Neck Radiotherapy Patients Research Articles

The First Report of Basilar Invagination and Brainstem Compression as a Complication of Head and Neck Radiation: Options for Treatment and Techniques for Endonasal Clivectomy and Odontectomy

• Advanced stage oropharyngeal carcinoma is commonly treated with multimodality therapy. Organs at risk in the head and neck region include the spinal cord, brainstem, salivary glands, swallowing structures, and mandible • Late complications occur months to years after treatment and include xerostomia, small vessel damage and osteoradionecrosis, soft tissue fibrosis, trismus, articulatory sequelae, xerostomia, and dysphagia. • It is estimated that between 5 and 15% of head and neck radiotherapy patients will have late tissue complications from radiotherapy. • In 236 patients with oropharyngeal carcinoma treated with combined chemoradiation therapy, osteomyelitis occurred in 9%. • We report the first case of cervical instability and basilar invagination as a rare complication of primary radiation therapy for head and neck cancer.

The dosimetric consequences of anatomic changes in head and neck radiotherapy patients

To investigate anatomical response-related changes in the head and neck region during a course of radical radiotherapy and their impact on the planned dosimetry. The study consisted of 10 patients with primary mucosal carcinoma. Patients' nutritional requirements were managed as per departmental protocol to minimise weight loss during treatment. Kilovoltage computed tomography (CT) scans were acquired once 40 to 50 Gy had been delivered. Gross tumour volumes (GTV) and organs at risk were delineated and the initial optimised treatment plan was overlaid on the repeat CT. Comparisons were made between scans and absolute volume variations, centres of structures, dice similarity coefficients and the subsequent dosimetric impact were assessed. Median weight loss at second scan was 3%. Primary and lymph node GTVs reduced by 49.9% (range 21.3-82%) and 73.7% (range 61.7-88.6%), respectively, yet continued to receive the prescribed dose. Maximum dose to spinal cord and brainstem changed minimally. Spared and un-spared parotid gland volumes reduced by median 23.5% and 20.5%, respectively, with no consistent translational displacement direction and minimal change in the mean dose. Despite some significant geometric changes, nutritional management ensured patient size and shape was maintained in these consecutively selected patients and subsequently there was no apparent under-dosing of targets or over-dosing of normal structures with this technique. Further investigations which model gradual change and allow cumulative dosimetry are required to better characterise what occurs during the treatment course.

Nurse led electronic toxicity scoring in head and neck radiotherapy

Purpose of the studyIn order to improve ‘adherence’ to a course of treatment for head and neck radiotherapy, patients need to be managed frequently. In order to achieve this in a busy clinical environment streamlined electronic tools must be utilised. By providing nursing teams with the capacity to conduct electronic toxicity scoring on a bi-weekly basis, adherence can be improved and closer attention paid to head and neck radiotherapy toxicities. Methods and MaterialsA convenience sample of 20 patients undergoing head and neck radiotherapy was analysed. Each of these patients had electronic toxicity data recorded on a bi-weekly basis for dysphagia, mucositis, skin reaction and weight loss. This information was then extracted from the ARIA™ patient information system and analysed. Additionally the time taken for the nursing team to undertake each patient review was also extracted from ARIA™. ResultsThe efficiencies offered by an electronic medical record allow comprehensive toxicity data to be recorded and analysed effortlessly. The average time taken to review these patients on a bi-weekly basis was 6.97 min and contained on average 60 words of toxicity description and action. ConclusionElectronic toxicity scoring offers many advantages to the radiation oncology nurse, increased efficiency allows more frequent patient interaction which will in turn aid adherence. In order to better manage the treatment course of head and neck radiotherapy patients, nurses must be provided with streamlined and efficient electronic means of recording data. In this way it is possible to review head and neck radiotherapy patients bi-weekly.

P5 Dental management of head and neck radiotherapy patients

P5 Dental management of head and neck radiotherapy patients

On Comparing the Quality of Head and Neck Imrt Plans Delivered with Two Different Linear Accelerator Manufacturers

The purpose of this work was to determine whether 2 different types of linear accelerators manufacturers with similar MLC leaf widths deliver equivalent IMRT distributions for head and neck radiotherapy patients. In this study, plans delivered with Siemens linacs were re-optimized with an Elekta linac and vice versa. To test for significance, paired t-tests were computed to examine differences in target and normal tissue doses and monitor units. Dose distributions, dose-volume histograms, and dose to targets and normal tissues were found to be equivalent irrespective of the linac type. However, approximately 15% more monitor units were delivered when planned on the Elekta machine ( p < 0.002). Both linear accelerators provide plans of comparable dosimetric quality; however, Elekta machines deliver slightly more monitor units than Siemens machines. This increase is likely due differences in geometric properties of the machine head designs, as modeled in the treatment planning system.

Treatment Results of Major Salivary Gland Cancer by Surgery with or without Postoperative Radiation Therapy

ObjectivesThis is to report treatment results of major salivary gland cancer by surgery with or without postoperative radiation therapy (PORT).MethodsBetween March 1995 and January 2006, 94 patients with primary major salivary cancer underwent curative surgical resection at Samsung Medical Center. The parotid gland was the most commonly involved (73, 77.7%), followed by the submandibular and the sublingual. Neck dissection was added in 28 patients, and PORT was individually recommended to those with risk factors. Seventy-five (79.8%) patients received PORT. PORT volume included primary tumor bed and pathologically involved regional lymphatics, and no additional effort was made for elective nodal irradiation. The median total doses were 56.0 Gy to primary site and 58.7 Gy to regional lymphatics.ResultsAfter median follow-up of 49 months, 21 patients had relapsed: 20 in PORT; and one in surgery alone group. As the first site of failure, distant metastasis was the most common (17 patients). Local recurrence occurred in three, and regional relapse in one. The lung was the most common site (10 patients), followed by the bone, and the brain. Five-yr disease free survival (DFS), local control, and overall survival (OS) rates were 74.4% and 94.7%, 96.0% and 100%, and 78.2% and 100% in PORT and surgery alone groups, respectively. On multivariate analysis, DFS was significantly affected by pN+ (hazard ratio [HR], 3.624; P=0.0319), while OS was by pN+ (HR, 7.138; P=0.0034) and perineural invasion (HR, 5.073; P=0.0187).ConclusionBased on our experience, the patients with early stage major salivary gland cancer with low risk can be effectively treated by surgery alone, and those who with risk factors can achieve excellent local and regional control by adding PORT. Omitting elective neck irradiation in patients with N0 disease seems a feasible strategy under accurate clinical evaluation. An effort is needed to decrease distant metastasis through further clinical trials.

Poster — Wed Eve—38: Comparison of IMRT Plan Quality from Two Different Linear Accelerator

The purpose of this work was to determine whether two different types of linear accelerators manufacturers with similar MLC leaf widths deliver equivalent IMRT dose distributions for head and neck radiotherapy patients. In the first study, a retrospective analysis of 197 head and neck IMRT patients delivered on Siemens Primus and Elekta Synergy machines was undertaken to test statistical differences in machine type, monitor units, maximum target dose, and number of target doses. Both machines have 1 cm MLC leaves but have different linac head geometries. Plan were created using the direct machine parameter optimization (DMPO) routine on Philips' Pinnacle treatment planning system (TPS) system, in step and shoot mode. A multi‐variate analysis was used to test for significance, Pearson's correlations, and coefficients of determination. In the second study, a replanning exercise was conducted where deliverable plans from a Siemens machine was re‐optimized with an Elekta machine and vice‐versa. In the first study, there was no evidence of any significant difference in the IMRT plans. Elekta machines delivered more MUs than the Siemens units but the difference was not significant (). In the second study, the presentation of the dose distributions, DVHs, and mean dose to target and normal tissue structures were equivalent. However, approximately 15% more monitor units were delivered when plans were planned or re‐planned on the Elekta machine. This work suggests that for plans of comparable quality, Elekta machines deliver more monitor units than Siemens machines, likely due to differences in the geometric properties of the machines.

P.350 The dental management of head and neck radiotherapy patients

P.350 The dental management of head and neck radiotherapy patients

Postoperative Radiotherapy for Maxillary Sinus Cancer: Long-Term Outcomes and Toxicities of Treatment

To determine the effects of three changes in radiotherapy technique on the outcomes for patients irradiated postoperatively for maxillary sinus cancer. The data of 146 patients treated between 1969 and 2002 were reviewed. The patients were separated into two groups according to the date of treatment. Group 1 included 90 patients treated before 1991 and Group 2 included 56 patients treated after 1991, when the three changes were implemented. The outcomes were compared between the two groups. No differences were found in the 5-year overall survival, recurrence-free survival, local control, nodal control, or distant metastasis rates between the two groups (51% vs. 62%, 51% vs. 57%, 76% vs. 70%, 82% vs. 83%, and 28% vs. 17% for Groups 1 and 2, respectively). The three changes were to increase the portals to cover the base of the skull in patients with perineural invasion, reducing their risk of local recurrence; the addition of elective neck irradiation in patients with squamous or undifferentiated histologic features, improving the nodal control, distant metastasis, and recurrence-free survival rates (64% vs. 93%, 20% vs. 3%, and 45% vs. 67%, respectively; p < 0.05 for all comparisons); and improving the dose distributions within the target volume, reducing the late Grade 3-4 complication rates (34% in Group 1 vs. 8% in Group 2, p = 0.014). Multivariate analysis revealed advancing age, the need for enucleation, and positive margins as independent predictors of worse overall survival. The need for enucleation also predicted for worse local control. The three changes in radiotherapy technique improved the outcomes for select patients as predicted. Despite these changes, little demonstrable overall improvement occurred in local control or survival for these patients and additional work must be done.

A feasibility study of an internal control methodology using hydrocortisone cream for the management of skin reactions in patients receiving radical radiation therapy for cancers of the head and neck

Background: The literature on the evaluation of the management of radiation-induced dermatitis demonstrates the methodological difficulties of studying this subject. Therefore, the feasibility of a methodology whereby the patient acted as their own control was used to study acute cutaneous side effects for head and neck radiotherapy patients using 1% hydrocortisone cream (HC).Methods: Twenty patients were asked to apply Hyderm (1% hydrocortisone) cream twice daily to one side of the treatment area (either right or left) beginning on day one of radiation therapy and ending 2 weeks post-radiation therapy. The centres standard skin care protocol using mild soap and water and no creams was used on the other side of the neck. Once weekly the patients were assessed and scored using the Radiation-Induced Skin Reaction Scale and Radiotherapy and Oncology Group assessment scales and the patient completed a symptom scoring scale each week was a baseline assessment undertaken before they started treatment. To document compliance with study instructions, patients were asked to keep a calendar indicating when they applied the cream and to which side, and this was collected by clinical staff.Results: At the conclusion of the study, 12 patients were enrolled. During the course of the study it became increasingly obvious that the side to which patients were applying the Hyderm scored higher on the assessment scale, indicating an increased skin reaction than the control side. This was confirmed with the photographs and patient symptom scale. As a result of these increased reactions, the study ceased accrual earlier than anticipated and all patients were advised to discontinue Hyderm use.Conclusion: The increase in skin toxicity was unexpected, particularly as the institutional standard of care recommended the use of HC as treatment for radiation dermatitis. The number of patients in the study was too small to make conclusive statements about the efficacy of HC. We were able to confirm the feasibility of using an internal control methodology in these patients. Compliance results indicate the skin care instructions were clearly written and patients were able to follow them.

SU‐DD‐A1‐03: IMRT Quality Assurance: Dosimetric Assessment of Three Current Methods

Purpose: To compare traditional IMRT quality assurance using film dosimetry and small volume ionization chamber measurements with two new commercial products, the Wellhofer® MatriXX ionization chamber array and Varian® Portal Dosimetry. Available analysis software, hardware requirements and approximate operator times for data preparation, measurement and analysis will also be examined. Method and Materials: Fluence patterns from several 6X and 18X IMRT treatment plans for pelvis and head and neck radiotherapy patients were measured using radiographic film, the MatriXX array, and the Portal Dosimetry array. In each case the fluence pattern predicted by the treatment planning system was compared to the measured fluence pattern using ordinary γ‐analysis. Absolute dose at a point in a low‐gradient region of the fluence was also measured in the solid water phantom with an ionization chamber and compared to the dose prediction of the TPS. The absolute dose measured at the same point by the MatriXX array was also compared. Results: The absolute dose measurements made in a region of low‐gradient using an ionization chamber were, on the average, within 3% of the TPS predicted dose. The absolute dose measurements made using the MatriXX were, on the average, within 5% of the predicted dose. The ion chamber and MatriXX agreed to within 3%. An average of about 4% of pixels failed an ordinary γ‐analysis using 5% dose agreement and 3mm DTA criteria for both film and MatriXX measurements. A smaller percentage of pixels measured using Portal Dosimetry failed. The time spent preparing the data was comparable for all methods. Data measurement and analysis times were significantly reduced using the MatriXX and Portal Dosimeter procedures. Conclusions: This work indicates significant time savings for the new methods. In addition, the MatriXX system measures absolute dose at each chamber position.

Calidad de vida en pacientes tratados mediante laringectomía parcial supracricoidea con cricohioidoepiglotopexia (chep)

ObjectivesTo assess quality of life in patients diagnosed with epidermoid carcinoma of the larynx, after supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP). To examine how quality-of-life may be associated to the treatment received: neck dissection, decannulation and radiotherapy Patients and methodA descriptive, observational, cross-sectional study was conducted involving 26 patients out of a group of 51. They were all males with an average age of 61.7 years at the time of the interview. We used the disease-specific quality of life questionnaire devised by the University of Michigan: the Head and Neck Cancer-specific Quality of life instrument (HNQOL) ResultsDuring an average follow-up period of 83.65 months, 2 patients (3,92 %) suffered a recurrence. Estimated survival after 3, 5 and 10 years was 95,83%. Communication and overall disturbances caused by treatment were found to be the two quality-of-life domains mainly affected. Generally speaking, patients who had received radiotherapy, those who had not had their tracheal cannula removed or those that had undergone neck dissection were the most affected ConclusionsSCPL with CHEP as a surgical technique allows good control of the condition and has a low impact on the patient’s quality of life

Diagnosing, managing, and preventing salivary gland disorders.

Salivary function provides host protection, assists in the initiation of food and fluid intake, and enables communication through speech. Without adequate salivary output, oral and pharyngeal health declines along with a person’s quality of life. The complaint of a dry mouth (xerostomia) and the objective finding of salivary dysfunction are common occurrences in older individuals, producing transient and permanent oral and systemic problems. Salivary dysfunction, however, is not a normal consequence of growing older, and is due to systemic diseases, medications, and head and neck radiotherapy. Diagnosis of salivary disorders begins with a careful medical history, head, and neck examination. While complaints of xerostomia may be indicative of a salivary gland disorder, salivary diseases can present without symptoms. Therefore, routine examination of salivary function must be part of any head, neck, and oral examination. Therapies are designed to prevent the development of oral and pharyngeal sequelae of salivary hypofunction. Current xerostomia-based treatments include replacement therapies and gustatory, masticatory, and pharmacological stimulants. Healthcare professionals can play a vital role in identifying patients at risk for developing salivary dysfunction, and should provide appropriate preventative and interventive techniques that will help preserve a person’s health, function, and quality of life.

Lymph node metastasis in maxillary sinus carcinoma

Purpose: To evaluate the incidence and prognostic significance of lymph node metastasis in maxillary sinus carcinoma. Methods and Materials: We reviewed the records of 97 patients treated for maxillary sinus carcinoma with radiotherapy at Stanford University and at the University of California, San Francisco between 1959 and 1996. Fifty-eight patients had squamous cell carcinoma (SCC), 4 had adenocarcinoma (ADE), 16 had undifferentiated carcinoma (UC), and 19 had adenoid cystic carcinoma (AC). Eight patients had T2, 36 had T3, and 53 had T4 tumors according to the 1997 AJCC staging system. Eleven patients had nodal involvement at diagnosis: 9 with SCC, 1 with UC, and 1 with AC. The most common sites of nodal involvement were ipsilateral level 1 and 2 lymph nodes. Thirty-six patients were treated with definitive radiotherapy alone, and 61 received a combination of surgical and radiation treatment. Thirty-six patients had neck irradiation, 25 of whom received elective neck irradiation (ENI) for N0 necks. The median follow-up for alive patients was 78 months. Results: The median survival for all patients was 22 months (range: 2.4–356 months). The 5- and 10-year actuarial survivals were 34% and 31%, respectively. Ten patients relapsed in the neck, with a 5-year actuarial risk of nodal relapse of 12%. The 5-year risk of neck relapse was 14% for SCC, 25% for ADE, and 7% for both UC and ACC. The overall risk of nodal involvement at either diagnosis or on follow-up was 28% for SCC, 25% for ADE, 12% for UC, and 10% for AC. All patients with nodal involvement had T3–4, and none had T2 tumors. ENI effectively prevented nodal relapse in patients with SCC and N0 neck; the 5-year actuarial risk of nodal relapse was 20% for patients without ENI and 0% for those with elective neck therapy. There was no correlation between neck relapse and primary tumor control or tumor extension into areas containing a rich lymphatic network. The most common sites of nodal relapse were in the ipsilateral level 1–2 nodal regions (11/13). Patients with nodal relapse had a significantly higher risk of distant metastasis on both univariate ( p = 0.02) and multivariate analysis (hazard ratio = 4.5, p = 0.006). The 5-year actuarial risk of distant relapse was 29% for patients with neck control versus 81% for patients with neck failure. There was also a trend for decreased survival with nodal relapse. The 5-year actuarial survival was 37% for patients with neck control and 0% for patients with neck relapse. Conclusion: The overall incidence of lymph node involvement at diagnosis in patients with maxillary sinus carcinoma was 9%. Following treatment, the 5-year risk of nodal relapse was 12%. SCC histology was associated with a high incidence of initial nodal involvement and nodal relapse. None of the patients presenting with SCC histology and N0 necks had nodal relapse after elective neck irradiation. Patients who had nodal relapse had a higher risk of distant metastasis and poorer survival. Therefore, our present policy is to consider elective neck irradiation in patients with T3–4 SCC of the maxillary sinus.

Prevention and treatment of chemotherapy- and radiotherapy-induced oral mucositis: a review.

Oral mucositis is a distressing toxic effect of systemic chemotherapy with many commonly utilized drugs and of head and neck irradiation in patients with cancer. The agents and methods that have been used and studied in chemotherapy- and radiotherapy-induced oral mucositis, their mechanisms of action, and the current knowledge of their efficiency to reduce the incidence, severity or shorten the duration of oral mucositis are reviewed in this article. Oral cooling is a cheap and available method to lower the severity of bolus 5-fluorouracil-induced oral mucositis. However, more effective methods are needed. Results of studies with granulocyte-macrophage colony-stimulating factor or granulocyte colony-stimulating factor are promising. Lasers are partly beneficial, but equipment-demanding. Modification of the chemotherapy regimen resulting in shortening of the exposition time to chemotherapy agents or chronomodulation of chemotherapy has been shown to lower mucosal toxicity of some regimens. Results of animal studies with locally applied transforming growth factor beta 3 and interleukin-11 are also promising. Based on the findings of the role of the inflammatory cascade in the response of normal tissues to chemotherapy and radiotherapy, anti-inflammatory drugs might be beneficial. At the present time, no agent has been shown to be uniformly efficacious and can be accepted as standard therapy of chemotherapy- and radiotherapy-induced oral mucositis. Further intensive research is needed.

Visual analogue scales: a screening tool for assessing nutritional need in head and neck radiotherapy patients

Background: It has been estimated that more than 80% of head and neck cancer patients have significant weight loss during multimodal treatment, leading to poor wound healing, impaired immune function and a decreased tolerance to therapy. This study assesses the use of visual analogue scales (VAS) as a clinical screening tool to identify the nutritional needs of head and neck cancer patients during radical radiotherapy. Methods: Twenty patients with squamous cell carcinoma (10 larynx, 10 pharynx) were assessed four times during their radiotherapy. They completed a VAS, subjectively assessing their appetite, ability to take solids and liquids and sense of taste on a 5‐point scale, with very poor and very good as the anchor points. Three‐day food diaries, weight, anthropometry and basal metabolic rate were also recorded. Results: The results indicate that although there were no significant differences between the larynx and pharynx groups at the start of radiotherapy, significant differences were apparent by the end of treatment. The VAS showed a significant correlation with energy intake from normal food. This correlation was stronger for solids and appetite than for liquids and taste. Conclusion: The VAS can quickly identify when radiotherapy patients require nutritional intervention and support.

Is prophylactic neck irradiation indicated in patients with squamous cell carcinoma of the maxillary sinus?

To determine the proportion of patients with squamous cell carcinoma of the maxillary sinus who will fail in regional nodes without elective neck treatment and to identify any prognostic factors that may influence neck control. From 1971-1995, 42 consecutive patients with squamous cell carcinoma of the maxillary sinus were seen at our department for curative treatment. There were 35 males and 7 females, with a median age at diagnosis of 63.5 years (range, 42-77 years). One tumor was classified as T1, 5 had T2, 15 had T3, and 21 had T4 disease. Four of 42 patients (9.5%) had cervical lymphadenopathy at initial presentation. Thirty-three patients had surgical resection and radiotherapy and nine had radiotherapy alone. None of the 38 patients with clinical N0 necks received elective treatment to the cervical nodes. Median overall survival was 30 months for all patients. Of the 38 patients with N0 disease, 11 (28.9%) had neck recurrence. Of the 11 neck failures, 9 were ipsilateral only, 1 was contralateral, and 1 had bilateral neck recurrence. The most common site of neck failure was in the upper neck (submandibular and jugulodigastric lymph nodes). Four of the 38 patients (10.5%) had isolated neck failure. Only tumor stage was found to be significant for neck relapse, with T1 and T2 doing worse compared to T3 and T4 tumors. Location of tumor (infrastructure vs. suprastructure), involvement of the oral cavity/oropharynx, nasal cavity, nasopharynx or orbit did not predict for cervical node relapse. Local control at the primary site was likewise not prognostic. The median overall survival for patients who remained N0 was 80 months and for those with initial cervical involvement or recurred in the neck without elective neck irradiation was 25 months (p = 0.05). Based on the 28.9% rate of neck recurrence and the poor median survival of patients who recur in the neck, we recommend prophylactic ipsilateral neck irradiation in patients with T1-T4 squamous cell carcinoma of the maxillary sinus.

Elective neck irradiation versus observation of the clinically negative neck of patients with oral cancer

Purposes: A retrospective study was conducted to determine the efficacy of elective neck irradiation (ENI) versus observation of patients with oral tumors of varying T stages and clinically negative necks, and to statistically evaluate outcome in the two groups with regard to the subsequent development of neck disease. Patients and Methods: Seventy-three patients were treated with surgery of their primary site; 31 received ENI, and 42 of the necks were observed. Of the ENI patients, 3.2% developed neck disease compared with 31% of those observed. When the two groups were evaluated by the T stage of the primary tumor, the results for ENI versus observation were as follows: T1 (0% vs 31 %), T2 (5.9% vs 26.7%), T3 + 4 (0% vs 31%), respectively ( P < .0000, adjusted odds ratio = 13.73, 95% confidence interval). The difference between the two groups was highly statistically significant. One hundred fourteen patients were treated with only radiation therapy alone at the primary site. In this group, 88 received ENI, and 16 necks were observed. Eight percent of the ENI group developed neck disease, compared with 3.8% of the observational group. Further evaluation by T stage of ENI versus observation showed T1 (3% vs 0%); T2 (9.3% vs 7.7%); T3 + 4 (5.6% vs 0%), respectively. The difference between these groups was not found to be statistically significant. Results: The 5-year disease-free survival rate for the surgical group was 90% for patients who received ENI and 40% for those observed. This difference was statistically significant ( P = .0007). No statistical difference was found in 5-year disease-free survival for the radiation group between ENI and observation. Conclusions: When comparing the above data for ENI versus observation, the survival advantages of elective neck irradiation in patients whose primary tumor was treated surgically is striking for all T stages. These results make the decision to observe the neck in such patients difficult to justify. Lack of statistical difference between ENI and observation in the radiation cohort likely reflects selection bias. If radiation therapy is being used to treat the primary disease, only low-risk sites or histologically favorable tumors would not, on a routine basis, have the neck fields treated as well.

Interstitial irradiation for carcinoma of the tongue and floor of mouth: Royal Marsden Hospital Experience 1970–1986

One hundred and forty nine patients with carcinoma of the tongue or floor of mouth were treated with interstitial irradiation ( ± external beam therapy) using caesium needles or iridium wires between 1970 and 1986. Multivariate analysis showed the main predictors of outcome to be tumour stage, site and histology. Caesium and iridium techniques gave similarly good local control rates of 90 % at 5 years for T 1 and T 2 tumours when used as the standard departmental method. Local failure was shown to have a major impact on the risk of dying from disease and elective neck irradiation (ENI) conferred a favourable benefit on neck control and survival provided the primary site was controlled. Patients less than 40 years of age appeared to have an unfavourable prognosis. Radical irradiation including interstitial techniques gives excellent results in early oral cancer and is the treatment of choice for T 2 tumours. We recommend elective neck irradiation in patients at high risk of developing lymph node metastases.