Northeast Florida Medicine
Vol. 66, No. 1 2015
37
Otolaryngology
Endoscopic surgical techniques have been adapted to the
treatment of many endonasal, sinus and skull base tumors
– both benign and malignant. These techniques are often
combined with image-guided navigational systems that
synchronize the surgical instruments with pre-operative
images – CT, MRI or both. This provides pinpoint surgical
accuracy. Studies have shown decreased rates of complica-
tions (CSF leakage, etc.), decreased pain, decreased hospital
stays, and more complete tumor resection. Patient and
tumor selection is critical. These surgical cases are usually
performed by a team of skull base surgeons comprising both
otolarynogologists and neurosurgeons.
Proton Beam Radiation
In 1946, Dr. Robert Wilson proposed using protons
for cancer treatment. The first patient was treated at UC
Berkeley eight years later. Loma Linda University Medical
Center opened the first hospital based proton center in
1990. In 2008, there were five proton facilities in the U.S.
There are now ten centers, with seven more planned at a
cost of $150 million to $200 million apiece. Proton beam
radiation has a theoretical advantage over other radiation
techniques in that peak doses of radiation can be delivered
to a pre-programmed tissue depth, without having the full
dose of radiation pass through all tissues in the path of
the beam. This is called the Bragg Peak. This property of
protons theoretically allows proton beam radiation to be
delivered in a very precise manner, sparing adjacent tissues.
This has advantages in treating tumors in close proximity
to brain, nerve and orbital structures.
14
There have been numerous reports describing the use of
proton beam radiation therapy for head and neck tumors.
In a recent review, Holliday and Frank examined 18 arti-
cles describing proton beam treatment for a total of 1,074
patients with head and neck tumors.
15
Studies showed that
it was possible to deliver high doses of radiation to these
tumors, resulting in good local control rates and overall
survival; neurotoxicities did occur, however. Proton beam
radiation was used successfully for retreatment of recurrent
chordomas in one series, with a local control rate of 85
percent and overall survival of 80 percent at two years.
Several studies looked at proton beam radiation for na-
sal cavity and paranasal sinus tumors. Local control rates
ranged from 86 percent to 93 percent at two years. Earlier
stage tumors did better. Some reports combined surgery or
photon external beam radiation therapy with proton beam
radiation. Toxicities were occasionally significant. In one
study of 39 patients from Japan, one patient died from
cerebrospinal fluid (CSF) leakage, and four other patients
suffered grade 3 and 4 toxicities including cataracts, visual
impairment, cranial nerve palsy and osteonecrosis.
16
Currently, standard treatment protocols for nasopha-
ryngeal carcinoma call for radiation therapy alone or
concurrent treatment with chemotherapy and IMRT.
17
At the Massachusetts General Hospital, a phase 2 trial is
underway using proton beam radiation with concurrent
cisplatin and fluorouracil to treat stage III and IVB nasao-
pharyngeal carcinoma. The local control rate at 28 months
was 100 percent. Two year disease free survival was 90
percent, and overall survival was 100 percent. Toxicities
were acceptable.
18, 19
Proton beam radiation has been proposed for treatment
of oropharyngeal carcinoma with hopes of reducing xe-
rostomia and dysphagia. Loma Linda University Medical
Center reported on a series of patients with stage II to
IV oropharyngeal carcinoma treated with a combination
of photon and proton beam radiation to a total dose of
75.9Gy. Local-regional control was 84 percent at five
years. The incidence of grade 3 toxicity was 16 percent,
compared to 26.8 percent to 37.2 percent in series with
conventional radiation.
20
Proton beam radiation is significantly more expensive
than conventional forms of radiation therapy, such as In-
tensity Modulated Radiation Therapy (IMRT).
21
To date,
randomized clinical trials have not been completed which
directly compare IMRT and proton beam radiation in terms
of survival benefit and rates and severity of toxicities. Until
such studies are conducted and the superiority of proton
beam radiation is proven, it will not be considered standard
of care for most head and neck cancers. One exception to
this might be its use in treatment of skull base tumors.
Thyroid Cancer
Thyroid cancer is increasing in prevalence in this coun-
try. It is estimated that in 2014, there will be 62,980 new
adult cases of thyroid cancer. It is also estimated there will
be 1,890 thyroid cancer deaths in 2014. There has been
a 2.6 fold increase in thyroid cancer between 1973 and
2006.
22
It is not clear whether this increase is due to a
true increase in the incidence of the disease or whether it
is due to an increase in diagnosis through better screening
techniques. While the incidence has increased, the death
rate has remained steady. Additionally, the cure rate is
quite high. Overall, the five year survival for thyroid cancer
is 97.8 percent. A notable exception to this is anaplastic
thyroid carcinoma, which, unfortunately, still carries a very
poor prognosis.
23,24
