In response to Dr. Vikram

Correspondence M. F. KARIU, M.D., F.R.C.R., PH.D. Academisch Ziekenhuis Vrije Universiteit Department of Radiation Oncology 1007 MB Amsterdam. The Netherlands A. B. 1. Parsons, J. T.; Mendenhall, W. M.; Stringer, S. P.; Cassisi, N. J.; Million, R. R. Salvage surgery following radiation failure in squamous cell carcinoma of the supraglottic larynx. Int. J. Radiat. Oncol. Biol. Phys. 32605~609; 1995. 2. Karim, A. 8. M. F.; Kralendonk, J. H.; Njo, K. H.; Tierie, A. H.; Hasman, A. Radiation therapy for advanced (T3T4N~N3MO) laryngeal carcinoma: The need for a change of strategy: A radiother apeutic viewpoint. Int. J. Radiat. Oncol. Biol. Phys. 13: 1625- 1633; 198-l. 971 complete response after 5 weeks should be considered for elective surgery, even if they subsequently do achieve complete response. We would be most interested to learn if Jaulerry et a!. ‘s patients who exhibited complete response after 5 weeks had an outcome appreciably better than those who achieved complete response at a later time also. BHADRASAIN VIKRAM, M.D. Department of Radiation Oncology Montefiore Medical Center Albert Einstein College of Medicine It I East 210th St. Bronx, NY 10467 1. Jaulerry, C.; Dubray, B.; Bmnin, F.; et aI. Prognostic value of tumor regression during mdi~r~y for head and neck cancer: A prospective study. Int. J. Radiat. OncoI. Biol. Phys. 33(2):271279; 1995. V&ram. B.: Mahunud. S.: Gold. J.: Nussbaum. M.: Kimmelman, C.; Lucente, F.; Pa&m, W.; P&h, J.; Chad& M.; Beattie, E. Chemotherapy rapidly alternating with accelerated radiotherapy for advanced carcinomas of the hypopharynx and upper esophagus: A feasibility study. Head Neck 13:415-419; 199 I. 3 Yu, L.; Vikram, B.; MaJamud, S.; Yudetman, 1.; Nussbaum, M.; Beattie, E. Chemotherapy rapidly alternating with twice-a&y accelerated radiation therapy in carcinomas involving the hypopharynx or esophagus: An update. Cancer Invest. 13567-572; 1995. 2. IN RB%‘ONSE TO DR. KARIM To rhe Editor: Dr. Karim has directed our attention to several papers (a few of which were aheady cited in our paper) that address the efficacy of salvage surgery following failure of irradiation to control supraglottic laryngeal cancer. Most of the papers include a sentence or two, or at best, a paragraph or table, detailing the control rates after salvage surgery. Little or no mention is usually made in these papers of the number of patients who experienced failure, the number of salvage procedures performed, the reasons for exclusion from surgical salvage, the length of follow-up after “successful” surgicaJ salvage, the 5-year survival pmbabili~ after surgery, the difficulties encountered in obtaining a positive biopsy after high-dose irradiation, the anatomic sites of failure after salvage surgery, tumor control results according to status of surgical margins, rates of salvage according to time to local failure, or how the neck was treated, Our statement that “most series contain few details of the subsequent clinical course of patients whose primary cancer was not controlled by irradiation” is accurate (Dr. Karim slightly misquoted our statement in the first paragraph of his Letter to the Editor). Incomplete reporting of the test&s of salvage treatment is common not only to supraglottic laryngeal cancer but to a number of other primary tumor sites as well. JAMES T. PARSONS, M.D. WILLIAM M. ME~DE~HALL, M.D. Department of Radiation Oncology University of Florida College of Medicine Gainesville, FL 32610-0385 PROGNOSTIC VALUE OF TLIMOR REGRESSION DURING RADWFEEMPY OR CVOTHRRAPY FOR ADVANCED HEAD AND NECK CANCERS: RRGARDING JAULERRY ET AL. IJROBF 33(2):271-279; 1995 IN RESPONSE TO DR. VWRAM To the E&oc We thank Dr. V&ram for his intereat in our pmapective study of tumor regression during exclusive tadifor head and neck cancer f 1). We are pleased to answer his question regarding a possible difference in outcome for the patients achieving a complete tumor regression either at week 5 of irradiation (CR,) or at the end of treatment (CR.,). Our total study population comprised 228 Tl-T4 patients. Among them, 29 had CR, and 94 experienced CR., after incomplete response at 5 weeks. The actuarial pmbabihties of loco-regional control at 2 years were 93% and 73% respectively (p logrank = 0.06). When the analysis was limited to T3-T4 patients, 5 CR5 and 30 CR, were recorded. The 2-year loco-regionaJ control probabiiities were tOO% and 64%, respectively, and the difference was not significant fp logrank = 0.5). We also looked at the T3-T4 patients who achieved a major response at 5 weeks fz 75% in volume, FAR,) or at the comber d therapy (UK,). The Z-year loco-regionaJ control agilities were 75 ( 5 1 MR,) and 49% (47 ML) with a p value of 0.06. Consistent with Dr. Vikram’s observation, our data suggest a trend towards better outcome for the patients experiencing an early response (either CR or MR) to exclusive radiotherapy. However, statistical significance was never reached, although borderhne p values were obtained. This may be due to the low statistical power resuhing from the small patient numbers. The early delivery of chemotherapy in Dr. V&ram‘s patients may have also contributed to the seiection of patients witb better prognostic features. M.D.* CHRISTEAN JAULERRY, To zhe .&&or: Jaulerry et al. ( 1) report an interesting study wherein tumor regression after 5 weeks of treatment by exclusive irradiation correlated well with fang-term Philip of local control in cancers of the head and neck. We have noted a similar fmding in our study of rapidly ahernating c~mor~o~y for advanced squamous cell carcinomas involving the hypopharynx. The details have been published elsewhere (2, 3) but briefly the treatment consisted of chemotherapy (cisplatin and 5 fluorouracil) during weeks 1, 4 and 7, alternating with n&therapy (2 Gy twice daily) during weeks 2,5 and 8. Eighty-seven oercent of the natients had T3T4.70% had N2N3. and 83% had Stage iV disease. R&me was assessedweekly during treatment by physic2 examination including fiberoptic laryngoscopy. Of 20 evaluable patients, 12 exhibited complete response after 5 weeks of treatment, 4 exhibited complete response at a later time, and 4 never achieved complete response. Subsequently, local-regional recurrence was obsened in $j (8%), i (75%), and f (lOtI%), respectively. of Local-regional control at 2 years was 86% among the p&eats who exhibited complete response after 5 weeks of ~a~~ and only 14% among those who did not (p = 0.03). The data suggest that patients treated in this manner who do not achieve BERNARD DUBRAY, M.D.* V~~RONIQUE MOSSERI. M.D.’ FRANQXSE BRUNIN, M.D.* Josl RODRIGUEZ, M.D.$ DANIEL POINT, M.D.” BRIGITE BLASZKA, BERNARII ASSELAIN, M.D.* M.D.’ JACQUES BRUGBRE, M.D.’ JEAN-MARC COSSET, M.D.* *Department of Radiotherapy ’ Department of Biostatistics iDepartment of Head and Neck Surgery Institut Curie 75231 Paris Cedex OS. France 1. Jaulerry, C.; Dubray, B.; Brunin, F.; Rodriguez, J.; Point, D.; Blaszka, B.; Asselain, B.; Mosseri. V.; Brt@m, J.; Cosset, J.-M. Prognostic value of tumor regression during my for head and neck cancer: A prospective study. Int. J. Radiat. Biol. 33{2):2?1-279; 1995.