VOL.
126,
No.
2
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SQUAMOUS CELL CARCINOMA TONGUE AND FLOOR EVALUATION By LUIS
OF
INTERSTITIAL
DELCLOS, M.D.,t and GILBERT
OF THE MOUTH*
OF RADIUM
THERAPY
ROBERT D. LINDBERG, H. FLETCHER, M.D.1:
HOUSTON,
ORAL
M.D.,t
TEXAS
ABSTRACT:
From January, 1965, to December, 1972, 46 patients with squamous cell carcinoma of the floor of the mouth and 102 patients with squamous cell carcinoma of the oral tongue were treated at M. 13. Anderson Hospital and Tumor Institute by interstitial irradiation alone or in combination with external irradiation. Through the years the combination of radiation therapy modalities has been adjusted in an attempt to improve local control, keeping complications to a minimum. In this paper we analyze local control, causes of failure and complications as related to the primary size (T Stage) and radiation therapy techniques employed.
T
patients with floor of the mouth and 17 patients with oral tongue T, to T3 lesions were treated by external irradiation alone. Most ofthese patients had lesions involving more than half of the tongue or massively involving the floor of the mouth, but a few early lesions were also treated by external beams only, based on contraindication for general anesthesia. During the same period of time, I I 8 patients with a floor of mouth lesion and 135 patients with an oral tongue lesion were treated by surgery. The staging for the primary lesion is as follows: T,-Tumors less than 2 cm in diameter T2-Tumors 2 to 4 cm in diameter, limited invasion of surrounding structures T3-Tumors more than cm in diameter, or having invasion of surrounding structures (periosteal involvement“pressure” defect in bone), or both T4-Massive tumor or bone invasion The techniques of implantation for these two anatomical areas have been described in detail.3
HE the
purpose of this paper is to analyze failures at the primary site, soft tissue ulcers, and bone necrosis as related to the size of the primary tumor (T Stage) and modality of radiation technique employed in a group of patients who had an interstitial implant as part of the treatment for the primary lesion. Although the management of the primary lesion and of the regional metastases in the neck are interrelated therapeutic problems, no attempt will be made to analyze the neck results.
28
MATERIAL
From January, 1965 to December, 1972, 46 patients with squamous cell carcinoma of the floor of the mouth and 102 patients with squamous cell carcinoma of the oral tongue were treated at M. 13. Anderson Hospital and Tumor Institute by interstitial irradiation alone or combined with external irradiation. The analysis was made in March, 1975 and, therefore, all patients have a minimum of a two year follow-up which is adequate for evaluation of results at the primary site. An additional *
Presented
at the Fifty-seventh
Annual
Meeting
of the American
Radium
Society,
Isla Verde,
From the Department of Radiotherapy, The University of Texas System Cancer Center, Institute, Houston, Texas. This investigation was supported in part by Public Health Service Research Grants CA-o6294, t Radiotherapist and Professor of Radiotherapy. Head, Department of Radiotherapy; Radiotherapist and Professor of Radiotherapy.
223
P”erto M.
Rico,
May
D. Anderson
CA-o64,
4-9,
Hospital
and CA-o5o99.
1975.
and
Tumor
L. Delclos, R. 13. Lindberg
224
and
CELL
CARCINOMA
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INTERSTITIAL
Number Patients Treated
Stage
T, T2
T3 T4 Total *
Single
t Single
ipsilateral
ipsilateral Submental and/or
OF
THE
IRRADIATION
of
FLOOR
ALONE
Fletcher
OF
OR
MOUTH
WITH
(ANALYSIS
EXTERNAL
1976
10 24 9 3
3 2 0
0 I 0
0
0
46
#{231}
I
MARCH,
1975)
IRRADIATION
2,000 rads External in -6 DayS*
Radium Alone
FEBRUARY,
I
TABLE SQUAMOUS
G. H.
5,ooo rads External in Weekst
Unusual Treatmentl
4
5 7 5
2
I
2 14
i8
22
field. 22
MeV photon or parallel opposed intraoral electron beam fields.
Co’#{176} fields.
BACKGROUND
Uneven distribution of the needles is the rule in large implants even in the most skillful hands. Since the combination with external irradiation buffers the swing of dose within the implant,4 half external and half interstitial irradiation had always been used for late T2, T3, and some T4 lesions. From January, 1965, the treatment policy for lesions of the oral tongue and floor of the mouth was modified for all lesions by using external irradiation prior to the implant except for the very early lesions in patients with a clinically negative neck. An added reason to use external irradiation first was the suggestion in a few patients that tumor cells driven by the needles had been producing a recurrence at some distance from the primary site. The data showing that elective irradiation of the neck lymphatics in squamous cell carcinomas of the upper respiratory and digestive tract is effective,5 increased the indications to irradiate the lymphatic areas when there is a significant probability of invasion. When an early lesion could be covered by a small-sized implant, 2,000 rads tumor dose has been given with external irradiation as a preneedling dose in five or six treatments encompassing also the first relay of regional lymphatics, i.e., the submaxillary triangle and subdigastric lymph
nodes.6 In moderate-sized lesions and in those located so that a good geometric implant would be unlikely, 5,ooo rads midline tumor
first
dose
with
in
five
weeks
has
been
given
external
irradiation. Low dosage rates were obtained by using low linear intensity needles, o.5 and o.66 mg/cm for single plane implants and 0.25 and 0.33 mg/cm for double and triple plane implants or volume implants. When computer dosimetry became available in 1961, a generous minimal tumor dose was selected from the isodoses knowing that the doses could be as much as 20 percent higher than the doses given in earlier years. When an analysis in January, 1963, showed an increased incidence of complications, the doses were reduced by ten percent by taking a less generous minimum tumor dose. During the following two years (1963 and 1964), there was a decrease in complications, but an increase in recurrences in patients with an oral tongue lesion, but not in those with a floor of the mouth lesion.2 Since 1965, lesions treated by interstitial radium or iridium alone have received doses from 6,ooo rads in 120 hours to 7,000 rads in 175 hours for floor of the mouth lesions and 5,800 rads in 46 hours to 7,000 rads in 175 hours for oral tongue lesions. After 2,000 rads with the external beam in five or six treatments the dose was 5,ooo
rads
in 166 hours
for one
case
of floor
VoL.
No.
126,
Carcinoma
2
of Oral
Tongue
and
CELL
CARCINOMA
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INTERSTITIAL
THE
IRRADIATION
Number
T, T2 T3 T4
FLOOR
ALONE
Unusual
9 3
treatments
of the
(gold
grain
implants)+submental
mouth
to
0/I
1/9
0/2
2/3
9
3/9t
6/46
electron
beam
MOUTH
CELL
CARCINOMA
INTERSTITIAL
Number Patients Treated
Stage
T, T2
T3
Total *
without
Healed.
recurrence.
of
ALONE
Soft
Tissue
Ulcers
FLOOR OR
OF
MOUTH
WITH
Healed By Conservative Treatment
1/7
1/I
3/21
2/3
4/8
2/4
0/I
8/37*
because
of trismus
anesthesia. and skin graft
(ANALYSIS
EXTERNAL
10
46
Patients
THE
24
9 3
1’4
OF
IRRADIATION
in one patient
to general after excision
(previous
squamous
for the first recurrence.
III
TABLE
t 7/8
fields
five of 3 patients with Stages T, and T2 lesions were treated by interstitial irradiation alone. Tumors of the floor of the mouth extend to the submucosal tissues of the submental and submandibular areas, the periosteum of the mandible, and the muscles of the tongue; and therefore external irradiation was given before implantation in the majority ofpatients. Eighteen of the 46 (T, to T4) were treated by unusual treatment modalities employing a submental electron beam field or a submental and lateral field plus the implant in an attempt to diminish the amount of radiation going through the mandible or trying to avoid an area previously treated for another primary
Table I shows the modalities of irradiation used according to the T stage of the primary lesion of the floor of the mouth. The choice of treatment has been based on subtle reasons. It is to be noted that only
SQUAMOUS
1/10
2/24
I
RESULTS THE
Ultimate Local Failures
By
2
and
OF
1975)
2/3t
5,600
FLOOR
MARCH,
I/3
of the oropharynx); in the other two because of contraindication was salvaged by radium implant following a second recurrence to determine result following surgery.
hours
225
IRRADIATION
Recurrences Salvaged Surgery
varied from 4,200 rads in rads in 140 hours for oral tongue lesions. After 5,ooo rads in five weeks with external beam, the radium dose has been 2,500 to 3,000 rads in 72 to 100 hours for floor of the mouth and 2,500 to 3,000 rads for oral tongue lesions in 42 to 100 hours. 70
(ANALYSIS
EXTERNAL
3* 3
10
46
cell carcinoma t One-third Too early
MOUTH
WITH
Recurrences
24
Total
OF OR
of
Patients Treated
Stage
*
OF
of Mouth
II
TABLE SQUAMOUS
Floor
-
s/8t
MARCH,
1975)
IRRADIATION
Still
Present
-
1/3 -
x/8
Treated Successfully By Surgery -
2/4 -
2/8t
L. Deiclos,
226
R.
13. Lindberg
and
CELL
CARCINOMA
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INTERSTITIAL
Number Patients Treated
Stage
Patients
7/8
FLOOR
ALONE
OF OR
of
MOUTH
WITH
(ANALYSIS
MARCH,
EXTERNAL
Healed By Conservative Treatment
Osteonecrosis
Still
10
1/7
I/I
-
5/21
2/5
-
9
2/8
-
3
0/I
-
without
8/37*
1975)
Treated Successfully By Surgery
Present
24
46
1976
IRRADIATION
T2
Total *
THE
FEBRUARY,
T, T3 T4
t
OF
IRRADIATION
Fletcher
IV
TABLE SQUAMOUS
G. H.
-
3/5
1/2
1/2
-
3/8t
-
4/8t
1/8
recurrence.
Healed.
lesion. Some superficial lesions in edentubus patients, in whom the floor of the mouth was relatively flat, were treated by intraoral cones plus an interstitial implant. Sixteen of 3 T, and T2 lesions and /9 T3 lesions receive 5,000 rads in five weeks generally with parallel opposed fields followed by an interstitial implant. Table II shows the recurrence rates, the number of recurrences salvaged by a surgical procedure, and the ultimate failure rates. There are three recurrences among T1 lesions; all three were treated by unusual modalities, one patient was unable to open the mouth because of trismus caused by previous treatment for a squamous cell carcinoma of the oropharynx and was treated with submental electron beam
field plus a gold grain implant; the other two patients were implanted with gold grains because of medical contraindication for general anesthesia. Gold grain implants are more subject to cold spots than radium or iridium implants. The control rates in the T2 and T3 lesions are excellent. Table III shows that the incidence of soft tissue necrosis is the same for T1 and T2 and higher for T3 lesions. In Table iv we see that osteonecrosis is less common in T1 lesions where lesser amounts of external irradiation were used and has about the same incidence for T2 and T3 lesions where most of the patients received large amounts ofexternal irradiation. It is to be noted that final healing of both soft tissue necrosis and bone necrosis is
V
TABLE SQUAMOUS
CELL
CARCINOMA
INTERSTITIAL
Stage
Number Patients Treated
T, T2 T3 Total
OF
IRRADIATION
THE
ORAL
ALONE
of
OR
TONGUE WITH
(ANALYSIS
2,000 rads External in -6 Days*
.
Radium Alone
MARCH,
EXTERNAL
6
-
g,ooo rads External in Weekst
18 57
8 2
30
27
I
0
23
36
44
102
*
Single ipsilateral field.
t
Single ipsilateral 22 MeV photon or parallel Submental and/or intraoral electron beam
II
opposed fields.
Co’#{176} fields.
1975)
IRRADIATION
Unusual Treatment
3 i8
I
7 3 II
VoL.
No.
126,
Carcinoma
2
of Oral
Tongue
and
CELL
CARCINOMA
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INTERSTITIAL
OF
THE
IRRADIATION
ALONE
Number of Patients
Stage
ORAL
TONGUE
OR
WITH
(ANALYSIS
EXTERNAL
i8 57
T3
27
*
rads/
2,000
irradiation.
days+radium
No
Evidence
(,2oo
Table tion in
shows
V
used
for
hours).
lesions
of
the
the
modalities stages
oral
1*
I/I
4/6 i/6
o/i8 x/#{231}i 5/27
6/13
6/102
Recurrence
pernecrosis necrosis
TONGUE
different
of irradiathe disease The choice of of
tongue.
radiation treatment modality has been based mainly on the size of the primary lesion and the presence of neck lymph nodes. In addition, attention was paid to extension or possible extension to the floor ofthe mouth, the glossopalatine sulcus, and the base of the tongue. Fourteen of I 8 patients with T1 lesions had relatively limited or moderate lesions with no clinically positive lymph nodes and were treated by radium alone or with 2,000 rads tumor dose
at
2 years
(primary+neck)
CELL
CARCINOMA
INTERSTITIAL
dling weeks.
(i
OF
IRRADIATION
ORAL OR
TONGUE WITH
(ANALYSIS EXTERNAL
10/12
T3
27
3/21
2/3
102
I9/89
15/19
without
Healed.
recurrence.
Tissue Ulcers
4/17
dose in five of patients unusual mo-
VII
12/51
Patients
postoperative
mainly with subone lateral field these were mainly of the tongue, and an attempt was made to minimize irradiation of the mandible; when bone has been extensively irradiated defense mechanisms are poor. External irradiation was
i8 57
t
and
dalities of irradiation, mental fields or combining and a submental field; lesions of the undersurface
T1 T2
Soft
rads tumor limited number were treated by 5,000
I /102)
Number Patients Treated
*
of
THE ALONE
with A
Stage
Total
-‘surgery
in five or six treatments before the implant. Half of the patients with T2 lesions were treated in the same fashion because of limited or moderate lesions and no clinically positive lymph nodes, but i 8 of 57 patients received a 5,000 rad tumor dose in five weeks which encompassed at least the primary and the first lymphatic relay. Most T, lesions were treated before nee-
TABLE SQUAMOUS
Local Failures
).
outstanding (8 percent). Twenty-five cent of the patients with soft tissue and 5o percent of those with bone required surgical procedures. ORAL
Ultimate
6 6 13
rads/12o
(
of Disease
1975)
Surgery
102
Total
MARCH,
IRRADIATION
Recurrences Salvaged By
Recurrences
Treated T1 T2
227
of Mouth
VI
TABLE SQUAMOUS
Floor
Healed By Conservative Treatment 3/4
I5/I9t
MARCH,
1975)
IRRADIATION
Still
Present
Treated Successfully By Surgery
1/4
2/12 -
3/19
-
1/3
I/I9t
L. Delclos,
228
R.
D. Lindberg
and
CELL
CARCINOMA
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INTERSTITiAL
Osteonecrosis
T1
i8
3/17
‘F2
57
9/51
T3
27
5/21
Total Patients 14/17
without
ORAL OR
TONGUE WiTH
(ANALYSIS
FEBRUARY,
MARCH,
EXTERNAL
2/3
1/3
-
3/9 3/5
‘/9 1/5
,/
8/I7t
3/17
recurrence.
radiation
therapy.
tongue. Table VI shows the recurrence rates, the number of recurrences salvaged by surgery, and the ultimate failure rate. The failures are low and the ultimate failure rates are excellent for T1 and T2 lesions and still very good for T, lesions. Tables VII and VIII show that the mcidence of soft tissue necrosis and osteonecrosis is the same for T1 to T, lesions. The final healing of both soft tissue necrosis and bone necrosis is outstanding (8o
necrosis,
when
surgical
avoided,
can
be reduced conservative
by an interstitial wire) through
iridium
8
percent),
five
soft tissue with bone
percent
necrosis necrosis
of
the
not
be extracted
when good established.
I.
J. M.,
BEDWINEK,
G. H., and treated mous
and 35 percent of requiring surgical
DALEY,
with
In
oropharynx. 2.
DISCUSSION
over-all
J. R., G. H. Clinical
CASTRO,
in
Textbook Lea & 4.
FLETCHER,
TYNE,
Radiation Cancer
of
soft
tissue
Charles
ne-
has diminished dramatically since 1965. A recent report shows that since July, 1969, there has been a 6o percent reduction in bone necrosis as compared with before 1969.1 This reduction is due to a very conservative approach and the recognition by the dental service that fairly good teeth crosis
FLETCHER,
L. T. E. Osteonecrosis
SHUKOVSKY,
is
oral
cavity
FLETCHER,
in patients
radiotherapy
for
and
R. D., and of computer
LINDBERG,
application
radium RAD.
/05,
J.,
squa-
naso-
and
press.
interstitial
1969,
MED.,
3.
previously. incidence
are
to a minimum oral hygiene
System Cancer Center and Tumor Institute
of
ROENTGENOL.,
discussed
after
osteoradio-
manipulations
definitive
carcinoma
etry
The
to nor
REFERENCES
patients
The control rates for squamous cell carcinoma of the floor of the mouth and the oral tongue are excellent. In the T1 cases, the choice of technique was not optimal in three cases for medical or technical reasons,
prior
Spontaneous
Luis Deiclos, M.D. The University ofTexas M. D. Anderson Hospital Houston, Texas 77025
procedures.
as
6/I7f
-
should
with those
Treated Successfully By Surgery
Still Present
needling (radium the dorsum of the
to
1975)
Healed.
followed or
1976
IRRADIATION
Healed By Conservative Treatment
17/89*
102
*
THE ALONE
Number of Patients Treated
Stage
t
OF
IRRADIATION
Fletcher
VIII
TABLE SQUAMOUS
G. H.
therapy.
THERAPY
165-17
&
FLETCHER,
dosimAM.
J.
NUCLEAR
I.
G. H. Oral cavity and oropharynx. In: of Radiotherapy. Second Edition. Febiger, Philadelphia, 1973. G. H., MACCOMB, W. S., BALLANA. J., SHALEK, R. J., and STOVALL, M. Therapy in the Management of of the Oral Cavity and Oropharynx. C Thomas, Publisher, Springfield, Ill.,
1962. .
G.
Radiation In: Neoplasia Year Book Medical 1974, pp. 19-38. R. D. Distribution
FLETCHER,
clinical Neck. Chicago, 6.
LINDBERG, node of
cer,
H.
disease.
metastaseS upper 1972,
from
respiratory 29,
1446-1449.
suband Inc.,
of cervical lymph cell carcinoma digestive tracts. Can-
squamous and
therapy and of the Head Publishers,
126,
No.
2
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SQUAMOUS CELL CARCINOMA TONGUE AND FLOOR EVALUATION By LUIS
OF
INTERSTITIAL
DELCLOS, M.D.,t and GILBERT
OF THE MOUTH*
OF RADIUM
THERAPY
ROBERT D. LINDBERG, H. FLETCHER, M.D.1:
HOUSTON,
ORAL
M.D.,t
TEXAS
ABSTRACT:
From January, 1965, to December, 1972, 46 patients with squamous cell carcinoma of the floor of the mouth and 102 patients with squamous cell carcinoma of the oral tongue were treated at M. 13. Anderson Hospital and Tumor Institute by interstitial irradiation alone or in combination with external irradiation. Through the years the combination of radiation therapy modalities has been adjusted in an attempt to improve local control, keeping complications to a minimum. In this paper we analyze local control, causes of failure and complications as related to the primary size (T Stage) and radiation therapy techniques employed.
T
patients with floor of the mouth and 17 patients with oral tongue T, to T3 lesions were treated by external irradiation alone. Most ofthese patients had lesions involving more than half of the tongue or massively involving the floor of the mouth, but a few early lesions were also treated by external beams only, based on contraindication for general anesthesia. During the same period of time, I I 8 patients with a floor of mouth lesion and 135 patients with an oral tongue lesion were treated by surgery. The staging for the primary lesion is as follows: T,-Tumors less than 2 cm in diameter T2-Tumors 2 to 4 cm in diameter, limited invasion of surrounding structures T3-Tumors more than cm in diameter, or having invasion of surrounding structures (periosteal involvement“pressure” defect in bone), or both T4-Massive tumor or bone invasion The techniques of implantation for these two anatomical areas have been described in detail.3
HE the
purpose of this paper is to analyze failures at the primary site, soft tissue ulcers, and bone necrosis as related to the size of the primary tumor (T Stage) and modality of radiation technique employed in a group of patients who had an interstitial implant as part of the treatment for the primary lesion. Although the management of the primary lesion and of the regional metastases in the neck are interrelated therapeutic problems, no attempt will be made to analyze the neck results.
28
MATERIAL
From January, 1965 to December, 1972, 46 patients with squamous cell carcinoma of the floor of the mouth and 102 patients with squamous cell carcinoma of the oral tongue were treated at M. 13. Anderson Hospital and Tumor Institute by interstitial irradiation alone or combined with external irradiation. The analysis was made in March, 1975 and, therefore, all patients have a minimum of a two year follow-up which is adequate for evaluation of results at the primary site. An additional *
Presented
at the Fifty-seventh
Annual
Meeting
of the American
Radium
Society,
Isla Verde,
From the Department of Radiotherapy, The University of Texas System Cancer Center, Institute, Houston, Texas. This investigation was supported in part by Public Health Service Research Grants CA-o6294, t Radiotherapist and Professor of Radiotherapy. Head, Department of Radiotherapy; Radiotherapist and Professor of Radiotherapy.
223
P”erto M.
Rico,
May
D. Anderson
CA-o64,
4-9,
Hospital
and CA-o5o99.
1975.
and
Tumor
L. Delclos, R. 13. Lindberg
224
and
CELL
CARCINOMA
Downloaded from www.ajronline.org by 119.99.128.243 on 10/24/15 from IP address 119.99.128.243. Copyright ARRS. For personal use only; all rights reserved
INTERSTITIAL
Number Patients Treated
Stage
T, T2
T3 T4 Total *
Single
t Single
ipsilateral
ipsilateral Submental and/or
OF
THE
IRRADIATION
of
FLOOR
ALONE
Fletcher
OF
OR
MOUTH
WITH
(ANALYSIS
EXTERNAL
1976
10 24 9 3
3 2 0
0 I 0
0
0
46
#{231}
I
MARCH,
1975)
IRRADIATION
2,000 rads External in -6 DayS*
Radium Alone
FEBRUARY,
I
TABLE SQUAMOUS
G. H.
5,ooo rads External in Weekst
Unusual Treatmentl
4
5 7 5
2
I
2 14
i8
22
field. 22
MeV photon or parallel opposed intraoral electron beam fields.
Co’#{176} fields.
BACKGROUND
Uneven distribution of the needles is the rule in large implants even in the most skillful hands. Since the combination with external irradiation buffers the swing of dose within the implant,4 half external and half interstitial irradiation had always been used for late T2, T3, and some T4 lesions. From January, 1965, the treatment policy for lesions of the oral tongue and floor of the mouth was modified for all lesions by using external irradiation prior to the implant except for the very early lesions in patients with a clinically negative neck. An added reason to use external irradiation first was the suggestion in a few patients that tumor cells driven by the needles had been producing a recurrence at some distance from the primary site. The data showing that elective irradiation of the neck lymphatics in squamous cell carcinomas of the upper respiratory and digestive tract is effective,5 increased the indications to irradiate the lymphatic areas when there is a significant probability of invasion. When an early lesion could be covered by a small-sized implant, 2,000 rads tumor dose has been given with external irradiation as a preneedling dose in five or six treatments encompassing also the first relay of regional lymphatics, i.e., the submaxillary triangle and subdigastric lymph
nodes.6 In moderate-sized lesions and in those located so that a good geometric implant would be unlikely, 5,ooo rads midline tumor
first
dose
with
in
five
weeks
has
been
given
external
irradiation. Low dosage rates were obtained by using low linear intensity needles, o.5 and o.66 mg/cm for single plane implants and 0.25 and 0.33 mg/cm for double and triple plane implants or volume implants. When computer dosimetry became available in 1961, a generous minimal tumor dose was selected from the isodoses knowing that the doses could be as much as 20 percent higher than the doses given in earlier years. When an analysis in January, 1963, showed an increased incidence of complications, the doses were reduced by ten percent by taking a less generous minimum tumor dose. During the following two years (1963 and 1964), there was a decrease in complications, but an increase in recurrences in patients with an oral tongue lesion, but not in those with a floor of the mouth lesion.2 Since 1965, lesions treated by interstitial radium or iridium alone have received doses from 6,ooo rads in 120 hours to 7,000 rads in 175 hours for floor of the mouth lesions and 5,800 rads in 46 hours to 7,000 rads in 175 hours for oral tongue lesions. After 2,000 rads with the external beam in five or six treatments the dose was 5,ooo
rads
in 166 hours
for one
case
of floor
VoL.
No.
126,
Carcinoma
2
of Oral
Tongue
and
CELL
CARCINOMA
Downloaded from www.ajronline.org by 119.99.128.243 on 10/24/15 from IP address 119.99.128.243. Copyright ARRS. For personal use only; all rights reserved
INTERSTITIAL
THE
IRRADIATION
Number
T, T2 T3 T4
FLOOR
ALONE
Unusual
9 3
treatments
of the
(gold
grain
implants)+submental
mouth
to
0/I
1/9
0/2
2/3
9
3/9t
6/46
electron
beam
MOUTH
CELL
CARCINOMA
INTERSTITIAL
Number Patients Treated
Stage
T, T2
T3
Total *
without
Healed.
recurrence.
of
ALONE
Soft
Tissue
Ulcers
FLOOR OR
OF
MOUTH
WITH
Healed By Conservative Treatment
1/7
1/I
3/21
2/3
4/8
2/4
0/I
8/37*
because
of trismus
anesthesia. and skin graft
(ANALYSIS
EXTERNAL
10
46
Patients
THE
24
9 3
1’4
OF
IRRADIATION
in one patient
to general after excision
(previous
squamous
for the first recurrence.
III
TABLE
t 7/8
fields
five of 3 patients with Stages T, and T2 lesions were treated by interstitial irradiation alone. Tumors of the floor of the mouth extend to the submucosal tissues of the submental and submandibular areas, the periosteum of the mandible, and the muscles of the tongue; and therefore external irradiation was given before implantation in the majority ofpatients. Eighteen of the 46 (T, to T4) were treated by unusual treatment modalities employing a submental electron beam field or a submental and lateral field plus the implant in an attempt to diminish the amount of radiation going through the mandible or trying to avoid an area previously treated for another primary
Table I shows the modalities of irradiation used according to the T stage of the primary lesion of the floor of the mouth. The choice of treatment has been based on subtle reasons. It is to be noted that only
SQUAMOUS
1/10
2/24
I
RESULTS THE
Ultimate Local Failures
By
2
and
OF
1975)
2/3t
5,600
FLOOR
MARCH,
I/3
of the oropharynx); in the other two because of contraindication was salvaged by radium implant following a second recurrence to determine result following surgery.
hours
225
IRRADIATION
Recurrences Salvaged Surgery
varied from 4,200 rads in rads in 140 hours for oral tongue lesions. After 5,ooo rads in five weeks with external beam, the radium dose has been 2,500 to 3,000 rads in 72 to 100 hours for floor of the mouth and 2,500 to 3,000 rads for oral tongue lesions in 42 to 100 hours. 70
(ANALYSIS
EXTERNAL
3* 3
10
46
cell carcinoma t One-third Too early
MOUTH
WITH
Recurrences
24
Total
OF OR
of
Patients Treated
Stage
*
OF
of Mouth
II
TABLE SQUAMOUS
Floor
-
s/8t
MARCH,
1975)
IRRADIATION
Still
Present
-
1/3 -
x/8
Treated Successfully By Surgery -
2/4 -
2/8t
L. Deiclos,
226
R.
13. Lindberg
and
CELL
CARCINOMA
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INTERSTITIAL
Number Patients Treated
Stage
Patients
7/8
FLOOR
ALONE
OF OR
of
MOUTH
WITH
(ANALYSIS
MARCH,
EXTERNAL
Healed By Conservative Treatment
Osteonecrosis
Still
10
1/7
I/I
-
5/21
2/5
-
9
2/8
-
3
0/I
-
without
8/37*
1975)
Treated Successfully By Surgery
Present
24
46
1976
IRRADIATION
T2
Total *
THE
FEBRUARY,
T, T3 T4
t
OF
IRRADIATION
Fletcher
IV
TABLE SQUAMOUS
G. H.
-
3/5
1/2
1/2
-
3/8t
-
4/8t
1/8
recurrence.
Healed.
lesion. Some superficial lesions in edentubus patients, in whom the floor of the mouth was relatively flat, were treated by intraoral cones plus an interstitial implant. Sixteen of 3 T, and T2 lesions and /9 T3 lesions receive 5,000 rads in five weeks generally with parallel opposed fields followed by an interstitial implant. Table II shows the recurrence rates, the number of recurrences salvaged by a surgical procedure, and the ultimate failure rates. There are three recurrences among T1 lesions; all three were treated by unusual modalities, one patient was unable to open the mouth because of trismus caused by previous treatment for a squamous cell carcinoma of the oropharynx and was treated with submental electron beam
field plus a gold grain implant; the other two patients were implanted with gold grains because of medical contraindication for general anesthesia. Gold grain implants are more subject to cold spots than radium or iridium implants. The control rates in the T2 and T3 lesions are excellent. Table III shows that the incidence of soft tissue necrosis is the same for T1 and T2 and higher for T3 lesions. In Table iv we see that osteonecrosis is less common in T1 lesions where lesser amounts of external irradiation were used and has about the same incidence for T2 and T3 lesions where most of the patients received large amounts ofexternal irradiation. It is to be noted that final healing of both soft tissue necrosis and bone necrosis is
V
TABLE SQUAMOUS
CELL
CARCINOMA
INTERSTITIAL
Stage
Number Patients Treated
T, T2 T3 Total
OF
IRRADIATION
THE
ORAL
ALONE
of
OR
TONGUE WITH
(ANALYSIS
2,000 rads External in -6 Days*
.
Radium Alone
MARCH,
EXTERNAL
6
-
g,ooo rads External in Weekst
18 57
8 2
30
27
I
0
23
36
44
102
*
Single ipsilateral field.
t
Single ipsilateral 22 MeV photon or parallel Submental and/or intraoral electron beam
II
opposed fields.
Co’#{176} fields.
1975)
IRRADIATION
Unusual Treatment
3 i8
I
7 3 II
VoL.
No.
126,
Carcinoma
2
of Oral
Tongue
and
CELL
CARCINOMA
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INTERSTITIAL
OF
THE
IRRADIATION
ALONE
Number of Patients
Stage
ORAL
TONGUE
OR
WITH
(ANALYSIS
EXTERNAL
i8 57
T3
27
*
rads/
2,000
irradiation.
days+radium
No
Evidence
(,2oo
Table tion in
shows
V
used
for
hours).
lesions
of
the
the
modalities stages
oral
1*
I/I
4/6 i/6
o/i8 x/#{231}i 5/27
6/13
6/102
Recurrence
pernecrosis necrosis
TONGUE
different
of irradiathe disease The choice of of
tongue.
radiation treatment modality has been based mainly on the size of the primary lesion and the presence of neck lymph nodes. In addition, attention was paid to extension or possible extension to the floor ofthe mouth, the glossopalatine sulcus, and the base of the tongue. Fourteen of I 8 patients with T1 lesions had relatively limited or moderate lesions with no clinically positive lymph nodes and were treated by radium alone or with 2,000 rads tumor dose
at
2 years
(primary+neck)
CELL
CARCINOMA
INTERSTITIAL
dling weeks.
(i
OF
IRRADIATION
ORAL OR
TONGUE WITH
(ANALYSIS EXTERNAL
10/12
T3
27
3/21
2/3
102
I9/89
15/19
without
Healed.
recurrence.
Tissue Ulcers
4/17
dose in five of patients unusual mo-
VII
12/51
Patients
postoperative
mainly with subone lateral field these were mainly of the tongue, and an attempt was made to minimize irradiation of the mandible; when bone has been extensively irradiated defense mechanisms are poor. External irradiation was
i8 57
t
and
dalities of irradiation, mental fields or combining and a submental field; lesions of the undersurface
T1 T2
Soft
rads tumor limited number were treated by 5,000
I /102)
Number Patients Treated
*
of
THE ALONE
with A
Stage
Total
-‘surgery
in five or six treatments before the implant. Half of the patients with T2 lesions were treated in the same fashion because of limited or moderate lesions and no clinically positive lymph nodes, but i 8 of 57 patients received a 5,000 rad tumor dose in five weeks which encompassed at least the primary and the first lymphatic relay. Most T, lesions were treated before nee-
TABLE SQUAMOUS
Local Failures
).
outstanding (8 percent). Twenty-five cent of the patients with soft tissue and 5o percent of those with bone required surgical procedures. ORAL
Ultimate
6 6 13
rads/12o
(
of Disease
1975)
Surgery
102
Total
MARCH,
IRRADIATION
Recurrences Salvaged By
Recurrences
Treated T1 T2
227
of Mouth
VI
TABLE SQUAMOUS
Floor
Healed By Conservative Treatment 3/4
I5/I9t
MARCH,
1975)
IRRADIATION
Still
Present
Treated Successfully By Surgery
1/4
2/12 -
3/19
-
1/3
I/I9t
L. Delclos,
228
R.
D. Lindberg
and
CELL
CARCINOMA
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INTERSTITiAL
Osteonecrosis
T1
i8
3/17
‘F2
57
9/51
T3
27
5/21
Total Patients 14/17
without
ORAL OR
TONGUE WiTH
(ANALYSIS
FEBRUARY,
MARCH,
EXTERNAL
2/3
1/3
-
3/9 3/5
‘/9 1/5
,/
8/I7t
3/17
recurrence.
radiation
therapy.
tongue. Table VI shows the recurrence rates, the number of recurrences salvaged by surgery, and the ultimate failure rate. The failures are low and the ultimate failure rates are excellent for T1 and T2 lesions and still very good for T, lesions. Tables VII and VIII show that the mcidence of soft tissue necrosis and osteonecrosis is the same for T1 to T, lesions. The final healing of both soft tissue necrosis and bone necrosis is outstanding (8o
necrosis,
when
surgical
avoided,
can
be reduced conservative
by an interstitial wire) through
iridium
8
percent),
five
soft tissue with bone
percent
necrosis necrosis
of
the
not
be extracted
when good established.
I.
J. M.,
BEDWINEK,
G. H., and treated mous
and 35 percent of requiring surgical
DALEY,
with
In
oropharynx. 2.
DISCUSSION
over-all
J. R., G. H. Clinical
CASTRO,
in
Textbook Lea & 4.
FLETCHER,
TYNE,
Radiation Cancer
of
soft
tissue
Charles
ne-
has diminished dramatically since 1965. A recent report shows that since July, 1969, there has been a 6o percent reduction in bone necrosis as compared with before 1969.1 This reduction is due to a very conservative approach and the recognition by the dental service that fairly good teeth crosis
FLETCHER,
L. T. E. Osteonecrosis
SHUKOVSKY,
is
oral
cavity
FLETCHER,
in patients
radiotherapy
for
and
R. D., and of computer
LINDBERG,
application
radium RAD.
/05,
J.,
squa-
naso-
and
press.
interstitial
1969,
MED.,
3.
previously. incidence
are
to a minimum oral hygiene
System Cancer Center and Tumor Institute
of
ROENTGENOL.,
discussed
after
osteoradio-
manipulations
definitive
carcinoma
etry
The
to nor
REFERENCES
patients
The control rates for squamous cell carcinoma of the floor of the mouth and the oral tongue are excellent. In the T1 cases, the choice of technique was not optimal in three cases for medical or technical reasons,
prior
Spontaneous
Luis Deiclos, M.D. The University ofTexas M. D. Anderson Hospital Houston, Texas 77025
procedures.
as
6/I7f
-
should
with those
Treated Successfully By Surgery
Still Present
needling (radium the dorsum of the
to
1975)
Healed.
followed or
1976
IRRADIATION
Healed By Conservative Treatment
17/89*
102
*
THE ALONE
Number of Patients Treated
Stage
t
OF
IRRADIATION
Fletcher
VIII
TABLE SQUAMOUS
G. H.
therapy.
THERAPY
165-17
&
FLETCHER,
dosimAM.
J.
NUCLEAR
I.
G. H. Oral cavity and oropharynx. In: of Radiotherapy. Second Edition. Febiger, Philadelphia, 1973. G. H., MACCOMB, W. S., BALLANA. J., SHALEK, R. J., and STOVALL, M. Therapy in the Management of of the Oral Cavity and Oropharynx. C Thomas, Publisher, Springfield, Ill.,
1962. .
G.
Radiation In: Neoplasia Year Book Medical 1974, pp. 19-38. R. D. Distribution
FLETCHER,
clinical Neck. Chicago, 6.
LINDBERG, node of
cer,
H.
disease.
metastaseS upper 1972,
from
respiratory 29,
1446-1449.
suband Inc.,
of cervical lymph cell carcinoma digestive tracts. Can-
squamous and
therapy and of the Head Publishers,
