Neoadjuvant radiotherapy of head and neck carcinoma: an obstacle for plastic reconstruction?

Head and neck carcinomas often are at an advanced stage at the time of diagnosis and therefore frequently primarily hardly operable. A downstaging achieved by neoadjuvant radiotherapy can facilitate a radical tumor resection. Because of radiogenic tissue alterations like scarring and impairment of blood supply, elaborate operations, such as microsurgical reconstructions, are aggravated to a degree, and most surgeons consider them impossible. In this paper, we report our experiences with plastic-surgical reconstruction in patients with neoadjuvant pretreated head and neck carcinoma.In the last 6 years, eight patients with an advanced head and neck carcinoma were subjected to neoadjuvant radiotherapy followed by a radical tumor resection and reconstruction within the same session. Therefore, pedicled pectoralis flaps (in three patients), microvascular radialis flaps (two), lateral upper arm flaps (one), parascapular flaps (one), and a microsurgical anastomosed jejunal graft were used. The mean follow-up period was 44.5 months.The surgical postoperative course was uneventful in 75 % of patients (six out of eight). An anastomosis venous thrombose in one patient and a wound dehiscence in another required revision. In the end, a satisfactory result could be achieved in all the patients.Sophisticated reconstructions in irritated patients with ENT carcinoma are challenging; therefore, efficient interdisciplinary cooperation can overcome this obstacle.

Combined radiotherapy and razoxane in the treatment of chondrosarcomas and chordomas.

BACKGROUND: Chondrosarcomas and chordomas are reported to have low radio-sensitivity. Therefore, a study was undertaken to explore the radioresponsiveness of these tumours using the sensitising agent razoxane. PATIENTS AND METHODS: Thirteen chondrosarcomas and five chordomas were irradiated with high-energy photons and razoxane in the period from 1984 to 2003. The median tumour dose was 60 Gy in the chondrosarcomas and 63 Gy in chordomas. Razoxane tablets were given at a dose of 125 mg twice daily starting 5 days before the first irradiation. The drug was continued on radiation days. RESULTS: Eight out of the 13 chondrosarcomas had unresectable or recurrent measurable disease. There were one complete and five partial responses, while two tumours remained unchanged (response rate 75%). The median duration of response was 22 months. Three out of four patients without clear surgical margins and one patient with clear margins had locally controlled disease. Overall, local control was achieved in seven out of twelve patients who were not radically resected. All five patients with chordomas survived 5 years and remained locally controlled at that time. Among four measurable tumours, two complete and one partial regression were noted. Razoxane was well tolerated; the dose limiting toxicity was leukopenia. CONCLUSION: Photon irradiation together with razoxane induces major responses in a majority of patients with chondrosarcomas and chordomas. This combination therapy seems to be more effective than photon irradiation alone.

Radiotherapy and razoxane in advanced bile duct carcinomas.

OBJECTIVES: Little is known about the radiation sensitivity of bile duct carcinomas. The current study was undertaken to prospectively assess the objective response rates in bile duct carcinomas treated with radiotherapy and razoxane. MATERIALS AND METHODS: Twenty-three patients with advanced cancer of the biliary tree were irradiated together with the radiosensitizer razoxane at a dose of 125 mg twice daily by mouth. There were 16 females and 7 males, median age 68 years. They received a total tumor dose of 48 Gy (range 1.7-60) at the ICRU point with single fractions of 1.7 to 2 Gy. RESULTS: Among the 23 patients, 14 had measurable disease. Objective tumor responses were seen in 4/4 gallbladder carcinomas (1 CR, 3 PR), 4/5 extrahepatic cholangiocarcinomas (2 CR 2 PR), and 1/5 hepatobiliary cancers (1 PR), leading to an overall response rate of 64%. The tumors remained locally controlled in 12 out of 16 assessable patients (75%). On an intention-to-treat basis, all patients with different biliary cancer without distant metastases had a median-survival time of 10 months (range 1 to 48) from the start of the radiotherapy; the 1-year survival was 43%. No patient survived beyond 4 years. Tolerance to the treatment was fairly good. Nausea and vomiting of grade 1 and 2 (WHO) was noted in 61%, and reversible leukopenia of grade 3 and 4 in 9% of the cases. The rate of inherent complications was high. CONCLUSION: Combined radiotherapy and razoxane led to local response rates which are superior to data from the literature when radiotherapy alone is used. Obstacles to the treatment were complications of the disease and frequent metastasis.

A small prospective study of chordomas treated with radiotherapy and razoxane.

PURPOSE: To evaluate the local effect of conventional photon irradiation in chordomas if the radiosensitizing agent razoxane is added. The rationale for this procedure were improved results previously seen in soft tissue and chondrosarcomas with this combination. PATIENTS AND METHODS: Between 1988 and 1996, five patients with histologically confirmed chordomas of the skull base or the spine (three females, two males) were irradiated with 6- and 25-MeV photons under razoxane medication, one patient was treated with a telecobalt unit. Single doses of 180-200 cGy were given five times a week. The median total tumor dose was 63 Gy (range 54-67 Gy). Concomitantly, the radiosensitizer razoxane was administered at a dose of 125 mg twice daily p.o., median total dose 7.6 g. The drug was started 3-5 days before the first irradiation, and continued until the end of radiotherapy. RESULTS: After a potential median follow-up time of 10 years, three of the five patients are alive and show neither symptoms nor signs of recurrence in CT or MR images. One patient with persistent sacral chordoma died after 8 years from cardiac insufficiency, and another patient died after 6.5 years from a bleeding complication following surgery for recurrence. The patients remained locally controlled for 5, 5.5+, 6.4, 11+, and 13+ years, respectively. Objective tumor regressions were noted in three of four patients with measurable disease. Acute side effects included mucosal reactions, two of five patients developed a leukopenia WHO grade 3 due to razoxane. Serious long-term complications were not observed. CONCLUSIONS: Although the patient series is small, there is an interesting trend in local control and survival. The cases are unselected, and the follow-up time is of considerable duration. The treatment can easily be performed at any institution and is tolerated fairly well.