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The purpose of this study is to report our institutional experience using radiotherapy in the treatment of ameloblastoma and ameloblastic carcinoma. Three patients with ameloblastoma and 3 patients with ameloblastic carcinoma were treated with radiotherapy alone (2 patients) or surgery and postoperative radiotherapy (4 patients) at the University of Florida between 1973 and 2007. Follow-up ranged from 4.0 to 13.1 years with a median of 7.8 years. Radiotherapy complications were scored using the Common Terminology Criteria for Adverse Events, version 4.0. Local control was achieved in 4 of the 6 patients. One patient treated with RT alone for an unresectable ameloblastoma developed a local recurrence and metastases in both the cervical lymph nodes and lungs, but had excellent response to dual BRAF/MEK inhibition with dabrafenib and trametinib. Another patient treated with surgery and postoperative radiotherapy for an ameloblastic carcinoma recurred locally without metastasis, but was not salvaged. No significant treatment-related complications were observed. For patients with local recurrence or inadequate margins after surgery, adjuvant radiotherapy provides the potential for disease control. In the setting of metastatic disease, targeted therapies may provide an additional opportunity for salvage.

Summary Objectives To report the results of a standardized program using positron emission tomography (PET)–computed tomography (CT) approximately 12 weeks after primary radiotherapy to determine the need for a planned neck dissection in patients with radiographic N2 squamous cell carcinoma (SCC) of the oropharynx. Methods Fifty consecutive patients with T1–4 and hemineck radiographic stage N2A–B SCC of the oropharynx for whom the only indication for planned neck dissection was a positive PET–CT performed ∼12 weeks after completing primary treatment with radiotherapy. Results Results of PET–CT to identify residual neck disease were as follows: sensitivity and positive predictive value, 0%; specificity, 89%; negative predictive value, 91%; potential neck recurrence from using this 12-week PET–CT program, 2%. The time between negative PET–CT and detection of neck recurrence was 0.5, 0.6, 1.2, and 2.0 years. The rate of successful (>1 year) salvage of neck recurrence was 25% (1/4). Conclusions PET–CT approximately 12 weeks after radiotherapy for oropharyngeal cancer is an excellent way to identify patients who do not need neck dissection. Approximately half of neck recurrences present over 1 year after negative PET–CT and the chance of successful salvage is low.

The purpose of this study is to update our institution's experience with ipsilateral radiation therapy (RT) for squamous cell carcinoma of the tonsillar area. Outcome study of 76 patients treated between 1984 and 2012 with ipsilateral RT for squamous cell carcinoma of the tonsil. Patients had either cT1 (n = 41, 54 %) or cT2 (n = 35, 46 %) primaries and cN0 (n = 27, 36 %), cN1 (n = 15, 20 %), cN2a (n = 8, 11 %), or cN2b (n = 26, 34 %) nodal disease. Of these, 32 (42 %) patients underwent a planned neck dissection and 21 (28 %) patients received concomitant chemotherapy. Median follow-up for all patients was 7.1 years (range 0.1-27.2) and 7.8 years (range 2.1-27.2 years) for living patients. The 2- and 5-year control and survival rates were as follows: local control, 98.6 and 96.9 %; local-regional control 95.8 and 92.6 %; cause-specific survival 95.9 and 93.1 %; and overall survival, 92.1 and 83.8 %. One patient failed in the contralateral, non-radiated neck 3 years after primary treatment. Univariate analysis revealed that overall survival was significantly influenced by whether the patient had a primary tumor in the anterior tonsillar pillar versus the tonsillar fossa with the latter performing better. The incidence of severe late complications was 16 %. Ipsilateral RT for patients with squamous cell carcinoma of the anterior tonsillar pillar or tonsillar fossa with no base of tongue or soft palate extension is an efficacious treatment that provides excellent control rates with a relatively low incidence of late complications.

Background Many guidelines recommend random directed biopsies of the nasopharynx, contralateral tonsil, and hypopharynx to evaluate an unknown primary squamous cell carcinoma of the head and neck. There are no published data documenting the need for these recommendations. The purpose of our study was to report the rate of positive blind biopsies in this setting. Methods We recorded the rate of positive random directed biopsies performed as part of the workup for 156 patients treated with radiotherapy between 1985 and 2014 for an unknown primary squamous cell carcinoma presenting with the main location of adenopathy in nodal stations 2, 3, 4, or 5. Results Rate of positive result by subsite: nasopharynx and pyriform sinus = 0%; tonsillectomy: ipsilateral = 39%, bilateral = 6%; and base of tongue = 18%. Conclusion With modern imaging, random directed biopsies of the nasopharynx and hypopharynx are unnecessary in the workup of unknown primary squamous cell carcinoma of the head and neck. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

The objective of this study is to report the long-term outcomes of primary radiotherapy (RT) for patients with T1-T2 squamous cell carcinomas (SCC) of the pyriform sinus. Between November 1964 and March 2008, 135 patients with T1-T2 pyriform sinus SCC were treated with primary RT at the University of Florida. Adjuvant chemotherapy was employed in 21 patients (16 %) and 62 patients (46 %) underwent a planned neck dissection. Median follow-up was 3.5 years (range 0.2-24.7 years); median follow-up on living patients was 8.3 years (range 3.8-24.0 years). The 5-year outcomes were as follows: local control, 85 %; regional control, 81 %; local-regional control, 71 %; distant metastasis-free survival, 76 %; cause-specific survival, 62 %; and overall survival, 38 %. The 5-year local control rate was 88 % for T1 cancers and 84 % for those with T2 SCCs (p = 0.5429). Sixteen patients (12 %) experienced severe late complications. Primary RT results in a high probability of cure with a relatively modest risk of severe late complications for patients with T1-T2 SCCs of the pyriform sinus.

BACKGROUND Paragangliomas of the head and neck are rare, slow-growing, generally benign tumors of neuroendocrine cells associated with the peripheral nervous system that commonly involve the carotid body, jugular bulb, vagal ganglia, and temporal bone. Treatment options include surgery, radiotherapy (RT), stereotactic radiosurgery (SRS), and observation. This article briefly reviews our 45-year institutional experience treating this neoplasm with RT. METHODS From January 1968 through March 2011, 131 patients with 156 benign paragangliomas of the temporal bone, carotid body, jugular bulb, or glomus vagale were treated with RT at a median dose of 45 Gy in 25 fractions. The mean and median follow-up times were 11.5 years and 8.7 years, respectively. RESULTS Five tumors (3.2%) recurred locally after RT, all within 10 years of treatment. The overall local control rates at 5 and 10 years were 99% and 96%, respectively. The cause-specific survival rates at 5 and 10 years were 98% and 97%, respectively. The distant-metastasis free survival rates at 5 and 10 years were 99% and 99%, respectively. The overall survival rates at 5 and 10 years were 91% and 72%, respectively. There were no severe complications. CONCLUSION RT for benign head and neck paragangliomas is a safe and efficacious treatment associated with minimal morbidity. Surgery is reserved for patients in good health whose risk of associated morbidity is low. SRS may be suitable for patients with skull base tumors

Purpose To evaluate the long-term effectiveness of radiotherapy (RT) in the treatment of sinonasal undifferentiated carcinoma (SNUC). Materials and methods The medical records of 23 patients treated with definitive or postoperative RT between 1992 and 2010 at the University of Florida were retrospectively reviewed. Fifteen patients (65%) received primary surgery and postoperative RT. Radiation doses ranged from 59.0 to 74.8 Gy (median, 70.2 Gy). The median follow-up time for all patients was 3.0 years (range, 0.9–19.9), and for living patients was 7.7 years (range, 2.5–19.9). Results The actuarial 5-year survival outcomes were as follows: progression-free survival, 42%; cause-specific survival, 43%; and overall survival, 32%. Actuarial 5-year disease control rates were as follows: local control (infield or marginal), 74%; local-regional control (excluding leptomeningeal spread), 58%, regional control 78%, freedom from leptomeningeal recurrence, 72%, and distant metastasis-free survival, 73%. Five of the 8 (62.5%) patients treated with definitive RT died with disease, and 6 of the 15 patients (40%) treated with primary surgery and postoperative RT died with disease. Three patients (13%) experienced severe complications including unilateral eye removal, osteoradionecrosis of the maxilla requiring hyperbaric oxygen and surgery, and brain necrosis. One patient died due to an infected bone graft and brain abscess. Conclusions A multimodal approach is best when treating SNUC patients. The prognosis for patients treated with definitive RT ± chemotherapy is less promising than for those who receive surgery and postoperative RT ± chemotherapy. Severe complications occur in about 17% of patients due to the high dose of RT alone or combined with surgery required for acceptable disease control.

Objectives The aim of this study was to evaluate the long-term effectiveness and complications of radiotherapy (RT) in the treatment of patients with mucosal melanomas of the head and neck. Materials and methods The medical records of 21 patients treated with definitive or postoperative (RT) between 1974 and 2011 at the University of Florida Department of Radiation Oncology in Gainesville, FL, and the University of Florida Proton Therapy Institute in Jacksonville, FL, were retrospectively reviewed under an Institutional Review Board-approved protocol. Primary sites included nasal cavity, oropharynx, and paranasal sinuses. Sixteen patients (76%) received surgery and postoperative RT and 5 patients (24%) received RT alone. Seventeen patients received photon RT alone, whereas 4 patients received combined photon-based and proton-based RT. Median follow-up for all patients was 1.05 years (range, 0.36 to 12.97 y); median follow-up for survivors was 2.2 years (range 0.9 to 13.0 y). Results The 5-year outcomes were: local control, 79%; regional control, 85%; local-regional control, 65%; distant metastasis-free survival, 20%; cause-specific survival, 22%; and overall survival, 22%. Three patients (14%) experienced severe complications including bilateral blindness and skin necrosis. Conclusions Definitive or postoperative RT for mucosal melanoma of the head and neck yields fairly good local-regional control of disease. The prognosis for patients treated with definitive RT is less promising than for those who receive surgery and postoperative RT.

Polymorphous low-grade adenocarcinomas are rare tumors that can arise from many areas of the head and neck. We reviewed the pertinent literature pertaining to the incidence, diagnostic evaluation, and treatment strategies for this malignancy. Histopathologic diagnosis always involves careful analysis of tissue and especially characteristic immunohistochemical staining patterns. Common differential diagnoses include adenoid cystic carcinoma, pleomorphic adenoma, and other benign or malignant salivary gland neoplasms. Although the ideal treatment is debated, surgical resection at times combined with adjuvant radiation therapy is preferred by many physicians. Further research will be needed to delineate optimal management.

Purpose We retrospectively reviewed long-term outcomes of patients with inverted papilloma (IP) treated with radiation therapy at our institution. Methods and Materials From 1969 to 2008, 13 patients with advanced or recurrent IP (n = 12) or cylindrical papilloma (n = 1) were treated with radiation therapy. The median age at radiation therapy was 53 years old (range, 32-84). Nine patients received postoperative radiation therapy, 3 received definitive radiation therapy, and 1 received preoperative radiation therapy. Of the 10 patients treated with combined-modality treatment, 1 underwent craniofacial resection and 9 underwent open resection. Eight patients, 4 patients, and 1 patient received once-daily fractionation, twice-daily fractionation, and planned split-course radiation therapy, respectively, to a median dose of 65 Gy (range, 45.3-70.4 Gy). Results The median follow-up was 16.2 years. Actuarial 15-year overall and cause-specific survival rates were 62% and 82%. Fifteen-year actuarial local and regional control rates were 45% and 73%. Fifteen-year local-regional control rates for IP alone and IP associated with squamous cell carcinoma (IP-SCC) at the time of treatment were 80% and 16%. Fifteen-year overall survival rates for IP alone and IP-SCC were 40% and 50%. The only severe treatment complication was a grade 3 central nervous system radionecrosis. The most common grade 1-2 toxicities were mucositis (61%), pain (46%), conjunctivitis (31%), xerostomia (31%), epiphora (31%), and anorexia (31%). Conclusions While surgery is the primary treatment for IP, radiation therapy should be considered in patients with SCC, multiply recurrent IPs, and incompletely resectable IP. Radiation therapy is associated with a relatively low risk of severe complications. Despite more aggressive treatment, local failure remains a considerable challenge.

Purpose The aim of this study was to update our experience in treating pleomorphic adenoma with radiotherapy (RT). Materials and Methods This is a retrospective analysis of 25 patients treated with RT alone (2 patients) or combined with surgery (23 patients), with follow-up ranging from 1.8 to 34.9 years (median, 10.5 years). Results Local control was achieved in 13 (75%) of 16 patients with subclinical disease and 5 (56%) of 9 patients with gross disease. Overall local control was achieved in 18 (72%) of 25 patients. The 5-, 10-, and 15-year overall local control rates were 76 %, 76%, and 68%, respectively. Ten patients died of the following causes: recurrent disease, 2; malignant transformation, 2; and intercurrent disease, 6. At last follow-up, 14 patients were alive without evidence of disease, and 1 patient was alive with disease. Dental carries and transient facial nerve deficits were the most common complications. No patients developed severe complications subsequent to RT. Conclusions In patients at high risk for developing recurrent pleomorphic adenoma after surgery, RT is effective in controlling subclinical disease.

Purpose This study reports the outcomes of adults with soft tissue sarcoma (STS) of the head and neck following resection and postoperative radiotherapy (RT), and provides a framework for explaining the issues that radiation oncologists must understand to manage patients with this diverse group of tumors. Methods and Materials Twenty-four patients met the following inclusion criteria of this study: age ≥19 years, head or neck primary site, STS, with the exception of rhabdomyosarcoma, Ewing, or angiosarcoma variants, and curative-attempt treatment with gross total tumor resection followed by RT. Results All patients underwent gross total tumor resection followed by adjuvant RT at our institution during the 28-year period between June 1, 1981, and December 31, 2009. This is a mature study with a median follow-up of 11 years (range, 0.6-27 years). No patient was lost to follow-up. All recurrences were at the primary site. No patient developed an isolated regional or distant recurrence. No patient developed synchronous nodal or distant recurrences at the time of local recurrence. Half of the recurrences presented within 1 year of completing RT, but there were 2 cases where we did not detect recurrence until years 6 and 8 after RT. No recurrence was successfully salvaged. The actuarial rate of local control and relapse-free survival was 83% (95% CI [confidence interval], 63%-94%) at 5 years and 73% (95% CI, 51%-87%) at 10 years. The incidence of moderate to severe treatment complications was 4%. Conclusions Our series documents that gross total resection followed by RT cures most patients (75%) with the most common types of STS of the head and neck. All recurrences were local, meaning near the primary site in tissue that received the full RT prescription dose. For this reason, modifying the approach to treatment of the primary tumor site is the only strategy that will meaningfully improve outcomes for this group of patients.

Purpose To report our experience using radiotherapy alone or combined with surgery to treat adenoid cystic carcinoma of the head and neck. Materials and methods Radiotherapy alone or combined with surgery was used to treat 120 previously untreated patients with adenoid cystic carcinoma (ACC) of the head and neck from August 1966 to March 2008. Patients were treated with curative intent. American Joint Committee on Cancer stage distribution was,T0 (n = 1), T1 (n = 26), T2 (n = 25), T3 (n = 14), T4 (n = 54), N0 (n = 113), N1 (n = 2), N2a (n = 1), N2b (n = 2), and N2c (n = 2). Treatment included surgery with postoperative radiotherapy (n = 71), radiotherapy alone (n = 46), and preoperative radiotherapy and surgery (n = 3). Incidental and clinical perineural invasion was found in 41 (34%) and 35 (29%) patients, respectively. Median follow-up was 8.6 and 11.6 years overall and among living patients, respectively. Results The10-year overall, cause-specific, and distant metastasis-free survival rates, respectively, were as follows: radiotherapy alone, 37%, 46%, and 76%; surgery and radiotherapy, 57%, 71%, and 62%; and overall, 50%. The10-year local control rates were as follows: radiotherapy alone, 36%; surgery and radiotherapy, 84%; and overall, 65%. The 10-year neck control rates were as follows: elective nodal irradiation (ENI), 98%; no ENI, 89%; and overall, 95%. Conclusions Surgery and adjuvant radiotherapy offer the best chance for cure for patients with resectable adenoid cystic carcinomas of the head and neck. Some patients with advanced, incompletely resectable disease can be cured with radiotherapy alone. ENI should be considered for primary sites located in lymphatic-rich regions.

OBJECTIVES Maxillary sinus squamous cell carcinoma is commonly diagnosed at an advanced stage and treated using radiotherapy, with or without surgical resection. METHODS Fifty-four patients with maxillary sinus squamous cell carcinoma were treated from 1969 to 2006, using radiotherapy, with or without surgical resection. Fifty-two (96%) patients had American Joint Committee on Cancer stages III to IV disease, and 45 (83%) patients had N0 neck disease. RESULTS Five-year local control (LC) rates by T-stage were 63% for T2/T3; and 43% for T4. Five-year LC rates for patients treated with radiotherapy preoperatively, postoperatively, and definitively were 61%, 65%, and 37%, respectively. Initially, overall 5-year LC, neck control, and local-regional control were 49%, 82%, and 45%, respectively. The ultimate 5-year LC, neck control, and local regional control after salvage of failures were 51%, 87%, and 50%, respectively. The overall 5-year cause-specific survival was 41%. Thirty-three percent of patients had a severe complication. CONCLUSIONS Radiotherapy, with or without surgical resection, remains an effective tool in treating patients with this disease. LC, cause-specific survival, and complication rates need significant improvement. Treatment details and recommendations are discussed herein.

Objectives/Hypothesis: To analyze the outcomes of patients treated for minor salivary gland carcinoma with radiotherapy (RT), either alone or combined with surgery. Study Design: Retrospective review. Methods: Between September 1966 and December 2006, 140 patients were treated with curative intent at our institution for previously untreated minor salivary gland carcinomas (RT alone, 64 patients; combined RT and surgery, 76 patients). Median follow-up for all patients was 5.5 years. Results: The 10-year local control rate was 66%, and multivariate analysis revealed that treatment group (P = .0004) and T stage (P = .0001) significantly influenced this endpoint. Patients treated with RT alone had a lower local control rate than patients treated with RT and surgery. The 10-year local-regional control rate was 61%, and multivariate analysis revealed that treatment group (P = .0174), overall stage (P = .0004), and N stage (P = .0492) significantly influenced this endpoint. The 10-year distant metastasis-free survival rate was 67%, and multivariate analysis revealed that overall stage (P = .0016) significantly influenced this endpoint. The 10-year cause-specific survival rate was 56%, and multivariate analysis revealed that overall stage (P < .0001) significantly influenced this endpoint. The 10-year overall survival rate was 45%, and multivariate analysis revealed that overall stage (P = .0047), N stage (P = .0173), and nerve invasion (P = .0409) significantly influenced this endpoint. Conclusions: Most patients with minor salivary gland carcinoma were cured with RT alone or combined with surgery. Treatment group, T stage, and overall stage significantly influenced the probability of cure. Patients treated with combined surgery and RT had a better prognosis, perhaps due in part to selection bias. Laryngoscope, 2009

Objectives/Hypothesis: To determine the outcomes after radiotherapy (RT) alone or combined with surgery at the University of Florida for patients with carcinomas of the nasal cavity and paranasal sinuses. Methods: Between November 1964 and June 2005, 109 patients were treated with curative intent. Patients with maxillary sinus carcinomas were excluded. Fifty-six patients were treated with definitive RT, and 53 patients received surgery and preoperative (eight patients) or postoperative (45 patients) RT. Median follow-up was 4.3 years (range, 0.2–35.9 years). Median follow-up on living patients was 9.4 years (range, 2.0–35.9 years). Results: The 5-year local control rates were: T1-T3, 82%; T4, 50%; and overall, 63%. Local control at 5 years was 43% after definitive RT versus 84% after surgery and adjuvant RT (P < .0001). Multivariate analysis of local control revealed that both overall stage and treatment group (definitive RT versus surgery and adjuvant RT) significantly impacted this endpoint. Cause-specific survival rates were: stages I to III, 81%; stage IV, 54%; and overall, 62%. Multivariate analysis revealed that T-stage, N-stage, and treatment group significantly influenced this endpoint. Thirty-one (20%) of 109 patients sustained severe complications; 17 of 56 patients (16%) after definitive RT and 14 of 53 patients (25%) after surgery and adjuvant RT. Conclusions: The probability of local control and cause-specific survival is better after surgery and RT compared with definitive RT. There is a modest increase in the risk of complications after surgery and RT. Thus, the preferred treatment is surgery combined with preoperative or postoperative RT. Laryngoscope, 2009

Introduction: Metastatic spread to parotid-area lymph nodes (PALN) occurs in 1% to 3% of patients with cutaneous squamous cell carcinoma of the head and neck. Presented herein is the University of Florida experience using radiation therapy (RT) to treat patients with PALN metastases from a skin primary. Methods and Materials: From November 1969 to February 2005, 121 parotids in 117 patients received irradiation for nonmelanotic skin carcinoma metastatic to PALN. Patients were staged by the O'Brien staging system. Of the 121 parotids receiving RT, 17 (14%) were treated preoperatively, 87 (72%) postoperatively, and 17 with RT alone. Results: Five-year actuarial probabilities of local (parotid) control, local-regional control, disease-free survival and overall survival were 78%, 74%, 70%, and 54%, respectively. When patients were separated by O'Brien P-stage, statistically significant differences were seen among the groups for local (parotid) control, local-regional control, and disease-free survival. A statistically significant decrease in local control was seen in patients treated with positive surgical margins (92% vs. 76%) and in local-regional control for patients treated with preoperative RT or RT alone when compared with postoperative RT (59% and 47% vs. 83%, respectively). The 5-year actuarial probability of freedom from distant metastases was 92%. Three (2.6%) patients suffered severe complications. Conclusions: PALN metastases from a cutaneous head and neck primary site are best treated with surgery and postoperative RT. Our data support the hypothesis that the O'Brien staging system is superior to the American Joint Committee on Cancer system for the staging of cutaneous metastases to PALN. Positive surgical margins confer a worse prognosis in terms of local-regional control and disease-free survival. Patients treated with preoperative RT seem to have a worse prognosis than those treated postoperatively, likely a result of patient selection and the surgeon's inability to accurately assess viable tumor extent after preoperative RT. Severe complications are uncommon after surgery and RT for PALN metastases.

Purpose To report the long-term results after definitive radiotherapy (RT) for T1-T2 pyriform sinus squamous cell carcinoma. Patients and Methods The data from 123 patients with T1-T2 pyriform sinus squamous cell carcinoma treated with RT with or without neck dissection between November 1964 and June 2003 were analyzed. The median follow-up for all patients was 3.2 years, and the median follow-up for living patients was 10.7 years. Results The 5-year local control, locoregional control, freedom from distant metastasis, cause-specific survival, and overall survival rate was 85%, 70%, 75%, 61%, and 35%, respectively. The ultimate local control rate, including successful salvage of RT failure, for T1 and T2 cancer patients was 96% and 94%, respectively. The overall local control rate with a functional larynx was 83%. Pretreatment computed tomography tumor volume data were available for 55 patients. The median computed tomography tumor volume was 4.2 cm3 (range, 0–22.4). Local control was worse for patients with a tumor volume >6.5 cm3 compared with those with a smaller tumor volume. Of the 123 patients, 16% developed moderate to severe acute (2%), late (9%), or postoperative (5%) complications. Conclusions Local control with larynx preservation after definitive RT for T1-T2 pyriform sinus squamous cell carcinoma likely results in local control and survival similar to that after total laryngectomy or larynx-conserving surgery. Two-thirds of our living patients retained a functional larynx.

Background. Our aim was to report the outcomes of treatment for sinonasal undifferentiated carcinoma (SNUC). Methods. Between September 1992 and October 2005, 15 patients were treated with curative intent with surgery (n = 1), surgery and adjuvant radiotherapy (n = 9), and definitive radiotherapy (RT) (n = 5). Follow-up ranged from 11 to 151 months (median, 30); follow-up on living patients ranged from 12 to 151 months (median, 22). No patient was lost to follow-up. Results. Seven patients (47%) developed a recurrence from 3 to 50 months (median, 9) after treatment. The 3-year outcomes were: local control, 78%; locoregional control, 65%; distant metastasis–free survival, 82%; cause-specific survival, 77%, and survival, 67%. The local control rates versus treatment modality were: surgery, 0/1 (0%); surgery and postoperative RT, 7/7 (100%); preoperative RT and surgery, 2/2 (100%); and definitive RT, 2/5 (40%). One patient (7%) treated with surgery and postoperative RT sustained a fatal complication. Conclusions. Combined surgery and adjuvant RT likely offer the best chance of cure compared with either modality alone. The impact of adjuvant chemotherapy is unclear. © 2008 Wiley Periodicals, Inc. Head Neck, 2008

The purpose of this chapter is to discuss the efficacy of adjuvant radiotherapy (RT) in the treatment of melanoma. The risk of local-regional recurrence after surgery alone for locally advanced melanoma is relatively high. The risk is usually related to metastatic regional nodes and, occasionally, to unfavorable findings at the primary site, such as in-transit metastases. The likelihood of a positive sentinel lymph node biopsy (SLNB) exceeds 20 % for melanomas >2 mm thick and 20 % or more of patients with a positive SLNB will have residual positive nodes on completion node dissection. Patients with positive regional nodes have approximately a 20 % or higher risk of regional relapse after surgery alone, particularly if multiple nodes are involved and/or extracapsular extension is present. Postoperative adjuvant RT results in local-regional control rates of 85–90 % or higher in high-risk patients with a modest risk of complications. The impact of adjuvant RT on survival is likely minimal.

We discuss the optimal treatment and outcomes for pleomorphic adenoma of the salivary glands by reviewing the pertinent literature. Pleomorphic adenoma is the most common benign salivary gland neoplasm. It is found mostly in the parotid gland in middle-aged women. It progresses slowly and, left untreated, can produce significant morbidity and, rarely, death. The optimal treatment is superficial or total parotidectomy with facial nerve preservation, which results in local control rates of 95% or higher. Radiotherapy (RT) is useful to obtain local control in patients with positive margins, unresectable tumors, and multifocal recurrences after prior resection. Local control rates after RT for microscopic and gross residual tumor are approximately 80% to 85% and 40% to 60%, respectively. The main complication is surgically induced 7th nerve injury. Surgery is the mainstay of treatment and results in a very high cure rate. RT increases the likelihood of local control in the small subset of patients with incompletely resectable tumors and/or multifocal recurrences.

Objective: To evaluate the efficacy of radiotherapy (RT) alone or combined with surgery for the treatment of the nasal vestibule squamous cell carcinomas. Methods: Seventy-one patients with squamous cell carcinoma of the nasal vestibule were treated with definitive RT at the University of Florida, and 8 patients with advanced T4 cancers were treated with combined surgery and RT. Patients were followed from 4 months to 27.7 years (mean 9.0 years, median 7.9 years). Follow-up on living patients ranged from 6 months to 27.7 years (mean 10.0 years, median 8.1 years). Results: The 5-year outcomes were: local control, 87%; localregional control, 77%; freedom from distant metastases, 94%; cause-specific survival, 90%; and survival, 76%. The 5-year local control rates for patients treated with definitive RT were: T1‐T2, 95%; T4, 71%; and overall, 86% (P 0.0046). Local control was achieved in 8 of 8 patients treated with surgery and RT. Conclusion: RT results in a high cure rate for T1‐T2 and favorable T4 tumors. Surgery and RT result in an improved likelihood of cure for patients with extensive T4.

Background. The role of salvage neck dissection for isolated regional recurrences after definitive radiotherapy (RT) is ill-defined. Methods. Five-hundred fifty patients were treated with RT for lymph node-positive head and neck cancer. RT consisted of a median dose of 74.4 Gy. Chemotherapy was administered in 133 patients (24%). Patients were followed for neck failure after planned neck dissection (n ¼ 341) or observation (n ¼ 209). Sal- vage therapy was offered to those with isolated neck recur- rences. Results. There were 54 (10%) failures in the neck at a median 3.7 months after RT (range, 0 to 17 months). Thirteen patients had isolated recurrences after receiving definitive RT with (n ¼ 11) or without (n ¼ 2) neck dissection. Nine patients underwent attempted surgical salvage with or without re-irradiation and 4 were successfully salvaged without major complications. Conclusions. Patients with neck failure after definitive ther- apy usually have poor outcomes, but salvage attempts may be successful in selected patients with an isolated neck recur- rence. V C 2007 Wiley Periodicals, Inc. Head Neck 29: 715-719

Purpose To report disease outcomes after proton therapy (PT) for sinonasal cancer. Methods and Materials Eighty-four adult patients without metastases received primary (13%) or adjuvant (87%) PT for sinonasal cancers (excluding melanoma, sarcoma, and lymphoma). Common histologies were olfactory neuroblastoma (23%), squamous cell carcinoma (22%), and adenoid cystic carcinoma (17%). Advanced stage (T3 in 25% and T4 in 69%) and high-grade histology (51%) were common. Surgical procedures included endoscopic resection alone (45%), endoscopic resection with craniotomy (12%), or open resection (30%). Gross residual disease was present in 26% of patients. Most patients received hyperfractionated PT (1.2 Gy [relative biological effectiveness (RBE)] twice daily, 99%) and chemotherapy (75%). The median PT dose was 73.8 Gy (RBE), with 85% of patients receiving more than 70 Gy (RBE). Prognostic factors were analyzed using Kaplan-Meier analysis and proportional hazards regression for multiple regression. Dosimetric parameters were evaluated using logistic regression. Serious, late grade 3 or higher toxicity was reported using the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4. The median follow-up was 2.4 years for all patients and 2.7 years among living patients. Results The local control (LC), neck control, freedom from distant metastasis, disease-free survival, cause-specific survival, and overall survival rates were 83%, 94%, 73%, 63%, 70%, and 68%, respectively, at 3 years. Gross total resection and PT resulted in a 90% 3-year LC rate. The 3-year LC rate was 61% for primary radiation therapy and 59% for patients with gross disease. Gross disease was the only significant factor for LC on multivariate analysis, whereas grade and continuous LC were prognostic for overall survival. Six of 12 local recurrences were marginal. Dural dissemination represented 26% of distant recurrences. Late toxicity occurred in 24% of patients (with grade 3 or higher unilateral vision loss in 2%). Conclusions Dose-intensified, hyperfractionated PT with or without concurrent chemotherapy results in excellent LC after gross total resection, and results in patients with gross disease are encouraging. Patients with high-grade histology are at greater risk of death from distant dissemination. Continuous LC is a major determinant of survival justifying aggressive local therapy in nearly all cases.

Background In patients at high risk for regional node metastasis from squamous cell carcinoma (SCC) of the skin of the face, ear, or scalp, radiotherapy to the regional nodes is an alternative to parotid or neck surgery. Data on the efficacy of elective nodal radiotherapy in this setting are scarce such that there is no publication specifically addressing the subject. The purpose of our study is to fill this void in the skin cancer literature. Methods This is a single-institution study of outcomes following elective nodal radiotherapy in 71 consecutively treated adults with SCC of the face, ears, or scalp. Primary site stage distribution per the American Joint Committee on Cancer, 7th Edition, was as follows: T1, 15 %; T2, 34 %; T3, 1 %; and T4, 50 %. Other disease characteristics included the following: clinical perineural invasion, 13 %; pathological perineural invasion, 78 %; recurrent disease, 32 %; and positive or close margin, 67 %. The median radiation dose to the first- and second-echelon nodal area was 50 Gy. Acute and late toxicity were graded per the Common Terminology Criteria for Adverse Events, version 4.0. Regional control was assessed using the Kaplan-Meier product limit method. Results Median followup was 4.5 years for all patients. The actuarial regional control rate at 5 years was 96 %. There were no (0 %) grade 3 or higher complications from elective nodal irradiation. Conclusions Elective nodal irradiation in patients with high-risk SCC of the face, ears and scalp is safe and effective.

The objective of this study is to determine if radiotherapy (RT) alone to the cervical lymphatics is a suitable alternative to elective neck dissection (END) in patients who undergo parotidectomy and postoperative RT for squamous cell carcinoma metastatic to the parotid area lymph nodes (PALN). We retrospectively reviewed the medical records of 107 patients consecutively treated from November 1969 to March 2012 for cutaneous squamous cell carcinoma metastatic to the PALN with a clinically node-negative neck. Primary therapy consisted of parotidectomy in all cases. We compared regional (cervical) control in two subgroups: 42 patients treated with END and RT and 65 patients treated with elective neck irradiation (ENI) alone. The median time of follow-up was 5.5 years (range 0.3-30 years) for all patients and 11 years for living patients (range 1.8-26 years). There was 1 neck recurrence in each subgroup: END and RT, 1/42 (2 %); and ENI alone, 1/65 (1.5 %). No patient experienced a complication related to neck RT. ENI to a dose of approximately 50-60 Gy is a suitable alternative to END and postoperative RT in patients with squamous cell carcinoma metastatic to the PALN.

We evaluated the treatment of squamous cell carcinoma (SCC) of the nasal vestibule. Eighty-six patients were treated with radiotherapy (RT) and 13 patients received surgery and RT. The mean follow-up was: 9.7 years (range 4 months–35.9 years). The 5- and 10-year outcomes were: local control (LC), 88 and 82 %; local–regional control (LRC), 78 and 73 %; freedom from distant metastases (FFDM), 96 and 96 %; cause-specific survival (CSS), 91 and 86 %; and overall survival, 75 and 51 %. The 5- and 10-year LC rates for patients treated with RT were 94 and 89 % overall. A multivariate analysis was performed. Tumor size predicted LC, LRC, OS, and CSS. Overall stage predicted LRC. RT cures most patients with T1–T2 and favorable T4 SCCs with acceptable toxicity. RT and surgery result in improved likelihood of cure for patients with advanced T4 lesions.

Objective: To determine the rates of local-regional control, survival, and complications for patients treated with postoperative radiation for squamous carcinomas of the larynx, hypopharynx, and oropharynx. Methods: There were 295 patients with previously untreated squamous cell carcinomas of the larynx (n = 199), hypopharynx (n = 80), and oropharynx (n = 16) treated postoperatively with radiotherapy (RT). Results: Five-year local-regional control rates according to site and pathologic American Joint Committee on Cancer (AJCC) stage were: stage III larynx, 89% versus stage IVA larynx, 85% (P = 0.33); stage III oropharynx/hypopharynx, 76% versus stage IVA oropharynx/hypopharynx, 79% (P = 0.72). Local-regional control rates steadily declined as the number of indications for administering postoperative RT increased. Five-year absolute survival rates versus pathologic AJCC stage for the entire group were: stage III 59% and stage IVA 40% (P = 0.40). Conclusion: Rates of local-regional control, survival, and complications support the use of postoperative radiation in selected patients. Tumor control and survival will hopefully improve further with the addition of chemotherapy to postoperative radiation.

This review discusses the role of postoperative radiotherapy (RT) for patients with squamous cell carcinoma of the head and neck. Patients with unfavorable pathologic features have a high-risk of local–regional recurrence and a decreased likelihood of survival after surgery alone. Postoperative RT reduces the risk of local–regional failure and probably improves survival. Patients who are at high risk for recurrence may benefit from more aggressive altered fractionation schedules to decrease the overall time from surgery to the completion of RT. Adjuvant cisplatin-based chemotherapy also appears to improve the probability of cure in high-risk patients.

The purpose of this study is to update our experience with definitive radiotherapy (RT) for carcinoma of the tonsillar area.There were 503 patients treated between October 1964 and May 2003 (potential follow-up for at least 2 years). Of these, 198 patients underwent a planned neck dissection and 57 patients received induction (18 patients) or concomitant (39 patients) chemotherapy.The 5-year local control rates were as follows: T1, 88%; T2, 84%; T3, 78%; and T4, 61%. Multivariate analysis revealed that local control was significantly influenced by T stage, primary site, and fractionation. Local control after RT for early stage cancers was higher for tonsillar fossa/posterior pillar tumors than for those arising from the anterior tonsillar pillar. The 5-year cause-specific survival rates were as follows: I, 100%; II, 86%; III, 84%; IVA, 73%; and IVB, 46%. Multivariate analysis revealed that cause-specific survival was significantly influenced by T stage, overall stage, neck dissection, race, and gender. The incidence of severe late complications was 9%.Based on our data and a review of the literature, definitive RT provides cure rates that are as good as those after surgery, and is associated with a lower rate of severe complications. Patients with lateralized tumors may be safely treated with ipsilateral field arrangements. Our limited experience with intensity modulated radiotherapy suggests that it is as efficacious as conventional RT.

Purpose To determine how to use node response on computed tomography (CT) to indicate the need for neck dissection. Patients and Methods Five hundred fifty patients with lymph node–positive head and neck cancer were treated between 1990 and 2002 with radiotherapy (RT) at a median dose of 74.4 Gy; 24% of these patients (n = 133) were treated with chemotherapy. Three hundred forty-one patients (62%) underwent planned post-RT neck dissection. Physical examination and contrast-enhanced CT were performed 30 days after completion of RT. CT images were reviewed in 211 patients for lymph node size (largest axial dimension) and presence of a focal abnormality (lucency, enhancement, or calcification). By correlating post-RT CT to neck dissection pathology, criteria associated with a low likelihood of residual disease were identified. A subset of patients who fit these criteria of radiographic response who did not undergo post-RT neck dissection was observed for recurrence. Results Radiographic complete response (rCR) was defined as the absence of any large (> 1.5 cm) or focally abnormal lymph node. Correlation of response with neck dissection pathology indicated a negative predictive value of 77% for complete clinical response and 94% for rCR. In 32 patients (median follow-up time, 3.2 years) with rCR who did not undergo post-RT neck dissection, the 5-year ultimate neck control rate (100%) and cause-specific survival rate (72%) were not significantly different from the rates of patients with a negative post-RT neck dissection. Conclusion Patients with rCR 4 weeks after RT can be spared from a post-RT neck dissection regardless of initial node stage.

BACKGROUND The purpose of the current study was to determine the outcomes of patients with previously untreated Merkel cell carcinoma of the skin who were treated with curative intent. METHODS Between October 1984 and January 2002, 34 patients were treated with radiotherapy alone (2 patients) or combined with surgery (32 patients). Nine patients received adjuvant chemotherapy. Patients had follow-up for a median of 3.0 years (range, 0.3 to 18.5 yrs). Follow-up on living patients ranged from 2.2 to 18.5 years (median, 7.1 yrs). RESULTS The 5-year outcomes were as follows: local control, 94%, locoregional control, 80%; freedom from distant metastases, 60%; cause-specific survival, 52%; and survival, 37%. No patient experienced a severe complication. CONCLUSIONS Patients treated aggressively with surgery and locoregional radiotherapy have about a 50% chance of cure. Limited data suggest that definitive radiotherapy alone or after incomplete macroscopic resection may control locoregional disease in a significant subset of patients. The dominant site of failure was distant. Cancer 2005. © 2005 American Cancer Society.

Purpose: To analyze the outcomes of adult patients with head and neck soft tissue sarcomas. Methods: Review of 39 patients treated with radiotherapy (RT) alone (6 patients) or combined with surgery (33 patients) with curative intent between December 1966 and February 2003. Follow-up for living patients ranged from 1 to 21 years (median, 8.7 years). Results: Five-year outcomes were as follows: local control, 78%; distant metastasis-free survival, 85%; cause-specific survival, 69%, and overall survival, 63%. Three of 6 patients (50%) treated with definitive RT were locally controlled compared with 27 of 33 patients (82%) treated with surgery and RT. Conclusions: Approximately two thirds of patients with head and neck soft tissue sarcomas are cured with RT alone or combined with surgery. Local recurrence is a significant mode of treatment failure. Outcome is influenced by tumor extent, histologic grade, and resectability.

The purpose of this article was to evaluate the role of radiotherapy (RT) in the treatment of pleomorphic adenoma. This is a retrospective analysis of 17 patients treated with RT alone (2 patients) or combined with surgery (15 patients). Follow up ranged from 1.8 to 27.1 years (median, 9.6 years). Local control was obtained in 8 of 10 patients (80%) with subclinical disease and 3 of 7 patients (43%) with gross disease. Overall local control was obtained in 11 of 17 patients (65%). The 5- and 10-year overall local control rates were 69% and 61%, respectively. One patient died secondary to tumor extension into the central nervous system, 1 patient had recurrence of carcinoma ex-pleomorphic adenoma and died of cancer at the primary site, 5 patients died free of disease, and 10 patients were alive at last follow up. RT is relatively effective at controlling subclinical disease in patients at high risk for developing recurrence after surgery for pleomorphic adenoma. Limited data suggest that RT may also occasionally control gross disease.

Background. Plasma cell granulomas are rare and heterogeneous tumor-like lesions of mixed inflammatory cell infiltrates of unknown etiology. Although they have the potential to occur in sites throughout the body, their occurrence in the paranasal sinuses and nasal cavity is uncommon and often associated with unique clinical characteristics and natural history. Methods. We present a case of an aggressive plasma cell granuloma of the maxillary sinus and a review of the literature (28 cases). Results. The patient was treated with definitive radiotherapy (45 Gy in 25 fractions) and experienced a local recurrence 2 years later. The lesion initially responded to corticosteroids and then progressed. Resection was performed and was followed by another recurrence. The patient was treated with radiosurgery and is disease free 8 years after initial treatment. Conclusions. Review of the literature indicates that the optimal first line of treatment is high-dose corticosteroids. Surgery is indicated if the lesion fails to respond. Radiotherapy is indicated if complete resection is not feasible. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX–XXX, 2005

BACKGROUND Treatment outcomes were analyzed for retromolar trigone squamous cell carcinoma. METHODS Between June 1966 and August 2003, 99 patients were treated with radiotherapy alone (35 patients) or radiotherapy combined with surgery (64 patients). Followup ranged from 0.2 to 23.8 years (median, 3.3 yrs). All living patients had followup for at least 1 year. RESULTS The 5-year local–regional control rates after definitive radiotherapy versus surgery and radiotherapy were as follows: Stages I–III, 51% and 87%; Stage IV, 42% and 62%; and overall, 48% and 71%, respectively. The 5-year cause-specific survival rates after definitive radiotherapy compared with surgery and radiotherapy were as follows: Stages I–III, 56% and 83%; Stage IV, 50% and 61%; and overall, 52% and 69%, respectively. Multivariate analyses revealed that the likelihood of cure was better with surgery and radiotherapy compared with definitive radiotherapy. CONCLUSIONS The likelihood of cure after treatment for retromolar trigone squamous cell carcinoma was influenced by the extent of disease and treatment. Patients treated with surgery and radiotherapy had a better outcome than those treated with radiotherapy alone. Cancer 2005. © 2005 American Cancer Society.

Purpose To assess the efficacy of postoperative radiotherapy (RT) in the treatment of cutaneous melanoma. Materials Between August 1981 and December 2009, 82 patients were treated with surgery and postoperative RT for cutaneous melanoma. Patients were thought to be high risk for local–regional recurrence after surgery alone because of the presence of one or more risk factors including recurrence after prior surgery, positive lymph nodes, extracapsular extension, incomplete regional node dissection, microscopically positive margins, gross residual disease, and in-transit metastases. The primary site was located in the head and neck in 64 patients and elsewhere in the remainder. Forty-two patients (47%) were treated with hypofractionated RT and the remainder with conventional fractionation. Median age was 62 years (range, 21 to > 89 years). Median follow-up overall and for survivors was 3.0 years (range, 0.1 to 17.4 years) and 6.4 years (1.6 to 17.4 years), respectively. Results The 5-year outcomes were: in-field local–regional control 82%; local–regional control, 76%; distant metastasis-free survival, 48%; cause-specific survival, 56%; and overall survival, 43%. In-field local–regional control at 5 years was 87% after hypofractionated RT and 78% after conventionally fractionated RT. Conclusions Postoperative adjuvant RT likely reduces the risk of local–regional recurrence after surgery for patients with high risk cutaneous melanoma. Hypofractionated RT is as effective as conventional fractionation and is logistically advantageous, particularly for patients with a relatively poor prognosis. The risk of RT complications is low.

The purpose of this study was to analyze the results of radiotherapy (RT) alone or combined with surgery for adenoid cystic carcinoma.Between September 1966 and November 2001, 101 previously untreated patients were treated with curative intent with RT alone or combined with surgery. Follow-up ranged from 0.4 to 30.6 years (median, 6.6 years). All living patients had follow-up for at least 1 year.The 5- and 10-year rates of local control were as follows: RT alone, 56% and 43%; surgery and RT, 94% and 91%; and overall, 77% and 69%. Multivariate analysis of local control revealed that T stage (p=.0101) and treatment group (p=.0008) significantly influenced this endpoint. The 5- and 10-year rates of distant metastases-free survival were 80% and 73%. The 5- and 10-year absolute survival rates were as follows: RT alone, 57% and 42%; surgery and RT, 77% and 55%; and overall, 68% and 49%. Multivariate analysis of absolute survival revealed that T stage (p=.0043) and clinical nerve invasion (p=.0011) significantly influenced this endpoint. The 5- and 10-year cause-specific survival rates were as follows: RT alone, 65% and 48%; surgery and RT, 81% and 71%; and overall, 74% and 61%. Multivariate analysis revealed that T stage (p=.0008) and clinical nerve invasion (p=.0005) significantly influenced cause-specific survival.The optimal treatment for patients with adenoid cystic carcinoma is surgery and adjuvant RT. A significant proportion of patients with incompletely resectable disease are cured after RT alone. Improvements in locoregional control are offset, in part, by the relatively high incidence of distant metastases.

T1-T2 glottic carcinomas may be treated with conservative surgery or radiotherapy. The goals of treatment are cure and laryngeal voice preservation. The aim of the current study was to review the pertinent literature and discuss the optimal management of early-stage laryngeal carcinoma. Literature review indicated that the local control, laryngeal preservation, and survival rates of patients were similar after transoral laser resection, open partial laryngectomy, and radiotherapy. Voice quality depended on the extent of resection for patients undergoing surgery; results for patients undergoing laser resection for limited lesions were comparable to the corresponding results for patients receiving radiotherapy, whereas open partial laryngectomy yielded poorer results. Costs were similar for laser resection and radiotherapy, but open partial laryngectomy was more expensive. Patients with well defined lesions suitable for transoral laser excision with a good functional outcome were treated with either laser or radiotherapy. The remaining patients were optimally treated with radiotherapy. Open partial laryngectomy was reserved for patients with locally recurrent tumors.

Purpose/objectives Treatment outcomes were analyzed for patients who received radiotherapy for squamous cell carcinoma of the retromolar trigone at a single institution. Materials/methods We reviewed the medical records of 110 patients treated with radiotherapy alone (n = 36) or radiotherapy combined with surgical resection of the primary tumor (n = 74) between June 1966 and October 2013. The median follow-up was 4.5 years for all patients and 11.8 years for living patients (range, 1.3–23.5 years). Results The 5-year local–regional control rates after definitive radiotherapy versus surgery and radiotherapy for stages I–III were 52% and 89% and for stage IV they were 46% and 58%, respectively. The 5-year cause-specific survival rates after definitive radiotherapy compared with surgery and radiotherapy for stages I-III were 57% and 82% and for stage IV they were 45% and 43%, respectively. Multivariate analyses revealed that the likelihood of cure was better with surgery and radiotherapy compared with radiotherapy alone (p = 0.041). Conclusion Patients treated with surgery and radiotherapy had a better chance of cure than those treated with radiotherapy alone. Complications of treatment were common in both groups but more common in patients who underwent surgery.

To update our experience with definitive radiotherapy (RT) for juvenile nasopharyngeal angiofibroma (JNA).Twenty-two patients received definitive RT for advanced JNA between June 1975 and March 2003 and were followed from 2.0 to 30.2 years (median, 12.7 years). Total dose ranged from 30 to 36 Gy.Twenty of 22 patients (91%) remained locally controlled after RT; both patients who developed a local recurrence were salvaged so that the ultimate local control rate was 100%. No patient experienced a severe complication.Patients with advanced and/or recurrent JNA thought not to be amenable to complete resection with acceptable morbidity have a high likelihood of cure after RT with a low risk of complications.

OBJECTIVES Esthesioneuroblastoma is an uncommon cancer of the nasal cavity. We describe the outcomes for 26 patients treated with curative intent with photon radiotherapy (RT) at the University of Florida. METHODS Between May 1972 and June 2007, 26 patients received RT for previously untreated esthesioneuroblastoma of the nasal cavity. Sixteen patients were males and 10 were females with a median age of 55 years (range, 3 to 82 y). The modified Kadish stage distribution was: B, 7 patients; C, 17 patients; and D, 2 patients. Treatment modalities included the following: definitive RT, 5 patients; preoperative RT, 2 patients; and postoperative RT after resection, 19 patients. Elective neck irradiation (ENI) was performed in 17 (71%) of 24 N0 patients. RESULTS Rates of local control, cause-specific survival, and absolute overall survival at 5 years were 79%, 72%, and 69%, respectively. Overall survival among patients treated with definitive RT was 20% at 5 years, compared with 81% among those who underwent surgery and adjuvant RT (P=0.01). One (6%) of 17 patients who received ENI developed a recurrence in the neck and was successfully salvaged. Ultimate neck control was 100% at 5 years for patients who received ENI versus 69% among those not receiving ENI (P=0.0173). CONCLUSIONS Resection combined with adjuvant RT is more effective than surgery or RT alone in the treatment of esthesioneuroblastoma. ENI reduces the risk of regional relapse in patients with Kadish stage B and C cancers.

Objective: Photodynamic therapy (PDT) is a promising new treatment modality for head and neck cancer that is based on the uptake of a systemically administered photosensitizer in tumor tissue and local illumination of the lesion by a high-intensity visible light source, typically a tunable argon-pumped dye laser. We developed a new photosensitizer named silicon phthalocyanine [SiPc(OH) OSi(CH3)2(CH2)3N(CH3)2, abbreviated as SiPc IV], which yields superior PDT responses in vitro and in vivo compared with other clinically used photosensitizers. However, tumor regrowth following SiPc IV—based PDT is still a therapeutic problem. The benzamide derivatives, for example, have been shown to enhance tumor ablation when used during radiotherapy and chemotherapy. Therefore, we used metoclopramide hydrochloride, a benzamide derivative, to evaluate its effects on PDT response. Design: Intradermally injected human squamous cell carcinoma cells were grown to 40 to 80 mm3in athymic nude mice and irradiated with 675-nm light (75 J/cm2, 75 mW/cm2) 24 hours after the intraperitoneal injection of SiPc IV (1.0 mg/kg). Metoclopramide hydrochloride (2 to 48 mg/kg) was injected intraperitoneally 1 hour before and 24 and 48 hours after irradiation. Results: Tumors exposed to PDT alone showed 80% to 90% tumor regression with regrowth in most animals within 20 days. Tumors treated with metoclopramide hydrochloride (48 mg/kg) plus PDT demonstrated 100% tumor regression without regrowth up to the time of killing (150 days). No observable toxic effects were clinically apparent with the high doses of metoclopramide. Conclusions: Our results show that administering metoclopramide in combination with PDT may be a promising approach to the management of head and neck cancer. (Arch Otolaryngol Head Neck Surg. 1995;121:783-789)

The objective of this study is to determine if radiotherapy (RT) alone to the cervical lymphatics is a suitable alternative to elective neck dissection (END) in patients who undergo parotidectomy and postoperative RT for squamous cell carcinoma metastatic to the parotid area lymph nodes (PALN). We retrospectively reviewed the medical records of 107 patients consecutively treated from November 1969 to March 2012 for cutaneous squamous cell carcinoma metastatic to the PALN with a clinically node-negative neck. Primary therapy consisted of parotidectomy in all cases. We compared regional (cervical) control in two subgroups: 42 patients treated with END and RT and 65 patients treated with elective neck irradiation (ENI) alone. The median time of follow-up was 5.5 years (range 0.3-30 years) for all patients and 11 years for living patients (range 1.8-26 years). There was 1 neck recurrence in each subgroup: END and RT, 1/42 (2 %); and ENI alone, 1/65 (1.5 %). No patient experienced a complication related to neck RT. ENI to a dose of approximately 50-60 Gy is a suitable alternative to END and postoperative RT in patients with squamous cell carcinoma metastatic to the PALN.

Purpose To explain the concepts that radiation oncologists need to understand to manage patients with juvenile nasopharyngeal angiofibroma (JNA). To accomplish this goal we first describe our institution's experience with radiotherapy for JNA and then use this data set as a framework for explaining the role of radiotherapy in the treatment of this uncommon tumor. Methods and Materials We studied the outcomes of all 24 patients treated with radiotherapy for JNA at our institution. All patients had at least 4 years of follow-up (median follow-up, 18 years). The standard dose in the first half of the series was 30 Gy in 22 treatments (1.43 Gy/treatment). After observing recurrences with this schedule, the prescription was changed to 35 to 36 Gy at 1.8 Gy/treatment. In all cases, the target volume was the primary site without an attempt to cover the regional nodes. Results All recurrences were at the primary site and presented within 5 years of completing radiotherapy. There appeared to be a dose response for tumor control: 77% with 30 to 32 Gy versus 91% with 35 to 36 Gy. All recurrences following radiotherapy were successfully salvaged with surgery. The only complications from radiotherapy were cataracts in 2 patients. No patient had a significant growth abnormality or second tumor. Conclusions Surgery is the best treatment for JNA when cure is likely with low morbidity, but the threshold for using radiotherapy should be low because moderate-dose radiotherapy cures about 90% of patients with a low risk of serious complications. We recommend 36 Gy at 1.8 Gy per treatment in most cases. Elective nodal irradiation is not necessary. Radiographic response should be almost complete within a year of radiotherapy. Patients should be followed with cross-sectional imaging every 6 months for at least 5 years.

Objective The objective of the study was to discuss the optimal management and treatment outcomes for patients with head and neck osteosarcomas. Study Design Review article. Methods Review of the pertinent literature. Results Osteosarcomas account for approximately 1% or less of all head and neck cancers. The vast majority occur in the mandible and maxilla. The median age is in the fourth decade, with a wide range. They are more likely to recur locally after treatment and distant metastases are observed less often than with the more common osteosarcomas arising in the long bones. The optimal treatment is complete resection. The role of adjuvant chemotherapy is ill-defined. The vast majority of recurrences are observed within 5 years. The 5-year disease-specific and overall survival rates are approximately 60% to 70%. Conclusions Osteosarcoma of the head and neck is a rare entity that occurs primarily in the mandible and maxilla. The optimal treatment is surgery. Adjuvant radiotherapy should be considered for those with close or positive margins. The role of adjuvant chemotherapy is ill-defined. The likelihood of cure is approximately 60% to 70%.

Background The purpose of this study was to describe the natural history and optimal treatment for head and neck paragangliomas (PGs). Methods Our methods were the review of the pertinent literature. Results PGs are rare tumors seen most commonly in the head and neck. Approximately 90% are sporadic; the remainder are familial and related to mutations of the succinate dehydrogenase (SDH) gene complex. Most PGs are benign and slow growing; 6% to 19% are malignant, as evidenced by the development of metastases. PGs may be treated by complete resection or moderate-dose radiotherapy with a ≥90% likelihood of cure. The optimal radiotherapy dose is approximately 45 Gy/25 fractions/5 weeks. The treatment modality selected depends on the risk of complications. Due to their rarity, the optimal treatment for malignant PGs is unclear. Conclusion PGs may be treated by either complete resection or radiotherapy with a high likelihood of success. Treatment depends on the location and extent of the PG and the morbidity associated with treatment. © 2010 Wiley Periodicals, Inc. Head Neck, 2010

Objectives/Hypothesis: To define the role of elective neck dissection during salvage surgery for locally recurrent head and neck squamous cell carcinoma (SCCA) initially treated with elective nodal irradiation (ENI). Study Design: Retrospective chart review. Methods: We reviewed the medical records of patients treated with ENI at our institution from 1965 to 2006 for T1-4 N0 M0 SCCA of the oropharynx, hypopharynx, or larynx who developed an isolated local recurrence and remained N0. Fifty-seven patients were salvaged, 40 with neck dissection and 17 with neck observation. We then compared toxicity and actuarial outcomes between the two groups. Results were compared to the pertinent literature in a pooled analysis. Results: Four of 46 (9%) heminecks were found to have occult metastases in dissected specimens. The 5-year local-regional control rate was 75% for all patients. Neck dissection resulted in poorer outcomes compared with observation. In the dissected group, the 5-year local control, regional control, cause-specific survival, and overall survival rates were 71%, 87%, 60%, and 45%, respectively, compared to 82%, 94%, 92%, and 56%, respectively, for the observed group. Toxicity was more likely with dissection. In the pooled analysis totaling 230 patients, the overall pathologic positive rate of neck-dissection specimens was 9.6%; the compiled data showed no improvement in outcomes when salvage included neck dissection. Conclusions: Routine elective neck dissection should not be included during salvage surgery for locally recurrent head and neck SCCA if initial radiotherapy includes ENI. The risk of occult neck disease is low, outcomes do not improve, and the likelihood of toxicity increases. Laryngoscope, 2010

Squamous cell carcinoma (SCCA) of the external auditory canal (EAC) is often treated with a combination of surgery and radiotherapy (RT) to optimize the chance of achieving locoregional control. This retrospective review describes a 27-year experience of treating these tumors at the University of Florida.Thirty patients with histologically confirmed SCCA of the EAC received external-beam radiation (RT) alone or combined with surgical resection between 1976 and 2003. Seven patients were treated with RT alone, 22 with postoperative RT, and 1with preoperative RT. Patients were grouped according to nodal status (N0/N1) and the Stell staging system for tumors of the EAC and middle ear. Early stage was defined as T1/T2 (n = 12) and advanced stage as T3 (n = 18). Median follow-up was 2 years (range, 0.1-19.4 years) with no patients lost to follow-up.The 5-year actuarial probabilities for local control, locoregional control, and cause-specific survival for patients with early stage (T1/T2) versus advanced-stage (T3) tumors were 74% and 55% (P = 0.27), 63% and 38% (P = 0.16), and 70% and 41% (P = 0.04), respectively. The regional control rate was 83% (P = 0.6). There were 12 local recurrences and 4 neck recurrences as the first site of failure. One failure was successfully salvaged with surgery. Five of 23 (21%) patients undergoing surgery had significant complications (grade 3 or 4), whereas 2 of 30 (7%) patients receiving RT experienced grade 3 complications.Patients with early stage disease achieved better local control, locoregional control, and cause-specific survival than those with advanced tumors. Less than half of the patients (13 of 30; 43%) were cured without significant complications, suggesting a suboptimal therapeutic ratio, using current treatment methods.

Background. We report the University of Florida experience with soft-palate carcinoma treated with radiotherapy alone or combined with adjuvant chemotherapy and/or neck dis- section for residual disease in the neck. Methods. A total of 145 patients treated with curative intent from 1963 to 2004 were included. Potential follow-up was � 2 years. Results. Local control rates at 5 years were: T1, 90%; T2, 91% ;T 3, 67%; T4, 57%. Nodal control rates at 5 years were: N0, 90%; N1, 82%; N2, 68%; N3, 71%. Ultimate local-regional control rates at 5 years were: stage I, 89%; stage II, 88%; stage III, 96%; stage IVA, 63% ;s tage IVB, 43%. In multivariate analysis, overall treatment time significantly affected local and ultimate local-re- gional control, and nodal stage significantly affected overall sur- vival. Overall survival rate at 5 years was 44%. Cause-specific sur- vival rate at 5 years was 73%. Conclusions. The likelihood of cure after definitive radiother- apy is relatively high and is impacted by disease extent and overall treatment time. V C 2008 Wiley Periodicals, Inc. Head Neck 30: 1114-1119, 2008