Harold Kim

Radiation therapy for stage i and iia testicular seminoma

PURPOSEnTo review the survival, cure rate, treatment morbidity, and late sequelae of histologically confirmed seminoma patients who underwent orchiectomy and radiation therapy at the Radiation Oncology Center, Mallinckrodt Institute of Radiology, from 1964 to 1988.nnnMETHODS AND MATERIALSnThere were 128 patients, with a median patient age of 37 years (range, 17-79 years). Follow-up ranged from 1-24 years, with a median of 6.7 years. There were 95 patients with Stage I and 33 with Stage IIA disease. All patients were treated with orchiectomy followed by iliac and paraaortic irradiation (median tumor dose: 2500 cGy for Stage I and 3400 cGy for Stage IIA patients). Twenty-five of 33 patients with Stage IIA disease received prophylactic mediastinal and left supraclavicular irradiation (median dose, 2700 cGy).nnnRESULTSnFor patients with Stage I disease, 5-year disease-free survival, overall survival, and survival corrected for intercurrent disease were 97%, 100%, and 100%, respectively. For patients with Stage IIA disease, the 5-year disease-free survival, overall survival, and survival corrected for intercurrent disease were 93%, 89%, and 97%, respectively. Four patients (3%) had recurrences; all were outside the radiation treatment field. Three of four were successfully salvaged with chemotherapy and rendered disease-free; the other patient refused treatment. There were no mediastinal recurrences whether prophylactic mediastinal irradiation was administered or not. Bowel obstruction and necrosis developed in one patient who received 3363 cGy midplane dose to the pelvic and paraaortic areas as well as additional intraperitoneal colloidal 198Au (150 mCi) for a ruptured seminoma from an undescended testis.nnnCONCLUSIONnIn summary, radical orchiectomy and irradiation of the iliac and paraaortic lymphatics is the treatment of choice for patients with Stage I and IIA testicular seminoma.

Unresectable Extraskeletal Myxoid Chondrosarcoma of the Neck: Early Tumor Response to Chemoradiotherapy

Extraskeletal myxoid chondrosarcoma (EMC) rarely occurs in the head and neck and is generally managed with primary surgery. To our knowledge, no cases of unresectable EMC of the neck have been reported. We present a case of an unresectable EMC treated with chemotherapy and radiation, and highlight the exceptional early response to therapy.

Utility of Abdominal Computed Tomography in Head and Neck Cancer Patients

Objective: Assess the role of abdominal computed tomography (CT) imaging in the staging and surveillance of patients with head and neck squamous cell cancer (HNSCC) for distant metastatic disease (DMD) and second primary tumors (SPT). Method: Retrospective review of 172 HNSCC patients treated at an academic center who underwent abdominal CT imaging from 2003 to 2007. These scans were categorized as suspicious, positive, or negative for DMD or SPT. Charts of patients with suspicious or positive results were reviewed to determine resultant work-up and outcomes. Results: After consideration of exclusion criteria, 165 patients were included in this retrospective study. Normal abdominal CT scans were seen in 139 patients while the remaining 27 patients had abnormal abdominal CT findings. Of these 27, 16 patients (9.7%) were determined to have malignancy. Twelve patients had DMD, and 4 were diagnosed with SPT. Conclusion: Abdominal CT imaging identified DMD or SPT in 9.7% of patients resulting in significant alteration in their comprehensive oncologic care. This rate is not inconsequential and might justify the use of abdominal CT in managing HNSCC patients. Prospective trials might help determine the impact of abdominal CT findings on survival.

Factors Predictive of Severity of ORN of the Mandible

OBJECTIVES: 1) Determine risk factors associated with severe osteoradionecrosis (ORN) of the mandible. 2) Aid future ORN management and prophylaxis based on results of the study. METHODS: We retrospectively analyzed 40 ORN patients diagnosed between June 2002 and November 2008. Of those, 92.5% were squamous cell cancers, 85% were oral cavity or oropharyngeal tumors, and 92.5% had mandibular ORN. All received 3D conformal radiation therapy (RT) or intensitymodulated RT, with 60 Gy median dose. 22.5% and 77.5% received primary and postoperative RT respectively. 75% received chemotherapy (CT), mostly concurrent (97%) and platinum-based (95%). ORN was staged based on Store-Boysen scores of 0-3. 90% of patients received antibiotics, and 32.5% hyperbaric oxygen. Debridement, plate removal, flap repair and external fixation were done in 87.5%, 42.5%, 22.5% and 7.5% patients respectively. RESULTS: Median time to ORN was 7.5 months (range,183). All primary RT, 96% Stage IV and 94% T4a patients had Stage 2/3 ORN. Secondary infection predicted Stage 3 ORN significantly (p 0.0001). Differences between proportions of Stage 3 patients with greater than, vs less than, or equal to 40 pack-year smoking history; and those who had primary surgery versus none, were significant (p 0.00001, 0.004 respectively). No significant association existed between ORN severity and CT, RT modality and dose, primary site, dental extractions, and alcohol intake. At 37 months average follow-up, 5%, 27.5%, 5% and 7.5% patients developed new primaries, local, regional and distant relapse respectively. CONCLUSIONS: Secondary infection, smoking, primary RT, surgery, T and overall stage were predictive of severity, and can potentially guide prophylaxis and management of mandibular osteoradionecrosis.

Neoadjuvant and Concomitant Chemotherapy and Radiotherapy for Advanced Head and Neck Carcinoma: P-19

Purpose: To determine the toxicity, survival and outcome of neoadjuvant and concomitant chemoradiation treatment for patients with advanced stage (III and IV) squamous cell carcinoma of the oropharynx, larynx and hypopharynx. Materials and Methods: Induction chemotherapy with cis-platin (100mg/m2) and 5-FU (1000mg/m2) for 2–3 cycles were given. Endoscopy and/or CT scanning were used to objectively evaluate response. Partial and complete responders received definitive radiotherapy (1.8 to 2.0 Gy fractions for 35 to 39 fractions for a total dose of 70Gy) with concurrent chemotherapy with cisplatin (100mg/m2) on days 1,22, and 43. Results: Thirty patients were eligible for primary analysis for survival and toxicity. The median follow-up was 23 months. Twenty percent of the patients were considered unresectable. The response rate to induction chemotherapy was 93%. The complete response rate after definitive chemoradiotherapy was 80%. The crude loco-regional control rate was 73%. The cumulative loco-regional control rates at 15 and 21 months were 87.5% and 65.7%, respectively. Twenty-three percent of patients underwent surgical salvage for persistent or recurrent loco-regional disease. The distant metastasis rate for this study population was 6.7%. The one-year and two-year cumulative overall survival rates were 89.4% and 83.4%, respectively. Grade 3 renal, gastrointestinal, mucosal, and hematological toxicities were observed in 7%, 10%, 17% and 20% of the patients, respectively. Grade 4 gastrointestinal and hematological toxicities were observed in 3% and 10% of the patients, respectively. Conclusion: The toxicity, loco-regional control and survival rates for this type of regimen in our study group are excellent. Neoadjuvant chemotherapy when added to chemoradiotherapy appears to be effective and should be investigated further with large scale multiinstitutional trials.