Palms of the past: can morphometric phytolith analysis inform deep time evolution and palaeoecology of Arecaceae?

BACKGROUND AND AIMS: Palm fossils are often used as evidence for warm and wet palaeoenvironments, reflecting the affinities of most modern palms. However, several extant palm lineages tolerate cool and/or arid climates, making a clear understanding of the taxonomic composition of ancient palm communities important for reliable palaeoenvironmental inference. However, taxonomically identifiable palm fossils are rare and often confined to specific facies. Although the resolution of taxonomic information they provide remains unclear, phytoliths (microscopic silica bodies) provide a possible solution because of their high preservation potential under conditions where other plant fossils are scarce. We thus evaluate the taxonomic and palaeoenvironmental utility of palm phytoliths. METHODS: We quantified phytolith morphology of 97 modern palm and other monocot species. Using this dataset, we tested the ability of five common discriminant methods to identify nine major palm clades. We then compiled a dataset of species' climate preferences and tested if they were correlated with phytolith morphology using a phylogenetic comparative approach. Finally, we reconstructed palm communities and palaeoenvironmental conditions at six fossil sites. KEY RESULTS: Best-performing models correctly identified phytoliths to their clade of origin only 59 % of the time. Although palms were generally distinguished from non-palms, few palm clades were highly distinct, and phytolith morphology was weakly correlated with species' environmental preferences. Reconstructions at all fossil sites suggested that palm communities were dominated by Trachycarpeae and Areceae, with warm, equable climates and high, potentially seasonal rainfall. However, fossil site reconstructions had high uncertainty and often conflicted with other climate proxies. CONCLUSIONS: While phytolith morphology provides some distinction among palm clades, caution is warranted. Unlike prior spatially restricted studies, our geographically and phylogenetically broad study indicates phytolith morphology may not reliably differentiate most palm taxa in deep time. Nevertheless, it reveals distinct clades, including some likely to be palaeoenvironmentally informative.

Comparison of antipsychotic drug use among Dutch Youth before and after implementation of the Youth Act (2010-2019).

OBJECTIVE: The Dutch law on youth care (the Youth Act) was implemented from 2015 onwards. One of the government's aims by implementing this new policy was de-medicalization of youths by separating youth mental healthcare from the rest of the healthcare system. A previous study conducted by our research group showed that prevalence rates of antipsychotic drug prescriptions stabilized among Dutch youth in the period 2005-2015, just before the introduction of the Youth Act. In our study, we aimed to describe antipsychotic drug use among Dutch children aged 0-19 years old before and after implementation of the Youth Act (2010-2019). METHODS: We analyzed prescription data of 7405 youths aged 0-19 years using antipsychotic drugs between 2010 and 2019, derived from a large Dutch community pharmacy-based prescription database (IADB.nl). RESULTS: Prevalence rates of antipsychotic drug use per thousand youths decreased significantly in youths aged 7-12 years old in 2019 compared to 2015 (7.9 vs 9.0 p < 0.05). By contrast, prevalence rates increased in adolescent females in 2019 compared to 2015 (11.8 vs 9.5 p < 0.05). Incidence rates increased significantly in adolescent youths in 2019 compared to 2015 (3.9 vs 3.0 p < 0.05), specifically among adolescent girls (4.2 per thousand in 2019 compared to 3.0 per thousand in 2015). Dosages in milligram declined for the most commonly prescribed antipsychotic drugs during the study period. The mean duration of antipsychotic drug use in the study period was 5.7 (95% CI 5.2-6.2) months. CONCLUSION: Despite the aim of the Youth Act to achieve de-medicalization of youths, no clear reduction was observed in prevalence rates of antipsychotic drugs or treatment duration in all subgroups. Prevalence rates even increased in adolescent females.

No influence of sarcopenia on survival of ovarian cancer patients in a prospective validation study.

OBJECTIVE: Decrease in skeletal muscle index (SMI) during neoadjuvant chemotherapy (NACT) has been associated with worse outcome in patients with advanced ovarian cancer. To validate these findings, we tested if a decrease in SMI was a prognostic factor for a homogenous cohort of patients who received NACT in the randomized phase 3 OVHIPEC-trial. METHODS: CT-scans were performed at baseline and after two cycles of neoadjuvant chemotherapy in stage III ovarian cancer patients. The SMI (skeletal muscle area in cm2 divided by body surface area in m2) was calculated using SliceOMatic software. The difference in SMI between both CT-scans (ΔSMI) was calculated. Cox-regression analyses were performed to analyze the independent effect of a difference in SMI (ΔSMI) on outcome. Log-rank tests were performed to plot recurrence-free (RFS) and overall survival (OS). The mean number of adverse events per patient were compared between groups using t-tests. RESULTS: Paired CT-scans were available for 212 out of 245 patients (87%). Thirty-four of 74 patients (58%) in the group with a decrease in ΔSMI and 73 of 138 of the patients (53%) in the group with stable/increase in ΔSMI had died. Median RFS and OS did not differ significantly (p = 0.297 and p = 0.764) between groups. Patients with a decrease in SMI experienced more pre-operative adverse events, and more grade 3-4 adverse events. CONCLUSION: Decreased SMI during neoadjuvant chemotherapy was not associated with worse outcome in patients with stage III ovarian cancer included in the OVHIPEC-trial. However, a strong association between decreasing SMI and adverse events was found.

Sentinel nodes in vulvar cancer: Long-term follow-up of the GROningen INternational Study on Sentinel nodes in Vulvar cancer (GROINSS-V) I.

OBJECTIVE: In 2008 GROINSS-V-I, the largest validation trial on the sentinel node (SN) procedure in vulvar cancer, showed that application of the SN-procedure in patients with early-stage vulvar cancer is safe. The current study aimed to evaluate long-term follow-up of these patients regarding recurrences and survival. METHODS: From 2000 until 2006 GROINSS-V-I included 377 patients with unifocal squamous cell carcinoma of the vulva (T1, <4 cm), who underwent the SN-procedure. Only in case of SN metastases an inguinofemoral lymphadenectomy was performed. For the present study follow-up was completed until March 2015. RESULTS: Themedian follow-up was 105 months (range 0­179). The overall local recurrence ratewas 27.2% at 5 years and 39.5% at 10 years after primary treatment, while for SN-negative patients 24.6% and 36.4%, and for SN-positive patients 33.2% and 46.4% respectively (p = 0.03). In 39/253 SN-negative patients (15.4%) an inguinofemoral lymphadenectomy was performed, because of a local recurrence. Isolated groin recurrence rate was 2.5% for SN-negative patients and 8.0% for SN-positive patients at 5 years. Disease-specific 10-year survival was 91% for SN-negative patients compared to 65% for SN-positive patients (p b .0001). For all patients, 10-year disease-specific survival decreased from 90% for patients without to 69% for patients with a local recurrence (p b .0001).

Long-term effects of cutting versus non-cutting instruments in FESS.

BACKGROUND: Currently most ENT surgeons advocate using cutting instruments in Functional Endoscopic Sinus Surgery (FESS), based on the assumption of superior wound healing due to mucosal preservation. However, there is no scientific evidence of superiority of the cutting instruments. METHODS: A prospective, randomized double blinded study was performed in 100 patients undergoing FESS, operated one side with non-cutting and the contra lateral side with cutting instruments. After a mean follow-up of 12 years after FESS, unilateral and global sino-nasal symptoms were scored by the patients using VAS, endoscopic abnormalities scored at both sides at the Outpatient clinic and radiologic abnormalities were described. RESULTS: No significant differences between the sides operated by cutting and non-cutting instruments were found for sino-nasal symptomatic or for radiologic abnormalities between both sides. For the endoscopic parameters there was no difference for secretion or mucosa. Only for the presence of endoscopic synechiae there was a statistically significant difference between both groups. At the non-cutting side more synechiae were noticed, but no interference with sinus access, neither ventilation nor drainage was observed. CONCLUSION: FESS performed with cutting instruments results in less synechiae formation compared to non-cutting instruments. However, the presence of synechiae is not associated with more symptoms or CT scan abnormalities.

Medullary thyroid cancer: prognostic factors for survival and recurrence, recommendations for the extent of lymph node dissection and for surgical therapy in recurrent disease.

BACKGROUND: We reviewed our experience with MTC (medullary thyroid cancer), focusing on recurrence and survival, recommendations for the extent of lymph node (LN) dissection and surgery for recurrent disease. METHODS: Of 51 MTC patients treated between 1988 and 2008 at the University Hospitals Leuven, 38 previously untreated patients were analysed. RESULTS: Overall and disease-specific (DSS) five-year survival rates were 75% and 82%. Variables univariately associated with DSS were age, pN, stage, vascular invasion, pre-operative recurrent laryngeal nerve function and last calcitonin level. Recurrence occurred in 10 patients (26%). For recurrence, age was no longer a prognostic factor and post-operative calcitonin, number of positive LN and of positive compartments proved to be prognostic factors. Of 21 clinical NO patients, 2 out of 6 (33%) undergoing a prophylactic central neck dissection (ND) based on per-operative palpatory suspicion proved pN+, and 2 out of 9 patients (22%) undergoing a prophylactic lateral ND were pN+. Five patients surgically treated for recurrence did not achieve long-term normalisation of calcitonin, but remained alive with locoregional control. CONCLUSION: Overall survival and DSS rates are within the range reported in the literature. The results confirm that (1) total thyroidectomy and central compartment dissection is the treatment of choice in the cN0 patients, (2) additional ipsilateral lateral ND is needed for cN+ disease in the ipsilateral lateral compartment, and (3) in the clinically uninvolved contralateral lateral neck, per-operative inspection should serve as a basis for a decision about further ND. Locoregional control and prolonged survival is achieved in surgically treated locoregionally recurrent MTC.

Malignant ectomesenchymoma of the paranasal sinuses with proptosis.

PROBLEM: A 36-year-old woman presented with a feeling of pressure in the right orbit and proptosis of the right eye after a "common cold". METHODOLOGY: Computed tomography (CT) of the maxillofacial region revealed, and endoscopy confirmed, a mass in the right ethmoid sinus, eroding the lamina papyracea and extending into the orbit. Pathology of multiple biopsies revealed a nasal neoplasm composed of neuroectodermal and mesenchymal neoplastic elements, suggestive of a malignant ectomesenchymoma (MEM). Magnetic resonance imaging was used for MEM staging. Computed tomography of the chest and abdomen show no evidence of distant metastases. RESULTS: Due to the intracranial and intraorbital extension of the tumour, radical surgery was not an option. Appropriate chemotherapy (6 cycles of vincristine/ifosfamide/adriamycin and 2 cycles of vincristine/ifosfamide/cisplatin) and intensity-modulated radiation therapy were administered. CONCLUSION: Twenty-eight months after treatment, there was no evidence of residual or metastatic disease.

3D Cranial Nerve Imaging, a Novel MR Neurography Technique Using Black-Blood STIR TSE with a Pseudo Steady-State Sweep and Motion-Sensitized Driven Equilibrium Pulse for the Visualization of the Extraforaminal Cranial Nerve Branches.

This study investigated the feasibility of a 3D black-blood STIR TSE sequence with a pseudo steady-state sweep and motion-sensitized driven equilibrium pulse for extraforaminal cranial nerve imaging on a 3T system. Assessments of healthy volunteers showed near-perfect agreement in nerve visualization with excellent to good visualization of the extraforaminal trigeminal, greater occipital, and facial nerves. Suppression of surrounding tissues was excellent to good. 3D cranial nerve imaging can produce nerve selective imaging of extraforaminal cranial and spinal nerve branches.

Health-related quality of life after interval cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with stage III ovarian cancer.

INTRODUCTION: The addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to interval cytoreductive surgery (CRS) improves recurrence-free (RFS) and overall survival (OS) in patients with FIGO stage III ovarian cancer. We evaluated the effect of HIPEC on patient's health-related quality of life (HRQoL) in the OVHIPEC trial. MATERIALS AND METHODS: OVHIPEC was a multicentre, open-label, randomized phase III trial for patients with stage III ovarian cancer. Patients were randomly assigned (1:1) to receive interval CRS with or without HIPEC with cisplatin. HRQoL was assessed using the EORTC QLQ-C30, and the ovarian (QLQ-OV28) and colorectal cancer (QLQ-CR38) modules. HRQoL questionnaires were administered at baseline, after surgery, after end of treatment, and every three months thereafter. HRQoL was a secondary endpoint, with the prespecified focus on the QLQ-C30 summary score and symptom scores on fatigue, neuropathy and gastro-intestinal symptoms. HRQoL was analysed using linear and non-linear mixed effect models. RESULTS: In total, 245 patients were randomized. One-hundred-ninety-seven patients (80%) completed at least one questionnaire. No significant difference over time in the QLQ-C30 summary scores was observed between the study arms (p-values for linear and non-linear growth: p > 0.133). The pattern over time for fatigue, neuropathy and gastro-intestinal symptoms did not significantly differ between treatment arms. CONCLUSION: The addition of HIPEC to interval CRS does not negatively impact HRQoL in patients with stage III ovarian cancer who are treated with interval CRS due to the extent of disease. These HRQoL results, together with the improvement in RFS and OS, support the viability of HIPEC as an important treatment option in this patient population. CLINICALTRIALS. GOV NUMBER: NCT00426257. EUDRACT NUMBER: 2006-003466-34.

Dynamic contrast-enhanced and diffusion-weighted MRI for early detection of tumoral changes in single-dose and fractionated radiotherapy: evaluation in a rat rhabdomyosarcoma model.

We aimed to examine different intratumoral changes after single-dose and fractionated radiotherapy, using diffusion-weighted (DW) and dynamic contrast-enhanced (DCE) MRI in a rat rhabdomyosarcoma model. Four WAG/Rij rats with rhabdomyosarcomas in the flanks received single-dose radiotherapy of 8 Gy, and four others underwent fractionated radiotherapy (five times 3 Gy). In rats receiving single-dose radiotherapy, a significant perfusion decrease was found in the first 2 days post-treatment, with slow recuperation afterwards. No substantial diffusion changes could be seen; tumor growth delay was 12 days. The rats undergoing fractionated radiotherapy showed a similar perfusion decrease early after the treatment. However, a very strong increase in apparent diffusion coefficient occurred in the first 10 days; growth delay was 18 days. DW-MRI and DCE-MRI can be used to show early tumoral changes induced by radiotherapy. Single-dose and fractionated radiotherapy induce an immediate perfusion effect, while the latter induces more intratumoral necrosis.

Salvage Transoral Laser Microsurgery for Radiorecurrent Laryngeal Cancer: Indications, Limits, and Outcomes.

PURPOSE OF REVIEW: The aim of this report is to identify relevant literature reports on salvage transoral laser microsurgery (TLM); to consider its oncologic and functional outcomes, as well as reported complications; and to address indications and limitations of salvage TLM. FINDINGS: The weighted average of local control after first salvage TLM was 57%. Repeated TLM procedures for second or third recurrences were required in up to 41% of cases, resulting in a weighted average of local control with TLM alone of 67%. The rate of definite laryngeal preservation was 73%. The ultimate local control rate, including cases that required total laryngectomy, was 90%. The overall complication rate after salvage TLM was 14%. SUMMARY: Salvage TLM of radiorecurrent laryngeal cancer yields excellent oncologic outcomes. Serious complications are scarce, hospitalization times are short, and functional outcomes in terms of voice and swallowing are favorable when compared to open conservation laryngeal surgery. The key to success is an optimal patient selection.

Preradiotherapy computed tomography as a predictor of local control in supraglottic carcinoma.

PURPOSE: To determine the utility of pretreatment computed tomography (CT) for predicting primary site control in patients with supraglottic squamous cell carcinoma (SCC) treated with definitive radiotherapy (RT). MATERIALS AND METHODS: Pretreatment CT studies in 63 patients were reviewed. Minimum length of follow-up was 2 years. Local recurrence and treatment complications resulting in permanent loss of laryngeal function were documented. Tumor volume was calculated using a computer digitizer, and pre-epiglottic space (PES) spread was estimated. The data were analyzed using a combination of Fisher's exact test, logistic regression modeling, and multivariate analyses. Five-year local control rates were calculated using the product-limit method. RESULTS: Local control rates were inversely and roughly linearly related to tumor volume, although there seemed to be a threshold volume at which primary site prognosis diminished. Local control was 89% in tumors less than 6 cm3 and 52% when volumes were > or =6 cm3 (P = .0012). The likelihood of maintaining laryngeal function also varied with tumor volume: 89% for tumors less than 6 cm3 and 40% for tumors > or =6 cm3 (P = .00004). Pre-epiglottic space involvement by tumor of > or =25% was associated with a reduced chance of saving the larynx (P = .0076). Multivariate analyses revealed that only tumor volume independently altered these end points. CONCLUSION: Pretreatment CT measurements of tumor volume permits stratification of patients with supraglottic SCC treated with RT alone (which allows preservation of laryngeal function) into groups in which local control is more likely and less likely. Pre-epiglottic space spread is not a contraindication to using RT as the primary treatment for supraglottic SCC.

[A woman with a vulvar swelling, a rare manifestation of the Klippel-Trenaunay-Weber syndrome]. / Een vrouw met een vulvaire zwelling, een zeldzame uiting van het Klippel-Trenaunay-Weber-syndroom.

A woman with a vulvar swelling, a rare manifestation of the Klippel-Trenaunay-Weber syndrome. - A 32-year-old woman presented with a vulvar swelling. The swelling had always been there but had increased after her last pregnancy, 5 years earlier. Because of progressive complaints, such as pain and a feeling of pressure, she now wished surgical correction. The swelling turned out to be varicosis of the right labium majus associated with the Klippel-Trenaunay-Weber syndrome. The vulvar swelling was removed by electrocoagulation. The pathological diagnosis was 'venous haemangioma'. The Klippel-Trenaunay-Weber syndrome is a congenital skin condition in which vascular angiomas, varicosis and trophic changes in the soft tissue and skeleton can arise. Vulvar involvement is rare. The abnormality can be removed surgically, for example by electrocoagulation. There is a chance of recurrence.

Chronic maxillary atelectasis.

Chronic maxillary atelectasis (CMA) is characterized by a reduced maxillary sinus volume due to an inward bowing of one or more of the sinus walls. The disorder is probably caused by an obstruction of the maxillary ostium, leading to a persistent negative pressure within the sinus lumen. To provide insight into the epidemiology, pathogenesis and treatment of this disorder, a retrospective study of twelve cases that met radiographic criteria of CMA was carried out. The patients were equally divided between both sexes and were on average 25 years old. Five of the twelve patients were under eighteen years of age. The patients had chronic sinonasal complaints except two, who had a "silent sinus syndrome", characterized by enophthalmos associated with a marked sinus deformation. This is the first report of CMA associated with a benign nasal tumour and also of CMA following cicatrisation due to nasal packing for bleeding after endoscopic sinus surgery. All patients were treated surgically by creating a middle meatal antrostomy, thus restoring sinus ventilation. To conclude, CMA is rare and probably underestimated, especially in the paediatric population. Different entities causing a complete ostial occlusion can lead to CMA. Endoscopically restoring maxillary sinus ventilation is the recommended treatment.

Elevated carcinoembryonic antigen tumour marker caused by head and neck cancer: a case report and literature study.

Carcinoembryonic antigen is a tumour marker commonly increased in gastrointestinal and pulmonary cancers. We report a case of a 46-year-old man with a mucoepidermoid carcinoma of the base of tongue with an elevated and traceable serum carcinoembryonic antigen level. This antigen proved to be a valuable marker in the treatment follow-up. When a raised carcinoembryonic antigen level is found, salivary gland malignancies should be taken into the differential diagnosis and clinical examination of the head and neck region should not be overlooked.

Value of computed tomography as outcome predictor of supraglottic squamous cell carcinoma treated by definitive radiation therapy.

PURPOSE: To investigate the value of several CT-derived tumor parameters as predictors of local outcome of supraglottic squamous cell carcinoma treated by definitive radiation therapy. METHODS AND MATERIALS: The pretreatment CT studies of 103 patients with supraglottic squamous cell carcinoma were reviewed for tumoral involvement of specific laryngeal anatomic subsites and extralaryngeal tumor spread. After redigitizing the films, tumor volume was calculated with the summation-of-areas technique. Mean follow-up time was 3.4 years. Actuarial statistical analysis of local and locoregional outcome was done for each of the covariates; multivariate analysis was performed using Cox's proportional hazards model. RESULTS: In the actuarial analysis CT-determined primary tumor volume was significantly correlated with local recurrence rate (p < 0.001). Degree of involvement of the paraglottic space at the level of the true vocal cord (p < 0.05) and subglottic extension (p < 0.001) were also significantly correlated with local recurrence rate. In the multivariate analysis, only degree of involvement of the preepiglottic space (p < 0.01) and subglottic extension (p < 0.01) were found to be independent predictors of local recurrence. Total tumor volume was the strongest independent predictor of locoregional failure (p < 0.01). CONCLUSIONS: CT-determined tumor parameters are strong predictors of local and locoregional outcome of supraglottic carcinoma treated by definitive irradiation.

Laryngeal tumor volume measurements determined with CT: a study on intra- and interobserver variability.

PURPOSE: To investigate the intra- and interobserver variability of computed tomography-based volume measurements of laryngeal tumors. METHODS AND MATERIALS: The volume of 13 laryngeal tumors was repeatedly measured by five independent observers in four different sessions, using the summation-of-areas technique. Mean tumor volume and its standard deviation were calculated for each tumor. Statistical analysis was done with analysis of variance, Spearman rank correlation, and linear regression. RESULTS: Both the effect of the observers (p < 0.0001) and the effect of the session (p < 0.01) on tumor volume was statistically significant. Interobserver variability was the most important component of total variability (89.3%). A significant rank correlation was found between mean volume and standard deviation (p < 0.01); the relationship between mean tumor volume and standard deviation can be described using linear regression [standard deviation = 0.28 volume + 0.35 (R = 0.79)]. CONCLUSION: Total variability in the computed tomography-based measurement of laryngeal tumor volume can be reduced by having the measurements done by a single trained observer.

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.

The relation of CT-determined tumor parameters and local and regional outcome of tonsillar cancer after definitive radiation treatment.

PURPOSE: To investigate the value of CT-derived tumor parameters as predictor of local and regional outcome of tonsillar squamous cell carcinoma treated by definitive radiation therapy. METHODS AND MATERIALS: The pretreatment CT studies of 112 patients with tonsillar squamous cell carcinoma were reviewed. After redigitizing the films, primary and nodal tumor volume was calculated with the summation-of-areas technique. The nodal CT aspect was graded using a 3-point scale (homogenous, inhomogeneous, and necrotic). Mean follow-up time was 33 months. Actuarial statistical analysis of local and regional outcome was done for each of the covariates; multivariate analysis was performed using Cox's proportional hazards model. RESULTS: In the actuarial analysis, CT-determined primary tumor volume was significantly correlated with local recurrence rate (p < 0.05) when all patients were considered, but primary tumor volume did not predict local control within the T2, T3, and T4 category. CT-determined nodal volume was significantly related to regional outcome (p < 0.01), but nodal density was not. Total tumor volume was not significantly related to locoregional outcome (p = 0.1). In the multivariate analysis, the T and N categories were the independent predictors of local and regional outcomes, respectively. CONCLUSION: Compared to other head-and-neck sites, primary and nodal tumor volume have only marginal predictive value regarding local and regional outcome after radiation therapy in tonsillar cancer.