Thyroid function should be monitored following radiotherapy to the low neck.

The purpose of this study was to determine whether the incidence of hypothyroidism following radiotherapy (RT) to the low neck is high enough to justify the routine monitoring of thyroid function in asymptomatic patients. A retrospective study of 504 patients with head and neck cancer whose RT fields included the thyroid gland was conducted. Patients were treated either with definitive or postoperative RT. Hypothyroidism was defined as a thyroid stimulating hormone (TSH) level > or =4.5 mIU/L, regardless of whether the patient had clinical symptoms. Of the 504 total patients, 206 had a serum TSH level checked at some point posttreatment. If we assume that patients who had no data did not have hypothyroidism, the actuarial freedom from hypothyroidism in the entire group was 78% at 5 years and 51% at 10 years. Of the 206 patients who had a documented posttreatment TSH, the actuarial freedom from hypothyroidism was 58% at 5 years and 26% at 10 years. Univariate analysis and multivariate analysis confirmed treatment modality to be a significant predictive factor. Definitive initial surgery that removed part of the thyroid gland increased the risk of developing hypothyroidism. Overall stage was also predictive on multivariate analysis. Head and neck irradiation results in biochemical hypothyroidism in at least 50% of patients. Thyroid function should be tested on a regular basis following RT to the low-neck region. Serum TSH should be checked every 6 months for the first 5 years and yearly thereafter. Thyroid hormone replacement should be initiated in any patient with a TSH of more than 4.5 mIU/L.

Long-term results of radiotherapy for early-stage testicular seminoma.

PURPOSE: We conducted an outcome and complications analysis of patients treated with adjuvant radiotherapy (RT) for early-stage testicular seminoma over a 35-year period at the University of Florida. METHODS AND MATERIALS: All 73 patients had the classic seminoma histology. No patient received chemotherapy as initial treatment. There were 57, 14, and 2 patients with Royal Marsden stage I, IIA, and IIB disease, respectively. All received RT to the paraaortic (PAN) and pelvic fields. One-third of the patients received prophylactic RT to mediastinal/supraclavicular fields. RESULTS: Median follow up was 15 years. Median RT dose to PAN and pelvic fields was 25 Gy. Local control and cause-specific survival at 20 years were 95% and 96%, respectively. Of the 3 recurrences, 1 was salvaged with chemotherapy. Subset analysis of 41 patients revealed 1 patient who developed peptic ulcer disease and 11 patients with gastrointestinal reflux symptoms after RT. Thirty-two patients fathered a child before or after RT. Cardiovascular complications were not greater in those treated with prophylactic RT to the mediastinal region. The rate of nontesticular second malignancy for the overall group was 8% at 15 years. CONCLUSIONS: Patients treated with adjuvant low-dose RT to the paraaortic and pelvic fields for treatment of early-stage seminoma enjoy an excellent long-term cure rate with minimal risk of late RT complications.

Carcinoma of the skin with perineural invasion.

PURPOSE: To evaluate the outcome and patterns of relapse in patients treated for skin carcinoma of the head and neck with either microscopic or clinical perineural invasion. METHODS AND MATERIALS: Radiotherapy alone or combined with surgery was used to treat 135 patients with microscopic or clinical evidence of perineural invasion of skin carcinoma. All patients had at least 2 years of follow-up. RESULTS: The 5-year local control rates without salvage therapy were 87% with microscopic perineural invasion and 55% with clinical perineural invasion. Overall, 88% of the local failures occurred in patients with positive margins. Almost half of the recurrences in patients with microscopic perineural invasion were limited to the first-echelon regional nodes. However, only 1 of 11 patients with basal cell carcinoma with microscopic perineural invasion had a nodal failure. Ninety percent of recurrences in patients with clinical perineural invasion occurred at the primary site. Cranial nerve deficits rarely improved after successful treatment of the primary disease. Radiographic abnormalities remained stable 30% of the time when patients had clinical evidence of progressive disease. CONCLUSIONS: Radiotherapy in patients with skin cancer with clinical perineural invasion should include treatment of the first-echelon regional lymphatics. The risk of regional node involvement is also relatively high for patients with squamous cell carcinoma with microscopic perineural invasion. In patients with clinical perineural invasion, the poor local control rates with conventional radiotherapy suggest a need for dose escalation with or without concomitant chemotherapy.

Management of neurotropic low-grade B-cell lymphoma: report of two cases.

BACKGROUND: Low-grade lymphomas do not commonly involve the central or peripheral nervous system. METHODS: Case report and review of the literature of two cases of B-cell lymphoma of the extranodal marginal zone type involving the head and neck region with evidence of extensive neurotropism are detailed in this report. RESULTS: One patient was initially seen with a mass in the temporalis muscle and the other with a masticator space mass. The clinical course was indolent in both cases, although associated imaging studies suggested a more aggressive tumor. Both patients were treated with moderate-dose radiotherapy only. At the time of writing, one patient has no evidence of disease 6.5 years after treatment and the other at 6 months. CONCLUSIONS: This suggests that some marginal zone lymphomas exhibit a low-grade clinical course despite an aggressive radiographic pattern of perineural and neurotropic spread. This type of lymphoma might be effectively treated with moderate-dose radiotherapy.

Radiotherapy for carcinoma in situ of the true vocal cords.

PURPOSE: To report long-term rates of tumor control after radiotherapy (RT) for carcinoma in situ (CIS) of the true vocal cords (TVC). A comprehensive literature review was performed, and outcomes with other modalities of treatment for CIS of the TVC were compared. METHODS AND MATERIALS: Thirty patients with CIS of the TVC were treated between July 1967 and May 1998 with curative intent using megavoltage RT. Most patients (28 of 30) were treated with cobalt-60 through small (usually 5 x 5 cm) fields. Median RT dose was 56.25 Gy (range, 56.25-75 Gy; mean dose, 59.15 Gy) at 2.25 Gy per fraction. One patient was treated for a synchronous head and neck primary malignancy with large fields to a total dose of 75 Gy at 1.8 Gy per fraction. Approximately two thirds of the patients (19 of 30) were referred for RT because of recurrence after at least one stripping procedure. RESULTS: With a mean follow-up of 7.1 years (range, 2-17 years), the 5-year rates of local control, local control with larynx preservation, and ultimate local control (including salvage surgery) were the following: 88%, 88%, and 100%, respectively. Invasive squamous cell carcinoma developed in three (10%) of the patients. Time to failure was 14 months, 34 months, and 48 months, respectively. All three patients were surgically salvaged with a total laryngectomy. Cause-specific survival at 5 years was 100%. There were no late complications. CONCLUSIONS: RT to approximately 60 Gy at 2.25 Gy per fraction using small (5 x 5 cm) fields produces excellent results with CIS of the TVC.