[Adenogenic pseudo-cystic form of a tonsillar neoplasm, followed for more than 5 years].
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While it is generally accepted that the treatment of choice in carcinoma of the tonsil is transcutaneous radiotherapy (including lymphatic drainage), opinion on additional surgical interventions is still divided. The possible operations are extended tonsillectomy followed by radical neck dissection or the composite operation with partial mandibulectomy. The importance of the composite operation for T3 stage tumors is emphasized. Chemotherapy (bleomycin) was rarely used in our patients, and only initially in extensive carcinoma.
Hyperbaric oxygen used in the treatment of 14 patients with intractable osteonecrosis of the mandible produced a favorable response in relief of pain, elimination of extraoral draining sinus tracts, the return of osseous union in areas of the abnormal fracture, and the rapid dissolution of sequestrum without suppuration, so that further loss of hard and soft tissue was minimized. This treatment is a more conservative approach in the management of osteoradionecrosis.
Surgical treatment was used in 45 cases of oral cavity carcinoma and in 23 cases of oropharyngeal carcinoma. The three-year cure rate was 47% for oral cavity tumors and 9% for orophayngeal lesions. The cure rate was substantially higher in female patients than in males and in white patients than in nonwhites. Results of composite resections in 23 previously irradiated patients and 23 nonirradiated patients with T-2 and T-3 lesions are compared. The irradiated patients with oral cavity carcinoma had a lower cure rate and a much greater incidence of postoperative morbidity than the patients treated with operation alone. Surgical results for oropharyngeal carcinomas were poor in both radiated and nonirradiated patients, although the incidence of postoperative morbidity and mortality was higher in the irradiated group.
From 1969 through 1975, 145 patients were treated for squamous cell carcinoma of the tonsil and tongue-base region; 119 received initial treatment, and salvage operations were done in 26. The overall five-year survival rate was 42%. Cervical metastasis was the most important determinant of survival. Pathologic stage I or II disease was controlled by surgical treatment. In patients with stage III or IV disease, operation alone controlled the primary lesion better than radiation alone or combined preoperative radiation and surgical treatment. With operation alone, however the rate of neck recurrence was higher than with the other two methods of treatment. In advanced disease, surgical treatment combined with postoperative radiation should be considered. Mandibular osteotomy and excision of the primary lesion are as effective in local tumor control as composite resection. In patients with a tumor-free margin, osteotomy can be used to preserve the mandible.
The optimum radiation treatment plan for any given clinical situation can be achieved by combining various irradiation modalities and beam energies. The availability of equipment that provides photon and electron beams of energies from 4 MeV to 25 MeV permits optimal dose distribution throughout the treatment volume. Since no difference in the biological effectiveness of electrons compared with megavoltage photons has been demonstrated in laboratory studies, there is no hesitation in combining electrons with photons. The selection of the various energies, the combination of electrons with photons, and the ratio of the given doses of each beam depend on the location of the tumor and the maximum depth to be treated. With the use of one beam alone, a combination of 25 MeV and 4 to 6 MeV photon beams, or a combination of photons and electrons, the most effective treatment plan with the available beams can be designed for any clinical situation.
A retrospective study of 702 patients with clinically positive nodes associated with squamous cell carcinoma of the oral cavity, supraglottic larynx, and hypopharynx observed from 1954 to 1968 was done. The policies of treatment for the neck were not standardized during those years. Three hundred eleven patients who survived 24 months with the primary lesion controlled were divided into two groups: 1) those whose neck was treated by surgery alone; and 2) those who had combined radiation therapy and surgery to the neck, to test the efficacy of the two forms of treatment. For the three sites, the recurrence rate in the necks for the surgically treated group was 14% for stage N1, 26% for N2 and 34% N3. Rates for the group receiving combined treatment were 2%, 11% and 25% respectively. Results of the study also showed that elective irradiation, 5,000 rads in five weeks, will prevent metastasis from occurring in the NO staged neck.
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This study examined swallowing transit times and motility problems in three groups of patients following ablative surgery for oropharyngeal carcinoma and in a control group of 10 normal subjects. A total of 30 patients was studied: 10 after anterior floor of mouth resection, 12 after tonsil/base of tongue resection, and 8 after supraglottic laryngectomy. Videofluoroscopic studies of liquid, thin paste, thick paste, and thick paste plus liquid swallows were completed 1 week post-initiation of oral feeding following surgery. From the videotapes, oral and pharyngeal transit times were measured, and motility disturbances were defined during each stage of the swallow. All three types of patients in this study showed severe problems with swallowing. The anterior floor of mouth resection patients had problems with preparation for the swallow and oral transit. Tonsil/base of tongue resection patients had slowing in the preparation for the swallow and in the oral and pharyngeal stages. After supraglottic laryngectomy, patients showed only slight slowing in oral transit and pharyngeal transit as compared to other types of surgical patients.
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A case of acinic cell carcinoma involving minor salivary gland tissue is reported. This is an exceptional occurrence. The response to radiotherapy is described and it is suggested that this form of treatment should be considered in these cases.
61 squamous cell cancers (27 laryngeal, 12 hypopharyngeal, 14 tonsillary, 8 tongue) with different keratinization and grading and seven lymph node metastases of HPV 16/18 positive carcinomas were analysed for the presence of HPV-DNA by in situ hybridisation. 65.5% of them were found to be positive. Twelve laryngeal carcinomas (44%), five tonsillary tumours (35.7%), eight tumours of the hypopharynx (66.6%) and three tongue carcinomas (37.5%) were shown to contain HPV 16/18 DNA. The detection rates of HPV 6/11 were lower. 44 of the analysed tumours (72.1%) had a grading G2. 29 of these tumours (65.9%) were HPV positive. Only eight of the patients were no heavy smokers or alcoholic drinkers. One of the lymph node metastases was positive for HPV 16/18. The results indicate that HPV may be involved in the pathogenesis of squamous cell carcinomas of head and neck tumours.
A multiple drug regimen was given to 36 patients with advanced carcinomas of the head and neck. In 19 of the 24 patients who were assessable the tumour regressed more than 50%; in one it regressed by 25%; and in four it did not respond at all. Multiple drug chemotherapy should be given much earlier in the course of these cancers, preferably as an adjuvant to surgery or radiotherapy.
Eleven hundred sixty-three patients with squamous cell carcinoma of the upper respiratory and digestive tracts, treated from January 1948 through December 1965, had no evidence of disease five years after the initial treatment and no other manifestation of squamous cell carcinoma within the first five years. After five years, the incidence of disease at the initial location, in the vicinity, or in remote sites was found to be identical in the surgical and irradiation groups. There is a correlation between severe late complications in the irradiated patients and the volume of tissue irradiated.