Evaluation of Elective Irradiation of the Neck for Squamous-Cell Carcinoma of the Nasopharynx, Tonsillar Fossa, and Base of Tongue

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Abstract
The value of preventing metastases to the lymph nodes of the neck in carcinoma of the nasopharynx, tonsillar fossa, and base of tongue by either surgical removal or sterilization of microscopic disease with radiation has been much debated. Radical neck dissection or irradiation of the neck without clinically palpable nodes has often been referred to as “prophylactic” management. However, “elective” management is conceptually more correct, and the purpose of this paper is to analyze experience acquired with elective irradiation of the neck to determine if this is a useful and safe technic in cancers with high metastatic aggressiveness. Review of the Literature A few reports were found in the literature on “prophylactic irradiation” of the neck for carcinomas arising from the lip and oral cavity (2, 4, 8, 10, 11, 14). The consensus among the several authors was that there is no difference in either the subsequent development of neck nodes or the five-year survivals when the groups with “prophylactic irradiation” are compared to those without it. The dosages used for “prophylactic irradiation,” however, were considerably less than what is now thought necessary for the eradication of microscopic disease. Baclesse (1) and Lederman (9) indicate that the entire neck from the mastoid tips to the clavicles must be irradiated in those cases where the carcinomas arise from the nasopharynx and oropharynx. However, they offer no evidence to show that this practice is of value. Clinical Material The carcinomas arising from the nasopharynx, tonsillar fossa, and base of tongue, as a rule undifferentiated tumors, have a high incidence of neck metastases. In the M. D. Anderson Hospital and Tumor Institute they have been managed originally with frequent and later with systematic elective irradiation of the neck. The anterior tonsillar pillar and retromolar trigone lesions are more keratinizing, with a 45 per cent metastatic rate, as compared to 75 per cent for those from the tonsillar fossa. Therefore, elective lower-neck irradiation for these tumors is reserved for cases with involvement of the upper neck. The metastatic rate is about 50 per cent in pharyngeal wall tumors. The elongated parallel opposed portals required for treatment of the primary neoplasm necessarily cover the majority of neck nodes. In 1962, 281 case histories (1948 to Dec. 31, 1960) were reviewed, and failures (i.e., local recurrence, uncontrolled neck disease, and distant metastases) were tabulated by site. Since the great majority of neck recurrences or extensions appear within two years, this is a satisfactory follow-up for the patients admitted in 1960.

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