Changing patterns of failure in advanced head and neck cancer

We treated 98 previously untreated patients with stages III and IV resectable epidermoid carcinoma of the oral cavity, oropharynx, and larynx with surgery and postoperative radiation therapy. The reasons for postoperative radiation therapy were unsatisfactory surgical margins in 36 patients, cervical metastases at multiple levels pathologically in 49, and both in 13. Historically, patients with similar findings, treated by surgery alone at our institution, had a relapse rate above the clavicles of more than 70% within two years. In the present series only 15% have had relapses above the clavicles, and distant metastases developed in another 20%. In addition, approximately 6% of patients per year have had second malignant neoplasms develop, predominantly in the esophagus or the lung. These changes in the patterns of failure have implications for future studies aimed at improving the cure rate and the survival of these patients.