Prevention of complications of composite resection after high dose preoperative radiotherapy

Recent reports have suggested that carcinoma of the tonsil and adjacent structures (tonsillar pillars, adjacent soft palate and lateral pharyngeal wall) can be treated with improved survival rates by combining definitive surgery with planned preoperative radiotherapy. Experience to date does not clearly demonstrate the ideal dose of preoperative radiotherapy; however, in general it appears that survival rates improve in proportion to increasing dosage of preoperative radiation. The use of preoperative radiation in doses approaching or exceeding tumoricidal levels (6,000‐6,500 rads at approximately 1,000 rads/week) has been limited by the unacceptable complication rate to be expected. The rate of major complications reported has ranged from 18 percent to almost 47 percent. For the past three years, all patients seen by the Department of Otolaryngology of the Upstate Medical Center with malignancies involving the tonsil and its adjacent structures have been managed by a combined modality of 5,500 rads preoperative radiotherapy followed by definitive surgical resection, using distant, unirradiated flaps for repair where necessary. There were 33 patients in the group, including three T2, 20 T3 and 10 T4 lesions. Joint evaluation and planning of treatment between radio‐therapy and otolaryngology coupled with meticulous attention to various aspects of surgical management has yielded the results reported in the table. The major complication rate has been limited to 3.03 percent. These results indicate that it is possible to undertake extensive resections for carcinoma of the tonsil and adjacent structures after high‐dose preoperative radiotherapy without incurring any significant increase in morbidity over surgery alone.