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Background The purpose of this study was to assess aspiration pneumonia (AsPn) rates and predictors after chemo-irradiation for head and neck cancer. Methods The was a prospective study of 72 patients with stage III to IV oropharyngeal cancer treated definitively with intensity-modulated radiotherapy (IMRT) concurrent with weekly carboplatin and paclitaxel. AsPn was recorded prospectively and dysphagia was evaluated longitudinally through 2 years posttherapy by observer-rated (Common Toxicity Criteria version [CTCAE]) scores, patient-reported scores, and videofluoroscopy. Results Sixteen patients (20%) developed AsPn. Predictive factors included T classification (p = .01), aspiration detected on videofluoroscopy (videofluoroscopy-asp; p = .0007), and patient-reported dysphagia (p = .02–.0003), but not observer-rated dysphagia (p = .4). Combining T classification, patient reported dysphagia, and videofluoroscopy-asp, provided the best predictive model. Conclusion AsPn continues to be an under-reported consequence of chemo-irradiation for head and neck cancer. These data support using patient-reported dysphagia to identify high-risk patients requiring videofluoroscopy evaluation for preventive measures. Reducing videofluoroscopy-asp rates, by reducing swallowing structures radiation doses and by trials reducing treatment intensity in patients predicted to do well, are likely to reduce AsPn rates.

Purpose Local failure in unresectable pancreatic cancer may contribute to death. We hypothesized that intensification of local therapy would improve local control and survival. The objectives were to determine the maximum tolerated radiation dose delivered by IMRT with FDR-G, freedom from local progression (FFLP) and overall survival (OS). Methods and Materials Eligibility included pathologic confirmation of adenocarcinoma, radiographically unresectable, performance status (PS) of 0–2, ANC of ≥1500/mm3, platelets ≥100,000/mm3, creatinine <2 mg/dl, bilirubin <3 mg/dl and ALT/AST ≤2.5 x ULN. FDR-G (1000 mg/m2/100-minutes I.V.) was given on days −22 and −15, 1, 8, 22, and 29. IMRT started day 1. Dose levels were escalated from 50 to 60 Gy in 25 fractions. DLT was defined as gastrointestinal toxicity ≥Grade (G)3, neutropenic fever, or deterioration in PS to ≥3 between day 1 and 126. Dose level was assigned using TITE-CRM with the target DLT rate set to 0.25. Results Fifty patients were accrued. DLTs were observed in 11 patients: G3/4 anorexia, nausea, vomiting, and/or dehydration (7); duodenal bleed (3); duodenal perforation (1). The recommended dose is 55Gy, producing a probability of DLT of 0.24. The 2-year FFLP is 59% (95% CI: 32–79). Median and 2-year overall survival are 14.8 months (95% CI: 12.6–22.2) and 30% (95% CI 17–45). Twelve patients underwent resection (10 R0, 2 R1) and survived a median of 32 months. Conclusions High dose radiotherapy with concurrent FDR-G can be delivered safely. The encouraging efficacy data suggest that outcome may be improved in unresectable patients through intensification of local therapy.

Purpose Doses actually delivered to the parotid glands during radiotherapy often exceed planned doses. We hypothesized that the delivered doses correlate better with parotid salivary output than the planned doses, used in all previous studies, and that determining these correlations will help decisions regarding adaptive re-planning (ART) aimed at reducing the delivered doses. Methods and Materials Prospective study: oropharyngeal cancer patients treated definitively with chemo-irradiation underwent daily cone beam CT (CBCT) with clinical set-up alignment based on C2 posterior edge. Parotid glands in the CBCTs were aligned by deformable registration to calculate cumulative delivered doses. Stimulated salivary flow rates were measured separately from each parotid gland pretherapy and periodically posttherapy. Results 36 parotid glands of 18 patients were analyzed. Average mean planned doses was 32 Gy and differences from planned to delivered mean gland doses were −4.9 to +8.4 Gy, median difference +2.2 Gy in glands whose delivered doses increased relative to planned. Both planned and delivered mean doses were significantly correlated with post-treatment salivary outputs at almost all post-therapy time points, without statistically significant differences in the correlations. Large dispersions [on average, standard deviation (SD) 3.6 Gy] characterized the dose/effect relationships for both. The differences between the cumulative delivered doses and planned doses were evident already at first fraction (r=0.92, p<0.0001) due to complex set-up deviations, e.g. rotations and neck articulations, uncorrected by the translational clinical alignments. Conclusions After daily translational set-up corrections, differences between planned and delivered doses in most glands were small relative to the SDs of the dose/saliva data, suggesting that ART is not likely to gain measurable salivary output improvement in most cases. These differences were observed already at first treatment, indicating potential benefit for more complex set-up corrections or adaptive interventions in the minority of patients with large deviations detected very early by CBCT.

stage, induction chemotherapy use, dose/ fractionation, mode of detection of recurrence, salvage therapy, and number and modality of scans were recorded. Deaths from disease recurrence or from other causes were also recorded. Imaging costs were calculated based on the 2016 Medicare fee schedule. Results: A total of 1508 patients were included. Median overall survival was 99 months (range: 6-199). Mean imaging follow-up period was 70 months. Of the total, 190 (12.6%) patients had disease recurrenced107 locoregional (LR) and 83 distant. Of the relapsed group, 119 (62.6%) were symptomatic and/or had an adverse clinical finding associated with recurrence. Majority (80%) of LR relapses presented with a clinical finding, while 60% of distant relapses were detected via imaging alone in asymptomatic patients. There was no difference between the successful salvage rates and overall survival between those with relapses detected clinically or via imaging alone. Seventy percent of relapses occurred within the first 2 years posttreatment. In those who relapsed after 2 years, the median time to relapse was 51 months (2 LR and 11 distant relapses). After 2 years, the average cost for detecting a salvageable recurrence for image-detected group was $395,223.09, and the cost for preventing 1 recurrence-related death for image-detected disease was $474,267.70. The number of scans required to detect a salvageable recurrence in an asymptomatic patient after 2 years was 1539. Conclusion: Surveillance imaging in asymptomatic patients without clinically suspicious findings beyond 2 years requires judicious consideration.