This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ozsahin, M. Articles by Stringer, S. P. Search for Related Content PubMed PubMed Citation Articles by Ozsahin, M. Articles by Stringer, S. P. Social Bookmarking                            What's this?

Radiation Therapy or Surgery for Base-of-Tongue Tumors?

Centre Hospitalier Universitaire Vaudois Lausanne, Switzerland

To the Editor:I read with interest the article by Mendenhall et al¹ in the January 2000 issue of the Journal of Clinical Oncology. In this retrospective nonrandomized study, the authors analyzed their single-center experience of radiation therapy alone in a series of 217 patients with previously untreated squamous cell carcinoma of the base of tongue treated between 1964 and 1996. They concluded that local-regional control rates and survival rates after radiation therapy were comparable to those after surgery, and the morbidity associated with radiation therapy was less.

I do not agree with their conclusion concerning morbidity in patients with T1 and T2, N0 or N1 tumors. In their article, Mendenhall et al¹ did not mention any data concerning xerostomia, a major late complication observed in almost all patients with base-of-tongue cancer treated with external radiation therapy with or without concomitant chemotherapy. Xerostomia is not observed after surgical treatment when no postoperative radiation therapy is indicated. The major complication after surgical treatment is the risk of permanent gastrostomy, which is rarely observed in smaller tumors treated with the transpharyngeal approach.² Xerostomia is not a fatal complication, but the quality of life with a fully preserved salivary function is obviously better than being without.

REFERENCES

1. Mendenhall WM, Stringer SP, Amdur RJ, et al: Is radiation therapy a preferred alternative to surgery for squamous cell carcinoma of the base of tongue? J Clin Oncol 18: 35-42, 2000[Abstract/Free Full Text]

2. Nasri S, Oh Y, Calcaterra TC: Transpharyngeal approach to base of tongue tumors: A comparative study. Laryngoscope 106: 945-950, 1996[Medline]

Response

University of Florida College of Medicine Gainesville, FL

In Reply:We appreciate Dr Ozsahin’s comments and agree that xerostomia adversely affects quality of life. Essentially, all of our patients were treated with parallel-opposed fields for some or all of their irradiation and had at least some degree of xerostomia.¹ We disagree with Ozsahin’s characterization of xerostomia as a major complication. The great majority of patients in our series speak normally and eat a regular diet.

There are several additional issues that should be addressed. The first is the proportion of patients who have tumors that are suitable for treatment with surgery alone. Eighteen (8%) of our unselected series of 217 patients had clinical stage T1N0 and T2N0 cancers.¹ A significant subset of these patients would have subclinical disease in the neck nodes and would likely require adjuvant irradiation. Eleven (85%) of 13 patients with T1 and T2 cancers operated on at the University of Pittsburgh received irradiation.² Twenty-four (77%) of 31 patients operated on at the University of California at Los Angeles had T1 and T2 tumors, and 24 of 31 patients received adjuvant irradiation.³ At most centers, the subset of patients who would be suitable for treatment with surgery alone is relatively small. Patients who undergo adjuvant radiation therapy receive doses greater than 45 Gy (usually 60 to 65 Gy at 1.8 to 2.0 Gy per fraction) and have xerostomia that is as pronounced as one would anticipate after radiation therapy alone.

A second issue is whether the likelihood of major complications is lower after surgery for patients with T1 and T2 cancers, compared with radiation therapy. Three (23%) of 13 patients reported by Weber et al² experienced complications that consisted of fistulae (two patients) and pneumonia (one patient). Both patients with fistulae healed with conservation therapy. No patient was feeding-tube dependent. In contrast, nine (38%) of 24 patients with T1 and T2 cancers reported by Nasri et al³ experienced complications that included swallowing disorders necessitating a permanent gastrostomy (three patients) or nasogastric tube feeding (one patient), fistulae (four patients), infected miniplate (one patient), and neck web (one patient). The incidence of severe late complications in our unselected series of 217 patients was 4%.¹ Thus the likelihood of major complications after surgery is higher than that observed after radiation therapy alone. Additionally, the vast majority of patients who undergo surgery also receive adjuvant irradiation and thus experience xerostomia in addition to their other problems.

A third question is whether quality of life after surgery is better than that observed after radiation therapy. Data pertaining to quality of life after treatment for base-of-tongue cancer are limited. Harrison et al⁴ reported 30 patients who underwent radiation therapy and compared them with 10 patients treated surgically. They concluded that quality of life was better after radiation therapy for patients with early-stage disease as well as for those with advanced lesions.

Because our goal is to maximize tumor cure and quality of life, it has been, and remains, our practice to treat essentially all patients with squamous cell carcinoma of the base of tongue with primary radiation therapy. New technologies, such as intensity-modulated radiation therapy, allow treatment of the primary lesion and both sides of the neck while limiting the dose to the parotid glands to reduce the severity of xerostomia. However, these techniques should be applied cautiously, because reduction of the treatment volume may result in an increased likelihood of patients with marginal recurrences, for whom salvage treatment will most likely be unsuccessful.

REFERENCES

1. Mendenhall WM, Stringer SP, Amdur RJ, et al: Is radiation therapy a preferred alternative to surgery for squamous cell carcinoma of the base of tongue? J Clin Oncol 18: 35-42, 2000

2. Weber PC, Johnson JT, Myers EN: The suprahyoid approach for squamous cell carcinoma of the base of the tongue. Laryngoscope 102: 637-640, 1992[Medline]

3. Nasri S, Oh Y, Calcaterra TC: Transpharyngeal approach to base of tongue tumors: A comparative study. Laryngoscope 106: 945-950, 1996

4. Harrison LB, Zelefsky MJ, Armstrong JG, et al: Performance status after treatment for squamous cell cancer of the base of tongue: A comparison of primary radiation therapy versus primary surgery. Int J Radiat Oncol Biol Phys 30: 953-957, 1994[Medline]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ozsahin, M. Articles by Stringer, S. P. Search for Related Content PubMed PubMed Citation Articles by Ozsahin, M. Articles by Stringer, S. P. Social Bookmarking                            What's this?