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Neck dissection prior to radiation therapy for squamous cell carcinoma of tongue base
Neck Dissection Prior to Radiation Therapy for Squamous Cell Carcinoma of Tongue Base Han G. Sohn, MD, and Gady Har-El, MD, FACS Background: Squamous cell carcinoma of the tongue base can be treated with comparable control and survival rates when neck dissection (ND) is performed before radiation therapy (RT). Methods: Fourteen patients were treated between 1990 and 2000. Tumor stage on presentation was: T2, 6; T3, 4; T4, 4. Average radiation dose was 7,268 cGy. Follow-up ranged from 2 to 11 years (median, 50 months). Ten patients (71.4%) who presented with cervical metastases underwent neck dissection. All neck dissections were performed prior to RT. Results: The initial local control rate was 85.7%. The 10-year survival rate was 62.8%. Patients tolerated their procedure well and were ready for RT within 2 to 4 weeks. Conclusions: Our preliminary data indicate that our treatment protocol results in control and survival rates which are comparable with other regimens. It is our impression that in contrast to patients undergoing ND after radiation, our patients tolerated their initial ND well and were better prepared for the second part of the treatment. Future studies will use quality-of-life research methods to study this aspect of the treatment protocol. (Am J Otolaryngol 2002;23:138-141. Copyright 2002, Elsevier Science (USA). All rights reserved.)
Squamous cell carcinoma of the base of the tongue can be particularly morbid, not only because of the tumor itself but also because of treatment modalities.1 Squamous cell carcinoma of the tongue base can be treated in several ways.2,3 One major treatment option is radiation therapy with or without neck dissection, and the other is surgical excision of the primary tumor and neck metastases with or without postoperative radiation therapy. Previous studies have shown that good treatment results for squamous cell carcinoma of the tongue base can be obtained with radiation therapy, with or without neck dissection.3,4 All previous studies have presented patients who received neck dissection after the primary radiation therapy. We present a retrospective review of 14 patients with squamous cell carcinoma of the tongue base who received radiation therapy with curative intent, which differs from previous studies in
From the Department of Otolaryngology, State University of New York Downstate Medical Center, and The Long Island College Hospital, Brooklyn, NY. Address correspondence to Gady Har-El, MD, FACS, Department of Otolaryngology, State University of New York Downstate, Box 126, 450 Clarkson Avenue, Brooklyn, NY 11203. Copyright 2002, Elsevier Science (USA). All rights reserved. 0196-0709/02/2303-0001$35.00/0 doi:10.1053/ajot.2002.123433 138
that our patients underwent neck dissection before radiation therapy. Our experience has indicated that patients are better prepared for their neck dissection when it is performed before radiation therapy, which often lasts 6-8 weeks and can cause significant morbidity during the therapy and thus psychologically and physiologically wear down the patient. However, before proceeding to study this aspect of the treatment, we have to ascertain that our protocol does not negatively impact control and survival rates. METHODS A retrospective review of the records of all patients treated at our institution for squamous cell carcinoma of the base of the tongue between 1990 and 2000 was conducted. Of those patients, only patients who had received radiation therapy as the initial treatment of the primary tumor were included in the study. Patients who had evidence of distant metastasis at presentation or patients who received any type of surgical procedure for their primary tumor were excluded.
RESULTS Fourteen patients with squamous cell carcinoma of the base of the tongue met the inclusion criteria— 8 males and 6 females ranging in age from 43 to 81 years with a median age of
American Journal of Otolaryngology, Vol 23, No 3 (May-June), 2002: pp 138-141
NECK DISSECTION BEFORE RADIATION THERAPY
139
TABLE 1. Distribution of Patients by the TNM System
T1 T2 T3 T4 Total
N0
N1
N2
N3
0 4 0 0 4 (28.5%)
0 2 0 1 3 (21.5%)
0 0 3 2 5 (36%)
0 0 1 1 2 (14%)
53 years. Tumor size and cervical nodal staging are presented in Table 1. Ten patients (71.4%) presented with cervical metastases and underwent neck dissection. Five patients had unilateral, and 5 patients had bilateral neck dissection, for a total of 15 neck dissections. All neck dissections were performed before radiation therapy. All patients received external beam radiation therapy with an average radiation dose of 7,268 cGy administered in an average of 37 sessions. Follow-up ranged from 33 to 136 months or until time of death, with a median of 50 months. Actuarial 5- and 10-year local control rates (Kaplan and Meier5) were both 85.7% (Fig 1). The graph indicates that there were no local failures after 10 months. One patient had only a partial response to the initial radiation therapy but refused salvage surgery and died. The other patient had a minimal response to the radiation therapy and underwent salvage surgery and is a long-term survivor. The local
Total 0 6 (43%) 4 (28.5%) 4 (28.5%) 14 (100%)
control rate rises to 92.8% if salvage is taken into account. Actuarial 5- and 10-year regional control was 75% and 75%, respectively (Fig 2). The one patient who developed regional failure underwent neck dissection and is a long-term survivor. If this patient is taken into account, then the regional control rate rises to 100%. Actuarial 5- and 10-year distant control was 90.1% and 90.1%, respectively (Fig 3). As can be seen in the graph, the one patient who failed distantly did so at 24 months. Overall survival is shown in Figure 4. This considers death from all causes. The actuarial 5- and 10-year overall survival was 62.8% and 62.8%, respectively. Overall disease-free survival for 5 and 10 years was 85.7%. Complications occurred in 3 patients. One patient had mucositis severe enough to interrupt RT. One patient had a significant case of thrush. Another patient developed osteoradionecrosis of the mandible and needed hyperbaric oxygen treatments and surgical curettage. DISCUSSION
Fig 1. Squamous cell carcinoma of the tongue base: local control; n ⴝ 14.
The main objective in treating head and neck cancer is to maximize cancer control and to minimize morbidity, whether it be from the disease itself or from the treatment. Out of the current treatment protocols available, it is evident that radiation to the primary cancer with or without neck dissection is the preferred method for reaching that objective. Previous studies have demonstrated that patients who undergo radiation to the primary cancer and those who receive surgery to the primary have comparable quality of life.1,6,7 Our long-term results are comparable to those in the literature.2,3 Harrison et al3 reported a 5-year local control of 89%, a disease-free survival of 80%, and an overall sur-
140
Fig 2. Squamous cell carcinoma of the tongue base: regional control; n ⴝ 14.
vival of 86% in a cohort of patients who had undergone radiation therapy followed by neck dissection for those who initially had been seen with cervical metastases. Kraus et al2 reported an overall 5-year survival rate of 55% and a cause-specific survival rate of 65% in patients treated with surgery. It has been our experience (although we have not yet formally demonstrated it) that patients are able to tolerate satisfactorily having their neck dissections before radiation therapy. Radiation therapy usually takes 6 to 8 weeks to complete and can be quite taxing. Patients undergoing radiation therapy develop xerostomia, mucositis, dysphagia, and
SOHN AND HAR-EL
Fig 4. Squamous cell carcinoma of the tongue base: overall survival; n ⴝ 14.
other complications. Consequently, many patients find it mentally and physically difficult to undergo major surgery after radiation therapy. Our patients tolerated their initial neck dissections well and were mentally and physiologically ready for the second part of their treatment. The patients were discharged from the hospital within 3 days of their neck dissections. All patients were ready for the radiation therapy within 2 to 4 weeks of the neck dissections and none experienced any delay in the start of treatment. In the next phase of researching this ongoing protocol, we will study formally the quality of life and compliance issues in patients undergoing neck dissection prior to radiation therapy. Before proceeding to investigate these aspects of the treatment, the present study has helped us to ascertain that our treatment protocol does not negatively impact control and survival rates. CONCLUSION Neck dissection before radiation therapy for squamous cell carcinoma of the tongue base results in long-term survival rates that are comparable with other treatment modalities, and the protocol may offer a better quality of life and improved compliance with therapy. REFERENCES
Fig 3. Squamous cell carcinoma of the tongue base: distant control; n ⴝ 14.
1. Rogers SN, Hannah L, Lowe D, et al: Quality of life 5-10 years after primary surgery for oral and oro-pharyngeal cancer J Craniomaxillofac Surg 27:187-191, 1999
NECK DISSECTION BEFORE RADIATION THERAPY
2. Kraus DH, Vastola AP, Huvos AG, et al: Surgical management of squamous cell carcinoma of the base of tongue. Am J Surg 166:384-388, 1993 3. Harrison LB, Lee HJ, Pfister DG, et al: Long term results of primary radiotherapy with/without neck dissection for squamous cell cancer of the base of tongue. Head Neck 20:668-673, 1998 4. Brunin F, Mosseri V, Jaulerry C, et al: Cancer of the base of the tongue: Past and future. Head Neck 21:751759, 1999 5. Kaplan E, Meier P: Non-parametric estimation from
141
incomplete observations. J Am Stat Assoc 53:457-481, 1958 6. Harrison LB, Zelefsky MJ, Armstrong JG, et al: Performance status after treatment for squamous cell cancer of the base of tongue-A comparison of primary radiation therapy versus primary surgery. Int J Radiat Oncol Biol Phys 30:953-957, 1994 7. Harrison LB, Zelefsky MJ, Phister DG, et al: Detailed quality of life assessment in patients treated with primary radiation therapy for squamous cell cancer of the base of tongue. Head Neck 19:169-175, 1997
Squamous cell carcinoma of the base of the tongue can be particularly morbid, not only because of the tumor itself but also because of treatment modalities.1 Squamous cell carcinoma of the tongue base can be treated in several ways.2,3 One major treatment option is radiation therapy with or without neck dissection, and the other is surgical excision of the primary tumor and neck metastases with or without postoperative radiation therapy. Previous studies have shown that good treatment results for squamous cell carcinoma of the tongue base can be obtained with radiation therapy, with or without neck dissection.3,4 All previous studies have presented patients who received neck dissection after the primary radiation therapy. We present a retrospective review of 14 patients with squamous cell carcinoma of the tongue base who received radiation therapy with curative intent, which differs from previous studies in
From the Department of Otolaryngology, State University of New York Downstate Medical Center, and The Long Island College Hospital, Brooklyn, NY. Address correspondence to Gady Har-El, MD, FACS, Department of Otolaryngology, State University of New York Downstate, Box 126, 450 Clarkson Avenue, Brooklyn, NY 11203. Copyright 2002, Elsevier Science (USA). All rights reserved. 0196-0709/02/2303-0001$35.00/0 doi:10.1053/ajot.2002.123433 138
that our patients underwent neck dissection before radiation therapy. Our experience has indicated that patients are better prepared for their neck dissection when it is performed before radiation therapy, which often lasts 6-8 weeks and can cause significant morbidity during the therapy and thus psychologically and physiologically wear down the patient. However, before proceeding to study this aspect of the treatment, we have to ascertain that our protocol does not negatively impact control and survival rates. METHODS A retrospective review of the records of all patients treated at our institution for squamous cell carcinoma of the base of the tongue between 1990 and 2000 was conducted. Of those patients, only patients who had received radiation therapy as the initial treatment of the primary tumor were included in the study. Patients who had evidence of distant metastasis at presentation or patients who received any type of surgical procedure for their primary tumor were excluded.
RESULTS Fourteen patients with squamous cell carcinoma of the base of the tongue met the inclusion criteria— 8 males and 6 females ranging in age from 43 to 81 years with a median age of
American Journal of Otolaryngology, Vol 23, No 3 (May-June), 2002: pp 138-141
NECK DISSECTION BEFORE RADIATION THERAPY
139
TABLE 1. Distribution of Patients by the TNM System
T1 T2 T3 T4 Total
N0
N1
N2
N3
0 4 0 0 4 (28.5%)
0 2 0 1 3 (21.5%)
0 0 3 2 5 (36%)
0 0 1 1 2 (14%)
53 years. Tumor size and cervical nodal staging are presented in Table 1. Ten patients (71.4%) presented with cervical metastases and underwent neck dissection. Five patients had unilateral, and 5 patients had bilateral neck dissection, for a total of 15 neck dissections. All neck dissections were performed before radiation therapy. All patients received external beam radiation therapy with an average radiation dose of 7,268 cGy administered in an average of 37 sessions. Follow-up ranged from 33 to 136 months or until time of death, with a median of 50 months. Actuarial 5- and 10-year local control rates (Kaplan and Meier5) were both 85.7% (Fig 1). The graph indicates that there were no local failures after 10 months. One patient had only a partial response to the initial radiation therapy but refused salvage surgery and died. The other patient had a minimal response to the radiation therapy and underwent salvage surgery and is a long-term survivor. The local
Total 0 6 (43%) 4 (28.5%) 4 (28.5%) 14 (100%)
control rate rises to 92.8% if salvage is taken into account. Actuarial 5- and 10-year regional control was 75% and 75%, respectively (Fig 2). The one patient who developed regional failure underwent neck dissection and is a long-term survivor. If this patient is taken into account, then the regional control rate rises to 100%. Actuarial 5- and 10-year distant control was 90.1% and 90.1%, respectively (Fig 3). As can be seen in the graph, the one patient who failed distantly did so at 24 months. Overall survival is shown in Figure 4. This considers death from all causes. The actuarial 5- and 10-year overall survival was 62.8% and 62.8%, respectively. Overall disease-free survival for 5 and 10 years was 85.7%. Complications occurred in 3 patients. One patient had mucositis severe enough to interrupt RT. One patient had a significant case of thrush. Another patient developed osteoradionecrosis of the mandible and needed hyperbaric oxygen treatments and surgical curettage. DISCUSSION
Fig 1. Squamous cell carcinoma of the tongue base: local control; n ⴝ 14.
The main objective in treating head and neck cancer is to maximize cancer control and to minimize morbidity, whether it be from the disease itself or from the treatment. Out of the current treatment protocols available, it is evident that radiation to the primary cancer with or without neck dissection is the preferred method for reaching that objective. Previous studies have demonstrated that patients who undergo radiation to the primary cancer and those who receive surgery to the primary have comparable quality of life.1,6,7 Our long-term results are comparable to those in the literature.2,3 Harrison et al3 reported a 5-year local control of 89%, a disease-free survival of 80%, and an overall sur-
140
Fig 2. Squamous cell carcinoma of the tongue base: regional control; n ⴝ 14.
vival of 86% in a cohort of patients who had undergone radiation therapy followed by neck dissection for those who initially had been seen with cervical metastases. Kraus et al2 reported an overall 5-year survival rate of 55% and a cause-specific survival rate of 65% in patients treated with surgery. It has been our experience (although we have not yet formally demonstrated it) that patients are able to tolerate satisfactorily having their neck dissections before radiation therapy. Radiation therapy usually takes 6 to 8 weeks to complete and can be quite taxing. Patients undergoing radiation therapy develop xerostomia, mucositis, dysphagia, and
SOHN AND HAR-EL
Fig 4. Squamous cell carcinoma of the tongue base: overall survival; n ⴝ 14.
other complications. Consequently, many patients find it mentally and physically difficult to undergo major surgery after radiation therapy. Our patients tolerated their initial neck dissections well and were mentally and physiologically ready for the second part of their treatment. The patients were discharged from the hospital within 3 days of their neck dissections. All patients were ready for the radiation therapy within 2 to 4 weeks of the neck dissections and none experienced any delay in the start of treatment. In the next phase of researching this ongoing protocol, we will study formally the quality of life and compliance issues in patients undergoing neck dissection prior to radiation therapy. Before proceeding to investigate these aspects of the treatment, the present study has helped us to ascertain that our treatment protocol does not negatively impact control and survival rates. CONCLUSION Neck dissection before radiation therapy for squamous cell carcinoma of the tongue base results in long-term survival rates that are comparable with other treatment modalities, and the protocol may offer a better quality of life and improved compliance with therapy. REFERENCES
Fig 3. Squamous cell carcinoma of the tongue base: distant control; n ⴝ 14.
1. Rogers SN, Hannah L, Lowe D, et al: Quality of life 5-10 years after primary surgery for oral and oro-pharyngeal cancer J Craniomaxillofac Surg 27:187-191, 1999
NECK DISSECTION BEFORE RADIATION THERAPY
2. Kraus DH, Vastola AP, Huvos AG, et al: Surgical management of squamous cell carcinoma of the base of tongue. Am J Surg 166:384-388, 1993 3. Harrison LB, Lee HJ, Pfister DG, et al: Long term results of primary radiotherapy with/without neck dissection for squamous cell cancer of the base of tongue. Head Neck 20:668-673, 1998 4. Brunin F, Mosseri V, Jaulerry C, et al: Cancer of the base of the tongue: Past and future. Head Neck 21:751759, 1999 5. Kaplan E, Meier P: Non-parametric estimation from
141
incomplete observations. J Am Stat Assoc 53:457-481, 1958 6. Harrison LB, Zelefsky MJ, Armstrong JG, et al: Performance status after treatment for squamous cell cancer of the base of tongue-A comparison of primary radiation therapy versus primary surgery. Int J Radiat Oncol Biol Phys 30:953-957, 1994 7. Harrison LB, Zelefsky MJ, Phister DG, et al: Detailed quality of life assessment in patients treated with primary radiation therapy for squamous cell cancer of the base of tongue. Head Neck 19:169-175, 1997