Tomografia computerizzata e risonanza magnetica nella patologia del distretto testa collo. Parte terza: Indicazioni alla radioterapia dei carcinomi e monitoraggio dei pazienti nella valutazione dell'efficacia del trattamento

This paper outlines the general indications for radiotherapy alone or in conjunction with surgery in patients with head and neck cancer, using CT and MR information. We also describe the morphological changes detected by radiological investigation, distinguishing those indicative of tumor persistence or recurrence from changes brought about by radiotherapy. Of 150 patients with clinical, endoscopic, CT and/or MR and histologically proven diagnosis of head-neck cancer over the last three years, we selected 95 patients who received radiotherapy alone or in conjunction with surgery. The choice of management in treating a primary carcinoma will depend on factors such as the functional and cosmetic outcome, the choice of the patient and his/her family, the patient's general educational level. Operative management aims as complete removal of the tumour and anatomical reconstruction which will restore function and appearance to a degree acceptable to the patient. The nature of the tumour and its site played an important role in determining treatment and entailed minimum morbidity in small lesions in the gums, retromolar trigone, tongue apex, epiglottis and skin. Surgical management was evaluated with caution in patients with advanced cancer. The main advantage of radiotherapy is the lack of immediate mortality, so that patients with medical contraindications were referred to radiotherapy rather than surgery. Tissue is not removed and hence the presence of precancerous lesions in the mucous membranes adjacent to the site of the primary tumour or multiple primary lesions were successfully treated by radiotherapy. Radiotherapy combined with surgery was avoided when a high percentage of regional and local control was envisaged with one procedure alone. Radiotherapy was administered as a precursor to surgery in case of 1) moderately advanced carcinomas of the piriform sinus and glottic larynx in an attempt to avoid radical surgery; 2) several concomitant primary lesions; 5) invasion of the dermis; 4) an inoperable primary tumour. Post-operative radiotherapy was administered when: 1) the margins of the surgical resection were positive for tumour cells at histological examination; 2) there was bone invasion, extension to the skin or soft tissues of the neck or perineural spread; 3) there was histological anaplasia. Even when the lymph nodes display physiological size and density-intensity, they may already be the site of metastatic disease. Lymph node radiotherapy was based on the following factors: tumour site, histological grade, size and extension of deep infiltration, risk of subclinical bilateral lymph node spread, invasion of the vascular space. When the lymph nodes were positive at clinical examination, the radiotherapy protocol depended on the treatment of the primary tumour and on the size, number and location of the affected lymph nodes. If the primary neoplasm had been treated by radiotherapy, the clinically positive lymph nodes and the adjacent clinically negative nodes were included in the treatment. If the controlateral lymph nodes were clinically negative, they were electively irradiated. The risk of subclinical controlateral spread was assessed in relation to each primary tumour site. Surgery for lymph node disease following radiotherapy was also entertained. The aim of radiation treatment was to obtain a thick fibrosclerotic tumour capsule which would facilitate surgical resection. Lymph node masses were 'frozen' and thus more amenable to operative removal. The treatment protocol was devised on an individual basis for patients with bilateral lymph node disease. If one of the two sides was subclinically affected, it was electively irradiated and surgical dissection confined to the opposite side. In cases of bilateral involvement, bilateral removal followed radiotherapy. When surgery was performed, radical neck dissection was followed by irradiation if necessary.