Kathryn E. Hitchcock

Lessons from a standardized program using PET–CT to avoid neck dissection after primary radiotherapy for N2 squamous cell carcinoma of the oropharynx

OBJECTIVES To report the results of a standardized program using positron emission tomography (PET)-computed tomography (CT) approximately 12 weeks after primary radiotherapy to determine the need for a planned neck dissection in patients with radiographic N2 squamous cell carcinoma (SCC) of the oropharynx. METHODS Fifty consecutive patients with T1-4 and hemineck radiographic stage N2A-B SCC of the oropharynx for whom the only indication for planned neck dissection was a positive PET-CT performed ∼12 weeks after completing primary treatment with radiotherapy. RESULTS Results of PET-CT to identify residual neck disease were as follows: sensitivity and positive predictive value, 0%; specificity, 89%; negative predictive value, 91%; potential neck recurrence from using this 12-week PET-CT program, 2%. The time between negative PET-CT and detection of neck recurrence was 0.5, 0.6, 1.2, and 2.0 years. The rate of successful (>1 year) salvage of neck recurrence was 25% (1/4). CONCLUSIONS PET-CT approximately 12 weeks after radiotherapy for oropharyngeal cancer is an excellent way to identify patients who do not need neck dissection. Approximately half of neck recurrences present over 1 year after negative PET-CT and the chance of successful salvage is low.

Radiation Therapy for Aneurysmal Bone Cysts.

Purpose: To evaluate the long-term effectiveness of radiation therapy (RT) as an adjuvant or alternative treatment for patients with aneurysmal bone cyst (ABC). Patients and Methods: The medical records of 12 patients who received RT at the University of Florida for ABC between 1964 and 2011 were reviewed and patients were contacted, when possible, for follow-up. Follow-up duration ranged from 3 to 36 years (median, 20.5 y). Patient age at the time of RT ranged from 3 to 23 years (mean, 12.75 y), with 7 females and 5 males. Four patients were treated for recurrent ABCs. Three patients were treated with surgical interventions (intralesional curettage, subtotal resection, or selective arterial embolization) before RT, and the rest received open biopsy only. The prescribed doses ranged from 20 to 60 Gy (mean, 30.15 Gy). Ten (83.3%) patients received between 1.5 and 2.0 Gy per fraction. Results: All patients were doing well and free of any adverse reaction to RT as of the latest follow-up, including 1 who passed away from cardiac problems 34 years since completing RT and 3 who were lost to follow-up (at 16, 16, and 19 y) but were doing well at the last follow-up. Conclusions: RT continues to result in an excellent prognosis for patients with ABC who receive either RT alone or adjuvant RT after surgery.

Retromolar trigone squamous cell carcinoma treated with radiotherapy alone or combined with surgery: a 10-year update.

PURPOSE/OBJECTIVES Treatment outcomes were analyzed for patients who received radiotherapy for squamous cell carcinoma of the retromolar trigone at a single institution. MATERIALS/METHODS We reviewed the medical records of 110 patients treated with radiotherapy alone (n=36) or radiotherapy combined with surgical resection of the primary tumor (n=74) between June 1966 and October 2013. The median follow-up was 4.5years for all patients and 11.8years for living patients (range, 1.3-23.5years). RESULTS The 5-year local-regional control rates after definitive radiotherapy versus surgery and radiotherapy for stages I-III were 52% and 89% and for stage IV they were 46% and 58%, respectively. The 5-year cause-specific survival rates after definitive radiotherapy compared with surgery and radiotherapy for stages I-III were 57% and 82% and for stage IV they were 45% and 43%, respectively. Multivariate analyses revealed that the likelihood of cure was better with surgery and radiotherapy compared with radiotherapy alone (p=0.041). CONCLUSION Patients treated with surgery and radiotherapy had a better chance of cure than those treated with radiotherapy alone. Complications of treatment were common in both groups but more common in patients who underwent surgery.

Feasibility of pancreatectomy following high-dose proton therapy for unresectable pancreatic cancer

AIM To review surgical outcomes for patients undergoing pancreatectomy after proton therapy with concomitant capecitabine for initially unresectable pancreatic adenocarcinoma. METHODS From April 2010 to September 2013, 15 patients with initially unresectable pancreatic cancer were treated with proton therapy with concomitant capecitabine at 1000 mg orally twice daily. All patients received 59.40 Gy (RBE) to the gross disease and 1 patient received 50.40 Gy (RBE) to high-risk nodal targets. There were no treatment interruptions and no chemotherapy dose reductions. Six patients achieved a radiographic response sufficient to justify surgical exploration, of whom 1 was identified as having intraperitoneal dissemination at the time of surgery and the planned pancreatectomy was aborted. Five patients underwent resection. Procedures included: Laparoscopic standard pancreaticoduodenectomy (n = 3), open pyloris-sparing pancreaticoduodenectomy (n = 1), and open distal pancreatectomy with irreversible electroporation (IRE) of a pancreatic head mass (n = 1). RESULTS The median patient age was 60 years (range, 51-67). The median duration of surgery was 419 min (range, 290-484), with a median estimated blood loss of 850 cm3 (range, 300-2000), median ICU stay of 1 d (range, 0-2), and median hospital stay of 10 d (range, 5-14). Three patients were re-admitted to a hospital within 30 d after discharge for wound infection (n = 1), delayed gastric emptying (n = 1), and ischemic gastritis (n = 1). Two patients underwent R0 resections and demonstrated minimal residual disease in the final pathology specimen. One patient, after negative pancreatic head biopsies, underwent IRE followed by distal pancreatectomy with no tumor seen in the specimen. Two patients underwent R2 resections. Only 1 patient demonstrated ultimate local progression at the primary site. Median survival for the 5 resected patients was 24 mo (range, 10-30). CONCLUSION Pancreatic resection for patients with initially unresectable cancers is feasible after high-dose [59.4 Gy (RBE)] proton radiotherapy with a high rate of local control, acceptable surgical morbidity, and a median survival of 24 mo.

Radiotherapy for juvenile ossifying fibroma of the maxillary sinus: Case report and literature review

Juvenile ossifying fibroma (JOF) is a benign fibro‐osseous lesion that can be locally aggressive. It is typically treated with surgical excision. A few cases using adjuvant radiotherapy have been reported in the literature.

Treatment of grade II–III intracranial meningioma with helical tomotherapy

Meningiomas account for 30-35% of intracranial tumors. Grade I meningiomas are most common and carry the best prognosis. Grade II and III meningiomas are more aggressive and the outcomes after surgical resection alone remain unsatisfactory. The main objective of this retrospective, single-center study was to assess our results of treatment of grade II-III intracranial meningioma with helical tomotherapy (HT). We retrospectively reviewed patients with histologically proven (WHO 2007) grade II-III meningioma irradiated with HT. Patients were treated one session a day, 5 days a week, to a total dose of 59.4 Gy and 68.4 Gy delivered in 33 and 38 fractions of 1.8 Gy each to the LR PTV and HR PTV, with or without simultaneous integrated boost. From May 2011 to January 2015, 19 patients (15 with grade II and 4 with grade III meningiomas) were treated. Median follow-up for patients with Grade II or Grade III meningiomas, was 29.2 months (range, 10.7-52.4) and 21.3 months (range, 2.4-51.3), respectively. Disease free survival at 1, 2 and 3 years was 89.2%, 83.6% and 56.3% respectively. Overall survival at 1, 2 and 3 years was 94.7%, 94.7% and 78.9%, respectively. No patient had neurological toxicity greater than grade 2 in the acute period. During follow-up, only one patient had neurological toxicity greater than or equal to grade 3. The management of grade II to III meningiomas using HT with doses exceeding 60 Gy is associated with good local control and acceptable survival results.

Transoral robotic surgery for oropharyngeal cancer: patient selection and special considerations

The increasing incidence of oropharyngeal squamous cell carcinoma (OPSCC) emphasizes the importance of optimizing treatment for the disease. Historical protocol has utilized definitive radiation and invasive open procedures; these techniques expose the patient to significant risks and morbidity. Transoral robotic surgery (TORS) has emerged as a therapeutic modality with promise. Here, the literature regarding proper patient selection and other considerations for this procedure was reviewed. Multiple patient and tumor-related factors were found to be relevant for successful use of this treatment strategy. Outcomes regarding early and advanced-stage OPSCC were analyzed. Finally, the literature regarding use of TORS in three distinct patient populations, individuals with primary OPSCC, carcinoma of unknown primary and those with recurrent OPSCC, was examined.

Adjuvant radiotherapy for pancreatic cancer: rationale and results

Pancreatic cancer is a highly aggressive disease with a poor prognosis. The mainstay of curative treatment remains surgical resection. Adjuvant chemotherapy has been clearly shown to improve survival. Yet because local-regional recurrence after surgery is the predominant pattern of failure, chemoradiation is often used as a component of treatment. Despite several prospective, randomized trials evaluating adjuvant chemoradiation, controversy persists as to whether it confers a survival benefit. Here we review the rationale for adjuvant chemoradiation and the results of the major studies evaluating the impact of postoperative radiotherapy on disease control and patient survival.