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Controversies Management of Tonsil Cancer

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Controversies Management of Tonsil Cancer CONTROVERSIES Ramon M. Esclamado, MD, Section Editor MANAGEMENT OF TONSIL CANCER Consultants: Carol R. Bradford, MD, Neal Futran, MD, DMD, Glenn Peters, MD A 43-year old man is examined for evaluation of nous primaries are seen in the upper aerodiges- a persistent, right-sided sore throat for 4 months, tive tract and esophagus. The biopsy is positive and a painless, slowly enlarging right neck mass for invasive moderately well-differentiated squa- for 3 months. On further questioning, he has right mous cell cancer, therefore staged as T2 N2a M0. otalgia, but denies dysphagia, odynophagia, he- moptysis, hoarseness, or weight loss. He has a 40 1. What treatment options are available pack/year smoking history, but is otherwise in for this patient that can be offered outside of good health. a clinical trial? Physical examination revealsa3cm×3cm exophytic mass involving the right tonsillar fossa and posterior tonsillar pillar. There is no trismus, Dr. Bradford: This 43-year old male with a T2 the tongue base and soft palate are not involved, N2a M0 moderately differentiated squamous cell and his teeth are in good repair. The remainder of carcinoma of the right tonsillar fossa could be the head and neck examination is remarkable treated either with primary surgery plus postop- only for a firm, freely mobile 4 cm×4cmright erative radiation therapy or radiation therapy level II lymph node. primarily followed by a modified neck dissection. A chest radiograph is normal, and a neck CT is A third alternative would be radiation therapy shown in Figure 1. Examination under anesthe- alone and close monitoring of the primary site sia confirmed the above findings, and no synchro- and neck. Dr. Futran: Treatment options include (1) ex- Readers are invited to submit particularly difficult cases for consideration ternal beam radiation therapy alone to the pri- to Ramon M. Esclamado, MD, Editor, Controversies, Department of Oto- laryngology and Communicative Disorders/A71, The Cleveland Clinic mary lesion and both sides of the neck followed by Foundation, 9500 Euclid Avenue, Cleveland, OH 44195. right modified neck dissection, (2) external beam From the Department of Otolaryngology, University of Michigan Medical radiation therapy as above with brachytherapy to Center, Ann Arbor, Michigan (Dr. Bradford); the Department of Otolaryn- gology, University of Washington, Seattle (Dr. Futran); Division of Otolar- the primary site followed by right modified radi- yngology, University of Alabama, Birmingham (Dr. Peters). cal neck dissection, (3) surgical extirpation of the Accepted for publication April 27, 1999. primary lesion with a modified radical neck dis- Head & Neck 21: 657–662, 1999 section and likely flap reconstruction followed by external beam radiation therapy, or (4) for T2 le- CCC 1043-3074/99/0070657-06 © 1999 John Wiley & Sons, Inc. sions, I do not recommend chemotherapy con- Management of Tonsil Cancer HEAD & NECK October 1999 657 most tonsillar fossa tumors are moderate- to well- differentiated lesions, the degree of differentia- tion would not significantly influence my decision making. (4) The presence of clinical trismus asso- ciated with the tumors suggests pterygoid muscle involvement and would influence me toward a primary surgical treatment plan. Dr. Peters: Although there is considerable ef- fort being put forth trying to identify pretreat- ment prognostic indicators, at this point in time I still rely chiefly on the clinical stage in making treatment recommendations. Despite the obvious weaknesses and shortcomings that exist with the current staging system, there has not yet been FIGURE 1. Axial CT scan with contrast demonstrating level II identified a reliable biologic or molecular marker node with superficial primary tumor and no pterygoid muscle of to assist us in making these decisions. mandible involvement. Dr. Bradford: A lymphoepithelioma or poorly comitant with radiotherapy or as an adjunct to differentiated carcinoma of the tonsillar fossa radiation therapy. should be more radiosensitive than moderately or well-differentiated tumors. A thin or exophytic tu- Dr. Peters: Outside of a protocol setting, the mor probably also would be more radiosensitive. treatment options include radiation therapy or These factors would include my decision to treat surgery. I would be reluctant to use chemo- with primary radiotherapy, particularly the lym- therapy as an additional treatment modality un- phoepithelioma histology. less the patient was on a protocol of some sort. Radiation could be given as a single daily fraction, 3. Assuming that the patient has no treat- but I feel that this patient would likely receive an ment biases, what would be your treatment accelerated fractionation treatment program recommendation? (BID, concomitant boost, etc.). Surgery would in- clude resection of the primary along with neck Dr. Peters: I think that this is an ideal patient dissection and free flap reconstruction. The need for which I would recommend treatment on a pro- for postoperative radiation would be assessed tocol using combined modality chemotherapy and based on the path report. radiation therapy with surgery held in the sal- 2. Are there any tumor characteristics vage mode. If protocol treatment is not an option, that are helpful in determining a preferred then I would recommend accelerated fraction ra- treatment option? diation therapy, again with surgery held for sal- vage. The patient would be followed very closely Dr. Futran: (1) Location of the tumor in the during therapy, monitoring him for an objective tonsillar fossa: tumors located within the tonsil- response at the end of two cycles of chemotherapy lar fossa tend to have a higher rate of metastasis or 50 Gy of radiation. If an appropriately good than tumors arising from the anterior pillar, but response is noted, then I would feel fairly comfort- also tend to be more radiosensitive. Tumors aris- able in continuing nonsurgical therapy to its ing from the anterior tonsillar pillar tend to be completion. If a less than adequate response is more well differentiated and may extend to the seen in this patient then we would go on to sur- retromolar trigone, making surgery a more at- gery. At the conclusion of therapy, any remaining tractive primary option. Further, if the tumor ex- mass in the neck, demonstrated either by physi- tends onto the tongue base, primary radiation cal examination or CT, would need to be removed therapy has a poorer control rate and would with a neck dissection. I have been using selective influence me to use surgical extirpation as the neck dissections (leaving level V undissected) primary option. (2) Several studies suggest that more in this setting as I have found a large num- exophytic tonsil tumors are much more radiosen- ber of patients who have pathologically negative sitive than ulcerated or indurated tumors. (3) As necks. Another important aspect of treatment is 658 Management of Tonsil Cancer HEAD & NECK October 1999 nutrition and I would place a PEG prior to the mary tumor, the ultimate functional result would initiation of any therapy. be better. My reason for choosing this treatment ap- proach is that it provides the patient with the best 4. If surgery followed by postoperative chance for preserving nearly normal swallowing radiation was recommended, how would the and speech. As long as the patient is monitored primary tumor be approached, and what closely and his response to therapy is carefully type of neck dissection would you perform? established I do not feel that oncologic control is compromised. Dr. Bradford: The specifics of this treatment approach are as follows. I have a very low thresh- old for mandibulotomy to improve visualization Dr. Bradford: The advantage of surgery and for surgical extirpation. In a teaching environ- postoperative radiation therapy is that both the ment, the mandibulotomy combined with lip split primary site and neck receive combined modality provides excellent exposure with minimal mor- treatment. Historically, tonsillar fossa lesions bidity. One can fashion the mandibulotomy to have been treated with radiation therapy primar- preserve mental nerve continuity. A stairstep ily. However, several reports indicate that such mandibulotomy is planned medial to the mental an approach may decrease locoregional control.1,2 foramen. Prior to bony cuts, a 3D, high profile, 2.0 Given the improved results for reconstruction fol- mm plate is fashioned with three bicortical screws lowing surgical excision of tonsillar carcinomas, I on either side of the planned mandibulotomy. The favor an approach that involves primary surgery lip split incision is performed in the midline with followed by postoperative radiation therapy. An- a step at the vermilliocutaneous junction and a other factor in this treatment preference is the Z-plasty between this junction and the chin opportunity for an in-continuity neck dissection. crease. I prefer the chin to be split in the midline There is very little distance between the primary rather than around the chin subunit. If the pa- site and the level II lymph node on this CT scan. tient does not have tight dental junctions, one can On several occasions we have identified high ret- perform the mandibulotomy between teeth (usu- ropharyngeal nodes that were positive for squa- ally between the canine and lateral incisor). The mous carcinoma on histopathologic analysis. Re- lingual nerve can be preserved provided it is not section of these nodes followed by postoperative involved with tumor, although this does limit the radiation therapy seems to provide the best swing of the mandible. Radical resection of tumor chance for locoregional control of disease. Fur- can then be accomplished with 2-cm margins and thermore, histopathologic analysis of the lymph frozen section control. nodes provides an opportunity to enroll patients The neck dissection I would recommend for a in randomized prospective protocols comparing 4-cm jugulodigastric node is a modified versus a radiation therapy to chemotherapy plus radiation radical neck dissection. I would plan to sacrifice therapy for high-risk pathology (numerous posi- the sternocleidomastoid muscle.
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