inferior (SI), lateral (LAT), and ventro-dorsal (VD) direction. The average interfractional motions of the center of the stomach were -4.1, 1.9 and 1.5 mm for the SI, LAT and VD direction. The average of the vector length was 13.0 mm. The systematic and random errors in SI direction were 5.1, and 4.6 mm, respectively. The corresponding figures in LAT and VD directions were 10.9, 5.4, 10.0, and 6.5 mm, respectively. Thus, the 15.9, 31.0 and 29.6 mm of margins are required for the SI, LAT, and VD directions, respectively. We have demonstrated not only intrafractional stomach motion, but also interfractional motion is considerable.

Induction of NKT cell-specific immune responses in cancer tissues after NKT cell-targeted adoptive immunotherapy.

Vα24 natural killer T (NKT) cells have potent anti-tumor activity. We performed a phase II clinical study in patients with head and neck squamous cell carcinoma (HNSCC) using ex vivo expanded Vα24 NKT cells and α-galactosylceramide (αGalCer; KRN7000)-pulsed antigen-presenting cells (APCs) to investigate the efficacy and induction of NKT cell-specific immune responses. The subjects were 10 patients with locally recurrent and operable HNSCC. One course of nasal submucosal administration of αGalCer-pulsed APCs and intra-arterial infusion of activated NKT cells via tumor-feeding arteries was given before salvage surgery. Anti-tumor effects, NKT cell-specific immune responses in extirpated cancer tissue and peripheral blood, safety, and pathological effects were evaluated. Five cases achieved objective tumor regression. The number of NKT cells increased in cancer tissues in 7 cases and was associated with tumor regression. The combination therapy induced NKT cell-specific immune responses in cancer tissues that were associated with beneficial clinical effects.

Fractionated stereotactic radiotherapy as a boost treatment for tumors in the head and neck region.

The objective of this retrospective study was to report initial results of CyberKnife stereotactic radiotherapy (SRT) boost for tumors in the head and neck area. Between March 2008 and August 2009, 10 patients were treated with SRT boost using CyberKnife system due mainly to unfavorable condition such as tumors in close proximity to serial organs or former radiotherapy fields. Treatment sites were the external auditory canal in two, the nasopharynx in one, the oropharynx in three, the nasal cavity in one, the maxillary sinus in two, and the oligometastatic cervical lymph node in one. All patients underwent preceding conventional radiotherapy of 40 to 60 Gy. Dose and fractionation scheme of the Cyberknife SRT boost was individualized, and prescribed dose ranged from 9 Gy to 16 Gy in 3 to 4 fractions. Among four patients for whom dose to the optic pathway was concerned, the maximum dose was only about 3 Gy for three patients whereas 9.6 Gy in the remaining one patient. The maximum dose for the mandible in one of three patients with oropharyngeal cancer was 19.7 Gy, whereas majority of the bone can be spared by using non-isocentric conformal beams. For a patient with nasopharyngeal cancer, the highest dose in the brain stem was 15 Gy. However, majority of the brain stem received less than 40% of the maximum dose. Although a small volume high dose area within the normal structure could be observed in several patients, results of the present study showed potential benefits of the CyberKnife SRT boost.

Radiation pneumonitis following twice-daily radiotherapy with concurrent carboplatin and paclitaxel in patients with stage III non-small-cell lung cancer.

OBJECTIVE: To examine the effects of dose-volume factors on the development of radiation pneumonitis in patients with non-small-cell lung cancer who received twice-daily radiotherapy concurrently with carboplatin and paclitaxel chemotherapy. METHODS: Radiotherapy consisted of twice-daily fractionation of 1.2 Gy, to a total dose of 60 Gy. Weekly carboplatin and paclitaxel were used as a concurrent chemotherapy. Effects of radiotherapy parameters on the development of radiation pneumonitis were retrospectively analyzed. RESULTS: Fourteen of 37 patients developed Grade 2 or worse (> or = G2) radiation pneumonitis. Grade 2 or worse radiation pneumonitis occurred in all 5 patients with V5 >40%, all 4 patients with V10 >35%, all 4 patients with V13 >32%, 9 of 14 patients with V20 >24% and 8 of 11 patients with V30 >22%, whereas 9 of 32 patients with V5 <40%, 10 of 33 patients with V10 <35%, 10 of 33 patients with V13 <32%, 5 of 23 patients with V20 <24% and 6 of 26 patients with V30 <22%, with respective P values of 0.0045, 0.015, 0.015, 0.015 and 0.008. Eight of 11 patients with a mean lung dose of >14 Gy developed > or = G2 radiation pneumonitis in contrast to 6 of 26 patients with a mean lung dose of <14 Gy (P = 0.008). CONCLUSIONS: Several cut-off values in the V(dose) and the mean lung dose differentiating probabilities of developing > or = G2 radiation pneumonitis were identified in this combination therapy.

Vessel-contouring-based pelvic radiotherapy in patients with uterine cervical cancer.

OBJECTIVE: The aim of this study was to assess clinically the adequacy of vessel-contouring-based pelvic radiotherapy with regard to nodal coverage for uterine cervical cancer. METHODS: Fifty patients with Stages I-III cervical cancer, treated with vessel-contouring-based three-dimensional radiotherapy since August 2002, were entered into the study (median age: 54, 47 received concurrent daily cisplatin). All patients were treated with external beam radiotherapy using a four-field box technique with or without brachytherapy. Pelvic blood vessels were identified and contoured on computed tomography simulation images. A generous margin was set outside these vessels outlined on digitally reconstructed radiograph accounting for normal size lymph nodes, patient's motion and set-up uncertainty. Multi-leaf collimator (MLC) was inserted and adjusted manually. Patterns of recurrence were clinically evaluated. RESULTS: Distance between major vessels and MLC edges varied inter- and intra-individually. Median distance in the mid-iliosacral joint level was 25 mm (left) and 24 mm (right). The maximum and the minimum distances ranged from 25 to 45 mm (median, 32) and 9 to 27 mm (median, 15) for left side and 24 to 41 mm (median, 30) and 7 to 28 mm (median, 15) for right side, respectively. With a median follow-up of 43 months, 10 patients developed recurrence. However, no marginal recurrence was occurred just lateral to the contoured vessels. All three patients who developed regional recurrence had recurred at the internal iliac node or the obturator node medial to contoured vessels. CONCLUSIONS: Contoured vessels can be used as surrogate markers for location of the pelvic lymph nodes.

Combination therapy of in vitro-expanded natural killer T cells and alpha-galactosylceramide-pulsed antigen-presenting cells in patients with recurrent head and neck carcinoma.

The aim of this clinical trial was to investigate the feasibility of intra-arterial infusion of in vitro-expanded Valpha24 natural killer T (NKT) cells combined with submucosal injection of alpha-galactosylceramide (KRN7000; alphaGalCer)-pulsed antigen-presenting cells (APC). A phase I clinical study was carried out in patients with head and neck squamous cell carcinoma (HNSCC). Patients with locally recurrent HNSCC refractory to standard therapy were eligible. Eight patients received super-selective transcatheter intra-arterial infusion of activated Valpha24 NKT cells into tumor-feeding arteries and nasal submucosal injections of alphaGalCer-pulsed APC twice with a 1-week interval. Valpha24 NKT cell-specific immune responses, safety, and antitumor effects were evaluated. The number of Valpha24 NKT cells and interferon-gamma-producing cells in peripheral blood mononuclear cells increased in seven out of eight patients enrolled. Grade 3 toxicity with a pharyngocutaneous fistula related to local tumor reduction was observed in one patient and mild adverse events with grade 1-2 symptoms occurred in seven patients. Regarding the clinical responses, three cases exhibited a partial but significant response, four were classified as stable disease, and one patient continued to develop progressive disease. The use of the intra-arterial infusion of activated Valpha24 NKT cells and the submucosal injection of alphaGalCer-pulsed APC has been shown to induce significant antitumor immunity and had beneficial clinical effects in the management of advanced HNSCC. The use of such therapeutic modalities may be helpful in the management of tumors and therefore needs to be explored in further detail. The clinical trial registration number was UMIN000000722.

Intrafractional gastric motion and interfractional stomach deformity during radiation therapy.

BACKGROUND AND PURPOSE: To evaluate intrafractional gastric motion and interfractional variability of the stomach shape during radiation therapy (RT) for gastric lymphoma. MATERIALS AND METHODS: For 11 patients with gastric lymphomas, we undertook fluoroscopic examinations at the time of the simulation, and once a week during RT to evaluate inter- and intrafractional gastric variations. We recorded anteroposterior and left to right X-ray images at inhale and exhale in each examination. We gave coordinates based on the bony landmarks in each patient, and identified the most superior, inferior, lateral, ventral, and dorsal points of the stomach on each film. The interfractional motion was assessed as the distance between a point at inhale and the corresponding point at exhale. We also analyzed interfractional variation based on each point measured. RESULTS: The intrafractional gastric motion was 11.7+/-8.3, 11.0+/-7.1, 6.5+/-6.5, 3.4+/-2.3, 7.1+/-8.2, 6.6+/-5.8mm (mean+/-SD) for the superior, inferior, right, left, ventral and dorsal points, respectively, which was significantly different between each point. The interfractional variability of stomach filling was -2.9+/-14.4, -6.0+/-13.4, 9.3+/-22.0mm for the superior-inferior (SI), lateral (LAT), and ventro-dorsal (VD) directions, respectively, and the differences of variabilities were also statistically significant. Thus, the appropriate treatment margins calculated from both systematic and random errors are 30.3, 41.0, and 50.8mm for the SI, LAT, and ventro-dorsal directions, respectively. CONCLUSIONS: Both intrafractional gastric motion and interfractional variability of the stomach shape were considerable during RT. We recommend regular verification of gastric movement and shape before and during RT to individualize treatment volume.

A case of gastric lymphoma with marked interfractional gastric movement during radiation therapy.

Radiation therapy (RT) with or without chemotherapy has been a widely accepted treatment for patients with localized gastric lymphoma. We encountered a patient with gastric diffuse large B-cell lymphoma, whose stomach volume, and the position and location of the clips that had been endoscopically placed to define the gastric lesions clearly differed considerably at three simulation times. The positions of the clips moved between 5 and 35 mm (mean 24 mm) laterally on simulation films. The mean movement of these clips along the cephalocaudal directions was 8 mm (range 0-15 mm). There have been no published articles which systemically evaluated interfractional gastric motion between each treatment session. Therefore this is an important observation in the management of patients with gastric lymphoma with RT.

Dose-volume factors predicting radiation pneumonitis in patients receiving salvage radiotherapy for postlobectomy locoregional recurrent non-small-cell lung cancer.

BACKGROUND: The correlation between treatment-related factors and lung toxicity has not been sufficiently evaluated in salvage radiotherapy. METHODS: Twenty-one patients with recurrent non-small-cell lung cancer (NSCLC) after lobectomy received salvage radiotherapy to a total dose of 46-60 Gy. The effects of radiotherapy parameters on the development of radiation pneumonitis (RP) were examined using dose-volume histograms. RESULTS: Grade 1 RP was observed in 4, grade 2 in 2, and grade 3 in 1 patient. Patients who developed RP had a significantly higher value in V dose (V13, V20) parameters and mean lung dose (MLD) than those who did not develop RP. Concerning G2 or higher RP, 3 patients who developed > or = G2 RP had a significantly higher value in V20, V13, and MLD than the remaining patients with P values of 0.01, 0.015, and 0.016, respectively. The mean V20, V13, and MLD in these 3 patients were 27%, 29.3%, and 14.8 Gy, respectively, whereas the mean V20, V13, and MLD in the remaining 18 patients were 15.8%, 18.3%, and 8.8 Gy, respectively. Three of 6 patients with a V20 > or = 20% developed > or = G2 RP whereas this did not occur in the remaining patients (P = 0.015). Similarly, 3 of 6 patients with a V13 > or = 23% developed > or = G2 RP whereas this did not occur in the remaining patients (P = 0.015). CONCLUSIONS: These data suggest that a somewhat lower V dose value or MLD, as compared with the setting of definitive radiotherapy, could be a surrogate for RP in patients undergoing salvage radiotherapy for recurrent NSCLC.

Extranodal natural killer/T-cell lymphoma, nasal type: the significance of radiotherapeutic parameters.

BACKGROUND: The objective of this study was to investigate the correlation between local recurrence and radiotherapeutic parameters, including dose and RT radiotherapy (RT) field. METHODS: The current study included 35 patients who were diagnosed with immunohistochemically confirmed nasal natural killer (NK)/T-cell lymphoma between 1976 and 2004. There were 21 males and 14 females, and they ranged in age from 18 years to 76 years (median, 51 yrs). The primary tumor originated in the nasal cavity in 28 patients, and 32 patients had Stage I disease. Seventeen patients received treatment solely with RT, and the remaining 18 patients received a combination of chemotherapy and RT. The median tumor dose was 50 grays (Gy) (range, 22-60 Gy). Twenty-seven patients received RT to include all macroscopic lesions, all paranasal sinuses, the palate, and the nasopharynx. Eight patients received RT to all macroscopic lesions with generous margins. RESULTS: A complete remission (CR) or a CR/unconfirmed was achieved in 28 patients (80%). The 5-year overall survival (OAS) rate, disease-free survival (DFS) rate, and local control probability (LCP) were 47.3%, 42.9%, and 65.2%, respectively. Patients who received RT only to macroscopic lesions fared less well in terms of LCP (LCP 5 years, 71.9% vs. 41.7%; P=0.007). The difference in RT field also affected both the OAS rate and the DFS rate. Patients who received RT doses>or=50 Gy tended to achieve favorable local control. CONCLUSIONS: In the management of nasal NK/T-cell lymphoma, the RT field affected treatment outcomes. RT doses>or=50 Gy resulted in favorable local control.

Preoperative chemotherapy and radiation therapy for squamous cell carcinoma of the maxillary sinus.

OBJECTIVE: This study was undertaken to assess the prognostic factors for the management of squamous cell carcinoma (SCC) of the maxillary sinus, who received preoperative chemotherapy and radiation therapy (RT). We also elucidated the appropriate sequence of chemotherapy. METHODS: A total of 124 patients (median age 62 years) with SCC of the maxillary sinus were analysed retrospectively. T3 or T4 disease was found in 93% of the patients. Thirty-nine patients received neoadjuvant chemotherapy (NA), 38 patients received concurrent chemoradiotherapy (CRT) and 47 patients received NA followed by CRT. The median dose of RT was 60 Gy. Maxillectomy was undertaken in 98 patients. RESULTS: The 5 year overall survival (OAS) and local control probability (LCP) were 56.6 and 73.7%, respectively. On univariate analysis, surgery (P < 0.0001) and T classification (P < 0.04) were significant prognostic factors for OAS and LCP. Histological grade and nodal status were also related to OAS. However, any chemotherapy sequence was not associated with the treatment outcome. On multivariate analysis, surgery (P < 0.0005) and T classification (P < 0.05) were identified as significant prognostic factors for LCP and OAS. CONCLUSIONS: This study suggests that both surgery and T stage are important prognostic factors for LCP and OAS in the management of SCC of the maxillary sinus. The appropriate sequence of chemotherapy remains to be elucidated in the future study.

Toxicities and effects of involved-field irradiation with concurrent cisplatin for unresectable carcinoma of the pancreas.

PURPOSE: To evaluate local effects and acute toxicities of involved field irradiation with concurrent cisplatin (CDDP) for unresectable pancreatic carcinoma. MATERIALS AND METHODS: Thirty-three patients with unresectable pancreatic carcinoma were treated with chemoradiotherapy. Sixteen were Stage IVA; 17 were Stage IVB. The total prescribed dose of radiotherapy was 50 Gy/25 fractions or 50.4 Gy/28 fractions, using a three-dimensionally determined involved-field that included only the primary tumor and clinically enlarged lymph nodes. Twelve patients received a daily i.v. infusion of CDDP; 21 patients received a combination of CDDP and 5-fluorouracil either i.v. or through the proper hepatic artery. RESULTS: Twenty-seven (82%) patients completed planned chemoradiotherapy. Nausea was the most frequent complaint. No patient experienced Grade 4 toxicities. More than half achieved pain relief. As for the primary site, only 4 patients (12%) achieved a partial response at 4 weeks; however, 3 additional patients attained >50% tumor reduction thereafter. The most frequent site of disease progression was the liver, and only 3 patients developed local progression alone. No regional lymph nodal progression outside the treatment field was seen. Median survival time and survival at 1 year were 7.1 months and 27%, respectively, for the entire group. Difference in overall survival between patients with and without distant metastases was significant (p = 0.01). CONCLUSIONS: Involved-field irradiation with concurrent daily CDDP was well tolerated without compromising locoregional effects.

Weekly cisplatin administration concurrent with radiation therapy for locoregionally advanced nasopharyngeal carcinoma.

Radiation therapy (RT) with concurrent and adjuvant chemotherapy has been a widely accepted treatment for patients with locoregionally advanced nasopharyngeal carcinoma (NPC). We administered 40 mg/m2 cisplatin (CDDP) weekly, concurrently with RT, to six consecutive patients with locoregionally advanced NPC to evaluate its toxicity and efficacy. The median number of courses of CDDP administration was 4.5 and the median radiation dose was 69.7 Gy. Grade 3 leukopenia was observed in three patients. All but one patient experienced grade 3 or 4 skin reactions, pharyngitis, or dysphagia. All but one patient achieved a complete response, and the remaining patient received radical neck dissection for persistent cervical lymphadenopathies, which contained no cancer cells. All six patients were disease-free at last contact, with a median follow up of 23.5 months. This regimen is well tolerated in patients with locoregionally advanced NPC.

Hyperfractionated radiation therapy for locoregionally advanced nasopharyngeal cancer.

OBJECTIVE: The purpose of this study is to clarify the efficacy and toxicity of hyperfractionated radiation therapy (RT) for patients with nasopharyngeal cancer (NPC). METHODS: Twenty-two patients with NPC treated at our hospital between April 1994 and December 2002 were the subjects of this study. They received hyperfractionated RT with a fraction size of 1.2 Gy, with a median tumor dose of 72 Gy (range 64.8-80.4). During this study period, our institutional strategy for locoregionally advanced NPC included neoadjuvant or concurrent chemotherapy combined with hyperfractionated RT, and 17 patients received some forms of cisplatin-containing chemotherapy. RESULTS: With a median follow-up of 59 months, the estimated 5-year disease-free survival rate and overall survival rate were 72.7 and 85.2%, respectively. Acute hematological toxicities were acceptable and manageable. However, >50% of patients required nutritional support, and experienced severe pharyngitis, skin reaction and body weight loss. With regard to late sequelae, one patient developed grade 3 osteomyelitis, and one patient each developed grade 4 passage disturbance and laryngeal edema. No patients experienced any grades of optic nerve injury or temporal lobe necrosis. CONCLUSIONS: Hyperfractionated RT using 1.2 Gy per fraction, for a total dose of 72 Gy, produces a comparable treatment outcome. Although deleterious neurological sequelae were not observed in this study, caution should be exercised regarding other late sequelae, such as osteomyelitis and passage disturbance.

Efficacy and toxicities of concurrent chemoradiation for elderly patients with esophageal cancer.

BACKGROUND: To evaluate the efficacy and toxicity of concurrent chemoradiation in patients with esophageal cancer aged 75 and older. PATIENTS AND METHODS: Twenty-two elderly patients were treated with concurrent chemoradiation. Seventeen received a combination of cisplatin/carboplatin and 5-fluorouracil, 5 received daily 5-fluorouracil. Total doses of radiotherapy ranged from 50 to 65 Gy. RESULTS: Nineteen out of 22 patients completed the planned chemoradiation. Five in 8 patients (63%) with T1-2 lesion and 1 in 14 patients (7o%) with T3-4 lesion achieved complete response (p=0.011). Only 2 patients experienced grade 3 toxicities. Grade 2 or worse hematological toxicities were less frequently observed in patients who received local-field radiotherapy (p=0.006). There was no isolated lymph node recurrence. The median survival time was 9 months. CONCLUSION: This study showed the potential for chemoradiation in elderly patients. A planning target volume of radiotherapy should include only clinically involved lesions in this setting.

Radiation therapy for idiopathic orbital myositis: two case reports and literature review.

We report two cases of idiopathic orbital myositis treated with radiation therapy (RT). Both patients visited our hospital with complaints of orbital pain on eye movement and eyelid swelling. There was no history of thyroid disease or trauma, and no signs of infection, neoplasm, or collagen disease. The laboratory investigations, including a thyroid function test, showed no abnormalities in either woman. They were initially treated with a combination of corticosteroids (CS) and nonsteroidal anti-inflammatory drugs (NSAIDs), however, they became dependent on or refractory to oral CS therapy, and received 20 Gy in 10 fractions of RT to the orbit. Their symptoms decreased immediately, and both patients were able to reduce the dosage of oral CS after RT. One patient could completely withdraw oral CS thereafter. However, they both experienced recurrence at eight months after RT, and have been receiving oral CS to control their symptoms. RT at doses of 20 Gy in 10 fractions for patients with idiopathic orbital myositis appears to be effective in palliating symptoms, but long-term control is not satisfactory.

A case of bronchiolitis obliterans organizing pneumonia syndrome with preceding radiation pneumonitis after breast-conserving therapy.

Recent case series have demonstrated that bronchiolitis obliterans organizing pneumonia (BOOP) after radiation therapy to the breast is a distinct clinicopathological entity. Most of the investigators speculated that radiation may prime the development of BOOP through an unidentified immunological process; however, none of them showed the relationship between direct radiation injury and BOOP. We report herein a case of a 67-year-old female with BOOP following direct radiation damage confined to the irradiated area after breast-conserving therapy. This is the first case demonstrating that BOOP after breast-conserving therapy arises from direct radiation injury.

Radiation bronchitis in lung cancer patient treated with stereotactic radiation therapy.

We report a case of chronic radiation bronchitis that developed in a patient with lung cancer treated with fractionated stereotactic radiation therapy. A 73-year-old woman with a medically inoperable T1N0M0 adenocarcinoma of the lung was treated with stereotactic radiation therapy. By using eight non-coplanar ports, 50 Gy/5 fractions was delivered in two weeks. At four weeks, a partial response was obtained with no acute adverse reaction. She developed severe cough at six months. Fiberoptic bronchoscopy revealed thick circumferentially coated bronchial mucosa in close proximity to the tumor site. At 12 months, follow-up study confirmed marked stenotic change in the B6 segmental bronchus without tumor progression.

Concurrent chemoradiotherapy for locoregionally advanced nasopharyngeal carcinoma: is intergroup study 0099 feasible in Japanese patients?

BACKGROUND: Since the publication of the significant results of the Intergroup Study 0099 (IGS) in 1998, radical radiation therapy (RT) with concurrent and adjuvant chemotherapy has become the standard care for patients with locoregionally advanced nasopharyngeal carcinoma (NPC) in the United States. An update in 2001 further strengthened the findings of the interim analysis, however, no prospective randomized trials other than this study have confirmed the feasibility of this strategy. METHODS: We attempted to adopt the same combined modality treatment for three consecutive Japanese patients with locoregionally advanced NPC to evaluate its toxicity and efficacy. They were planned to receive radical RT concurrently with cisplatin every 3 weeks, and to receive adjuvant chemotherapy thereafter. RESULTS: The hematological toxicities were mild and well tolerated in all three patients; however, they all experienced severe (grade 3 and/or 4) skin reactions, pharyngitis and dysphagia, which led to the discontinuation of the planned chemotherapy. They were able to complete RT without treatment breaks, and all three patients achieved complete response at the end of treatment. However, two experienced recurrences after 8 and 10 months, respectively, and died of their disease. CONCLUSIONS: Due to these severe acute adverse events, poor compliance and unsatisfactory outcomes, we have concluded that physicians should be careful in applying the concurrent chemoradiotherapy protocol employed by the IGS for locoregionally advanced Japanese NPC patients.

Preoperative radiation therapy for carcinoma of the oropharynx: prognostic factors for locoregional control and survival.

BACKGROUND: To assess the role of preoperative irradiation and surgery in patients with oropharyneal cancer. MATERIALS AND METHODS: Seventy-five patients were treated with radiotherapy alone or followed by surgery. The stage distribution was stage II in 15 patients, stage III in 16 patients, stage IVA in 38 patients and stage IVB in 6 patients. RESULTS: Thirty-five patients were treated with radiotherapy alone and the remaining 40 underwent definitive surgery after radiation therapy. In the multivariate analysis, both good Karnofsky Performance Status (KPS) and complete response (CR) after radiation therapy had positive impact on locoregional control and survival. Overall survival at 5 years was 65% and 20% for KPS > or = 90% and KPS < 90%, respectively (p < 0.0001). Corresponding values for CR and non-CR were 80% and 35%, respectively (p = 0.0001). CONCLUSION: The results indicated that the KPS and complete response after radiation therapy were very sensitive surrogates for locoregional control and survival for cancer of the oropharynx.