Clinical Investigations
Carcinoma of the tonsillar fossa: prognostic factors and long-term therapy outcome

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Abstract

Purpose: To identify prognostic parameters and evaluate the therapeutic outcomes for patients with carcinoma of the tonsillar fossa treated with three treatment modalities.

Methods and Materials: The results of therapy are reported in 384 patients with histologically proven epidermoid carcinoma of the tonsillar fossa; 154 were treated with irradiation alone (55–70 Gy), 144 with preoperative radiation therapy (20–40 Gy), and 86 with postoperative irradiation (50–60 Gy). The operation in all but four patients in the last two groups consisted of an en bloc radical tonsillectomy with ipsilateral lymph node dissection.

Results: Treatment modality and total irradiation doses had no impact on survival. Actuarial 10-year disease-free survival rates were 65% for patients with T1 tumors, 60% for T2, 60% for T3, and 30% for T4 disease. Patients with no cervical lymphadenopathy or with a small metastatic lymph node (N1) had better disease-free survival (60% and 70%, respectively) at 5 years than those with large or fixed lymph nodes (30%). Primary tumor recurrence (local, marginal) rates in the T1, T2, and T3 groups were 20–25% in patients treated with irradiation and surgery and 31% for those treated with irradiation alone (difference not statistically significant). In patients with T4 disease treated with surgery and postoperative irradiation, the local failure rate was 32% compared with 86% with low-dose preoperative irradiation and 47% with irradiation alone (p = 0.03). The overall recurrence rates in the neck were 10% for N0 patients, 25% for N1 and N2, and 35–40% for patients with N3 cervical lymph nodes, without significant differences among the various treatment groups. The incidence of contralateral neck recurrences was 8% with the various treatment modalities. On multivariate analysis the only significant factors for local tumor control and disease-free survival were T and N stage (p = 0.04–0.001). Fatal complications were noted in 7 of 144 (5%) patients treated with preoperative irradiation and surgery, 2 of 86 (2%) of those receiving postoperative irradiation, and 2 of 154 (1.3%) patients treated with radiation therapy alone. Other moderate or severe nonfatal sequelae were noted in 30% of the patients treated with preoperative irradiation and surgery, in 53% treated with postoperative irradiation, and in 19% receiving radiation therapy alone.

Conclusion: Primary tumor and neck node stage are the only significant prognostic factors influencing locoregional tumor control and disease-free survival. Treatment modality had no significant impact on outcome. Radiation therapy remains the treatment of choice for patients with stage T1–T2 carcinoma of the tonsillar fossa. In patients with T3–T4 tumors and good general condition, combination surgery and postoperative irradiation offers better tumor control than single-modality and preoperative irradiation procedures, but with greater morbidity.

Introduction

Definitive radiation therapy is an effective method of treatment for early-stage tonsillar fossa carcinoma. Extensive lesions that invade the base of the tongue or metastatic cervical lymphadenopathy have less satisfactory tumor control and survival. A combination of preoperative or postoperative irradiation and surgery has been advocated in more advanced disease.

This analysis updates previous reports on the treatment of tonsillar carcinoma at our institution (1), and we analyze prognostic factors, anatomic sites of failure, survival, and sequelae of therapy for various treatment modalities.

Section snippets

Methods and materials

Three hundred eighty-four patients with histologically confirmed epidermoid carcinoma (keratinizing and nonkeratinizing) of the tonsillar fossa were treated with definitive intent at the Radiation Oncology Center, Mallinckrodt Institute of Radiology, Barnes-Jewish Hospital, between January 1959 and December 1991. All radiation therapy and hospital records and pathology reports were reviewed. A large number of the pathology slides were reviewed as part of a previous study. All patients were

Tumor spread

Only 16 patients (5.4%) had tumor localized to the tonsillar fossa at diagnosis. Tumor extension to adjacent sites, usually multiple, was frequently noted. Overall, tumor spread to the soft palate/anterior tonsillar pillars was recorded in 65% of patients, to the base of the tongue and posterior tonsillar pillar in 44%, to the pharyngeal wall in 31%, and to the vallecula or oral cavity in 10–15%.

Two hundred thirty-two (60%) patients had metastases to the ipsilateral cervical lymph nodes (48% to

Discussion

As in our review, Bataini et al.(4), in a multivariate analysis of 465 patients with tonsillar region cancer treated with irradiation alone (65–68 Gy in 6–7 weeks), noted that the stage and site of the primary tumor were the only significant prognostic factors influencing tumor control. Contrary to our experience, the length of overall treatment time was the only technical variable associated with local tumor control.

Lee et al.(5) updated a report by Mendenhall et al.(6) of 243 patients with

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