13 Oropharynx

284 Oropharynx

haemorrhage is exceptional but has to be anticipated, and presence of two persons is recommended. It is also prudent to put an intravenous access before removing the implant. In case of bleeding eight to 10 min bimanual compression usually effectively stops arterial bleeding. Mucositis develops 1 - 2 weeks after brachytherapy. The reaction is maximal after 3 - 4 weeks, and heals progressively in 5 - 8 weeks. Mouth washes, analgesics, and adapted alimentation should be given. 11 Results T1 - 3 squamous cell carcinomas of the base of tongue can be treated by surgery followed by radiation therapy, by external radiation followed by interstitial implant or by external beam irradiation alone. In a retrospective analysis of results obtained with these three modalities in 110 T1 - 2 squamous cell carcinoma of the base of tongue at the same institution (Necker Hospital, Paris), local failure occurred twice as often in patients treated by external beam alone (43%) compared to the other two modalities (20.5% for external beam radiation followed by brachytherapy and 18.5% for surgery plus irradiation) (8). The 5-year survival rate for N0-1 patients was 30.5% for patients treated by external beam irradiation alone and 50% with the other two methods. Similar conclusions were drawn from another retrospective single-institution comparison of these three modalities in 131 T1 - 4N0 - 3 squamous cell carcinoma of the base of tongue (Centre Alexis-Vautrin) (9). Five-year local control rates were 39%, 32%, and 19%, and five-year overall survival rate, 45%, 44%, and 19%, respectively. Reguiero et al reviewed 65 patients with T1 - 3 squamous cell carcinomas of the base of tongue (1). Thirty-five patients were treated with external irradiation alone, and 30 with external irradiation plus brachytherapy boost. The 3-year relapse-free survival rates were 67% and 42% (p < 0.05), respectively. By contrast, others, including Foote et al in the University of Florida, concluded, reviewing the results achieved with external beam irradiation alone in 84 patients with T1 - 4 squamous cell carcinomas of the base of tongue, that interstitial implantation is not essential for the successful radiotherapeutic treatment of base of tongue (4). Table 12.1 summarizes local control and complication rates obtained with combined external beam radiotherapy and brachytherapy boost according to TNM classification. At Memorial Sloan-Kettering Cancer Centre, New York, a retrospective analysis compared results of external beam irradiation followed by interstitial implant (30 patients) and primary surgery followed by external beam irradiation (10 patients) for T1 - 4 squamous cell carcinoma of base of tongue. Similar local control rates (80-90%) were observed, but consistently better performance status score and quality of life, as seen with primary radiation therapy (5). A dose response relationship was observed in T1 - 2 squamous cell carcinoma of the base of tongue at the Henri Mondor hospital (Créteil, France), with local control rate of 79% (26/33) obtained with a combined dose > 75 Gy, but only 50% (4/8) with < 70 Gy (1). It was then recommended that T1 - 2 (and some limited T3) tumours of the base of tongue should be treated with 45 - 50 Gy radiation or chemoradiation followed as soon as possible by a 30 - 35 Gy interstitial boost. For node positive patients, a 20 - 30 Gy electron boost is added to the involved nodes or a neck dissection is performed. With such strategy, a local control rate of 80 - 90% can be expected in T1 - 2 tumour patients with a 5-year overall survival rate of about 50%, and with the occurrence of a temporary late necrosis of the mucosa in about 25% of cases (1, 5, 6,16). The largest experience with exclusive irradiation including an interstitial implant for T1 - 3 squamous cell carcinoma of the velotonsillar area was accumulated in Nancy, France (15). Patients were treated with brachytherapy alone (18) or with a combination of external beam irradiation (343 patients) and using an afterloading interstitial technique with plastic tubes. Five-year and 10-year local control rates were 80% and 74%, and overall survival rates 53% and 27%, respectively.The