Objectives: Unilateral radiation to cervical nodes has been used as a deescalation strategy in well-lateralized tonsil cancers. The efficacy of this approach with multiple ipsilateral nodes is not established. The study hypothesis was that unilateral radiation for American Joint Committee on Cancer (AJCC)-7 T1-2N2b tonsillar cancer results in a low rate of contralateral nodal failure. Materials and Methods:This study was a retrospective chart review of patients with AJCC-7 T1-2N2b tonsillar cancer from 2 academic institutions who were treated with unilateral radiation. The primary endpoint was the contralateral nodal failure rate. Locoregional control, overall survival, and the need for gastrostomy tube placement were additional endpoints. Results:The study cohort included 66 patients treated between 2005 and 2016. The median follow-up time was 80.9 months; contralateral nodal failure occurred in 2/66 (3.0%) patients at 4.1 and 20.9 months, respectively. Both patients underwent salvage treatment with long-term subsequent survival. Overall locoregional control at both 2 and 5 years was 93.9% and the median duration of control was not reached. Overall survival at 5 years was 92.4%. Conclusions:The use of unilateral radiation for AJCC-7 T1-2N2b tonsillar cancer resulted in low rates of contralateral nodal failure. This outcome demonstrates the safety of considering unilateral radiation treatment in patients with a relatively high ipsilateral nodal burden.
Background: Lumpectomy/ partial mastectomy may result in asymmetry of the treated breast relative to the unaffected breast. Volume loss is the most common cause of the negative cosmetic outcome in patients undergoing BCS. To help improve cosmetic results the practice of breast oncoplasty at the time of lumpectomy AE sentinel node surgery is gaining popularity. In this paper, we report our experience on patients who underwent autologous flap partial breast reconstruction or bilateral reduction mammoplasty at the time of BCS. Postoperatively, all patients received WBRT. The objective of the study was to evaluate cosmetic outcomes and local control. In addition, we sought to study the incidence for the recommendations of BIRADS 3 or 4, and fat necrosis on follow up mammograms and sonograms. Methods and Materials: In this retrospective study, we identified 24 breast cancer patients who at the time of BCS either underwent partial breast reconstruction using autologous flap or had bilateral reduction mammoplasty. Postoperatively, all patients received WBRT to a dose ranging from 50.4Gy to 60Gy. Adjuvant systemic therapy was prescribed at the discretion of the treating oncologist. In follow up, all patients were seen at regular intervals by the multidisciplinary team, and mammograms and directed sonograms were obtained at scheduled intervals. Results: A total of 27 breasts in 24 patients (3 bilateral) are included in this review. The median follow up is 48 months (range: 4 months to 79 months). The median age is 52 years (range: 29 to 71 years). The pathologic stage distribution was: 7 stage 0, 13 stage I, 5 stage II, and 2 had stage ypT0N0M0 having presented with clinical stage IIB and undergone BCS following neoadjuvant therapy. All but 1 patient had negative resections margins. The median number of excisions to achieve clear margins was 2 (range 1 to 3). Fifteen patients underwent bilateral reduction mammoplasty, while 9 had either thoracodorsal artery perforator flap (TDAP), lateral intercostal artery perforator flap (LICAP), or other autologous free flaps. Twenty patients also received systemic chemotherapy and/or hormonal therapy. Cosmetic results in the majority were excellent/very good. In follow up we observed that 4 patients underwent additional revisions for cosmetic indications; and 3 of the 4 patients were among those who had partial breast reconstruction using free-flaps. Follow up mammography noted recommendation of BIRADS 3 and 4 in 3/27 (11.1%) and 2/27 (7.4%) breasts, respectively. Additionally, 5/27 (18.5%) had radiographic evidence of fat necrosis. No patient has developed a local recurrence. Conclusion:In the multidisciplinary care of breast cancer the integration of plastic surgery procedures is increasingly gaining acceptance. We observed that partial breast reconstruction as an adjunct to BCS prior to WBRT results in excellent cosmetic result and local control. Radiographically, the incidence of fat necrosis was the most common finding and the recommendation for BIRADS 4 was low. In select cases,...
Purpose/Objective(s): Dose constraint recommendations to limit mandible (MN) osteoradionecrosis (ORN) are largely unchanged since the advent of head and neck intensity modulated radiotherapy (IMRT). Updated MN dose volume histogram (DVH) constraints have been proposed but not validated in a prospective dataset. We hypothesize that after adopting more stringent MN constraints at our institution, we lowered the estimated ORN rate without compromising target coverage / organ at risk (OAR) avoidance. Materials/Methods: This is a single institution retrospective study of a prospective database of non-metastatic oropharynx cancer (OPC) patients ≥ 18 years treated with standard fractionation adjuvant or definitive IMRT from 01 / 2014 − 08 / 2020. In 09 / 2017, MN dose constraint was changed from 0.1 cm 3 < 70 Gy − historical constraints (HC) − to V44 < 42%, V58 < 25%, 0.5cc < 70 Gy − modified constraints (MC). No other target / OAR criteria were altered. ORN was defined as having exposed MN bone for ≥ 3 months without recurrence. Impact on ORN rate and resulting dosimetric changes in MN and other OARs (parotid and submandibular glands, oral cavity, pharyngeal constrictors) between HC and MC groups were evaluated. Continuous variables were compared via the Wilcoxon test, discrete variables via Fisher's exact test. Due to shorter follow-up (FU), regression modeling was used to estimate ORN cases in MC group. Results: There were 174 patients total, 71 in MC group. The mean prescription dose was 67.7 Gy and 68.5 Gy in HC and MC groups, respectively. More of the HC group (37%) had clinical T3 -T4 tumors compared to MC group (25%). More patients in the MC group met both the V44 < 42% (62 v 87%, P < 0.01) and the V58 < 25% constraints (73 v 92%, P < 0.01). Percent of patients meeting neither, one, or both MN constraints in the HC group was 23%, 13%, and 63%, versus 8%, 4%, and 87% in the MC group, respectively (P < 0.01). Mandible V44 and V58 were significantly associated with ORN (P < 0.01 and P = 0.03, respectively) across entire patient cohort. In HC group, mean MN V44 was significantly associated with ORN (62% in ORN cases vs 38%, P = 0.01) while mean MN V58 was approaching significance (P < 0.06). There were too few ORN cases in the MC group for similar analysis. Mean dose to OARs was not increased in MC group. There were 7 cases (76%) of ORN in the HC group at median FU 39 months (range: 2 -78 months) and 2 cases (33%) of ORN in the MC group at median FU 11 months (range: 2 -39 months). To account for shorter FU in MC group, logistic regression of ORN based on V44 in HC patients resulted in a model to predict ORN cases in MC group. This model estimates a total of 3.2 ORN cases (55%) in MC group (95% CI: 0.00 -6.4). Conclusion:We confirm MN V44 and V58 are predictive of ORN development. The goals of MN V44 < 42% and V58 < 25% were achievable in 87% of cases without sacrificing target coverage or other OAR constraints. Regression modeling estimates fewer ORN cases in MC group.
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