Bruce J. Davidson

Fractionated Stereotactic Radiosurgery for Reirradiation of Head-and-Neck Cancer

PURPOSEnStereotactic radiosurgery (SRS) is an appealing treatment option after previous radiotherapy because of its precision, conformality, and reduced treatment duration. We report our experience with reirradiation using fractionated SRS for head-and-neck cancer.nnnMETHODS AND MATERIALSnFrom 2002 to 2008, 65 patients received SRS to the oropharynx (n = 13), hypopharynx (n = 8), nasopharynx (n = 7), paranasal sinus (n = 7), neck (n = 7), and other sites (n = 23). Thirty-eight patients were treated definitively and 27 patients with metastatic disease and/or untreated local disease were treated palliatively. Nine patients underwent complete macroscopic resection before SRS. Thirty-three patients received concurrent chemoradiation. The median initial radiation dose was 67 Gy, and the median reirradiation SRS dose was 30 Gy (21-35 Gy) in 2-5 fractions.nnnRESULTSnMedian follow-up for surviving patients was 16 months. Fifty-six patients were evaluable for response: 30 (54%) had complete, 15 (27%) had partial, and 11 (20%) had no response. Median overall survival (OS) for all patients was 12 months. For definitively treated patients, the 2-year OS and locoregional control (LRC) rates were 41% and 30%, respectively. Multivariate analysis demonstrated that higher total dose, surgical resection, and nasopharynx site were significantly associated with improved LRC; surgical resection and nonsquamous histology were associated with improved OS. Seven patients (11%) experienced severe reirradiation-related toxicity, including one treatment-attributed death.nnnCONCLUSIONnSRS reirradiation for head-and-neck cancer is feasible. This study demonstrates encouraging response rates with acceptable toxicity. Fractionated SRS reirradiation with concurrent chemotherapy in select patients warrants further study.

First bite syndrome: A complication of surgery involving the parapharyngeal space

First bite syndrome (FBS) is the development of pain in the parotid region after the first bite of each meal and can be seen after surgery of the parapharyngeal space. The cause is not clear but has been proposed to involve a loss of sympathetic nerve function to the parotid, causing a denervation supersensitivity of salivary gland myoepithelial cells. The purpose of this study was to review the records of 12 patients with FBS to determine any common features of the operations performed that would support this theory of parotid “sympathectomy” as an etiologic factor of FBS.

Papillary and follicular variant of papillary carcinoma of the thyroid: Initial presentation and response to therapy

INTRODUCTION : The 2 most common histologic variants of papillary carcinoma are pure papillary carcinoma (PTC) and follicular variant of papillary thyroid carcinoma (FVPTC). The purpose of this study is to compare the presentation and short-term response to therapy of these variants and to determine if FVPTC is a more aggressive form of thyroid cancer that warrants intensive therapy. METHODS : A retrospective chart review of patients treated for PTC and FVPTC between 1996 and 1999 was performed. Clinical variables were compared with the Wilcoxon Rank-Sum test or the Fischers Exact Test. RESULTS : Of 160 patients with papillary thyroid carcinoma included, 114 (71%) had PTC and 46 (29%) had FVPTC. Mean follow-up was 38.6 months. FVPTC presented with larger tumors (median 1.5 cm vs 1.0 cm, P = 0.007) and higher tumor stage than PTC. PTC patients were more likely to present with local invasion and to have local recurrence (9.65% vs 0% for both variables). There were no significant differences in patient age, gender, vascular invasion, lymph node or distant metastases, surgical treatment, radioactive iodine therapy, remission, or mortality. CONCLUSION : FVPTC presented with larger original tumor size and higher tumor stage but a lower local invasion rate and recurrence rate than patients with PTC despite similar therapies. These data suggest that FVPTC and PTC carry similar prognoses in early stages and that FVPTC may have a reduced predilection for local invasion. Although further studies with longer follow-up are required, these results do not suggest that FVPTC warrants more aggressive therapy than PTC.

9p21 deletion correlates with recurrence in head and neck cancer

Deletion of 9p21 is a common event in many human tumors, including head and neck squamous cell carcinoma (HNSCC). The gene CDKN2, which encodes the protein p16, a cyclin‐dependent kinase‐4 inhibitor, maps to 9p21. The role of CDKN2 as the tumor suppressor gene in these neoplasms is unclear. The role of loss of heterozygosity (LOH) as a prognostic tool has not been described in HNSCC.

Safety and efficacy of hypofractionated stereotactic body reirradiation in head and neck cancer: Long-term follow-up of a large series.

The purpose of this study was to report long‐term outcomes for a large cohort of patients with head and neck squamous cell carcinoma (HNSCC) who underwent stereotactic body radiotherapy (SBRT) reirradiation.

Reirradiation of recurrent salivary gland malignancies with fractionated stereotactic body radiation therapy.

PurposeThe purpose of this study was to review a single-institution experience with the reirradiation of recurrent salivary gland tumors using fractionated stereotactic radiosurgery (SBRT).MethodsBetween 2003 and 2011, 18 patients diagnosed with recurrent, previously irradiated, salivary gland carcinomas were treated with SBRT reirradiation. Median age was 68 for all patients with most tumors being of major salivary gland origin. Most patients did not undergo surgical resection, and among those that did, all had positive margins. Only seven patients received chemotherapy, and the median SBRT dose was 30xa0Gy given in five fractions with a median cumulative dose of 91.1xa0Gy.ResultsThe median overall survival (OS), progression-free survival (PFS), and local control (LRC) were 11.5, 3.5, and 5.5xa0months, respectively. The 2-year OS, PFS, and LRC rates were 39%, 24%, and 53%, respectively. Statistical analysis identified presence of gross disease and interval to reirradiation as negative predictors of survival outcomes on both univariate and multivariate analyses (pxa0<xa00.05). On multivariate analysis, tumor volume was a negative predictor of survival outcomes (pxa0<xa00.05). Long-term toxicity analysis revealed four patients in the reirradiated group with soft tissue necrosis, which correlated with the cumulative dose (pxa0=xa00.01).ConclusionOur data suggest that SBRT is a reasonable treatment option for reirradiation of salivary gland tumors, but further studies are warranted.

Adopting the operating microscope in thyroid surgery: Safety, efficiency, and ergonomics

Our aim was to assess the safety and efficiency of operating microscope use by surgeons in thyroid surgery to reduce static neck flexion.

A six-month crossover chemoprevention clinical trial of tea in smokers and non-smokers: methodological issues in a feasibility study

BackgroundChemoprevention crossover trials of tea can be more efficient than parallel designs but the attrition and compliance rates with such trials are unknown.MethodsAttrition (dropouts) and compliance with treatment were assessed in a 25-week randomized, placebo controlled, crossover, feasibility clinical trial of four tea treatments to investigate the effect of tea on oral cancer biomarkers. Each treatment lasted 4u2009weeks with 2u2009weeks of washout in between. Participants were 32 smokers and 33 non-smokers without any evidence of premalignant oral lesions. The interventions consisted of packets of green tea, black tea, caffeinated water, or placebo. Participants were assigned to each treatment for four weeks, and were instructed to drink five packets per day while on the treatment. Dropout from the trial and compliance (consumption ofu2009≥u200985% of the prescribed treatment packets) are the main outcome measures reported.ResultsThere was a high rate of dropout (51%) from the study, and the rates were significantly higher among smokers (64%) than non-smokers (36%). Among participants who completed the study the rate of compliance was 72%. The highest rates of dropouts occurred between the first and second treatment visits in both smokers (38% dropout) and non-smokers (18% dropout). Throughout the study smokers were more likely to dropout than non-smokers. Black tea treatment was associated with the highest rates of dropout among smokers (37%), but was associated with the lowest rate of dropout among non-smokers (4%).ConclusionsIn a study conducted to test the feasibility of a four-treatment crossover tea trial, a high rate of dropout among smokers and non-smokers was observed. Multi-arm crossover tea trials might pose a higher burden on participants and research is needed to improve adherence and treatment compliance in such trials.Trial registration numberISRCTN70410203

Survival Outcomes of Patients Treated with Hypofractionated Stereotactic Body Radiation Therapy for Parotid Gland Tumors: a Retrospective Analysis

Background: to review a single-institution experience with the management of parotid malignancies treated by fractionated stereotactic body radiosurgery (SBRT). Findings: Between 2003 and 2011, 13 patients diagnosed with parotid malignancies were treated with adjuvant or definitive SBRT to a median dose of 33u2009Gy (range 25–40u2009Gy). There were 11 male and two female patients with a median age of 80. Ten patients declined conventional radiation treatment and three patients had received prior unrelated radiation therapy to neighboring structures with unavailable radiation records. Six patients were treated with definitive intent while seven patients were treated adjuvantly for adverse surgical or pathologic features. Five patients had clinical or pathologic evidence of lymph node disease. Conclusion: at a median follow-up of 14u2009months only one patient failed locally, and four failed distantly. The actuarial 2-year overall survival, progression-free survival, and local-regional control rates were 46, 84, and 47%, respectively. Statistical analysis revealed surgery as a positive predictor of overall survival while presence of gross disease was a negatively correlated factor (pu2009<u20090.05).

Pathologic Collision of Inverted Papilloma with Esthesioneuroblastoma

Background: Inverted papilloma (IP) of the nasal cavity is a benign tumor that represents 0.5–4% of all nasal tumors and have been known to rarely undergo malignant transformation to squamous carcinoma and even more rarely adenocarcinoma. Synchronous association with low-grade esthesioneuroblastoma (ENB) has been reported in only one case report where a small-sized lesion was treated with surgery alone. Here we report the first case of invasion of IP by high-grade ENB with nodal metastasis that was treated with combined modality therapy. Case Presentation: A case of a 64-year-old African American gentleman presented to the otolaryngology with a 3-month history of recurrent epistaxis. Imaging revealed a large right nasal cavity mass extending into the right sphenoid sinus but without intracranial extension. Surgical pathology revealed high-grade ENB invading IP. An orbitofrontal craniotomy approach was used to achieve complete resection of the mass but with positive margins. Post-operative positron emission tomography/computed tomography showed nodal metastasis. The patient was then treated with adjuvant chemoradiation and remains without evidence of disease at 42u2009months post-treatment. We discuss the disease presentation, histopathologic features, and disease management with literature support. Conclusion: In this very rare disease presentation where two extremely rare malignancies collide, we show that aggressive management with trimodality therapy of surgery, adjuvant radiation with stereotactic radiosurgical boost, and adjuvant chemotherapy gives excellent results. Given the natural history of the disease, however, long follow-up is needed to declare complete freedom from the disease.