D. Blakaj

Exploration of the Role of Radiotherapy in the Management of Early Glottic Cancer with Complete Carotid Artery Occlusion

Background: The aim of this study was to compare intensity-modulated radiation therapy (IMRT) vs. 2D and 3D radiotherapy (RT) in the treatment of T1 glottic squamous cell carcinoma in an effort to highlight the advantages of IMRT in this particular clinical situation. Case Report: We present the case of an 82-year-old female patient with T1 left true vocal cord squamous cell carcinoma and complete occlusion of the left carotid artery resulting in multiple strokes. The patient underwent definitive RT with 63 Gy (28 × 2.25 Gy). 3 plans were generated: 2D RT, 3D RT, and IMRT. The right carotid artery (Rt.CA) mean dose was 865, 2,065, and 4,268 cGy for IMRT, 3D RT, and 2D RT, respectively. The inferior pharyngeal constrictor (IPC) mean dose was 5,341, 6,456, and 6,451 cGy for IMRT, 3D RT, and 2D RT, respectively. IMRT provided the best homogeneity but at a higher cost and with prolonged treatment time. Conclusion: IMRT provided the finest planning target volume coverage with minimal Rt.CA and IPC doses. IMRT is recommended in certain clinical scenarios which are not manageable with other techniques.

Clinical validation and applications for CT-based atlas for contouring the lower cranial nerves for head and neck cancer radiation therapy

OBJECTIVES Radiation induced cranial nerve palsy (RICNP) involving the lower cranial nerves (CNs) is a serious complication of head and neck radiotherapy (RT). Recommendations for delineating the lower CNs on RT planning studies do not exist. The aim of the current study is to develop a standardized methodology for contouring CNs IX-XII, which would help in establishing RT limiting doses for organs at risk (OAR). METHODS Using anatomic texts, radiologic data, and guidance from experts in head and neck anatomy, we developed step-by-step instructions for delineating CNs IX-XII on computed tomography (CT) imaging. These structures were then contoured on five consecutive patients who underwent definitive RT for locally-advanced head and neck cancer (LAHNC). RT doses delivered to the lower CNs were calculated. RESULTS We successfully developed a contouring atlas for CNs IX-XII. The median total dose to the planning target volume (PTV) was 70Gy (range: 66-70Gy). The median CN (IX-XI) and (XII) volumes were 10c.c (range: 8-12c.c) and 8c.c (range: 7-10c.c), respectively. The median V50, V60, V66, and V70 of the CN (IX-XI) and (XII) volumes were (85, 77, 71, 65) and (88, 80, 74, 64) respectively. The median maximal dose to the CN (IX-XI) and (XII) were 72Gy (range: 66-77) and 71Gy (range: 64-78), respectively. CONCLUSIONS We have generated simple instructions for delineating the lower CNs on RT planning imaging. Further analyses to explore the relationship between lower CN dosing and the risk of RICNP are recommended in order to establish limiting doses for these OARs.

The impact of computed tomography on early glottic cancer outcomes.

Purpose: Aim of this study was to evaluate the impact of computed tomography (CT)-based simulation and planning on early glottic cancer outcomes and toxicity. Methods: This is a single-institution retrospective study of 253 patients with T1-2 glottic cancer who underwent radiation therapy (RT) from January 1998-2010. Group A (80%) underwent 2-dimensional RT (2DRT) and group B (20%) 3-dimensional RT (3DRT). 76% of patients in group A and 84% in group B had T1 cancer. The median dose and fraction size were 63 Gy and 2.25 Gy, respectively. Results: With a median follow-up of 83, 93, and 30 months for the whole cohort, group A and B, respectively, the loco-regional control (LRC) was 97.6%. The rate of LRC for T1 disease was 99.5% and for T2 disease 91%. According to the RT modality, rates of LRC were 99.4 and 100% in groups A and B for T1, and 89.8 and 100% for T2. Long-term toxicity was negligible in both groups. Kaplan-Meier Curve showed the 5-year cause-specific survival to be 100%. Chi-square and multivariate analysis tests showed a significant relationship between CT simulation (3DRT) and LRC (p < 0.0001). Conclusion: CT-based simulation and planning provided better LRC and less acute side effects compared to 2DRT.

Lack of Adjuvant Radiotherapy May Increase Risk of Retropharyngeal Node Recurrence in Patients with Squamous Cell Carcinoma of the Head and Neck after Transoral Robotic Surgery

Purpose. Transoral robotic surgery (TORS) has increased in popularity in the management of squamous cell carcinoma of the head and neck. However, TORS does not address the neck or retropharyngeal nodes (RPN). In the current report, we highlight the impact of the lack of adjuvant radiotherapy on RPN recurrence after TORS. Materials and Methods. A 58-year-old Caucasian male presented with squamous cell carcinoma of the head and neck of unknown primary. He was offered radiotherapy as a definitive management for clinical stage T0N2aM0, stage IVA, but he opted to left neck dissection. Follow-up PET-CT scan revealed recurrence in the left base of tongue and right level II lymph node. He was offered radiotherapy which he declined and opted to TORS and right neck dissection. Follow-up PET-CT scan showed recurrence in left RPN for which he underwent salvage concurrent chemoradiotherapy to 70 Gy. Results. After a followup of 9 months from the date of salvage chemoradiotherapy completion, the patient is with no evidence of disease. Conclusions. TORS followed by adjuvant radiotherapy seems reasonable in the context of squamous cell carcinoma of the head and neck due to the odds of RPN involvement. Further reports are warranted to optimize post-TORS adjuvant treatment.

Decision making in advanced larynx cancer: An evidenced based review

Organ preservation versus total laryngectomy for advanced laryngeal cancer continues to be hotly debated. This review presents evidence-based decision making points for these patents.

Sinonasal adenoid cystic carcinoma: Treatment outcomes and association with human papillomavirus

The purpose of this study was to review long‐term outcomes of sinonasal adenoid cystic carcinoma (ACC) and to clarify its association with human papillomavirus (HPV).

Clinical and molecular exploration of the impact of radiation therapy on Marfan syndrome patients

Marfan syndrome (MFS) is a heritable disorder of the connective tissue and has been linked to mutations in the fibrillin-1 (FBN) gene. Radiation-induced fibrosis has been considered a risk for radiation-induced toxicities in treating cancers in this patient population. FBN is an inhibitor of transforming growth factor beta (TGF-β) expression and its mutation is thought to result in TGF-β upregulation.1 MFS clinically presents in a conglomeration of symptoms that affect wound healing and have modulatory effects on TGF-β. Because abnormal TGF-β expression has previously been linked to radiation-induced fibrosis, the expectation is that these patients will experience higher levels of fibrosis or fibrotic sequelae. In this study, we report the clinical course of a MFS patient who is treated with breast conservation radiation therapy (RT) for ductal carcinoma in situ (DCIS) status post lumpectomy. With a reported incidence of 1 case per 10,000 people, MFS is typically characterized by tall stature, arachnodactyly, pectus, scoliosis and lordosis, nocturnal enuresis, joint laxity, mitral or aortic valve prolapse, and ectopia lentis (lens dislocation).2 Aortic dissection, rupture or cardiac failure, is the cause of death in 90% of patients.2

Das nicht-kleinzellige Lungenkarzinom – Status Quo 2012

aOnkologischer Schwerpunkt, LungenClinic Groshansdorf, bRangauklinik Ansbach GmbH, Ansbach, cThoraxklinik, Abteilung Innere Medizin – Pneumo logie, Universitatsklinikum Heidelberg, dSektion Pneumologie Innenstadt und Thorakale Onkologie, Klinikum der Universitat Munchen, Lungentumorzentrum Munchen, eUniversitatsmedizin Mannheim, Chirurgische Klinik Interdisziplinare Thorakale Onkologie, Mannheim, fZentrum fur Palliativmedizin, Uniklinik Koln, gPathologisches Institut, Sektion Thoraxpathologie, Universitatsklinikum Heidelberg, hKrankenhaus Martha-Maria, Halle-Dolau, iKlinik fur Strahlen therapie und Radioonkologie, Universitatsklinikum Mannheim, Universitat Heidelberg, Mannheim

Toxicity of hypofractionated adjuvant radiation after breast-conserving surgery for DCIS.

128 Background: Traditional fractionation for whole breast radiation therapy after breast-conserving surgery has been 50Gy in 25 fractions over a 5-week period, with or without a 10 Gy boost. Hypofractionation has recently been adapted for early-stage invasive breast cancer, typically treating with 42.5 Gy in 16 daily fractions. This approach has been shown to have equivalent efficacy as the more traditional schedule. Its application to patients with DCIS has been an extrapolation of these data, and warrants further examination. This retrospective analysis reviews toxicity outcomes in women with DCIS treated with hypofractionation at our institution. METHODS 59 women with DCIS treated with lumpectomy and hypofractionated radiotherapy with or without boost between 2006 and 2010 at the Einstein-Montefiore Cancer Center were identified. Median age was 65 (39-85). Median follow-up was 13.7 months (2-37.6). Surgical margin status was negative in 55, positive in 1, and unknown in 3. Thirteen patients had high-grade DCIS, 17 intermediate-grade, and 13 low-grade nuclear features, and 16 did not have grade delineation. 68% of patients (40 women) had disease that was positive both for ER and PR receptors, 2 women were simultaneously positive for ER and PR, 5 women had ER-only positive disease, 2 women had HER2-neu-only positive disease, 1 woman was positive for both ER and HER2-neu receptors, 1 woman was positive only for PR receptors, and 6 women were negative for all receptors; receptor status of specimens from 2 patients is not known. All women were treated with whole-breast hypofractionated therapy (42.4 Gy, in 16 fractions of 2.65 Gy each). 49 women received a boost to the lumpectomy cavity consisting of 10Gy in 5 fractions or 9.6 Gy in 4 fractions at the physicians discretion. RESULTS With this regimen, no patient experienced acute RTOG grade 3 or higher skin, or other toxicity. No treatment breaks were required due to toxicity. The most common side effects were grade 1 dermatitis, followed by grade 2 dermatitis with mild edema of the treated breast. CONCLUSIONS Our results suggest that postoperative hypofractionated radiation to the breast is well tolerated by women with DCIS and does not result in untoward acute toxicity.