Brachytherapy versus surgery in carcinoma of tonsillar fossa and/or soft palate: late adverse sequelae and performance status: can we be more selective and obtain better tissue sparing?

To report on the tumor control, adverse late normal tissue sequelae, and functional performance in patients with tonsillar fossa and/or soft palate (SP) tumors. The aim of the study is to validate the use of a more selective clinical target volume in conjunction with highly conformal radiotherapy (RT) techniques to better spare the surrounding normal tissues. Between 1986 and 2001, T1-T3 tonsillar fossa/SP tumors were treated in the Erasmus Medical Center using external beam radiotherapy (EBRT) to 46 Gy in 2-Gy fractions to the primary tumor and neck, followed by brachytherapy (BT) to the primary. Neck dissection was performed for node-positive disease (BT group; 104 patients). If BT was not feasible, patients underwent surgery and postoperative RT (PORT) to a dose of 50–70 Gy in 2-Gy fractions (surgery group; 86 patients). Local control, regional control, disease-free survival, and overall survival were determined. Late side effects were scored using the Radiation Therapy Oncology Group criteria. Univariate and multivariate Cox regression analyses were performed for regional failure (RF), with the parameters gender, age, site, TN stage, modality, dose, and overall treatment time. Recurrences in the contralateral neck were also related to significant ipsilateral involvement of the base of tongue and/or involvement of the SP crossing the midline. To determine the performance status scale scores and degree of xerostomia, a survey was conducted among patients living with no evidence of disease and a minimum of 2 years of follow-up. For that purpose, a research nurse interviewed patients regarding eating in public, normalcy of diet, normalcy of speech, and xerostomia. The tumor control rates after BT vs. surgery at 5 years were 88% vs. 88% for local control; 93% vs. 85% for regional control; 57% vs. 52% for disease-free survival; 67% vs. 57% for overall survival; and 5% vs. 6% for RF. No patient had RF in the contralateral untreated N0 neck (0 of 14 vs. 0 of 15). Multivariate Cox regression analysis for RF was statistically significant for Stage T2 vs. T3 (hazard ratio 0.09) and for the dose to the neck >46 Gy (hazard ratio, 8.7; 95% confidence interval, 1.3–57.1). The significant late side effects in the BT group vs. surgery group were ulcer in 39% vs. 7% ( p = 0.001) and trismus in 1% vs. 21% ( p = 0.005). The performance status scale scores and response to questions regarding xerostomia for BT vs. surgery revealed no statistically significant differences fo