Patients and Methods
Between 1993 and 1998, 52 patients with advanced oral-cavity tumours were treated. There were 44 males and 8 females at a mean age of 63 years. The most frequent tumour sites were the floor of the mouth (16) and mandibula (10), and 15 patients had polytopic manifestations. Thirtynine patients (75%) had a T4-stage tumour (see Figure 1), 49 were nodalpositive (94%) and 33 patients had a G3-tumour. In 60% of the cases, difficulties in swallowing led to the final diagnosis; in a further 27%, pain was reported. In the patient history, at least 87% of patients either were smokers or consumed alcohol; in 46%, a combined misuse was apparent. Radiotherapy was performed up to a total dose of 36Gy at single doses of 2Gy, five fractions a week. Radiotherapy was combined with one cycle of cisplatin (12.5 mg/sqm, days one to five) chemotherapy. Radical surgery was performed approximately three weeks after completion of radiochemotherapy. The tumour was resected with a security margin of 1cm; lymph nodes were removed with a neck dissection. Forty-eight patients underwent radical surgery: in 41 cases with R0-status, two patients had an R1-resection and five patients had an R2-resection. Patients with R1- or R2-status, N2 nodal involvement or lymphangiosis carcinomatosa continued radiation therapy up to a total dose of 66–70Gy. Twenty-two patients continued radiotherapy after surgery; 30 patients had only follow-up examinations. All of the patients were followed up in the author’s institution and in the facial surgery department. Quality of life was scored in orientation to the Eastern Co-operative Oncology Group (ECOG) score by an individual scaling of the general performance status and the capability to speak and swallow.
Results
Three years after therapy, 33 of 52 patients (63.5%) were alive, and after five years 19 of 33 evaluable patients (57.6%) were still alive. There was a steep decline in survival rate between the first and the second year in follow-up, from 83 to 67% overall survival. Divided in orientation to negative prognostic factors leading to continuation of radiotherapy, 22 of 30 only pre-operatively treated patients (73.3%) survived more than five years, whereas only 8 of 22 patients (36.4%) treated post-operatively by radiotherapy or not radically resected patients survived five years. Seven patients (14.6%) had a local recurrence. Six of seven local recurrences occurred in the first two years after surgery in the original tumour site. Related to the number of R0-resections, in only four of 41 cases (9.8%) the tumour locally recurred.
Side effects of radiotherapy according to Radiation Therapy Oncology Group (RTOG) scoring were minor: only one patient (1.9%) had grade 3 toxicity. Of 48 patients, nine (18.7%) had no surgical complications. In 39 patients, however, there were surgical complications such as necrosis, inadequate wound healing or severe infection. Long-term quality of life was good in only 14 patients (29.2%); all the other patients (70.8%) suffered from impaired quality of life. The main problems were difficulties in speaking and pronunciation (69%), swallowing (60%) and reduced performance status (39%).
Discussion
Pre-operative radiochemotherapy in advanced oral-cavity carcinomas with subsequent radical surgery is an effective treatment in terms of long-term survival. Historical papers indicated a five-year survival rate of only 14–43% for oral-cavity carcinomas.1–3 With the introduction of neoadjuvant radiochemotherapy with subsequent radical surgery, the five-year-survival rate, with the protocol used at the author’s clinic, raised this to 71%.4 The treatment is, however, burdened by lasting impaired quality of life. Owing to the vital indication, this treatment is justified after obtaining informed consent of the patient. The extent of the radical surgery is, however, debatable. By introducing neoadjuvant treatment and the application of radiotherapy and chemotherapy prior to surgery, minor mutilation should be a goal for surgeons. High scientific priority should hence be directed to an improvement of surgical techniques and capable new chemotherapy agents in neoadjuvant protocols. This should lead to a steady improvement of quality of life in these patients. Quality of life questionnaires should be part of the tumour treatment and should be a secondary end-point to measure the success of tumour treatments.5 Five-year survival rate and local recurrence are, when taken alone, not sufficient end-points to describe the effectiveness of tumour treatment6 and should therefore be augmented by data concerning therapy-related toxicity and long-term quality of life in our patients.