Frances Wong

Whole brain radiotherapy with hippocampal avoidance and simultaneous integrated boost for 1-3 brain metastases: a feasibility study using volumetric modulated arc therapy.

PURPOSEnTo evaluate the feasibility of using volumetric modulated arc therapy (VMAT) to deliver whole brain radiotherapy (WBRT) with hippocampal avoidance and a simultaneous integrated boost (SIB) for one to three brain metastases.nnnMETHODS AND MATERIALSnTen patients previously treated with stereotactic radiosurgery for one to three brain metastases underwent repeat planning using VMAT. The whole brain prescription dose was 32.25 Gy in 15 fractions, and SIB doses to brain metastases were 63 Gy to lesions >or=2.0 cm and 70.8 Gy to lesions <2.0 cm in diameter. The mean dose to the hippocampus was kept at <6 Gy(2). Plans were optimized for conformity and target coverage while minimizing hippocampal and ocular doses. Plans were evaluated on target coverage, prescription isodose to target volume ratio, conformity number, homogeneity index, and maximum dose to prescription dose ratio.nnnRESULTSnTen patients had 18 metastases. Mean values for the brain metastases were as follows: conformity number = 0.73 +/- 0.10, target coverage = 0.98 +/- 0.01, prescription isodose to target volume = 1.34 +/- 0.19, maximum dose to prescription dose ratio = 1.09 +/- 0.02, and homogeneity index = 0.07 +/- 0.02. For the whole brain, the mean target coverage and homogeneity index were 0.960 +/- 0.002 and 0.39 +/- 0.06, respectively. The mean hippocampal dose was 5.23 +/- 0.39 Gy(2). The mean treatment delivery time was 3.6 min (range, 3.3-4.1 min).nnnCONCLUSIONSnVMAT was able to achieve adequate whole brain coverage with conformal hippocampal avoidance and radiosurgical quality dose distributions for one to three brain metastases. The mean delivery time was under 4 min.

CANCER OF THE TONSIL : THE RESULTS OF IPSILATERAL RADIATION TREATMENT

BACKGROUND AND PURPOSEnThe use of ipsilateral irradiation techniques to treat patients with carcinoma of the tonsil reduces the acute radiation reaction in the contralateral pharynx and late damage to the contralateral salivary tissue. However, this may also spare microscopic disease in apparently uninvolved contralateral lymph nodes. The purpose of this study was to analyse the survival and recurrence rates and sites of recurrance in a group of patients with carcinoma of the tonsil treated with ipsilateral techniques.nnnMATERIALS AND METHODSnBetween 1975 and 1993, 271 patients with invasive squamous cell cancer of the tonsil were referred to the Vancouver Cancer Centre (VCC). One hundred and seventy-eight received ipsilateral radiation treatment. Three received surgery only, six post-operative radiation, 12 supportive treatment only and 72 bilateral radiation treatment. In the absence of bilateral neck nodes and extensive lymphodenopathy, field sizes were generally kept small to include the primary tumour and the first echelon of nodes. The most common dose was 60 Gy in 25 daily fractions in 5 weeks (2.4 Gy per day).nnnRESULTS AND DISCUSSIONnThe disease specific survival for all patients treated by radical radiation treatment was 61% at 5 years. For the 178 patients who received ipsilateral radiation treatment the overall primary tumour control rate by ipsilateral radiation treatment alone was 75% and for T1 and T2 tumours 84%. Eight (7.5%) of 101 of these patients with N0 nodes at presentation and without prior failure at the primary site, developed nodal recurrence (four within the initially radiated high dose volume). Two developed contralateral nodes, and two developed field edge nodal recurrence, one cured by surgery. In 54 patients with N1 disease, five developed nodal recurrence, two within field, two contralateral, one of whom was cured by surgery, and one at field edge. In 23 patients with N2a, N2b or N3 disease node control was achieved from radiation treatment in 11 and two more were cured by surgery. All nodal failures were within the radiated volume. Overall, 10 of the 25 patients with nodal failure were cured by subsequent surgery.nnnCONCLUSIONSnIpsilateral treatment of patients with carcinoma of the tonsil gives survival results that are at least as good as those reported with bilateral treatment with fewer side effects and a very low risk of failure in the contralateral neck.

25 Year survival outcomes for squamous cell carcinomas of the head and neck: Population-based outcomes from a Canadian province

OBJECTIVESnLong term outcomes of patients with head and neck cancer (HNC) are rarely reported, but of potential benefit to clinicians and researchers. Squamous cell carcinomas (SCC) of the head and neck represent a heterogeneous group of cancers. The purpose of this population based study is to describe primary site specific, long term outcomes of HNC.nnnMETHODSnAll patients from a Canadian province diagnosed between 1986 and 1990 with SCC of the oral cavity, pharynx, and larynx were identified. Chart review and patient data were abstracted through the provincial cancer registry database. Survival analysis was performed with Kaplan Meier methods, while differences in survival between groups were assessed with log-rank tests. Multivariable analysis was performed using Cox-regression.nnnRESULTSn1657 patients were analyzed during the study period. Almost half (50.9%) of the cases were advanced stage (stage III IV) at presentation. Two, 5, 15 & 25year overall survival (OS) and HNC specific survival for all the patients were 64%, 46%, 21%, 11% and 74%, 63%, 53% & 49%, respectively. OS and HNC-specific mortality were statistically inferior among men, older age at diagnosis, advanced stages of disease, and was primary cancer site specific, with worse survival in oropharyngeal & hypopharyngeal sites, p<0.001.nnnCONCLUSIONSnSurvival rates vary by primary HNC site, and the overall survival & HNC specific survival differ over this long follow up assessment. Head and neck cancer specific death is most common in the first five years, and is subsequently dominated by competing causes of mortality. These results are useful as a reference tool for clinicians, researchers, and trainees.

Population-based comparison of two feeding tube approaches for head and neck cancer patients receiving concurrent systemic–radiation therapy: is a prophylactic feeding tube approach harmful or helpful?

PurposeThe purpose of this study is to compare patient outcomes between a therapeutic versus a prophylactic gastrostomy tube (GT) placement approach in patients treated with concurrent systemic and radiation (SRT) therapy for head and neck cancer (HNC).MethodsOutcomes were compared between all HNC patients treated with concurrent SRT from January 2001 to June 2009 from a center that only places GTs therapeutically when clinically necessary (center A) versus a center that generally places them prophylactically (center B).ResultsA total of 445 patients with HNC were identified, with 63xa0% from center A. As anticipated, GTs were placed less commonly in center A compared to B (31 versus 88xa0%; pu2009<u20090.001). Center B had a significantly higher number of GT complications (pu2009<u20090.001), including infection (16 versus 5xa0%), leakage (10 versus 2xa0%), and blockage (3 versus 1xa0%). Conversely, center A had a higher admission rate (27 versus 13xa0%, pu2009=u20090.001), most prominent for GT-related issues (15 versus 6xa0%). Center B had higher GT dependence at 90xa0days post-radiation therapy (34 versus 12xa0%; pu2009<u20090.001), but not at 1xa0year (11 versus 10xa0%; pu2009=u20090.74). There was no significant difference in the proportion of head and neck patients who had a 10xa0% weight loss at 1xa0year (compared to baseline) between centers A and B (42 versus 53xa0%, pu2009=u20090.07). There was no significant difference in the overall survival (A versus B, HRu2009=u20090.99; pu2009=u20090.96).ConclusionA prophylactic GT approach results in exposing higher number of patients to GT complications. The higher rate of hospitalizations using a therapeutic approach suggests that patients are sicker when GTs are required. Given the similar weight loss and survival, a therapeutic approach at an earlier stage of need may be a preferable approach, when access to prompt GT placement is available.

Incidence of second metachronous head and neck cancers: Population‐based outcomes over 25 years

The primary objective was to determine the incidence of second metachronous head and neck cancers (HNC) following an index HNC and estimate their overall survival.