Surgical treatment versus concurrent chemoradiotherapy as an initial treatment modality in advanced olfactory neuroblastoma

OBJECTIVE: Olfactory neuroblastomas are very aggressive tumors with a high locoregional recurrence rate and distant metastasis. Surgical treatment, including craniofacial resection, has been the main treatment modality, but treatment outcomes of concurrent chemoradiotherapy remain unclear. We present our experiences regarding the treatment outcome of patients with advanced olfactory neuroblastoma undergoing surgical treatment and concurrent chemoradiotherapy. METHODS: We retrospectively analyzed 16 patients treated for advanced olfactory neuroblastoma within the past 10 years. RESULTS: The disease-free 5-year survival rate of the patients (n = 10) who underwent surgical treatment was 68%. The survival rate for patients (n = 6) who received concurrent chemoradiotherapy was 42%. The difference in the survival rate was not statistically significant, and no difference in the recurrence rate between the two groups. In the group having surgical treatment, post-operative radiotherapy and salvage therapy were important to increase the survival rate. In the group having concurrent chemoradiotherapy, no patient experienced primary tumor progression. CONCLUSION: Complete surgical resection, including craniofacial resection (CFR), and post-operative radiotherapy seem to be essential in the treatment of advanced olfactory neuroblastoma. However, concurrent chemoradiotherapy may be another primary treatment modality.     

Outcomes of 18 cases with squamous cell carcinoma of middle ear who underwent both surgery and post-operative radiotherapy

Conclusions: Early diagnosis and treatment were critical to prevent recurrence, and the long-term outcomes were satisfactory after surgery and post-operative radiotherapy. Objectives: To present outcomes of 18 cases with squamous cell carcinoma of the middle ear who underwent both surgery and post-operative radiotherapy. Methods: Eighteen cases with squamous cell carcinoma of the middle ear (two cases of T1, five of T2, and 11 of T3) underwent surgery and post-operative radiotherapy, and a surgical approach was determined by tumour sites. Extended mastoidotympanectomy was performed on two cases, with subtotal temporal bone resection on 12 cases and temporal bone resection on four cases. The patients who had cervical metastasis underwent additional radical neck resection and post-operative radiotherapy at the neck. The patients were followed-up after surgery. Results: During the follow-up, no cases of T1 recurred, and six cases of T2 or T3 recurred, with the total recurrence rate of 37.5% among the patients of T2 and T3. At the fifth year after surgery, 15 patients were still alive, and the actual 5-year survival rate was 83.3% among all patients.     

上颌骨翻转径路手术在鼻咽癌治疗中的应用

目的探讨上颌骨翻转径路手术在鼻咽癌治疗中的临床应用和价值。方法回顾性分析20例应用上颌骨翻转径路手术治疗的鼻咽癌患者,其中15例为放疗后复发（4例为再程放疗后）,3例为放疗后未控,2例为首诊行手术治疗。总结其临床病理资料、手术方法、治疗及随访结果。采用Kaplan-Meier法行生存分析,并绘制生存曲线。结果全组患者均手术顺利,肿瘤根治性切除,无术中并发症。术后2例患者出现明显的张口困难,5例出现腭瘘,1例出现分泌性中耳炎,1例出现上颌骨坏死行再次手术,另11例患者无明显术后并发症。术后随访4-80个月,3例出现局部复发,1例颈部复发,1例远处转移,11例患者无瘤生存,1例带瘤生存,8例死亡。总的中位生存期为35个月,2年累积生存率为66．1％。结论经上颔骨翻转径路切除鼻咽部肿瘤术野暴露良好,直视下可操作性强,手术切除彻底,是鼻咽癌手术径路的一种理想选择。     

Lymphatic metastasis in the neck from unknown primary. Analysis of treatment results and prognostic factors

The aim of this study is to analyze the results of treatment results and prognostic factors related to clinical and treatment characteristics in patients with neck lymph nodes metastases from the unknown primary site. 90 patients with pathology proven cancer metastases in the neck lymph nodes from the unknown primary site were treated between 1984-1998. Most of them (58 patients--63%) had advanced disease in lymph nodes N3. The rest had stage N2abc before initial treatment. 40 patients underwent combined treatment--surgery and definitive radiotherapy. 3 patients had induction chemotherapy followed by resection and radiotherapy. 30 patients received radiotherapy alone or radiotherapy and chemotherapy. In 7 cases chemotherapy after surgical resection were used. Curves of overall survival were estimated using Kaplan-Meier method. Analysis of the prognostic factors was performed using Cox's multivariate proportional risk model. 5 years overall survival probability was 24%. In the group of patients who underwent surgery and radiotherapy probability of 5 years overall survival was 43%. In patients who received radiotherapy alone or radiotherapy and chemotherapy probability of 5 year overall survival was 2%. Multivariate analysis showed significant influence of the performance status (PS--WHO scale), sex and stage N3 on overall survival. The patients with PS 0-1 had better prognosis comparing with PS 2-3 (p < 0.001). Male had worse prognosis then female (p = 0.05). N3 stage reduced overall survival in comparison to N2abc (p = 0.06). In the analysis of disease free survival N3-stage was the only independent factor concerning with poor outcome (p = 0.03). Patients who had surgery followed by radiotherapy had better prognosis. Poor performance status, sex-male and N3 stage were identified as the important factors influencing overall survival. N3-stage was an independent factor influencing disease free survival.     

Treatment and outcome of middle ear cancer

This study addressed the clinical characteristics, treatment, and outcome of middle ear cancer. A series of 33 patients with middle ear cancer were analyzed with survival, the primary outcome. Altogether, 25 patients underwent surgery with adjuvant radiotherapy, seven patients had surgery alone, and one patient had only radiotherapy. The patients were staged according to the Stell staging system. Among patients with T₁/T₂ cancers, five underwent lateral temporal bone resection (LTBR) and three underwent subtotal temporal bone resection (STBR). Among those with T₃/T_x cancers, 11 underwent LTBR, and 13 had STBR. Of the total 33 patients, 18 died of their disease during follow-up. The overall 5-year survival rate was 37.4 %. The 5-year survival rates for patients with T₁/T₂ disease and T₃/T_x disease were 85.7 and 22.0 %, respectively. There was a statistically significant difference in 5-year survival rates between the two groups using the log-rank test (P < 0.05). The 5-year survival rates after LTBR and STBR for the T₃/T_x group were 15.2 and 30.8 % (P > 0.05), respectively, and those for the T₁/T₂ group were 100 and 66.7 % (P > 0.05), respectively. The 5-year survival rates for patients who underwent preoperative or postoperative radiotherapy were 38.9 and 40.4 %, respectively (P > 0.05). En bloc resection is favored in an effort to produce negative surgical margins for middle ear cancer. Adjunctive radiotherapy is used for advanced lesions.     

Laser resection of T1a glottic carcinomas: results and postoperative voice quality

Objectives—To calculate recurrence, mortality and complication rates and evaluate postoperative voice quality after laser resection of T_1a glottic carcinoma.

Material and Methods—Since 1995 we have treated 118 patients with a T_1a glottic carcinoma with laser surgery. In order to evaluate postoperative voice quality, patients who were alive and free of recurrence were sent the Voice Handicap Index (VHI) questionnaire containing 30 questions concerning how their voice affects their daily life physically, emotionally and socially.

Results—Twelve patients (10%) had a local recurrence and received further treatment, either a second laser treatment, radiotherapy or a total laryngectomy. One patient (0.84%) died due to the laryngeal cancer. Ninety-nine patients were sent the VHI questionnaire and 94 of the completed questionnaires were included in the study and analyzed. The mean total score was 13.2, with mean subscores of 6.5 (physical), 4.1 (functional) and 2.5 (emotional).

Conclusions—The results indicate that these patients as a group do not consider that their voice has a negative impact on their daily life. Good surgical technique is essential to obtain a good functional result. The laser strength should be kept low and the surgical margins small in order to minimize scarring and vocal cord stiffness.     

Pediatric rhabdomyosarcoma of the head and neck: is there a place for surgical management?

OBJECTIVE: To review and evaluate the place of surgical treatment in the management of rhabdomyosarcoma of the head and neck in children. DESIGN: Retrospective analysis of patient charts from January 1, 1972, to December 31, 1998. SETTING: Tertiary pediatric referral center. PATIENTS: Twenty-nine consecutive children with nonorbital head and neck rhabdomyosarcoma. INTERVENTIONS: Surgery, chemotherapy, and radiotherapy. MAIN OUTCOME MEASURES: Disease-free survival and long-term morbidity from treatment. RESULTS: Twenty patients had parameningeal and 9 had nonparameningeal head and neck tumors. All were treated with chemotherapy. For 18 patients, diagnostic biopsies were performed and they received radiotherapy. Eleven patients underwent surgery as definitive therapy. Using the Intergroup Rhabdomyosarcoma Study (IRS) staging system, 5 of these 11 patients had complete resection of tumor (IRS group I) and avoided radiotherapy. The other 6 patients required radiation because of compromised, regional, or incomplete resection of tumor. One had undergone regional resection with nodal involvement, and 2 had compromised resections with microscopic residual disease (IRS group II). Three had incomplete resections with gross residual tumor (IRS group III). Only 1 patient who underwent surgery ultimately died from recurrence at 2.7 years after an incomplete resection. The other 10 patients were relapse free at a median follow-up of 3.7 years (range 0.8-21.0 years). Long-term surgical morbidity was seen in 36% (4/11) of the patients and included facial nerve paralysis, trismus, and cosmetic deformity. CONCLUSIONS: Children with localized disease of the head and neck are able to undergo complete surgical resection, with low long-term surgical morbidity. By undergoing complete surgical resection, these children are able to avoid radiotherapy and its long-term complications, with no compromise in survival.     

Transmandibular buccopharyngectomy after radiotherapy for orpharyngeal cancer

MATERIALS & METHODS: We present a retrospective study of 95 patients with recurrence of oropharyngeal carcinoma after exclusive radiotherapy. The treatment consisted in a salvage composite resection in all cases. RESULTS & DISCUSSION: Since the use of muscular flaps, the post-operative complications have been relatively minimised but the carcinologic results were disappointing: only 20% of patients were alive free of disease at 5 years. The main prognostic factors for overall survival were the stage rT of the relapse, the histologic invasion of the nodes and the quality of the resection. The anatomic site of relapse did not influence the survival. CONCLUSION: Our serie confirms the high frequency of second primary tumors in oropharyngeal cancers. Rigorous selection of patients for exclusive radiotherapy is mandatory to decrease the number of relapses and might avoid salvage surgery.     

The treatment of early squamous cell carcinoma of the piriform fossa

The treatment of early piriform fossa cancer can be either primary radiotherapy with salvage surgery, if necessary, or with primary surgery. The present study investigates 65 patients with T₁, ≥₂ or T₃ stage disease with no cervical lymph node metastases at presentation. Of this group, 17 were treated by primary irradiation, 34 underwent primary surgery and 14 were unsuitable for any curative treatment. The adjusted actuarial 5-year survival rate for those patients receiving primary radiotherapy was 55% (95% CI 16–78%) and for the surgery group it was 44% (95% CI 18–67%). This difference was not significant (χ²₁= 1.29). The median survival for untreated patients was 7 months (4–12 months). There was no significant differences in the time to recurrence at the primary site or in the neck, or in survival after recurrence at these sites. Thirty-five per cent of patients treated by primary irradiation were controlled at the primary site compared with 68% in the surgical group. Failure in the neck was similar for the two groups at 12% and 15% respectively. Salvage surgery was effective for the radiotherapy group with eight out of 11 patients being suitable for treatment. In the final analysis in the radiotherapy group two patients were alive and with their larynx and two alive without their larynx, the remainder of patients having died from the original tumour, intercurrent disease or second primary tumours. The survival figures for the surgery group were proportionately similar except of course, that all patients had lost their larynx. Radiotherapy with salvage surgery for recurrence is a safe oncological treatment option. A high failure rate at the primary site is disappointing but if placed in perspective still allows half the survivors to retain their larynx.     

Minimally invasive endoscopic resection of sinonasal malignancies and skull base surgery

CONCLUSIONS: Sinonasal malignancies without far lateral extension, intracranial invasion or orbital infiltration can be safely excised and reconstructed endoscopically with a satisfactory outcome. OBJECTIVES: To evaluate the safety and efficacy of strictly endoscopic resection of malignant sinonasal neoplasms. PATIENTS AND METHODS: Seven patients with sinonasal malignancies had received a minimally invasive endoscopic resection. Among them, two cases invaded the skull base. All patients were operated with curative intent. RESULTS: All the tumors were removed successfully by strictly endoscopic surgery. Two patients who had invasion of the skull base (28.6%) accepted postoperative radiotherapy. No complications associated with the operation occurred. The patients were followed up for 15-57 months (average 36.4 months). No local recurrence was noted in this series to date. The disease-free survival rate was 100% at a mean follow-up duration of 36.4 months.     

Kadish C期嗅神经母细胞瘤行鼻内镜手术切除及综合治疗的临床分析

目的回顾性分析Kadish C期嗅神经母细胞瘤行鼻内镜手术切除及综合治疗的效果，探讨手术适应证、方法及围术期管理经验。方法收集2004年12月—2018年9月首都医科大学附属北京同仁医院接受鼻内镜手术并证实为Kadish C期嗅神经母细胞瘤患者17例的临床资料。其中男13例，女4例；年龄26～67岁，平均45.4岁。所有患者术前均行鼻窦CT和 MRI、颈部超声及胸部CT检查。采用Kaplan Meier法进行生存分析、计算总体生存率和无瘤生存率。结果17例患者中初次手术11例，术后复发再次手术6例。所有患者均行鼻内镜手术切除，１２例患者行颅底重建，其中1０患者切除硬脑膜和嗅球。术后病理确诊为嗅神经母细胞瘤，病理采用Hyams评分系统进行病理分级，Ⅱ级9例，Ⅲ级8例。１６例辅助放疗；８例辅助化疗，其中４例接受术前诱导化疗。无严重手术并发症；随访8~109个月，平均随访44.2个月，失访1例，复发和/或转移4例。死亡3例，均死于肿瘤脑转移。1年和5年总体生存率为94.1%和80.7%，1年和5年无瘤生存率为76.5%。结论Kadish C嗅神经母细胞瘤采用鼻内镜切除加术后辅助综合治疗可以获得满意的5年生存率；术者经验和技术及多层颅底重建修复是手术成功的关键。     

The management of early hypopharyngeal cancer: primary radiotherapy and salvage surgery

Carcinoma of the hypopharynx tends to present late and to occur in old age. Surgical treatment almost always involves a total laryngectomy as well as a major procedure to reconstruct the pharynx. Early tumours up to and including T₃ tumours with no, or very early (nodes < 2 cm) nodal disease may be treated with radiotherapy with the option of salvage surgery if recurrence supervenes. In 106 previously untreated patients the 5-year recurrence rate was 50% and the 5-year survival rate was 41%. Sixty-nine patients were referred from other departments because of recurrent disease. The 5-year survival for those patients was 21%. The 5-year survival for those who developed a recurrence at the primary site was 23%. Seventy-eight patients had a resection and 42% suffered a major complication. Only 2 of the methods of reconstruction appear to be satisfactory: for disease confined to the neck free revascularized jejunal loop-repair is effective whereas for more extensive disease gastric transposition is recommended. Twenty-three per cent of patients developed neck node metastases and the 5-year survival rate for these patients was 16%. Cox's regression showed that no host or tumour factors predicted survival. At 5 years, 46% of patients were alive with a larynx, 4% were alive without a larynx, 34% were dead of the original cancer and 16 were dead of other causes.     

Surgical treatment of squamous cell carcinoma of the hypopharynx: analysis of treatment results, failure patterns, and prognostic factors

Patients with squamous cell carcinoma of the hypopharynx (HPSCC) are often seen in advanced stages and have a poor prognosis. The authors analysed 104 patients who had HPSCC and underwent surgery as the primary treatment between 1986 and 1995 in their institute. Of the 104 patients, 83 patients (80 per cent) had advanced T(3) or T(4) staged and 64 patients (62 per cent) had cervical metastasis. Thirteen patients (13 per cent) had conservation surgery with laryngeal preservation and 69 patients (66 per cent) received post-operative radiotherapy. The five-year overall and disease-specific survival was 47 per cent and 62 per cent, respectively. Recurrence occurred in 38 patients (37 per cent), including 12 (12 per cent) with local, 22 (21 per cent) with regional, and 12 (12 per cent) with distant recurrence. Sixteen patients (15 per cent) had recurrence at multiple sites. The site and size of the primary tumour, neck biopsy before surgery, early post-operative complications, and pathological nodal stage were significant prognostic factors of disease-specific survival (DSS) in univariate analysis. Neck biopsy before surgery and site of primary tumour were significant factors in multivariate analysis. In conclusion, surgical treatment for the HPSCC patients has achieved good local-regional control and survival. Bilateral neck dissection for the tumour across the midline and avoiding neck biopsy before surgery may reduce regional recurrence.     

Laser surgery of T<Subscript>1a</Subscript> glottic carcinomas; significance of resection margins

Since 1995 patients with T_1a glottic carcinomas have been treated with laser surgery at the Department of Otorhinolaryngology, Rikshospitalet in Oslo. During this period we have in many cases noticed an inconsistency between the clinical outcome and the histopathological report describing that the resection margins were not free. We wanted to investigate this discrepancy, and the charts with the histopathological reports of 171 patients treated between 1995 and 2005 have been reviewed. Seventeen patients (10%) experienced a recurrence of the initial disease and were treated by repeated laser surgery, radiotherapy, or radiotherapy and laryngectomy. Two patients (1%) had died from the disease. In 36% of the cases (62 patients) the histopathological report indicated “not free” or “probably not free” resection margins. The discrepancy between the histopathological reports and the clinical outcome reflects the pathologist’s difficulty in orienting and determining resection margins in laser-resected specimens. Because of the low number of recurrences or metastases, the verdict of a violated resection margin should probably not be crucial for further treatment. The surgeon’s peroperative judgement may be trusted, however, with very close follow-up in order to detect early recurrences.     

T3N0M0 glottic carcinoma—a pathologic analysis of 41 patients treated surgically following radiotherapy

T₃N₀M₀ glottic carcinoma—a pathologic analysis of 41 patients treated surgically following radiotherapy Forty-one patients undergoing surgery for recurrent or residual tumour following radical radiotherapy for T₃N₀M₀ glottic carcinoma had their larynges evaluated pathologically by whole organ laryngeal sectioning. All patients had been staged initially as T₃N₀M₀ glottic carcinoma and treated according to a protocol of radical radiotherapy (50–55 Gy in 4–5 weeks) with surgery reserved for radiation failure. Seventeen of the 41 patients died as a result of locoregional or distant recurrence or complications following surgery. Twenty-four patients were either alive or dead with intercurrent disease. Pathologic staging demonstrated 58% of these tumours to be rpT₄, 29% rpT₃ and the remainder rpT₀₂. The incidence of major cartilage invasion, vascular or perineural invasion, and subglottic extension greater than 15 mm was more frequent in patients with locoregional recurrence than in patients without recurrence. The presence of these pathologic features had a positive predictive value of 0.78 in relation to probability of locoregional failure. In addition, there was a significant difference in the frequency of these pathologic features between patients with and without locoregional recurrence (P < 0.001). The frequency of positive margins (19%) and pattern of involvement are described. The incidence of occult nodes (0%) in patients undergoing neck dissection is presented. The frequency (23%) and pattern of osteo-chondroradionecrosis are also described. The patterns of growth and spread observed were similar to those described previously. The importance of performing wide surgical resections in patients with recurrence following radiotherapy is emphasized.     

Analysis of recurrence and survival after hypopharyngeal ablative surgery with radial forearm free flap reconstruction

OBJECTIVES/HYPOTHESIS: To address the controversial acceptable distal resection margin for the surgical management of patients with hypopharyngeal cancer. STUDY DESIGN: Retrospective review of the records of 28 consecutive patients who underwent pharyngoesophagectomy and reconstruction with radial forearm free flaps between 1996 to 2001. METHODS: The Kaplan-Meier method was used to estimate survival and recurrence-free time. RESULTS: The minimum follow-up time was 2 years, and there were 14 (50%) patients who had recurrences. Analysis revealed that only one (3%) patient experienced a recurrence at the inferior resection margin, the junction of the free flap reconstruction, and the cervical esophagus. Estimated 4 year survival was 48.5%. CONCLUSIONS: Total laryngopharyngectomy and partial esophagectomy with radial forearm free flap reconstructions in appropriately selected patients with hypopharyngeal cancer does not compromise local recurrence rates at the distal esophageal margin.     

How often is total laryngectomy necessary for the treatment of T1 failures after radiotherapy or cordectomy?

Between 1992 and 1998, 547 patients (pts) with laryngeal SCC were diagnosed and treated in our department, 145 (27%) of whom presented with glottic tumors T₁N₀M₀ (125 T_1a and 20 T_1b). Seventy-eight (54%) were treated surgically with cordectomy and 67 (46%) with radiotherapy. After a median follow-up time of 43 months, 22 (15.2%) of the 145 pts presented with recurrent disease. In more detail, 16 (13%) of the 125 T_1a pts and 6 (30%) of the 20 T_1b pts had recurrences. Among the 78 surgically treated patients only 4 (5%) had recurrence, while 18 (27%) of the radiotherapy group relapsed. The difference is statistically significant (log rank test, P = 0.0001 < 0.05). After salvage treatment, of the 67 pts of the radiotherapy group 57 (85%) remain disease-free, 49 (73%) retaining their larynx intact and 1 only having undergone cordectomy. Among the cordectomy group 75 (96%) pts remain disease-free with only 1 having had a total laryngectomy. Using the Kaplan-Meier method and calculating the disease-free survival regardless of salvage treatment, there is no doubt that surgical treatment statistically is more successful than radiotherapy (log rank test, P = 0.01 < 0.05). Analysis of parameters such as tumor differentiation and T_1a or T_1b staging, which indeed influence the overall recurrence rate, did not alter the favorable outcome after surgical treatment. Received: 6 August 2000 / Accepted: 25 May 2001     

Craniofacial resection for nonmelanoma skin cancer of the head and neck

OBJECTIVES/HYPOTHESIS: We reviewed our experience with craniofacial resection for advanced, nonmelanoma skin cancer of the head and neck to determine prognostic factors, local control rate, disease free survival, morbidity, and mortality. STUDY DESIGN: Retrospective review of consecutive patients treated at a tertiary referral center from 1982 to 1993. METHODS: Charts of patients having craniofacial resection for aggressive nonmelanoma cutaneous malignancies were reviewed and living patients followed for 10 additional years. Demographics, histology, previous interventions, treatment, surgical pathology, reconstructions, and complications were examined. The product-limit method was used to calculate survival functions, and the log-rank test was used to compare survival distributions. RESULTS: Thirty-five patients, mean age 66.7 years, received treatment at our facility. Follow-up ranged from 2 to 191 (mean 47.4) months. Histology included 20 squamous cell carcinomas (SCC) and 15 basal cell carcinomas (BCC). Sixty percent had craniofacial resection alone, and 28.6% also had postoperative radiotherapy. There were two perioperative deaths, and 37.1% suffered early and 14.3% late surgical complications. Two- and five- year survival was significantly better (P=.02) with BCC (92% and 76%) than with SCC (54% and 24%). Long-term disease-specific survival was 20%, and 11.4% of our subjects were living with disease. Intracranial extension (P=.02), perineural invasion (P=.049), and prior radiotherapy significantly decreased 5-year survival. CONCLUSIONS: Acceptable mortality and morbidity is possible using craniofacial resection to treat advanced nonmelanoma skin cancer. Although disease-specific survival remains poor, positive trends were noted in local control beginning at 2 years of follow-up. Because patients often have few remaining options for cure, craniofacial resection is justified when technically feasible.     

Adenoid cystic carcinoma of the head and neck

Adenoid cystic carcinoma has a long natural history but frequently proves fatal. The present study describes 108 patients with an adenoid cystic carcinoma of the head and neck seen over a 30-year period. Analysis of the data utilized both univariate and multivariate methods. Forty per cent of patients had tumours arising from the oral cavity and half of these were in the hard palate; 29% occurred in the major salivary glands; 41% of tumours were locally advanced at presentation and 11% had lymph node metastases at this time. The histological pattern was solid in 25%, cribriform in 40% and tubular in 20%. In addition, 15% of patients had a polymorphous low-grade adenocarcinoma and these were analysed separately. Primary site recurrence was more common in the presence of locally advanced tumours at presentation (T_3–4) (P = 0.0093). Only six patients had surgery with adjuvant radiotherapy. Six patients had no curative treatment, 21 had primary radiotherapy, 39 had local excision and 42 radical excision. The actuarial primary site recurrence rate was 100% at 30 years. The neck node recurrence rate was 23% at 15 years. Tumour specific survival was 40% at 20 years. Solid histology had a worse prognosis than other histological types (P = 0.0429) but those patients with polymorphous low-grade adenocarcinomas fared very well. Patients with tumours of the hard palate fared better than those patients with tumours at other sites (P = 0.0301). Early disease at the primary site (T_1–2) was a good prognostic sign (P = 0.0013). Patients with neck node metastases at presentation tended to do badly (P = 0.009).     

Prevention of complications of composite resection after high dose preoperative radiotherapy

Recent reports have suggested that carcinoma of the tonsil and adjacent structures (tonsillar pillars, adjacent soft palate and lateral pharyngeal wall) can be treated with improved survival rates by combining definitive surgery with planned preoperative radiotherapy. Experience to date does not clearly demonstrate the ideal dose of preoperative radiotherapy; however, in general it appears that survival rates improve in proportion to increasing dosage of preoperative radiation. The use of preoperative radiation in doses approaching or exceeding tumoricidal levels (6,000-6,500 rads at approximately 1,000 rads/week) has been limited by the unacceptable complication rate to be expected. The rate of major complications reported has ranged from 18 percent to almost 47 percent. For the past three years, all patients seen by the Department of Otolaryngology of the Upstate Medical Center with malignancies involving the tonsil and its adjacent structures have been managed by a combined modality of 5,500 rads preoperative radiotherapy followed by definitive surgical resection, using distant, unirradiated flaps for repair where necessary. There were 33 patients in the group, including three T₂, 20 T₃ and 10 T₄ lesions. Joint evaluation and planning of treatment between radio-therapy and otolaryngology coupled with meticulous attention to various aspects of surgical management has yielded the results reported in the table. The major complication rate has been limited to 3.03 percent. These results indicate that it is possible to undertake extensive resections for carcinoma of the tonsil and adjacent structures after high-dose preoperative radiotherapy without incurring any significant increase in morbidity over surgery alone.