Initial Local Control Research Articles

Regression after 50 Gy as a selection for therapy in advanced laryngeal cancer

Radiation alone for advanced laryngeal cancer will result in an initial local control rate of 50%. When a local recurrence is diagnosed, only 50% will be successfully salvaged by surgery. To identify patients with a high chance of local control with radiation alone in advanced laryngeal cancer, the clinical response following radiotherapy was assessed a few days after 50 Gy/5 weeks. In patients with T-stage reduction or >50% tumor regression radiotherapy was continued, if not, laryngectomy was performed after 4–6 weeks. According to this protocol 30 patients (out of 50) with T3/T4 laryngeal cancer were treated. Initial local control was assessed 6 weeks after radiotherapy, the ultimate local control included successful salvage surgery. Initial local control in patients, treated with a full course of radiotherapy after T-stage reduction or >50% tumor regression, was 69% for T3 and 43% for T4 while the ultimate local control rate was 85% and 71% respectively. Although the percentage of voice preservation in our study was slightly lower (40%) than data from literature with radiation alone, the ultimate local control was high and comparable with those of combined therapy (in which laryngectomy is a part). The corrected actuarial 5-year survival in all T3 and T4 patients treated with radiation alone and salvage surgery was 73% and 31% respectively and was not different compared to surgery with pre- or post-operative radiotherapy, 74% and 53% respectively. We believe that this protocol may select a favorable group of patients for high dose radiation alone in T3 and probably in T4 laryngeal cancer.

Chemodectoma of the temporal bone: a comparison of surgical and radiotherapeutic results

Between January 1950 and December 1981, 32 patients with chemodectomas of the temporal bone were treated at the University of Iowa Hospitals and Clinics. Thirteen patients were treated with surgery alone, 15 with radiation therapy alone, one with preoperative radiation therapy and surgery, and three with surgery and postoperative radiation therapy. In general, the patients treated with radiotherapy alone or combined therapy (radiotherapy group) had more advanced tumors than those treated with surgery alone (surgery group). For the surgery group, the initial local control rate was 46% and the ultimate local control rate 84% following salvage with additional surgery, 31% developed complications, and 78% survived 10 years. For the radiotherapy group, 84% had local tumor control, 11% developed complications, and 77% survived 10 years. These results demonstrate that radiation therapy is an effective treatment modality for chemodectomas of the temporal bone.

Squamous cell carcinoma of the tonsillar area treated with radical irradiation

This is an analysis of 136 patients treated with radiation therapy alone (104) or in conjunction with planned neck dissection (32) for squamous cell carcinoma of the tonsillar area between October 1964 and August 1983. All patients have a 2-year follow-up and 94 (69%) have a minimum 5-year follow-up. Patients were excluded from analysis of disease control at the primary site and/or neck if they died within 2 years of treatment with that site continuously disease-free. All patients were treated with continuous-course irradiation; those treated with the planned split-course technique are not included. Once-a-day fractionation was used in 105 patients and twice-a-day fractionation in 31 patients. External beam alone was used in 93 patients, and external beam followed by a radium needle implant boost to the primary site was employed in 43 patients. Rates of initial local control with irradiation and ultimate local control after surgical salvage of irradiation failures are as follows: T1, 10/12 (83%) and 12/12; T2, 36/46 (78%) and 41/46 (89%); T3, 28/39 (72%) and 28/39 (72%); T4, 5/16 (31%) and 5/16 (31%). Local control data are also presented as a function of tumor site within the tonsillar area, total dose, dose per fraction, and external beam alone versus external beam plus radium needle implant. The 5-year determinate survival rates by modified AJCC stage are as follows: I, 3/3; II, 13/14; III, 14/17; IVA, 6/14; and IVB, 4/19.

Carcinoma of the soft palate treated with irradiation: Analysis of results and complications

This is an analysis of 75 patients with squamous cell carcinoma of the soft palate and/or uvula treated with radical radiation therapy alone (64) or in conjunction with planned neck dissection (11) between October 1964 and September 1983. All patients have a minimum follow-up of 2 years and 60 (80%) have a minimum follow-up of 5 years. Patients were excluded from analysis of disease control at the primary site and/or neck if they died within 2 years of treatment with the site(s) continuously disease free. The initial local control rates and ultimate local control rates after surgical salvage of irradiation failures for patients treated with continuous-course irradiation were as follows: T1, 8/8 (100%) and 8/8 (100%); T2, 14/19 (74%) and 16/19 (84%); T3, 5/11 (45%) and 5/11 (45%); and T4, 1/4 (25%) and 1/4 (25%). Overall, 7/55 patients (13%) treated with continuous-course irradiation experienced irradiation-related bone or soft tissue complications; there was only one severe complication. The 5-year determinate survival rates by modified AJCC stage for patients treated with continuous-course irradiation are as follows: I, 83%; II, 78%; III, 38%; IVA, 0/2; and IVB, 25%.

Extramedullary plasmacytoma of the rectum: Two cases treated by radiotherapy

Two cases of extramedullary plasmacytoma of the rectum treated by radiotherapy are reported. In one patient local control of disease was achieved at 36 months. A second patient treated by a palliative course of radiotherapy had initial good local regression and control of symptoms at 3 months. In view of the radiosensitivity of this tumour, consideration should be given to treating extramedullary plasmacytoma of the rectum by primary radiotherapy.

Concurrent radiotherapy and chemotherapy with cisplatin in inoperable squamous cell carcinoma of the head and neck. An RTOG Study.

In patients who have locally advanced and inoperable head and neck cancer, the achievement of initial local control (complete response) of the disease with initial definitive treatment with radiotherapy (RT) with or without chemotherapy, is an important prognostic factor for overall survival. Cisplatin 100 mg/M2-intravenously (IV) with hydration and mannitol diuresis was given every 3 weeks for three doses concurrently with definitive radiotherapy (followed by salvage surgery [if possible] for persistent disease) was activated by the Radiation Therapy Oncology Group (RTOG) in 1981. One hundred thirty-four patients were initially registered and 124 were eligible and analyzed for this report. Eighty-two percent of the patients had Stage IV disease and greater than 50% of the primary sites were in oropharynx (39%), nasopharynx (22%), and oral cavity (18%). Eighty-seven percent of the patients are known to have finished the planned RT greater than 6450 cGy and 60% received three courses of cisplatin. Overall, 60% finished the planned combined treatment. Complete response to initial treatment occurred in 69% and an additional one patient (1%) was rendered disease-free after radical node dissection. Severe toxicities were as follows: leukopenia, 11%; anemia, 8%; nausea and vomiting, 6%; stomatitis, 31%; and renal, 6%. One toxic death occurred when a nephrotoxic antibiotic was administered at the same time. All patients were evaluated for total disease and survival regardless of compliance to the treatment or the cause of death. At 1 year, an estimated 51% of the patients had their disease totally controlled and an estimated 66% were alive. Incidence of initial complete response by various patient characteristics also were analyzed. The authors concluded that the combination of cisplatin and radiotherapy is an effective and safe treatment in patients with advanced head and neck cancer and needs to be tested against radiotherapy alone.

Renal involvement in diffuse aggressive lymphomas: results of treatment with combination chemotherapy.

Nine (5.1%) of 175 patients with advanced disseminated diffuse aggressive non-Hodgkin's lymphoma presented with renal involvement and were initially treated with combination chemotherapy alone. These patients were classified as having renal involvement based on histologic and radiographic criteria. Five of the nine patients presented with a serum creatinine level greater than 2.5 mg/dL. Four patients achieved a complete remission of all systemic disease. Eight patients had complete resolution of renal involvement. Two patients later had recurrent renal disease associated with other sites of recurrence. All five patients who presented with an elevated serum creatinine level recovered normal renal function; in fact, four patients had normal renal function by the end of the first cycle of therapy. No patient required hemodialysis. Only one patient remains alive and free of disease at 55 months; five patients have died with disseminated disease; two patients have died without evidence of disease; and one patient was lost to follow-up while in remission. Initial local control of renal involvement including normalization of renal function in diffuse aggressive lymphoma can be rapidly achieved by combination chemotherapy alone.

Squamous cell carcinoma of the supraglottic larynx Treated with radical irradiation: analysis of Treatment parameters and results

Eighty-one patients were treated with radical radiation therapy, with or without immediate neck dissection(s), for squamous cell carcinoma of the supraglottic larynx from October 1964 through May 1981. There is a 2-year minimum follow-up on all patients; 75/81 (93%) have a minimum 3-year follow-up, and 58/81 (72%) have at least a 5-year follow-up. Patients were staged according to the 1983 AJCC staging system. Patients were excluded from the local control analysis if they died less than 2 years from treatment with the primary site controlled. The initial local control rates and ultimate local control rates after surgical salvage of irradiation failures were as follows: TI, 11 12 (92%) and 12 12 (100%); T2, 20 26 (77%) and 23/26 (88%); T3, 9 14 (64%) and 11 14 (79%); and T4, 2 11 (18%) and 5 11 (45%). The incidence of severe complications was 3 81 (3.7%). The 5-year absolute and determinate survival rates by AJCC stage were as follows: I, 6 12 (50%) and 6 6 (100%); II, 5 6 (83%) and 5 5 (100%); III, 4 8 (50%) and 4 5 (80%); and IV, 6 32 (19%) and 6 26 (23%).

A 'watchful waiting' policy for in situ carcinoma of the vocal cords.

Forty-five patients with vocal cord (VC) carcinoma in situ diagnosed by biopsy or VC stripping have been retrospectively analyzed. Eighteen patients received irradiation therapy immediately on diagnosis. The initial local control (LC) rate was 72% (13/18); the salvage-augmented LC rate was 94% (17/18). Twenty-seven patients with in situ carcinoma were treated expectantly ("watchful waiting"), receiving definitive radiotherapy or definitive surgery only if invasion was subsequently verified histologically. One third of the patients' carcinomas have not become invasive (mean follow-up, 50 months). Of the two thirds that became invasive, one third were more advanced than T1N0 when treated--often because patients missed scheduled follow-up appointments. Nevertheless, the initial LC rate was 65% (11/17); the salvage-augmented LC rate was 88% (15/17). Total laryngectomy was required twice as often in the watchful waiting group as in the immediately treated group.

Fast neutron teletherapy for advanced carcinomas of the oropharynx

A study was performed to assess the efficacy of using fast neutron irradiation to treat advanced squamous cell carcinomas of the oropharynx. Twenty-seven patients were treated with neutrons alone and 21 patients received a combination of fast neutrons and megavoltage photons as part of a mixed beam fractionation scheme. All patients in the study were judged to have less than a 10% chance for 5-year survival with conventional therapy. In the neutron-only group, the initial complete remission rate was 44% (12/27) and the duration of local control ranged between 2–41 months (mean = 12.4 months). At the time of writing, 2 patients in this group were still alive and free of disease while 5 patients had died without evidence of tumor at the primary site. The other 15 patients achieved only a partial remission and after completing therapy, their survival ranged between 1 and 15.5 months (mean = 3.2 months). In the mixed beam group, the initial complete remission rate was 67% (14/21) and the duration of local control ranged between 4 and 44 months (mean = 18 months). At the time of writing, 5 patients in this group were still alive and free of disease at the primary site. An additional 3 patients were salvaged successfully with surgery after either an initial control failure or a recurrence. Three other patients died free of disease at the primary site. The survival of the 6 patients in whom there was no initial local control or surgical salvage ranged between 0.5 and 8.5 months (mean = 4.0 months) after completing therapy. Actuarially calculated curves for the duration of local control are shown for the 2 groups of patients and at all follow-up times, the mixed beam group shows a higher degree of local control at the primary site than the neutron-only group. However, because of the small number of patients at risk for the longer follow-up times, this difference is statistically significant only for the initial rate of local control. Assuming an RBE = 3 for the neutron radiation, in all cases the spinal cord dosage was limited to 4500 photon rad equivalent. In the neutron-only group, 10 patients survived 10 months or longer and of these, 5 developed an apparent cervical myelitis. No such complications were noted in the mixed beam group and so it appears that the RBE is greater than 3 for late damage to the spinal cord. In the context of this study, it appears that mixed beam (neutron/photon) irradiation is superior to neutrons alone, both in terms of local control and long-term morbidity, for treating advanced tumors of the oropharynx.