Limiting radiation therapy to lymph nodes on one side of the neck for advanced tonsil cancer (tonsillar squamous cell carcinoma or TSCC) resulted in good local regional control and no cancer recurrence on the untreated side. This is one of the outcomes of a study presented at the 2014 Multidisciplinary Head and Neck Cancer Symposium, sponsored by the American Society for Radiation Oncology (ASTRO), the American Society of Clinical Oncology (ASCO) and the American Head & Neck Society (AHNS) which is being held at the JW Marriott Camelback Inn Resort & Spa in Scottsdale, Arizona, February 20 – 22, 2014. The study results further indicate that primary tumor location, rather than the amount of lymph node involvement on the tumor side of the neck, dictates the risk for disease in the opposite side of the neck. [1]
Squamous cell carcinoma
Tonsillar cancer affects a diverse patient population. Typical patients include those with a strong history of tobacco (tobacco, particularly of cigarettes,is thought to be implicated in well over 80% of cases of throat cancers) and alcohol exposure (Because this risk factor is based on dose-response relationship, heavy drinkers are being at greater risk. Furthermore, drinkers of spirits may be at greater risk than those who drink wine). While relatively uncommon, this type of cancer occurs with increasing age and is strongly male predominant. However, more recently, young individuals and elderly female patients without exposure to these chemical carcinogens also develop tonsillar cancer. Researchers have found that tonsillar carcinoma may be related to the presence of human papilloma virus or HPV. However, until now, it is not clear whether the association of specific HPV subtypes with TSCC represents a true cause-and-effect relationship.[2][3]
Radiotherapy is considered one of the appropriate options to threat this type of cancer and is generally preferred because it offers a high cure rate and is associated with the potential for less post-treatment morbidity. But surgery and, in the care of patients with recurrent and/or metastic throat cancer are, chemotherapy can be used for transient symptomatic benefit. In this setting, drugs with single agent activity include methotrexate, 5FU, cisplatin, paclitaxel, docetaxel. However, combinations of cisplatin and 5-FU, carboplatin and 5FU, and cisplatin and paclitaxel are also used.
One of the most serious complications in the treatment of malignancies of the head and neck, including advanced stage tonsil cancer is radiation necrosis. It is important to recognize the often subtle signs and symptoms of radiation necrosis and, where possible, prevent this serious side effect. [4]
Study design
The study focused on 46 out of 153 total patients with squamous cell carcinoma of the tonsil who received treatment between 1997 and 2012 at Washington University in St. Louis. Tumor location was well-documented in the 46 patients who received unilateral radiation therapy (RT), with 40 patients (87%) having lateralized (located on one side of the throat) primary tumors; two patients (4%) had non-lateralized tumors, and in four patients (9%), lateralization could not be determined retrospectively.
The patients underwent surgical resection and postoperative intensity modulated radiation therapy (IMRT), with 30 patients also receiving concurrent chemotherapy.
…in appropriately selected patients with tonsil cancer, the volume of radiation therapy necessary to control their cancer can be significantly reduced, therefore reducing the side effects and toxicity of radiation…
Of the subset of 46 patients treated unilaterally, 72% were men, and the average patient age was 59. Sixty-one percent of patients were current or former smokers. The cancer stage/classification for the study group was: TX = 2% (1); T1 = 44% (20); T2 = 41% (19); and T3 = 13% (6). The patients’ stages of lymph node involvement were: N0 = 11 percent (5); N1 = 13 percent (6); and N2 = 76% (35). The prescribed radiation doses were 60-66 Gy to the postoperative bed and involved neck; and 52-54 Gy to the elective neck in 30-33 fractions using a simultaneous integrated boost technique.
Follow-up
The median follow-up period was 2.8 years (range was .4 to 8.7 years). There were no local or regional recurrences reported, meaning the cancer did not recur in the adjacent nodes or the original location of the cancer in any of the patients. Distant metastasis, meaning the cancer spread from the original tumor site to distant organs or lymph nodes, developed in four (9%) of the patients. Two patients developed second primary (new) cancers.
High rate of tumor control
“All treatments for cancer?surgery, radiation therapy, chemotherapy?although effective, can cause temporary and/or permanent toxicity which can affect long-term quality of life,” said study author Wade Thorstad, MD, chief of Head and Neck Services and associate professor of Radiation Oncology at Washington University School of Medicine. “Our research indicates that for appropriately selected patients with tonsil cancer, the volume of radiation therapy necessary to control the cancer can be significantly reduced, therefore reducing the side effects and toxicity of radiation, while maintaining a high rate of tumor control.”
For mor information:
[1] Unilateral Radiotherapy in Node Positive Patients with Lateralized Tonsillar Carcinoma; presented by Wade Thorstad, MD, chief of Head and Neck Services and associate professor of Radiation Oncology at Washington University School of Medicine at the 2014 Multidisciplinary Head and Neck Cancer Symposium, February 20 ? 21, 2014 the JW Marriott Camelback Inn Resort and Spa in Scottsdale, Arizona.
[2]Gillison ML, Koch WM, Shah KV. Human papillomavirus in head and neck squamous cell carcinoma: are some head and neck cancers a sexually transmitted disease? Curr Opin Oncol. 1999 May;11(3):191-9.[PubMed]
[3]Strome SE, Savva A, Brissett AE, Gostout BS, Lewis J, Clayton AC,et al.Squamous cell carcinoma of the tonsils: a molecular analysis of HPV associations. Clin Cancer Res. 2002 Apr;8(4):1093-100.[Article][PubMed]
[4] Hunter SE, Scher RL.Clinical implications of radionecrosis to the head and neck surgeon. Curr Opin Otolaryngol Head Neck Surg. 2003 Apr;11(2):103-6.[Article][PubMed]
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