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Part 2 Site-Specifi c Indications and Techniques
SUGGESTED READINGS
Al-Sarraf M, LeBlanc M, Giri PG, et al. Chemoradiotherapy
versus radiotherapy in patients with advanced nasopharyngeal
cancer: phase III randomized intergroup study 0099. J Clin Oncol
1998;16:1310.
Chan AT, Teo P, Huang DP. Pathogenesis and treatment of
nasopharyngeal carcinoma. Semin Oncol 2004;31:794.
Chan ATC, Teo PM, Leung TW, et al. A prospective randomized study of chemotherapy adjunctive to de nitive radiotherapy in advanced nasopharyngeal carcinoma. Int J Radiat Oncol Biol
Phys 1995;33:569.
Chua DT, Ma J, Sham JS, et al. Long-term survival a er cisplatin-based induction chemotherapy and radiotherapy for nasopharyngeal carcinoma: a pooled data analysis of two phase III trials.
J Clin Oncol 2005;23:1118.
Delclos L, Moore BE, Sampiere VA. A disposable “a erloadable” nasopharyngeal applicator for radioactive point sources. Endo-
cur Hypertherm Oncol 1994;10:43.
Geara FB, Sanguineti G, Tucker SL, et al. Carcinoma of the
nasopharynx treated by radiotherapy alone: determinants of distant
metastasis and survival. Radiother Oncol 1997;43:53.
Hunt MA, et al. Treatment planning and delivery of intensitymodulated radiation therapy for primary nasopharynx cancer. Int J
Radiat Oncol Biol Phys 2001;49:623.
International Nasopharynx Cancer Study Group. Preliminary
results of a randomized trial comparing neoadjuvant chemotherapy
(cisplatin, epirubicin, bleomycin) plus radiotherapy vs. radiotherapy alone in stage IV (≥N2, M0) undi erentiated nasopharyngeal carcinoma: a positive e ect on progression-free survival. Int J
Radiat Oncol Biol Phys 1996;35:463.
Kam MK, Teo PM, Chau RM, et al. Treatment of nasopharyngeal carcinoma with intensity-modulated radiotherapy: the
Hong Kong experience. Int J Radiat Oncol Biol Phys 2004;60:1440.
Kwong DL, Pow EH, Sham JS, et al. Intensity-modulated
radiotherapy for early-stage nasopharyngeal carcinoma: a prospective study on disease control and preservation of salivary function.
Cancer 2004;101:1584.
Le QT, Tate D, Koong A, et al. Improved local control with
stereotactic radiosurgical boost in patients with nasopharyngeal
carcinoma. Int J Radiat Oncol Biol Phys 2003;56:1046.
Lee AWM, Poon YF, Foo W, et al. Retrospective analysis
of 5037 patients with nasopharyngeal carcinoma treated during
1976–1985. Overall survival and patterns of failure. Int J Radiat
Oncol Biol Phys 1992;23:261.
Lee AW, Lau WH, Tung SY, et al. Preliminary results of a randomized study on therapeutic gain by concurrent chemotherapy for
regionally-advanced nasopharyngeal carcinoma: NPC-9901 Trial
by the Hong Kong Nasopharyngeal Cancer Study Group. J Clin
Oncol 2005;23:6966.
Lee AW, Tung SY, Chan AT, et al. Preliminary results of a
randomized study (NPC-9902 Trial) on therapeutic gain by concurrent chemotherapy and/or accelerated fractionation for locally
advanced nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys
2006;66:142.
Lee N, Xia P, Quivey JM, et al. Intensity-modulated radiotherapy in the treatment of nasopharyngeal carcinoma: an update
of the UCSF experience. Int J Radiat Oncol Biol Phys 2002;53:12.
Lee N, Harris J, Garden AS, et al. Intensity-modulated radiation therapy with or without chemotherapy for nasopharyngeal
carcinoma: radiation therapy oncology group phase II trial 0225.
J Clin Oncol. 2009;27:3684.
Levendag PC, Lagerwaard FJ, Noever I, et al. Role of endocavitary brachytherapy with or without chemotherapy in cancer of
the nasopharynx. Int J Radiat Oncol Biol Phys 2002;52:755.
Sanguineti G, Geara FB, Garden AS, et al. Carcinoma of
the nasopharynx treated by radiotherapy alone: determinants
of local and regional control. Int J Radiat Oncol Biol Phys 1997;
37:985.
Slevin NJ, Wilkinson JM, Filby HM, et al. Intracavitary
radiotherapy boosting for nasopharynx cancer. Br J Radiol 1997;
70:412.
Teo P, Shiu W, Leung SF, et al. Prognostic factors in nasopharyngeal carcinoma investigated by computer tomography—an
analysis of 659 patients. Radiother Oncol 1992;23:79.
Teo P, Tsao SY, Shiu W, et al. A clinical study of 407 cases of
nasopharyngeal carcinoma in Hong Kong. Int J Radiat Oncol Biol
Phys 1989;17:515.
Teo PM, Leung SF, Chan AT, et al. Final report of a randomized trial on altered-fractionated radiotherapy in nasopharyngeal carcinoma prematurely terminated by signi cant increase in
neurologic complications. Int J Radiat Oncol Biol Phys 2000;48:1311.
Wolden SL, Chen WC, P ster DG, et al. Intensity-modulated
radiation therapy (IMRT) for nasopharynx cancer: update of the
Memorial Sloan-Kettering experience. Int J Radiat Oncol Biol Phys
2006;64:57.
Oropharynx
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Key Points
• e oropharynx comprises the so palate, tonsillar
(faucial) pillars, tonsillar fossa, base of tongue, and
pharyngeal walls.
• e majority of oropharyngeal squamous cell carci-
nomas arise in the tonsil and base of tongue, particularly those that are associated with human papilloma
virus (HPV).
• e incidence of oropharyngeal carcinoma is rising
in North America and Europe due to the increase
in HPV-associated carcinoma a icting mainly
younger individuals (40 to 60 years of age) with no
or minimal history of tobacco consumption (see
Chapter 1).
• Radiation alone is o en the preferred modality of
therapy for early-stage oropharyngeal carcinomas.
Ipsilateral radiotherapy is highly successful in
8
controlling tonsillar carcinomas con ned to the fossa
or with minimal extension to the so palate.
• Combination of radiation with chemotherapy (con-
current or induction) or cetuximab (antibody against
epidermal growth factor receptor) is recommended for
patients with locally advanced oropharyngeal carcinoma. e tumor volume, the general condition of the
patients, and preference determine the speci c choices.
• Intensity-modulated radiation therapy is commonly
used to spare normal tissues, principally to reduce
the incidence and severity of xerostomia.
• Patients with residual nodal disease a er radiation or
combined therapy are managed with neck dissection.
• Patients with HPV-positive oropharyngeal carci-
noma treated with established therapy regimens have
very favorable prognoses.
Although the detail of radiation planning and delivery may
di er among cancers arising from di erent anatomical subsites within the oropharynx, the treatment outcomes have
been usually reported in aggregate. erefore, this chapter
begins by summarizing the general background outcome
data before addressing individual subsites.
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Part 2 Site-Specifi c Indications and Techniques
Background Data
Table 8.1
Outcomes of 1,042 Patients with Squamous Carcinoma of the Oropharynx Treated with Radiotherapy at
the M.D. Anderson Cancer Center 1975 to 1998 (Analysis, 2005)
Primary Site No. of Patients 5-yr Local Control (%) 5-yr Overall Survival
a
(%)
Soft palate 138 70 44
Tonsillar fossa 324 76 56
Base of tongue 383 77 49
Pharyngeal wall 168 68 39
T stage
b
T1 123 98 69
T2 324 84 63
T3 383 69 41
T4 168 45 23
c
Tx
Total
a
95% of surviving patients alive >5 yr.
b
Fifth edition AJCC staging manual.
c
Most common presentation—tonsillectomy done prior to evaluation.
Table 8.2
First Site of Failure Distribution for Stage I and II Oropharynx Cancer Treated with Radiation at the M.D.
44 95 80
1,042 75 50
Anderson Cancer Center (1970 to 1998)
First Site of Failure
None L R LR DM L and DM R and DM Total
T stage T1 and Tx 45 3 1 1 1 0 0 51
T2 87 21 5 1 8 1 1 124
Total 132 24 6 2 9 1 1 175
L, local recurrence; R, regional recurrence; LR, loco-regional recurrence; DM, distant metastases; L and DM, synchronous local recurrence and distant
metastases; R and DM, synchronous regional recurrence and distant metastases.
Modifi ed from Selek U, Garden AS, Morrison WH, et al. Radiation therapy for early-stage carcinoma of the oropharynx. Int J Radiat Oncol Biol Phys 2004;59:743–775.
Table 8.3
First Site of Failure Distribution for Stage T1, T2, and TX Oropharynx Cancer Treated with IMRT at the
U.T.M.D. Anderson Cancer Center 2000 to 2002
First Site of Failure
None L R LR DM L and DM R and DM Total
T stage T1 and Tx 30 0102 0 0 33
T2 131013 0 0 18
Total 43 1115 0 0 51
L, local recurrence; R, regional recurrence; LR, loco–regional recurrence; DM, distant metastases; L and DM, synchronous local recurrence and distant
metastases; R and DM, synchronous regional recurrence and distant metastases.
Modifi ed from Garden AS, Morrison WH, Wong P-F, et al. Disease-control rates following intensity-modulated radiation therapy for small primary oropharyngeal
carcinoma. Int J Radiat Oncol Biol Phys 2007;67:438–444.
Table 8.4
Survival of Patients with Oropharyngeal Carcinoma Based on Tumor HPV Status
First Author Patient number Marker Overall Survival Rates (Positive vs. Negative)
Ang 223 p16
INK4A
84% vs. 51% (3-yr)
Fahkry 62 HPV 84% vs. 50% (3-yr)
Lassen 74 p16
Rischin 185 p16
INK4A
INK4A
66% vs. 28% (5-yr)
91% vs. 74% (2-yr)
Shi 111 HPV 88% vs. 67% (3-yr)
Data from Ang KK et al. N Engl J Med 2010;363:24–35; Fahkry C, et al. J Natl Cancer Inst Phys 2008;100:261–269; Lassen P, et al. J Clin Oncol 2009;27:
1992–1998; Rischin D, et al. J Clin Oncol 2010;28:4142–4148; Shi W, et al. J Clin Oncol 2009;27:6213–6221.
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Table 8.5
First Author Year Patient Number Median follow-Up (mo) Disease Control Rate (%)
Feng 2005 94 36 94 (LRC–crude)
De Arruda 2006 50 18 98 (LC, 2-yr)
Yao 2006 66
Studer 2007 105
Garden 2007 51 45 94 (LRC, 2-yr)
Huang 2008 71 29 90 (LRC, 3-yr)
Sanguineti 2008 38 33 94 (LC, 3 -yr)
Eisbruch 2010 69 32 91 (LRC, 2-yr)
Mendenhall 2010 130 42 84 (LRC, 5-yr)
Daly 2010 107
LRC, locoregional control; LC local control; ND, not described
a
Included patients treated with defi nitive and postoperative radiation.
Data from Feng M, et al. Radiother Oncol 2005;77:32–38; de Arruda FF, et al. Int J Radiat Oncol Biol Phys 2006;64:363–373; Yao M, et al. Am J Clin Oncol
2006;29:606–612; Studer G, et al. Strahlenther Onkol 2007;183:417–423; Garden AS, et al. Int J Radiat Oncol Biol Phys 2007;67:438–444; Huang K, et al.
Cancer 2008;113:497–507; Sanguineti G, et al. Int J Radiat Oncol Biol Phys 2008;72:737–746; Eisbruch A, et al. Int J Radiat Oncol Biol Phys 2010;76:
1333–1338; Mendenhall WM, et al. Laryngoscope 2010;120:2218–2222; Daly ME, et al. Int J Radiat Oncol Biol Phys 2010;76:1339–1346.
SOFT PALATE
Results of Intensity-Modulated Radiation Therapy for Cancer of the Oropharynx
a
a
a
27 99 (LRC, 3-yr)
ND 88 (LC, 2-yr)
29 92 (LRC, 3-yr)
postoperative radiotherapy and, in the presence of extracapsular extension or positive margin, combined with
Treatment Strategy
concurrent cisplatin.
Primary radiotherapy is preferred for T1 to T2 N0 to N1 carcinomas. Super cial T1 lesions without lymphadenopathy
may be amenable to local excision only.
Combination of radiation with systemic therapy is
the treatment of choice for T3 and selected T4 or N2 to
N3tumors. As presented in Chapter 1, outside the protocol
study setting, the three currently available treatment options
established by randomized trials are radiation with concurrent cisplatin (either conventional fractionation plus three
cycles of cisplatin or accelerated fractionation in 6 weeks
plus two cycles of cisplatin), radiation with cetuximab (antibody against epidermal growth factor receptor), and a tripleagent induction chemotherapy regimen, referred to as TPF
(docetaxel, cisplatin, and uorouracil), followed by radiotherapy± carboplatin. Radiation with concurrent high-dose
2
cisplatin (100 mg/m
, given every 3 weeks) has the longest
track record and the strongest evidence-based results.
ere is now a consensus that patients presenting with
N2 to N3 nodal disease achieving a complete clinical and
radiographic response do not require a planned neck dissection. e value of PET-CT scan obtained 10 to 12 weeks
a er the completion of therapy in determining the need for
planned neck dissection for those with small, indeterminate
residual nodal mass on CT scan is being investigated.
T4a tumors with bone invasion or extensive normal tissue destruction resulting in deformation and/
or impaired functions are best treated with surgery and
Primary Radiotherapy
Target Volume
e initial target volume is primary tumor with at least 2-cm
margins and bilateral neck nodes, including the retropharyngeal and level II, III, and IV nodes. e target volume also
includes ipsilateral level IB in the presence of level II node(s).
For lateralized tumors, the target volume includes the ipsilateral tonsillar pillars, parapharyngeal space, and lateral aspect
of the pterygoid muscle.
e boost volume encompasses the primary tumor and
involved node(s) with 1- to 2-cm margins.
Setup and Field Arrangement for Conventional
Radiotherapy T
Insertion of metal seeds at the borders of the tumor, when
feasible, and marking of oral commissures and palpable
nodes facilitate portal shaping. e patient is immobilized
in a supine position with thermoplastic mask. An extended
head and shoulder mask is used for conformal radiotherapy.
With conventional technique, lateral parallel–opposed
photon elds are used to treat the primary tumor and upper
neck nodes (see Case Study 8-1).
• Anterior border: at least 2 cm anterior to the tumor.
• Superior border: at least 1.5 cm above the so palate. If the
primary tumor spreads into the tonsillar fossa, this border
echnique
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Part 2 Site-Specifi c Indications and Techniques
Case
Study
8-1
rior tonsillar pillar. The hard palate was not involved.
There were no palpable neck nodes. Biopsy showed
a moderately differentiated squamous cell carcinoma
(SCC). Stage: T2 N0 M0. This patient was treated with
primary radiotherapy according to the concomitant
boost regimen. The fields were designed to encompass
the primary tumor and upper neck nodes (Fig. 8.1).
The boost volume covered the primary tumor with
generous margins. The seed indicated the superior
and anterior border of the tumor on the palate. The
mid and lower neck nodes were treated through a matching anterior photon field with a midline block to shield
the larynx. The dose to the primary tumor was 70.5 Gy
in 41 fractions over 6 weeks. Areas of subclinical disease in the upper neck received 54 Gy in 30 fractions
over 6 weeks. The mid and lower neck received 50 Gy
in 25 fractions over 5 weeks. He had no evidence of
disease 5 years after therapy. However, there was a
slight retraction of the soft palate without functional
repercussion.
A 55-year-old man sought medical attention
for a 6-month history of sore throat.
Physical examination revealed a 3.5-cm
exophytic tumor of the uvula and soft palate
with minimal extension to the right ante-
Figure 8.1
is extended superiorly to encompass the medial pterygoid
muscle to the pterygoid plate.
• Posterior border: behind the mastoid tip when N0, behind
the spinous processes when N+, or more posteriorly in the
presence of large nodal mass.
• Inferior border: just above the arytenoids except when the
extent of nodal disease requires a lower inferior border.
A matching anterior appositional photon eld is used to treat
the mid and lower neck nodes when indicated.
For the boost volume:
• Lateral elds are reduced to cover the primary tumor with
1- to 2-cm margins
T1 and small, super cial T2 tumors, it may be preferable to administer the boost dose with an intraoral cone
when feasible (i.e., the lesion is accessible and the patient
can tolerate an intraoral cone without gagging) to reduce
treatment morbidity by limiting the dose to the mandible and so tissues (see Case Study 8-2). In such cases,
it is desirable to administer the boost dose rst while the
tumor is clearly visible and palpable. e introduction of
intensity-modulated radiation therapy (IMRT), which can
focus the boost dose to a small, well-de ned volume, has
reduced the need for intraoral cone irradiation.
(see Case Study 8-1). For selected
• Nodal metastases in the upper neck are encompassed in
the lateral portals. Nodes in the mid or lower neck can
receive boost dose with an appositional glancing photon
eld or electron portal.
Dose
For patients with T1 N0 and super cial T2 N0 tumors: conventional fractionation delivering 50 Gy in 25 fractions to
the initial target volume followed by a boost dose of 16 Gy
in 8 fractions by external beam or 15 Gy in 5 to 6 fractions
given by intraoral cone.
For patients with larger T2 N0 to N1 tumors or T3 to T4
tumors who do not receive systemic treatment: concomitant
boost schedule to total doses of 72 Gy in 42 fractions. e initial volume receives 1.8-Gy fractions to 54 Gy in 6weeks. e
boost volume receives an additional 1.5 Gy to a dose of 18Gy
given as second daily fractions during the last 2.5weeks of
the wide- eld irradiations. e spinal cord dose is limited to
45 Gy or less.
For patients with T3 to T4 or N2 to N3 tumors who receive
systemic therapy: options are (1) conventional fractionation
(70 Gy in 35 fractions over 7 weeks) with three cycles of
concurrent cisplatin or a er TPF induction chemotherapy
(± carboplatin), or (2) accelerated fractionation in 6 weeks,
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119
Case
Study
8-2
anterior faucial pillar on the le side (Fig. 8.2A). ere was
no palpable lymphadenopathy. Further examination was
unremarkable. Biopsy of this lesion showed poorly di erentiated carcinoma. Stage T2 N0 M0. He received treatment
A B
A 38-year-old man sought medical attention
because of a slight irritation behind the le jaw
and blood-streaked saliva.
Physical examination revealed a 2.5-cm
tumor at the junction of the so palate and
with an intraoral cone followed by external beam irradiation. A customized device was made to ensure reproducible
cone positioning (Fig. 8.2B,C). A 3-cm cone was used to
deliver irradiations with 125 KVp x-rays to a dose of 15Gy
in ve fractions (Fig. 8.2D). e remaining therapy was
given through an ipsilateral external beam portal. A combination of electrons and photons was used to administer
50 Gy in 25 fractions over 5 weeks. is patient was alive
and well 6 years a er completion of therapy.
C
Figure 8.2A-D
either by concomitant boost regimen (72 Gy in 42 fractions
as described above) or in 2-Gy fractions, 6 fractions per week
(1 day a week of twice-a-day irradiation), when combined
with two cycles of cisplatin or weekly cetuximab.
Intensity-Modulated Radiation Therapy
IMRT has now been widely adopted for the treatment of
patients with oropharyngeal carcinomas because of its
potential for exclusion of a large portion of at least one of
the parotid glands from the high-dose volume, thereby
reducing xerostomia without compromising the coverage
of the primary tumor and draining lymphatics. e patient
D
is immobilized in a supine position with an extended head
and shoulder thermoplastic mask. in-cut CT scans are
obtained in treatment position. e gross target volume
(GTV), CTVs, and planning target volumes (PTVs) are
outlined for dosimetric planning (see Case Study 8-3).
Gross Target Volume
GTV represents all areas determined from clinical examination and imaging studies to contain gross disease. It is very
important to integrate the physical examination ndings in
treatment planning as CT scan may not detect super cial
mucosal tumor extension.
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Case
Study
8-3
ferentiated SCC. Staging workup included a CT scan of the
head and neck, which showed a thickened so palate and a
1.5 cm le level II node. She was treated with IMRT delivered in 30 fractions.
CTVHD (66 Gy) encompassed the so palate and le
upper jugular involved node with margin. e remainder of le level II not included in CTVHD and le level
IB nodes were de ned as CTVID. e retropharyngeal
A 79-year-old woman presented with nasal
voice, mild bilateral otalgia, and a globus sensation. Physical examination revealed a 2.5-cm
exophytic lesion on the posterior aspect of the
so palate. A biopsy revealed moderately dif-
nodes and right level II nodal bed were delineated as
CTVED (54 Gy).
Figure 8.3A–D show CTVHD (red), CTVID (blue), and
(yellow) on representative axial cuts from the level
CTV
ED
of the retropharyngeal nodes and so palate superiorly and
to the hyoid inferiorly. Figure 8.3E,F: show the isodose distributions on two axial images through the palate.
e isocenter was placed above the thyroid notch, and
the low neck was treated with a matching anterior beam.
Alarynx block was used for the rst 40 Gy (Fig. 8.2G), and
then a full midline block was added for 10 Gy. e le mid
neck (level III) was boosted to 60 Gy with glancing photon
elds. e patient remained well without disease 5 years later.
A
C
Figure 8.3A-D
B
D
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121
E
G
Figure 8.3E-G
Clinical Target Volumes
ree CTVs are generally delineated.
• CTVHD delineates volumes to receive the highest dose,
which includes the primary and nodal GTVs with 0.5- to
1-cm margins. Margins should be more generous if the
tumor borders are less well de ned.
• CTV
delineates volumes to receive an intermediate dose,
ID
which includes the remaining so palate and the adjacent
parapharyngeal space. CTVID covers the superior aspect of
the tonsillar pillars for lateral tumors and, in the presence
of positive node(s), the adjoining nodal compartment(s).
• CTVED delineates volumes to receive an elective dose
for potential subclinical disease. In the N0 neck, CTVED
includes nodal levels II to IV and retropharyngeal nodes.
F
When level II node is involved, CTV
also includes
ED
clinically uninvolved ipsilateral level IB nodes.
Dose
For patients with T1 N0 and super cial T2 N0 tumors: 66 Gy
to CTVHD, 60 Gy to CTVID, and 54 Gy to CTVED, given in
30fractions over 6 weeks.
For patients with larger tumors who do not receive
systemic therapy: options are (1) 70 Gy to CTVHD, 63 Gy
to CTVID, and 56 Gy to CTVED given in 35 fractions over
6weeks (1 day a week of twice-a-day irradiation), (2) 70Gy
to CTVHD, 60 Gy to CTVID, and 57 Gy to CTVED given
in 33 fractions over 6.5 weeks, or (3) a concomitant type
regimen, which requires two IMRT plans (see IMRT Section
of Chapter 1).
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For patients with T3 to T4 or N2 to N3 tumors who
receive systemic therapy: options are (1) 70 Gy to CTV
HD
60Gy to CTVID, and 57 Gy to CTVED given in 35 fractions
over 7weeks combined with three cycles of concurrent cisplatin or a er TPF induction chemotherapy (± carboplatin),
(2)70 Gy to CTVHD, 63 Gy to CTVID, and 56 Gy to CTVED
given in 35 fractions over 6 weeks (1 day a week of twicea-day irradiation) when combined with two cycles of cisplatin or weekly cetuximab, or (3) 70 Gy to CTVHD, 60 Gy
to CTVID, and 57 Gy to CTVED given in 33 fractions over
6.5weeks combined with high-dose cisplatin.
Postoperative Radiotherapy
Adjuvant radiotherapy is indicated in occasional patients treated
with upfront surgery. e principles are similar to those for the
treatment of retromolar trigone or posterior oral cavity tumors
as presented in detail, including illustrative cases, in Chapter 6.
Target Volume
e initial target volume encompasses the entire surgical bed
and all nodal areas of the neck. e boost volume encompasses
areas of known disease location with 1- to 2-cm margins.
Setup and Field Arrangement
e general technique is the same as that described under
Primary Radiotherapy.” Marking of the external surgical
scar facilitates portal design. e anterior and superior eld
borders or CTVs are mainly determined by the local spread
of the primary tumor and the extent of surgery (scar/ ap).
,
It is prudent to include 1- to 2-cm margins beyond the
mucosalscar.
Dose
• A dose of 60 Gy in 30 fractions to areas with high-risk
features; that is, close or microscopically positive margins,
perineural extension, vascular invasion, positive nodes,
or extranodal extension. An additional boost dose of 6
Gy may be given when indicated, such as when multiple
adverse features are present or when the interval between
surgery and radiation is much longer than 6 weeks.
• A dose of 56 Gy in 28 fractions to the surgical bed.
• A dose of 50 Gy in 25 fractions to undissected regions to
receive elective irradiation.
Timing of Postoperative Radiotherapy
It is desirable to commence postoperative radiotherapy as soon
as possible a er healing of surgical wounds. With good communication between surgical, radiation, and dental oncologists,
simulation can usually take place 3 to 4 weeks a er surgery, and
radiotherapy can start within a week in most patients. When
delayed wound healing postpones commencement of postoperative radiation to beyond 5 to 6 weeks, we administer accelerated fractionation, such as concomitant boost, by delivering
twice-a-day irradiations for 5 treatment days, either once a
week or daily toward the end of the radiation course, to reduce
the potential hazard of prolonged cumulative treatment time.
Background Data
Table 8.6
Stage No. of Patients 5 yr (%)
T1 53 90–92
T2 111 67–90
T3 93 58–67
T4 34 37–57
Adapted from Keus RB, et al. Radiother Oncol 1988;11:311–317; and Chera BS, et al. Head Neck 2008;30:1114–1119.
Table 8.7
Primary Treatment No. of Patients (No. Controlled)
Surgery 2 (2) 9 (9) 12 (11) 4 (4) 1 (0) 28 (26)
Radiation 4 (3) 24 (21) 79 (60) 30 (23) 13 (4) 150 (111)
Surgery + radiation — 1 (1) 1 (0) 5 (3) 3 (2) 10 (6)
Total 6 (5) 34 (31) 92 (71) 39 (30) 17 (6) 183 (143)
Modifi ed from Weber RS, Peters LJ, Wolf P, et al. Squamous cell carcinoma of the soft palate, uvula, and anterior faucial pillar. Otolaryngol Head Neck Surg
1988;99(1):16–23.
Local Control of Soft Palate Tumors by T Stage
Therapy Modality and Outcome by T Stage
Stage
Tx T1 T2 T3 T4 Total
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123
TONSILLAR FOSSA
Treatment Strategy
Primary radiotherapy is preferred for T1 to T2 N0 to N1 carcinomas. Combination of radiation with systemic therapy
is the treatment of choice for T3 and selected T4 or N2 to
N3 tumors. As presented in Chapter 1, outside the protocol
study setting, the three currently available treatment options
established by randomized trials are radiation with concurrent cisplatin (either conventional fractionation plus three
cycles of cisplatin or accelerated fractionation in 6 weeks
plus two cycles of cisplatin), radiation with cetuximab (antibody against epidermal growth factor receptor), and a tripleagent induction chemotherapy regimen, referred to as TPF
(docetaxel, cisplatin, and uorouracil), followed by radiotherapy± carboplatin. Radiation with concurrent high-dose
cisplatin (100 mg/m2, given every 3 weeks) has the longest
track record and the strongest evidence-based results.
ere is now a consensus that patients presenting with
N2 to N3 nodal disease achieving a complete clinical and
radiographic response do not require a planned neck dissection. e value of PET-CT scan obtained 10 to 12 weeks
a er the completion of therapy in determining the need for
planned neck dissection for those with small, indeterminate
residual nodal mass on CT scan is being investigated.
T4a tumors with bone invasion, laryngeal dysfunction,
or severe trismus, for example, are best treated with surgery
followed by adjuvant radiotherapy and, in the presence of
extracapsular extension or positive margin, combined with
concurrent cisplatin.
Primary Radiotherapy
Target Volume
For the initial target volume:
• T1 and T2 (with limited extension to the so palate, and
no base of tongue involvement), N0 to N1 tumors: primary
lesion with 2-cm margins and ipsilateral retropharyngeal
and level II to IV nodes (Case Study 8-4). e target volume also includes ipsilateral level IB in the presence of
level II node(s).
• T2 (with base of tongue or signi cant so palate involve-
ment), T3 and selected T4 or N2 to N3 tumors: tonsillar
fossa, faucial pillars, so palate, base of tongue, medial
pterygoid muscle, and bilateral neck nodes (parapharyngeal–retropharyngeal, level II to IV, and ipsilateral levelIB).
For the boost volume: primary tumor and involved node(s)
with 1- to 2-cm margins.
Conventional Radiation Planning for Ipsilateral
Treatment (for T1 to T2 N0 to N1 Tumors)
Insertion of metal seeds at the borders of the tumor, when
feasible, and marking of oral commissures facilitate portal
shaping. e patient is immobilized in a supine position
Case
Study
8-4
nal margins a er additional resection were free. On presentation to our center, she had postsurgical changes without evidence of residual disease and was, therefore, staged
as having a Tx (pT1) N0 tonsil carcinoma. We elected to
treat this patient ipsilaterally with a wedged-pair technique,
using “ eld-in- eld” compensation (see Chapter 3). e
total dose was 66 Gy in 33 fractions.
Figure 8.4 shows that the initial volume encompassed
the tonsillar bed and upper neck, and was reduced a er
50Gy. is target (red) included the pterygoid muscle, parapharyngeal space, the lateral base of tongue, the lateral so
palate, and the ipsilateral retropharyngeal nodes. e boost
volume encompassed the tonsillar bed only (green). An axial
isodose distribution through the superior tonsillar region is
shown. e initial wedged-pair elds were matched above
the arytenoids to an anterior eld that covered ipsilateral
levels III and IV nodes to 50 Gy. She had no evidence of
disease and had no sequelae 2 years a er therapy.
A 47-year-old woman presented with a swollen right tonsil and, a er some delay, underwent tonsillectomy. Histologic examination
revealed invasive poorly di erentiated SCC
with lymphatic and perineural invasion. e
Figure 8.4
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