Original Paper ORL 1992;54:103-107
Departments of a Otolaryngology. Radiotherapy, and b Oncology. National Hospital, and c Norwegian Radium Hospital, University of Oslo, Norway
Key Words Head and neck carcinoma Squamous cell carcinoma Elective radiotherapy Recurrences
Elective Radiotherapy of the Neck in Patients with Squamous Cell Carcinoma of the Head and Neck
Abstract A prospectively recorded 5-year series of 254 patients receiving elective neck irradiation is evaluated. All had clinically negative necks and initial control at the primary site. Forty-seven percent of the patients had T 3-4 tumours. Radiotherapy was delivered from a megavolt source at 2 Gy/day 5 days a week to a total dose of 46-50 Gy. All but 3 patients completed the treatment as planned. Neither tumour stage nor site of the primary tumour was related to the inci dence of regional recurrences. Of 30 patients receiving 46-49 Gy, 5 died from neck node recurrences. Of 221 patients treated to 50 Gy or more, 16 (7.2%) developed regional recurrences. Two of these recurrences were avoided, giving a regional failure rate of 6.3%. As a whole, 7.8% died from regional, 11.4% from local, and 3.1 % from distant recurrences.
Great controversy exists as to how the clinically nega tive neck in patients with squamous cell carcinoma of the head and neck should be treated. The precondition com mon to the various treatment plans for the clinically nega tive neck is based on the probability of regional métas tasés. This probability or risk factor has been determined by studying the incidence of positive nodes in elective neck dissections and by evaluating the incidence of recur rences in the untreated neck. The incidence of occult métastasés varies between 19 and 66% [ 1], with an aver age of approximately 30% [2]. The highest incidences are seen in tumours of the oro- and hypopharynx [3-5] and of the oral tongue [5-8], The lowest incidences are reported
in tumours located in buccal mucosa, gingiva, and larynx [3, 9], Whether the incidence of occult metastases in creases with increasing size of the primary tumour has not yet been settled. Some find no such association [10]- oth ers do [ 1, 11-13]. Elective radiotherapy [13-16], neck dissection [4, 17], and delayed treatment [18, 19] of cervical metastases, all have their proponents. This study is based on our pro spective recordings of all patients with cancer of the head and neck in patients with squamous cell carcinoma of the upper aerodigestive tract in whom the primary tumour was controlled.
Supported by The Norwegian Cancer Society.
M. Boyscn. MD Department of Otolaryngology National Hospital 0027 Oslo 1 (Norway)
Received: July 9. 1991 Accepted: September 2, 1991
© 1992 S. Kargcr AG. Basel 0301 -1569/92/0542-0103 $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 7:01:47 PM
Morten Boy sen3 Oscar Lovdala Randulf Soberga Anne-Birgitte Jacobsen b Johan Tausjob Jan FolkvardEvensenc
Table 1. Tumor classification according to the site of the primary tumour in patients with No necks receiving elective radio therapy of the neck
Primary site
Tumour classification X
Oral cavity Oropharynx Hypopharynx Sinonasal cavities3 Larynx
Total
1
2
3
4
36 6 1
46 13 5
10 2
23 8 8
7
7
25
50
71
37
n
%
44
115 29 14 13 83
45 11 6 5 33
83
254
13
Total
a There is no UICC 1982 classification for carcinomas of nose and paranasal sinuses.
Site of primary tumour
Number of patients
Recurrences regional
local
distant
Oral cavity Oropharynx Hypopharynx Sinonasal Larynx
115 29 14 13 83
10 1 4
27 5 3 3 18
2 4 -
Total
254
22(8.7%)
Patients and Methods From May 1983 to May 1988 a total of 807 previously untreated patients with histopathologically confirmed squamous cell carci noma of the head and neck were admitted to the Department of Oto laryngology, National Hospital, Oslo, Norway. Clinical findings, treatment, and the results of follow-up examinations have been recorded prospectively. Forty-five patients with disseminated dis ease, other serious illnesses, or poor general condition which pre vented curative treatment were excluded from this study. Also excluded were 268 patients with clinical positive neck, 172 patients who did not receive treatment of the neck (mainly T g l o t t i c and sinonasal carcinomas), 4 patients with nasopharyngeal carcinomas, 22 patients treated surgically only, and 42 patients in whom initial control of the primary tumour was not achieved. Included in the remaining 254 eligible patients with clinical negative necks receiving elective neck irradiation were also patients who did not complete the treatment as originally planned. For deceased patients death certifi cates were obtained, and autopsy records were reviewed when avail able. None of the patients were lost to follow-up, and all have been followed closely for a minimum of 2 years after completion of the treatment. The mean follow-up period was 3 years. Of the 254 patients 74% were male and 26% female, ranging in age from 26 to 86 years (mean 63 years). The tumours were classified
104
-
7
Total
56(22%)
3
39 10 7 3 28
9(3.5%)
87(34%)
-
according to the 1982 edition of the UICC TNM classification of malignant diseases [20], Table 1 shows the distribution of the tumour according to anatomical site and tumour classification of the 254 patients receiving elective radiotherapy of the neck. Seventy-eight percent of the patients had oral or laryngeal carcinomas, and T3-4 tumours accounted for 47% of the cases. The primary tumour was treated according to site and category. In general, small tumours were treated with radiotherapy alone, and larger tumours with combined radiotherapy and surgery. If tolerated, the primary site received 4770 Gy by external-beam irradiation. The lower doses were reserved for oral carcinomas that received an additional 20-30 Gy with an iridium implant. Thirteen patients with advanced inoperable pri mary tumours received adjuvant chemotherapy (Cis-dichlordiaminplatina or cis-diamincyclobutan-dicarboxylatplatina) in combina tion with 5-fluorouracil). The possible effect of adjuvant chemother apy on recurrence rate and survival is not analyzed in this study. Elective neck irradiation was given as a once-a-day fractionated regimen, delivering 2-2.35 Gy 5 days a week from a megavolt source to a total dose of 46-50 Gy. One anterior field, including both sides of the entire neck, was given. The upper margin had a calculated junction to the irradiation volume of the primary tumour. The first echelon nodes were often included in the irradiation volume of the primary tumour and thus often received 70 Gy. Gingival, buccal, and tonsillar T1/T2 tumours received unilateral neck irradiation. In T-,
Boysen/Lövdal/Söberg/Jacobsen/Tausjö/ Evensen
Elective Radiotherapy of the Neck
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 7:01:47 PM
Table 2. Recurrences according to the site of the primary tumour in patients treated with elective radiotherapy of the neck
Table 3. Regional and distant recurrences according to tumour stage in patients receiving elective radiotherapy of the neck T,
Recurrences/ number of patients
Recurrences
T
Departments of a Otolaryngology. Radiotherapy, and b Oncology. National Hospital, and c Norwegian Radium Hospital, University of Oslo, Norway
Key Words Head and neck carcinoma Squamous cell carcinoma Elective radiotherapy Recurrences
Elective Radiotherapy of the Neck in Patients with Squamous Cell Carcinoma of the Head and Neck
Abstract A prospectively recorded 5-year series of 254 patients receiving elective neck irradiation is evaluated. All had clinically negative necks and initial control at the primary site. Forty-seven percent of the patients had T 3-4 tumours. Radiotherapy was delivered from a megavolt source at 2 Gy/day 5 days a week to a total dose of 46-50 Gy. All but 3 patients completed the treatment as planned. Neither tumour stage nor site of the primary tumour was related to the inci dence of regional recurrences. Of 30 patients receiving 46-49 Gy, 5 died from neck node recurrences. Of 221 patients treated to 50 Gy or more, 16 (7.2%) developed regional recurrences. Two of these recurrences were avoided, giving a regional failure rate of 6.3%. As a whole, 7.8% died from regional, 11.4% from local, and 3.1 % from distant recurrences.
Great controversy exists as to how the clinically nega tive neck in patients with squamous cell carcinoma of the head and neck should be treated. The precondition com mon to the various treatment plans for the clinically nega tive neck is based on the probability of regional métas tasés. This probability or risk factor has been determined by studying the incidence of positive nodes in elective neck dissections and by evaluating the incidence of recur rences in the untreated neck. The incidence of occult métastasés varies between 19 and 66% [ 1], with an aver age of approximately 30% [2]. The highest incidences are seen in tumours of the oro- and hypopharynx [3-5] and of the oral tongue [5-8], The lowest incidences are reported
in tumours located in buccal mucosa, gingiva, and larynx [3, 9], Whether the incidence of occult metastases in creases with increasing size of the primary tumour has not yet been settled. Some find no such association [10]- oth ers do [ 1, 11-13]. Elective radiotherapy [13-16], neck dissection [4, 17], and delayed treatment [18, 19] of cervical metastases, all have their proponents. This study is based on our pro spective recordings of all patients with cancer of the head and neck in patients with squamous cell carcinoma of the upper aerodigestive tract in whom the primary tumour was controlled.
Supported by The Norwegian Cancer Society.
M. Boyscn. MD Department of Otolaryngology National Hospital 0027 Oslo 1 (Norway)
Received: July 9. 1991 Accepted: September 2, 1991
© 1992 S. Kargcr AG. Basel 0301 -1569/92/0542-0103 $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 7:01:47 PM
Morten Boy sen3 Oscar Lovdala Randulf Soberga Anne-Birgitte Jacobsen b Johan Tausjob Jan FolkvardEvensenc
Table 1. Tumor classification according to the site of the primary tumour in patients with No necks receiving elective radio therapy of the neck
Primary site
Tumour classification X
Oral cavity Oropharynx Hypopharynx Sinonasal cavities3 Larynx
Total
1
2
3
4
36 6 1
46 13 5
10 2
23 8 8
7
7
25
50
71
37
n
%
44
115 29 14 13 83
45 11 6 5 33
83
254
13
Total
a There is no UICC 1982 classification for carcinomas of nose and paranasal sinuses.
Site of primary tumour
Number of patients
Recurrences regional
local
distant
Oral cavity Oropharynx Hypopharynx Sinonasal Larynx
115 29 14 13 83
10 1 4
27 5 3 3 18
2 4 -
Total
254
22(8.7%)
Patients and Methods From May 1983 to May 1988 a total of 807 previously untreated patients with histopathologically confirmed squamous cell carci noma of the head and neck were admitted to the Department of Oto laryngology, National Hospital, Oslo, Norway. Clinical findings, treatment, and the results of follow-up examinations have been recorded prospectively. Forty-five patients with disseminated dis ease, other serious illnesses, or poor general condition which pre vented curative treatment were excluded from this study. Also excluded were 268 patients with clinical positive neck, 172 patients who did not receive treatment of the neck (mainly T g l o t t i c and sinonasal carcinomas), 4 patients with nasopharyngeal carcinomas, 22 patients treated surgically only, and 42 patients in whom initial control of the primary tumour was not achieved. Included in the remaining 254 eligible patients with clinical negative necks receiving elective neck irradiation were also patients who did not complete the treatment as originally planned. For deceased patients death certifi cates were obtained, and autopsy records were reviewed when avail able. None of the patients were lost to follow-up, and all have been followed closely for a minimum of 2 years after completion of the treatment. The mean follow-up period was 3 years. Of the 254 patients 74% were male and 26% female, ranging in age from 26 to 86 years (mean 63 years). The tumours were classified
104
-
7
Total
56(22%)
3
39 10 7 3 28
9(3.5%)
87(34%)
-
according to the 1982 edition of the UICC TNM classification of malignant diseases [20], Table 1 shows the distribution of the tumour according to anatomical site and tumour classification of the 254 patients receiving elective radiotherapy of the neck. Seventy-eight percent of the patients had oral or laryngeal carcinomas, and T3-4 tumours accounted for 47% of the cases. The primary tumour was treated according to site and category. In general, small tumours were treated with radiotherapy alone, and larger tumours with combined radiotherapy and surgery. If tolerated, the primary site received 4770 Gy by external-beam irradiation. The lower doses were reserved for oral carcinomas that received an additional 20-30 Gy with an iridium implant. Thirteen patients with advanced inoperable pri mary tumours received adjuvant chemotherapy (Cis-dichlordiaminplatina or cis-diamincyclobutan-dicarboxylatplatina) in combina tion with 5-fluorouracil). The possible effect of adjuvant chemother apy on recurrence rate and survival is not analyzed in this study. Elective neck irradiation was given as a once-a-day fractionated regimen, delivering 2-2.35 Gy 5 days a week from a megavolt source to a total dose of 46-50 Gy. One anterior field, including both sides of the entire neck, was given. The upper margin had a calculated junction to the irradiation volume of the primary tumour. The first echelon nodes were often included in the irradiation volume of the primary tumour and thus often received 70 Gy. Gingival, buccal, and tonsillar T1/T2 tumours received unilateral neck irradiation. In T-,
Boysen/Lövdal/Söberg/Jacobsen/Tausjö/ Evensen
Elective Radiotherapy of the Neck
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 7:01:47 PM
Table 2. Recurrences according to the site of the primary tumour in patients treated with elective radiotherapy of the neck
Table 3. Regional and distant recurrences according to tumour stage in patients receiving elective radiotherapy of the neck T,
Recurrences/ number of patients
Recurrences
T
