|SYMPOSIUM: HEAD AND NECK
|Year : 2012 | Volume
| Issue : 2 | Page : 220-224
Carcinoma base of tongue: Single institution 15 year experiences
RPS Banipal, MK Mahajan, G George, J Sachdev, P Jeyaraj
Department of Radiotherapy, Christian Medical College and Hospital, Ludhiana, Punjab, India
|Date of Web Publication||25-Oct-2012|
Department of Radiotherapy, Christian Medical College and Hospital, Ludhiana, Punjab
Source of Support: None, Conflict of Interest: None
Aims: To report the outcome with radiotherapy and concomitant chemoradiotherapy in patients with locally advanced squamous cell carcinoma base of tongue treated and followed up at single institution over a period of 15 years. Materials and Methods: This study was carried out by auditing the medical records of 103 patients treated at our institution between 1991 and 2006. Mean age with standard deviation of patients in the Radiotherapy only (group I) and chemoradiotherapy (group II) was 55.26 ± 14.16 and 49.81 ± 12.16 years. 46 patients were treated with radiotherapy alone and 57 patients were treated with concurrent chemo radiotherapy using infusion cisplatinum 3 weekly and 5 fluorouracil twice weekly. Mean follow up was 13.35 months. All the patients characteristic and treatment characteristics were recorded. Results: There were 81 men and 22 women in the study. Group I contains 15 and 31 cases of stage III and IV tumors while group II contains 19 and 38 cases of stage III and IV respectively. Group II has shown improved loco regional control rate for the T3 and T4 tumors as compared to group I. Disease free survival and overall survival in the group II is 25.51 months and 22.53 months while group I has 8.67 months and 6.74 months respectively. Grade III mucosal toxicity incidence was higher in group II as compared to group I. Conclusions: In locally advanced squamous cell carcinoma of base of tongue tumors concomitant chemoradiotherapy with infusional cisplatinum and 5 fluorouracil results in higher disease free and overall survival as compared to radiotherapy as single modality. This better tumor response with chemoradiotherapy comes at cost of higher incidence of mucosal toxicity.
Keywords: Radiotherapy, chemoradiotherapy, carcinoma base of tongue
|How to cite this article:|
Banipal R, Mahajan M K, George G, Sachdev J, Jeyaraj P. Carcinoma base of tongue: Single institution 15 year experiences. Indian J Cancer 2012;49:220-4
| » Introduction|| |
The optimal management of squamous cell carcinoma of the base of tongue remains controversial, as treatment has shifted away from surgery with postoperative radiotherapy (RT) towards organ-preservation combined- modality approaches. There are no randomized data to support surgery versus RT, and published single-institution results indicate that both are effective in the treatment of stage I and II disease.  However, a report from the National Cancer Data Base examined over 16,000 BOT cancers and found the 5-year disease-free survival was only 44.2% for stage III and 30% for stage IV cancers.  Poor outcome have led some to argue that patients presenting with T3 and T4 tumors should consider palliative care alone.  Results of chemotherapy alone in advanced head and neck cancers per se have not been very promising but induction and concomitant chemotherapy do have a role in organ preservation. , Chemotherapy, in neoadjuvant setting as well as in recurrent disease, is known to decrease incidence of distant metastasis and delay it.  Further, the response to chemotherapy is intricately related to the response to radiotherapy. 
| » Materials and Methods|| |
Between 1991 and 2005, 103 patients with high risk stage III (34) and stage IV (69) base of tongue cancer were treated with curative-intent radiotherapy (46) and chemoradiotherapy (57). In the initial years from 1991 till 1997 majority of the patients were treated with external beam radiotherapy only. From mid-1997 onwards majority of the patients with advanced stage III and IV base of tongue tumors were treated with concomitant chemoradiotherapy. For this subgroup analysis patients were followed through December 2010. Eligible patients had squamous cell carcinoma of the BOT and were required to have stage III or IV disease. All patients were retrospectively staged with the American Joint Committee on Cancer (AJCC) staging system, sixth edition. Patients were evaluated at a joint conference of surgical, radiation and medical oncology before study entry. Eastern Cooperative Oncology Group performance status was used for the performance status of patients.  A performance status on scale of 0 to 2 was required, and no patient should have received prior radiation or chemotherapy. Initial staging procedure consisted of a detailed history and physical examination, Chest X-ray, pan endoscopy with tumour measurement, biopsy, pre External Beam Radiotherapy dental evaluation, head and neck CT where required, oropharyngeal swallowing, and quality of life assessments. All patients were informed of the disease, required treatment and complication by verbal communication. Placement of a feeding tube was recommended for those patients presenting with an impaired swallowing. Patients refusing chemotherapy were treated with RT alone.
All patients underwent conventional treatment with two lateral parallel opposed fields including face and neck, and all were immobilized in custom masks. All patients were treated with Co-60 Teletherapy machine. Patients were treated with a 2 Gy once daily fractionation (5 fractions per week). Radiation doses of 60 to 66 Gy were prescribed. Target volume includes whole neck with spinal cord sparing after 40 Gy. In group II, chemotherapy comprises of injection cisplatinum in a dose of 50 mg/m 2 on Day 1, 22, and 42 and injection 5-Flourouracil 500 mg twice-weekly over 6 hours (4 hour before radiotherapy and 2 hour after) concomitant with radiotherapy.
| » Chemotherapy Schema|| |
Patient characteristics are shown in [Table 1].
Chi-Square test was used for non-parametric comparisons like loco regional control etc. One Way ANOVA was used for comparing the means like disease free survival or overall survival etc. All statistical analysis was done using SPSS 17.0.
| » Results|| |
The mean age with standard deviation of patients in group I and group II is 55.26 ± 14.16 and 49.81 ± 12.16 years respectively. Locoregional control rate at the completion of treatment according to T stage has been shown in [Table 2]. In group I, 13 (28.26%) patients had residual disease on completion of treatment in contrast to group II where only 11 (19.29%) patients had residual disease at completion of treatment. Out of 46 patients in the group I, 1 (2.17%) patient had recurrence of local disease. In group II, out of 57 patients, 9 (15.78%) patients presented with recurrence. 5 patients had only primary site recurrence, 2 patients had primary and nodal recurrence and 2 patients had only nodal recurrence. Mean disease-free survival and mean overall survival with standard deviation in both the group I and group II are shown in [Table 3]. Treatment-related toxicity in the form of acute mucosal toxicity occur in both the groups and details (in %) are given in [Table 4]. 1 patient in group II presented with second primary in lung after 3 years. [Figure 1] and [Figure 2] show progression free survival and overall survival in both groups respectively.
|Table 2: Loco regional control rates at completion of treatment according to T stage|
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| » Discussion|| |
Squamous cell carcinoma of the head and neck region is the largest group of cancer seen in India and in many countries with limited resources.  Jones et al, have reported 5-year survival rates of 9% and 15% for patients with BOT cancer treated with radiation and surgery, respectively. This was not significantly better than patients who received no treatment, leading the authors to suggest that treating patients with T3-T4 tumors does not yield benefits superior to palliation alone.
In patients with an advanced disease, outcome still remains poor. Yet, the subgroup of patients who still do not have metastasis can be offered potentially curative therapy in the form of chemo radiotherapy. Concurrent chemotherapy and RT has been shown to improve loco regional control and survival for many tumor types.  This translates into absolute survival benefit of 6.5% at 5 years for concurrent chemo radiotherapy as per the MACH-NC collaborative group meta-analysis.  The best results have been with cisplatinum- and carboplatin- based chemotherapy combined with radiotherapy, the survival being prolonged by 16.8 and 6.7 months, respectively.  As such, concurrent chemoradiotherapy has been established as the standard of care for many patients with locally advanced head and neck cancer. In a study comparing RT alone to chemoradiotherapy for stage III and IV oropharynx cancers, the 5-year loco regional control was improved by 23% (48% vs. 25%) with the addition of carboplatin and fluorouracil to standard daily-fractionated RT.  In the present study, concurrent chemoradiotherapy with infusional cisplatinum 3 weekly and infusional 5 fluorouracil biweekly has shown superior results as compared to use of single modality radiotherapy. Although the present study has shown a definite improvement in disease free survival and overall survival as shown in literature but the less follow-up of patients does not give the equivalent figures in the present study. This benefit is also seen in the setting of altered-fractionation. There was noted to be a 13% to 15% survival advantage at 2-years noted in a meta-analysis of altered fractionation RT plus concurrent chemotherapy.  Published local control rates with RT alone are 18% to 38% for T4 tumors and 79% to 96% for T1 tumors. ,,,, Local control rates in the chemoradiotherapy and radiotherapy only groups in the present study are 82.14% and 56.21% respectively for T3 tumors and 80.04% and 57.14% respectively for T4 tumors. In the present study, grade III mucosal toxicity incidence was higher (50.87%) in the chemoradiotherapy group as compared to (23.91%) in the radiotherapy only group. Grade II toxicity incidence was almost equal in both the groups. Denham et al. (1996) reported that reactions evolved more rapidly at greater rates of dose accumulation.  The timing of reactions suggested the presence of a strong regenerative mucosal response that started before the manifestation of "patchy" (grade II) mucosal reactions. Kostler et al, 2001 had shown that pathogenesis of this debilitating side effect can be attributed to the direct mucosal toxicity of cytotoxic agents and ionizing radiation and to indirect mucosal damage caused by a concomitant inflammatory reaction exacerbated in the presence of neutropenia and the convergence of bacterial, mycotic and viral infections. 
| » Conclusion|| |
Concomitant chemoradiotherapy in locally advanced carcinoma of base of tongue results in higher disease-free and overall survival. Increased incidence of mucosal reactions with concomitant chemoradiotherapy should be taken care of with proper antibiotics and supportive care.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]