Unilateral Radiotherapy for the Treatment of Tonsil Cancer

doi:10.1016/j.ijrobp.2011.06.1975

International Journal of Radiation OncologyBiologyPhysics

Volume 83, Issue 1, 1 May 2012, Pages 204-209

https://doi.org/10.1016/j.ijrobp.2011.06.1975 Get rights and content

Purpose

To assess, through a retrospective review, clinical outcomes of patients with squamous cell carcinoma of the tonsil treated at the M. D. Anderson Cancer Center with unilateral radiotherapy techniques that irradiate the involved tonsil region and ipsilateral neck only.

Methods and Materials

Of 901 patients with newly diagnosed squamous cell carcinoma of the tonsil treated with radiotherapy at our institution, we identified 102 that were treated using unilateral radiotherapy techniques. All patients had their primary site of disease restricted to the tonsillar fossa or anterior pillar, with <1 cm involvement of the soft palate. Patients had TX (n = 17 patients), T1 (n = 52), or T2 (n = 33) disease, with Nx (n = 3), N0 (n = 33), N1 (n = 23), N2a (n = 21), or N2b (n = 22) neck disease.

Results

Sixty-one patients (60%) underwent diagnostic tonsillectomy before radiotherapy. Twenty-seven patients (26%) underwent excision of a cervical lymph node or neck dissection before radiotherapy. Median follow-up for surviving patients was 38 months. Locoregional control at the primary site and ipsilateral neck was 100%. Two patients experienced contralateral nodal recurrence (2%). The 5-year overall survival and disease-free survival rates were 95% and 96%, respectively. The 5-year freedom from contralateral nodal recurrence rate was 96%. Nine patients required feeding tubes during therapy. Of the 2 patients with contralateral recurrence, 1 experienced an isolated neck recurrence and was salvaged with contralateral neck dissection only and remains alive and free of disease. The other patient presented with a contralateral base of tongue tumor and involved cervical lymph node, which may have represented a second primary tumor, and died of disease.

Conclusions

Unilateral radiotherapy for patients with TX–T2, N0–N2b primary tonsil carcinoma results in high rates of disease control, with low rates of contralateral nodal failure and a low incidence of acute toxicity requiring gastrostomy.

Introduction

Historically, carcinomas of the tonsillar region have been treated with radiotherapy to the bilateral neck and oropharynx, though some centers routinely irradiated the ipsilateral neck and tumor bed only in patients with well-lateralized tumors as early as 1970 (1). It is well recognized that irradiation of both parotid and submandibular glands results in long-term xerostomia in the majority of patients, with the attendant sequelae of tooth decay, tongue atrophy, dysphagia, and dysguesia (2). Irradiation of the ipsilateral neck and tonsillar region has the ability to spare the contralateral mucosa and functional swallowing tissues and salivary glands. This has been shown to significantly reduce the incidence of severe xerostomia and its associated morbidity (3).

Since 1970 selected patients with TX, T1, or T2 squamous cell carcinoma of the tonsil were irradiated at the University of Texas M. D. Anderson Cancer Center (MDACC) using techniques that irradiated only the ipsilateral tonsillar region and neck. We undertook this retrospective review to assess their clinical outcomes.

Section snippets

Methods and Materials

Between 1970 and 2007, 901 patients at MDACC were irradiated for a squamous cell carcinoma of the tonsillar region. Of these patients, we identified 102 who were treated using techniques that treated only the ipsilateral tonsillar region and neck. Patient characteristics are presented in Table 1. Patients had TX, T1, or T2 tumors confined to the tonsillar fossa or with extension to the anterior tonsillar pillar, with <1 cm of soft palate involvement, or none at all, without tongue base

Results

The median follow-up for the entire series was 39 months, and median follow-up for surviving patients was 38 months (range, 1.5–232). One patient who received only two fractions of radiotherapy elected to discontinue therapy and was lost to follow-up. Five-year overall survival for the entire series was 95%, and 5-year disease-free survival was 96%. Four patients (4%) developed distant metastases.

Locoregional control at the primary site and ipsilateral neck was 100%. Two patients (2%)

Discussion

Our study demonstrates that in carefully selected patients, ipsilateral radiation results in excellent outcomes. The high rates of locoregional control (100%) in our series are likely attributable to the selection of relatively lower-volume primary tumors and involved lymph nodes. Sixty percent of patients underwent diagnostic tonsillectomy before radiotherapy and thus had minimal primary disease at the time of radiation. None of the patients had N3 nodal disease, with N0–N2a disease

Conclusion

Patients with well-lateralized TX–T2 primary tumors of the tonsil, not involving the base of tongue, who are treated with radiotherapy to the ipsilateral tonsillar region and neck exhibit excellent rates of locoregional control and survival, with low rates of contralateral neck recurrence. Our data also suggest that with modern diagnostic staging techniques, ipsilateral radiation seems safe not only for patients with TX, T1, and T2 primary tumors, but for patients staged N0–N2b, provided Level

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Cited by (89)

Low contralateral failure rate with unilateral proton beam radiotherapy for oropharyngeal squamous cell carcinoma: A multi-institutional prospective study from the proton collaborative group
2024, Radiotherapy and Oncology
Unilateral radiation therapy is appropriate for select patients with oropharyngeal squamous cell carcinoma (OPSCC). The use of proton beam therapy (PBT) in the unilateral setting decreases the dose to the contralateral neck and organs at risk. This study aims to evaluate contralateral recurrences in patients who received ipsilateral PBT.
We evaluated the Proton Collaborative Group database for patients treated with PBT for head and neck squamous cell carcinoma between the years 2015–2020 at 12 institutions. Dosimetric analysis was performed in five cases.
Our analysis included 41 patients that received ipsilateral PBT with a mean follow-up of 14.7 months. 37% patients (n = 15) were treated for recurrent disease, and 63% (n = 26) were treated for de novo disease. Oropharyngeal sites included tonsillar fossa (n = 30) and base of tongue (n = 11). The median dose and BED delivered were 69.96 CGE and 84 Gy, respectively. Eight (20%) patients experienced at least one grade 3 dysphagia (n = 4) or esophagitis (n = 4) toxicity. No grade ≥ 4 toxicities were reported. There was one (2.4%) failure in the contralateral neck. The 1-year locoregional control was 88.9% and the freedom from distant metastasis was 95.5% (n = 2). The dosimetric analysis demonstrated similar ipsilateral level II cervical nodal region doses, whereas contralateral doses were higher with photon plans, mean: 15.5 Gy and 0.7 CGE, D5%: 25.1 Gy and 6.6 CGE.
Our series is the first to report outcomes for patients with OPSCC receiving unilateral PBT. The contralateral neck failure rate was excellent and comparable to failure rates with photon irradiation.
Management of unknown primary head and neck cancer with radiation therapy in the era of human papillomavirus (HPV): No longer cutting down the tree to get an apple
2023, Radiotherapy and Oncology
Given the central role that radiation has in the management of head and neck squamous cell carcinoma of unknown primary origin, it is imperative to review how treatment paradigms have been refined and continue to evolve in the modern era.
This study was designed based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement. A literature search of peer-reviewed publications was undertaken to identify works pertaining to the use of radiation for squamous cell carcinoma of unknown primary origin presenting as cervical lymph node metastases. Articles published from January 2002 to January 2023 with full text available on PubMed and restricted to the English language and human subjects were included. The full bibliographies of identified articles were reviewed and irrelevant studies were removed.
While such breakthroughs as intensity-modulated radiotherapy, positron emission tomography, biomarker testing with immune-histochemistry, and minimally invasive surgical techniques such as transoral robotic surgery have fundamentally changed the approach to this disease in recent decades, controversies still exist with respect to the manner in which radiation is delivered. Although the incidence of head and neck unknown primary cancer is relatively low, questions regarding the necessity of comprehensive radiation using the age-old standard method of targeting the bilateral necks and entire pharyngeal axis to encompass all putative sites of mucosal disease persist.
Prospective evidence is lacking, and the available studies have been complicated by such factors as the relatively limited sample sizes, as well as the variability in work-up, treatment, inclusion criteria, and follow-up. Regardless, advances in science and technology have ushered in more precise approaches with a high degree of customization, particularly given the increased proportion of patients presenting with human papillomavirus-related disease.
Unilateral Radiation Therapy for Tonsillar Cancer: Treatment Outcomes in the Era of Human Papillomavirus, Positron-Emission Tomography, and Intensity Modulated Radiation Therapy
2022, International Journal of Radiation Oncology Biology Physics
The goal of this study was to evaluate disease, survival, and toxic effects after unilateral radiation therapy treatment for tonsillar cancer.
A retrospective study was performed of patients treated at our institution within the period from 2000 to 2018. Summary statistics were used to assess the cohort by patient characteristics and treatments delivered. The Kaplan-Meier method was used to determine survival outcomes.
The cohort comprised 403 patients, including 343 (85%) with clinical and/or radiographic evidence of ipsilateral cervical nodal disease and 181 (45%) with multiple involved nodes. Human papillomavirus was detected in 294 (73%) tumors. Median follow-up time was 5.8 years. Disease relapse was infrequent with local recurrence in 9 (2%) patients, neck recurrence in 13 (3%) patients, and recurrence in the unirradiated contralateral neck in 9 (2%) patients. Five- and 10-year overall survival rates were 94% and 89%, respectively. Gastrostomy tubes were needed in 32 (9%) patients, and no patient had a feeding tube 6 months after therapy.
For patients with well-lateralized tonsillar tumors and no clinically evident adenopathy of the contralateral neck, unilateral radiation therapy offers favorable rates of disease outcomes and a relatively low toxicity profile.
Detailed patient-individual reporting of lymph node involvement in oropharyngeal squamous cell carcinoma with an online interface: Patterns of lymphatic progression in 287 oropharyngeal SCC patients
2022, Radiotherapy and Oncology
Citation Excerpt :
The dataset can in the future be pooled with other datasets without loss of information, and the software platform and GUI developed may serve as the basis for collecting large multi-institutional datasets. Lymph node involvement observed in this study is consistent with previous publications regarding prevalence [8,12,13], dependence on upstream levels [17], contralateral spread [11,18–21], and HPV-dependence [14]. This is discussed in more detail in the supplementary materials, appendix A.
Whereas the prevalence of lymph node level (LNL) involvement in head & neck squamous cell carcinomas (HNSCC) has been reported, the details of lymphatic progression patterns are insufficiently quantified. In this study, we investigate how the risk of metastases in each LNL depends on the involvement of upstream LNLs, T-category, HPV status and other risk factors.
We retrospectively analyzed patients with newly diagnosed oropharyngeal squamous cell carcinoma (OPSCC) treated at a single institution, resulting in a dataset of 287 patients. For all patients, involvement of LNLs I-VII was recorded individually based on available diagnostic modalities (PET, MRI, CT, FNA) together with clinicopathological factors. To analyze the dataset, a web-based graphical user interface (GUI) was developed, which allows querying the number of patients with a certain combination of co-involved LNLs and tumor characteristics.
The full dataset and GUI is part of the publication. Selected findings are: Ipsilateral level IV was involved in 27% of patients with level II and III involvement, but only in 2% of patients with level II but not III involvement. Prevalence of involvement of ipsilateral levels II, III, IV, V was 79%, 34%, 7%, 3% for early T-category patients (T1/T2) and 85%, 50%, 17%, 9% for late T-category (T3/T4), quantifying increasing involvement with T-category. Contralateral levels II, III, IV were involved in 41%, 19%, 4% and 12%, 3%, 2% for tumors with and without midline extension, respectively. T-stage dependence of LNL involvement was more pronounced in HPV negative than positive tumors, but overall involvement was similar. Ipsilateral level VII was involved in 14% and 6% of patients with primary tumors in the tonsil and the base of tongue, respectively.
Detailed quantification of LNL involvement in HNSCC depending on involvement of upstream LNLs and clinicopathological factors may allow for further personalization of CTV-N definition in the future.
Early T1-T2 stage p16+ oropharyngeal tumours. Role of upfront transoral robotic surgery in de-escalation treatment strategies. A review of the current literature
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Human papillomavirus is responsible of approximately 70% oropharyngeal tumours and is related with more favourable outcomes. It has led to an increasing interest for de-escalation treatment strategies such as Trans Oral Robotic Surgery (TORS). A literature review was performed searching for the role of TORS as de-escalation modality of treatment in patients with p16 positive oropharyngeal squamous cell carcinoma (OPSCC). Special attention was paid to the potential advantage offered by TORS in reducing adjuvant radiation therapy. Six questions were formulated. 67 studies were selected. Several trials analysing the role of upfront TORS to treat early stage p16+ OPSCC and the possibility of reducing the adjuvant radiotherapy were founded. A lot of studies based on the experience of single centres show promising results. Nevertheless to date no definitive data can be extrapolated. The continued investigation of this line of de-escalation therapy with randomized prospective clinical trials is needed.
A Dosimetric Comparison of Oral Cavity Sparing in the Unilateral Treatment of Early Stage Tonsil Cancer: IMRT, IMPT, and Tongue-Deviating Oral Stents
2020, Advances in Radiation Oncology
Tongue-deviating oral stents (TDOS) are commonly used during unilateral neck radiation therapy to reduce unnecessary dose to nontarget oral structures. Their benefit in the setting of highly conformal treatment techniques, however, is not defined. The goal of this study was to investigate the potential benefit of TDOS use on dosimetric parameters in unilateral intensity modulated radiation therapy (IMRT) and intensity modulated proton therapy (IMPT).
A total of 16 patients with T1-2 tonsil cancer treated at a single institution were selected, of which 8 were simulated/treated with a TDOS and 8 without a TDOS. All received definitive unilateral IMRT to a dose of 66 Gy in 30 fx. IMPT plans were generated for each patient for study purposes and optimized according to standard institutional practice.
For IMRT plans, the presence of a TDOS (vs without) was associated with a significantly lower oral mucosa mean dose (31.4 vs 35.3 Gy; P = .020) and V30 (42.7% vs 57.1%; P = .025). For IMPT plans, the presence of TDOS (vs without) was not associated with any improvement in oral mucosa mean dose (18.3 vs 19.9 Gy; P = .274) or V30 (25.0% vs 26.2%; P = .655). IMPT plans without TDOS compared with IMRT plans with TDOS demonstrated reduced oral mucosa mean dose (P < .001) and V30 (P < .001).
The use of a TDOS for the unilateral treatment of well-lateralized tonsil cancers was associated with oral mucosa sparing for IMRT, but not for IMPT. Moreover, mucosa sparing was improved for IMPT plans without a TDOS compared to IMRT plans with a TDOS.

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Clinical InvestigationUnilateral Radiotherapy for the Treatment of Tonsil Cancer

Purpose

Methods and Materials

Results

Conclusions

Introduction

Section snippets

Methods and Materials

Results

Discussion

Conclusion

Int J Radiat Oncol Biol Phys

Radiother Oncol

Radiother Oncol

Int J Radiat Oncol Biol Phys

Radiother Oncol

Eur J Cancer

Int J Radiat Oncol Biol Phys

Eur J Cancer

Clinical Investigation
Unilateral Radiotherapy for the Treatment of Tonsil Cancer