Role of primary surgery in resectable stage III/IV tonsillar carcinoma

Objective: This study intends to define the role of primary surgery for patients with resectable stage III/IV tonsillar carcinoma. Materials and Methods: From 1987 to 2004, 82 patients with resectable stage III/IV tonsillar carcinoma were treated curatively with surgery plus radiotherapy (n=22), concurrent chemoradiotherapy (n=25), or radiotherapy alone (n=35). We compared surgery plus radiotherapy with concurrent chemoradiotherapy and radiotherapy alone. The primary endpoint was 5-year overall survival. Results: The median follow-up time was 39 months (range, 1-216 months). All living patients were followed-up for at least 2 years. The 5-year overall survival for surgery plus radiotherapy was similar to that of concurrent chemoradiotherapy (52.9% vs. 58.9%; hazard ratio (HR), 1.46; 95% confidence interval (CI), 0.71-3.01; p=0.31) and radiotherapy alone (52.9% vs. 45.7%; HR, 0.87; 95% CI, 0.47-1.62; p = 0.66). For 5-year local control, surgery plus radiotherapy was better than radiotherapy alone (68.1% vs. 42.8%; HR, 0.39; 95% CI, 0.16-0.98; p=0.045). T4 disease resulted in poorer local control than T1-3 disease (HR, 5.89; 95% CI, 2.36-14.70; p<0.0001). After multivariate analysis, treatment modality had a consistent statistically insignificant impact on all clinical outcomes of interest. Conclusion: For patients with resectable stage III/IV tonsillar carcinoma, surgery plus radiotherapy is comparable to concurrent chemoradiotherapy and results in better local control than radiotherapy alone. Current evidence is still insufficient to definitively recommend replacing primary surgery with nonsurgical treatment modalities.