Soft Tissue Invasion Research Articles

Classification of Parathyroid Cancer

Parathyroid cancer is rare and often has a poor outcome. There is no classification system that permits prediction of outcome in patients with parathyroid cancer. This study was designed to validate two prognostic classification systems developed by Talat and Schulte in 2010 ("Clinical Presentation, Staging and Long-term Evolution of Parathyroid Cancer," Ann Surg Oncol 2010;17:2156-74) derived from a retrospective literature review of 330 patients. This study contains 82 formerly unreported patients with parathyroid cancer. Death due to disease was the primary end point, and recurrence and disease-free survival were the secondary end points. Data acquisition used a questionnaire of predefined criteria. Low risk was defined by capsular and soft tissue invasion alone; high risk was defined by vascular or organ invasion, and/or lymph node or distant metastasis. A differentiated classification system further classified high-risk cancer into vascular invasion alone (class II), lymph node metastasis or organ invasion (class III), and distant metastasis (class IV). Statistical analyses included risk analysis, Kaplan-Meier analysis, and receiver-operating characteristic (ROC) analysis. Follow-up ranged 2-347 months (mean 76 months). Mortality was exclusive to the high- risk group, which also predicted a significant risk of recurrence (risk ratio 9.6; 95% confidence interval 2.4-38.4; P < 0.0001), with significantly lower 5-year disease-free survival (χ(2) = 8.7; P < 0.005 for n = 45). The differentiated classification also provided a good prognostic model with an area under the ROC curve of 0.83 in ROC analysis, with significant impairment of survival between classes (98.6%, 79.2%, 71.4%, 40.0%, P < 0.05 between each class). This study confirms the validity of both classification systems for disease outcome in patients with parathyroid cancer.

Evaluation of Discordance in Differentiated Thyroid Cancer Patients with Negative Radioiodine Scans and Positive Thyroglobulin Values at the Ablation Outcome Control

Objective: We aimed to evaluate the discordance of 5 mCi (185 MBq) I-131 whole body scan (WBS) and thyroglobulin (Tg) values at the ablation outcome control in differentiated thyroid cancer (DTC) patients who had thyroidectomy and then received radioiodine (RAI) ablation. Materials and Methods: We retrospectively evaluated 36 DTC patients who had RAI treatment in our department between 1992-2009 and whose 5 mCi (185 MBq) I-131 WBS were negative, but Tg values were age;2 ng/ml during the ablation outcome control (Patient group). Thirty-six patients whose Tg values were alt; 2 ng/ml and showed no discordance at the same control made up the control group. Patient and control groups were compared in terms of age, gender, histopathological features, ablation dose, Tg value before ablation, and 24. hour RAI uptake value during ablation. The patient group was then evaluated for the cause of the discordance. Results: There were 28 female and 8 male patients whose mean age was 45.6aplusmn;11.39 in patient group. In the control group, there were 29 female and 7 male patients whose mean age was 41.5aplusmn;11.69. According to the reason of discordance at the ablation outcome control, the patient group was divided into 2 groups: 15 (42%) patients (9 female, 6 male patients, mean age: 50.66aplusmn;10.73) who had metastatic lymph nodes as the reason of discordance constituted the lymph node group. The remaining 21 (58%) patients (19 female, 2 male patients, mean age: 41.5aplusmn;10.44) were the micrometastatic group in which the cause of discordance could not be determined. There were statistically significant differences in soft tissue invasion (palt;0.003), Tg levels before RAI treatment (palt;0.002), and diameter of tumor agt;2 cm (palt;0.035) between patient and control groups. Among the patient group, male gender (palt;0.03), diameter of tumor agt;2 cm (palt;0.05), thyroid capsule invasion (palt;0.03), and ageagt;40 (palt;0.01) were significantly different between lymph node and micrometastatic groups. Conclusion: I-131 WBS/Tg level discordance at the ablation outcome control is mainly caused by metastatic lymph nodes. Turkish Baslik: Diferansiye Tiroid Karsinomlarinda Ablasyon Kontrolu Sirasinda Ortaya Cikan 5 Mci Iyot-131 Sintigrafisi Negatif, Tiroglobulin Pozitif Uyumsuzlugunun Degerlendirilmesi Anahtar Kelimeler: Diferansiye tiroid karsinomu, radyoaktif iyot tedavisi, I-131 tum vucut tarama, lenf nodu metastazi Amac: Diferansiye tiroid karsinomu (DTK) hastalarinda, ablasyon kontrolu sirasinda ortaya cikan 5 mCi Iyot-131 tum vucut sintigrafisi ve tiroglobulin degeri uyumsuzlugunu ve bunun olasi nedenlerini incelemeyi amacladik. Hastalar ve Yontemler: DTK tanili hastalarda ablasyon kontrolu icin yapilan 5 mCi TVS (-) ve Tg degeri age;2ng/ml olan 36 hasta retrospektif olarak incelendi(hasta grubu). Tg degerleri alt;2ng/ml olan ve uyumsuzluk bulunmayan 36 hasta ise kontrol grubu olarak alindi. Hasta ve kontrol grubunun karsilastirilmasinda yas, cinsiyet, histopatoloji, ablasyon dozu, ablasyon oncesi Tg degeri ve 24. saat RAI uptake degeri kullanildi. Ayrica hasta grubu da uyumsuzluk nedeni acisindan incelendi. Bulgular: Hasta grubunda 28K, 8E, yas ort:45.6aplusmn;11.39 ; kontrol grubunda 29K, 7E , yas ort:41.5aplusmn;11.69 idi. Hasta grubunda uyumsuzluk nedenine yonelik yapilan tetkikler sonucunda 15(%42) hastada lenf bezi metastazi saptanirken (lenf nodu grubu), 21(%58) hastada uyumsuzluk nedeni bulunamadi (mikrometastatik grup). Yapilan istatistiksel calismada, hasta ve kontrol gruplari arasinda yumusak doku invazyonu, ablasyon oncesi Tg degeri ve tumor capiagt;2cm acisindan anlamli fark bulundu. Hasta grubundaki degerlendirmede ise, E cinsiyet, tumor capiagt;2cm, tiroid kapsul invazyonu ve yasagt;40 gibi parametrelerin karsilastirilmasinda lenf nodu ve mikrometastatik grup arasinda anlamli fark bulundu. Sonuc: Ablasyon kontrolu sirasinda ortaya cikan 5 mCi-TVS (-), Tg (+) uyumsuzlugunda tespit edilebilen baslica neden lenf nodu metastazidir.

Consultation with the Specialist: Thyroid Nodules

Based on strong research evidence, thyroid nodules in children and teenagers are more likely to be malignant than in adults. Based on strong research evidence, a history of ionizing radiation to the head or neck is an independent risk factor for the development of thyroid malignancies. There is strong research evidence, including a recent meta-analysis, supporting the use of fine-needle aspiration biopsy in the evaluation of all pediatric and adolescent patients presenting with a thyroid nodule. The surgical management and postoperative care of pediatric and adolescent patients who have well-differentiated thyroid carcinomas remains controversial, because the rarity of the disease limits the ability to conduct randomized, prospective research studies. Numerous studies have demonstrated that, despite presenting with more advanced disease, pediatric and adolescent patients with thyroid carcinoma have a higher survival rate than adults. The American Thyroid Association has issued strong evidence-based recommendations for the management of medullary thyroid carcinoma, including RET mutation testing and early prophylactic total thyroidectomy in children with high-risk mutations.

Parathyroid Carcinoma Presenting as a Hyperparathyroid Crisis

Parathyroid Carcinoma Presenting as a Hyperparathyroid Crisis

Unusual Location of Hydatid Cysts: A Case Report and Literature Review

Hydatid cysts develop most frequently in the liver and lungs, but they are occasionally found in other organs. Hydatid cysts in the axillary space are an extremely rare event in areas where the disease is endemic, and are still common in many countries, including Turkey. A 73-year-old man presented to our clinic with a painful axillary mass. Thoracoabdominal computed tomography revealed multilocular cystic masses localized in the left axillary space, with minimal invasion of the peripheral soft tissue and no pulmonary or hepatic involvement. An echinococcal indirect hemagglutination test was negative. The masses were dissected through their stalks and removed completely. Macroscopic and microscopic examination of the specimens confirmed hydatid cysts. This case report demonstrates that hydatid cysts should be considered as a possible cause for palpable lesions in the axillary region or chest wall, especially in endemic locations.

Three-Dimensional Printing of Bone Repair and Replacement Materials

Solid freeform fabrication techniques such as direct write technology can be used to fabricate tissue-engineering scaffolds in 3 dimensions with high levels of reproducibility and precision. These can comprise complex structures made of osteoconductive, remodelable lattices to conduct bone ingrowth and solid barriers to prevent soft tissue invasion. As such, they act as a combination of bone graft and barrier membrane. Results from animal studies have shown that these structures fill rapidly with healing bone and can conduct bone across critical-size defects to fill large defects in rabbit skull. Results indicate that this technology can be used to produce both off-the-shelf and custom-fabricated bone graft substitutes. These may initially be used to restore alveolar ridge defects, but could also be used, in the future, to repair or replace complex craniofacial bone defects such as cleft palate defects. In the more distant future, these technologies could be combined with controlled-release bioactive substances such as growth factors and pharmaceuticals to regenerate complex structures comprising multiple tissue types.

Patterns of failure and histopathologic outcome predictors following definitive radiotherapy and planned neck dissection with residual disease

Our aim was to report patterns of failure and histopathological predictors in patients with head and neck cancer treated by planned neck dissection. We reviewed all new patients with head and neck cancer who underwent a planned neck dissection in our institution from 1998 to 2007. Patterns of failure after positive planned neck dissection were reported. The frequency and predictive value of histopathologic features were analyzed. Fifty positive planned neck dissection and 144 negative planned neck dissection cases were identified. The positive planned neck dissection cohort had lower 5-year overall survival (OS; 33% vs 77%; p < .01), a significantly higher distant metastasis (DM; 44% vs 11%; p < .01), a moderately lower local (86% vs 96%; p < .01), and a similar regional control (94% vs 99%; p = .07) compared to the negative planned neck dissection cohort. Extracapsular extension/carcinoma within soft tissue and lymphovascular invasion were adverse survival predictors for patients with positive planned neck dissection on univariate and multivariate analysis. Positive planned neck dissection is associated with lower survival, predominantly attributed to significantly increased DM rather than reduced locoregional control.

Bilateral pleurisy revealing a myelome with free light chains complicated with an osseous amylase

The osseous amyloidosis associated with a pleural effusion in a myeloma is a rare situation. We report a case of an association of these three disease entities for discussion. A 75-year-old man was admitted for chest pain and dyspnea with left sacred bone pain. The radiological assessment reported pleurisy and bilateral lytic images of the sacrum with soft tissue invasion, the biochemical tests showed a lambda free light chain myeloma and bone biopsy reported amyloidosis. The occurrence of systemic amyloidosis in myeloma is well documented, but the osseous location is rare and rarely revealed. Pleural effusion is a known complication of myeloma but is exceptionally revealing; it is usually seen in the myeloma IgG and IgA but very rarely in free light chain myeloma. We reported here a case that represents an exceptional situation of complications of light chains myeloma to remember their possible occurrence and to insist for the clinician sensitizing to carry out investigations on time and avoid complications or at minimum to retard them.

Treatment of soft tissue invasion of a large recurrent keratocystic odontogenic tumour by marsupialisation alone

Introduction: A 72-year old man presented with a keratocystic odontogenic tumour (KOT) in the posterior mandible which was treated by enucleation. Good bony infill and no recurrence were seen in the first 3 years. He was re-referred 9 years post-op with massive recurrence perforating lingual and buccal cortices of the mandible and extending well into the lingual, peri-tonsillar and buccal tissues.

Significance of microscopic invasion into hilar peribronchovascular soft tissue in resection specimens of primary non-small cell lung cancer

IntroductionThe significance and handling of microscopic invasion of non-small cell lung cancer (NSCLC) into hilar peribronchovascular soft tissue (SHEATH+) have not been defined in the TNM classification by AJCC/UICC; nevertheless, SHEATH+ may be equivalent to spread into the mediastinum. Also, assessment of the margin of peribronchial resection is challenging because of the technical difficulty of inking, and intraoperative and postoperative artifacts. MethodsRecords of 592 consecutive Asian patients with primary NSCLC (excluding adenocarcinoma in situ) who had, without any preoperative therapy, undergone lobectomy, sleeve lobectomy and pneumonectomy were examined. SHEATH+, simply defined as invasion of hilar peribronchovascular soft tissue, without categorizing any invasive patterns, and its significance were statistically analyzed. ResultsForty-four SHEATH+ cases demonstrated significantly advanced TNM stages, and were statistically associated with central occurrence, pN1-3, and vascular invasion, as assessed by logistic regression analysis. No statistically significant differences were observed between TNM stage-adjusted frequency of recurrence and recurrence-free intervals. Kaplan–Meier's estimates of the rate of overall and recurrence-free survival after surgery showed no statistically significant differences between SHEATH+ and SHEATH−. Cox's multivariate analysis suggested SHEATH was not a statistically independent prognostic factor under the TNM classification by AJCC/UICC (7th edition). ConclusionsSHEATH+ in NSCLC was simply associated with central occurrence and advanced TNM stages. To the best of our knowledge, this is the first report on the significance of SHEATH+ in NSCLC.

Parathyroid Cancer

Parathyroid cancer is an uncommon malignancy and rare cause of primary hyperparathyroidism (HPT) with a high morbidity and patient death in advanced cases usually resulting from intractable hypercalcemia. Inactivation of the HRPT2/CDC73 gene, encoding the putative tumor-suppressor protein parafibromin and discovered in the context of the hyperparathyroidism-jaw tumor (HPT-JT) syndrome, is a common, somatic event in most parathyroid cancers. Approximately 25% of patients with apparently sporadic parathyroid cancer carry germline HRPT2/CDC73 mutation. Germline DNA analysis for HRPT2/CDC73 mutation is recommended in all patients with parathyroid cancer because of the potential benefit for first-degree relatives, who should nevertheless undergo serum calcium screening. The histopathologic diagnosis of parathyroid cancer is nonspecific unless vascular, lymphatic, capsular, or soft tissue invasion is seen, or metastases are clinically evident. Immunohistochemical analysis of parathyroid tumors for loss of parafibromin expression offers promise as a diagnostic tool. En bloc tumor resection offers the highest chance of cure in patients with suspected parathyroid carcinoma. No adjuvant chemotherapy regimen has yet proven effective, and the role of local adjuvant radiotherapy is being evaluated. Metastatic disease can be palliated with surgical debulking. Medical therapy with the calcimimetic cinacalcet and bisphosphonates can ameliorate hypercalcemia in patients with inoperable disease.

Group B streptococcal necrotizing fasciitis from a decubitus ulcer

A 29-year-old man with paraplegia secondary to a gunshot wound presented to the emergency department (ED) with worsening abdominal pain over the past 2 weeks with associated fever, dysuria, nausea, and vomiting. He had been diagnosed with a urinary tract infection (UTI) 2 days earlier and was started on antibiotics without improvement. On examination he was afebrile, tachycardic up to 140, tachypneic, and diaphoretic. His abdomen was rigid and diffusely tender to palpation with hypoactive bowel sounds. He had a mildly tender 3 × 3 cm decubitus ulcer on his buttocks. His WBC was elevated at 18, with an absolute neutrophil count of 11.09 and 3.17 bands. The creatine kinase was elevated at 1,001 and a serum lactate level was 8.7. Abdominal computed tomography (CT) showed free air dissecting into the retroperitoneal and peritoneal fascial planes consistent with necrotizing fasciitis (Fig. 1, Fig. 2, Fig. 3, and Fig. 4). Fig. 1 Chest X-ray showing subdiaphragmatic free air Fig. 2 CT scan through the abdomen showing free air Fig. 3 CT scan through the pelvis showing free air Fig. 4 CT scan through the lower pelvis showing air tracking The patient was taken for emergent exploratory laparotomy and extensive debridement. Throughout his hospital course he returned to the operating room (OR) a total of 11 times for further debridement and repair of complications, which included a perforated cecum and a colocutaneous fistula. Cultures from the wound grew Prevotella bivia and group B streptococci, while cultures of the peritoneal tissue grew only group B streptococci. Neither blood nor urine cultures grew any bacteria. In addition to his numerous surgeries he was treated with IV clindamycin and piperacillin/tazobactam. After 10 weeks of hospitalization he was transferred to a rehab facility. Necrotizing fasciitis, more commonly known as the “flesh-eating disease,” is an aggressive and highly destructive infection of fascia and muscle with a high morbidity and mortality. Necrotizing fasciitis from decubitus ulcers is rare, with only a few reported cases [1, 2]. The diagnosis can be difficult, as symptoms are nonspecific and the initial skin lesions are often benign compared to the underlying tissue destruction [3]. A high index of suspicion should be present when abdominal radiographs demonstrate subcutaneous emphysema in a patient with skin lesions [4]. On CT, free air with evidence of soft tissue invasion is consistent with the diagnosis [2]. This case is unique because the decubitus ulcer and peritoneal samplings both grew and isolated group B streptococci as the causative agents; necrotizing fasciitis is typically caused by group A streptococci, Staphylococcus aureus, Vibrio vulnificus, Clostridium perfringens, Bacteroides fragilis, or mixed flora.

Recurrence of benign meningiomas: predictive value of proliferative index, BCL2, p53, hormonal receptors and HER2 expression

Introduction. The biological behaviour of meningiomas and the risk of recurrence in individual cases cannot be predicted by using conventional histological criteria alone. A number of histologically benign meningiomas may recur, even after gross complete surgical removal.Material and methods. A retrospective immunohistochemical and statistical analysis of 60 patients with benign intracranial meningiomas (that have been grossly totally resected) was undertaken to determine the correlation of clinicopathological characteristics and expression of biological markers (proliferation index (PI) assessed by Ki67, hormonal receptors, p53, BCL2 and HER2, estrogen receptors, ER and progesterone receptors, PR) with prediction of recurrence.Results. HER2 expression showed a significant inverse correlation with PR and a significant direct correlation with PI. PR-negative and HER2-positive cases showed a statistically significant higher mean PI than PR positive and HER2-negative cases. Univariate analysis showed that recurrence was significantly associated with male gender, cranial base location, the presence of bone and soft tissue invasion, some atypical histological features, higher PI, negative PR expression, and positive p53, BCL2 and HER2 expression. Multivariate analysis showed that the presence of bone and soft tissue invasion and/or the expression of p53 proved to be independent predictors of tumour recurrence. The presence of some atypical histological features and high PI were significant predictors of tumor recurrence, however, they were statistically excluded to avoid multicolinearity.Conclusions. Risk stratification based on histomorphology alone remains problematic. We conclude that soft tissue and bone invasion, some atypical histological features, p53 expression and high PI identify meningiomas with benign histological features but unfavourable clinical outcome. We suggest that those patients should be followed more closely for evidence of recurrent tumour or may be treated more aggressively at the time of diagnosis.

Prognostic factors for relapse in stage I seminoma managed with surveillance: A validation study.

4535 Background: A prognostic model for stage I seminoma managed by orchiectomy alone has limited predictive value since the high risk group has only a 30% relapse rate. Although the model has not been validated in an independent data set, it has been applied widely in treatment policies. We tested the value of the model in a consecutive series of patients managed by surveillance in the past decade. Methods: Individual data on 687 stage I seminoma patients managed by surveillance between 1998 and 2005 at the Copenhagen National Hospital, Princess Margaret Hospital and British Columbia Cancer Agency was retrospectively analyzed. Impact of age at diagnosis, original pathology [tumor size, histologic subtype, rete testis invasion, epidydimis, extratesticular soft tissue, spermatic cord, tunica albuginea, and small vessel invasion (SVI)] were analyzed for prognostic importance for relapse. The analysis was limited by missing data in significant proportion of reports [rete testis (33%), SVI (25%), tumor size 2...

Primary meningeal sarcoma with leiomyoblastic differentiation complicating pregnancy

Intracranial malignant tumors during pregnancy are rare. Primary meningeal sarcoma with leiomyoblastic differentiation during pregnancy has not been reported. We present the case of a 25-year-old woman in the third trimester of pregnancy with a large intracranial tumor destructing the parietal calvaria and invasion of soft tissues. Histological examination revealed primary meningeal sarcoma with leiomyoblastic differentiation. A gross macroscopical resection of the tumor with removal of the infiltrated parietal calvaria was performed after delivery of a healthy baby through caesarean section. A mass on the head rapidly enlarging during pregnancy should be considered for a malignancy of intracranial origin. Early radiological exams as well as tumor resection followed by staging and multimodality treatment should be urgently performed.

Cytokeratin-, calponin-, and p63-positive chondroblastoma with extensive soft tissue involvement and vascular invasion: a potential diagnostic dilemma

Chondroblastomas are rare bone tumors, accounting for less than 2% of all bone tumors. Although generally benign, there are instances of aggressive tumor behavior with extensive soft tissue invasion and even metastasis. In this report, we detail an instance where the tumor displayed extensive soft tissue invasion. As there is tumor heterogeneity in terms of morphologic appearance as well as a varied immunohistochemistry profile, a diagnosis of chondroblastoma may not be straightforward if the initial biopsy sample did not include the more characteristic area. In our case, the tumor expressed cytokeratin, calponin, and p63 in addition to S-100, potentially raising a diagnosis of a mixed tumor. The differential diagnosis and biologic behavior of chondroblastomas are discussed.

Giant cell tumor of the anterior rib masquerading as a breast mass: a case report and review of current literature

IntroductionGiant cell tumor (GCT) is an aggressive, but usually benign bone neoplasm most commonly arising in the metaphysis/epiphyses of long bones. While they are categorized as benign tumors, they can be locally aggressive and clinically have metastatic potential. The most common locations of this tumor include the distal femur, proximal tibia, and distal radius. We report a GCT arising in an atypical location and mimicking a breast mass.Case PresentationThis case was diagnosed at a large cancer center in Florida. Pertinent clinical findings were obtained from chart review and inter-departmental consultation. Radiologically, the initial impression included a deep-seated breast cancer with local chest wall invasion. Further evaluation revealed the mass to be an expansile rib lesion with extraosseous soft tissue invasion. Histological examination of the biopsy specimen showed bland multi-nucleated giant cells and mononuclear cells whose nuclei were morphologically similar. No necrosis, pleomorphism or mitotic activity was identified. No chondroid or osseous elements were present.ConclusionThe histological features of bland mononuclear and multinucleated giant cells along with the lack of any additional mesenchymal elements led to the diagnosis of giant cell tumor. Resection of tumor was performed. The patient is disease free as of the last follow-up visit. This case is important as it shows where the physician must keep this diagnosis in mind whenever a deeply located breast mast is present.

Permanent hypocalcemia in patients operated for thyroid carcinoma

The incidence and risk factors for permanent hypocalcemia in thyroid carcinoma were investigated. The records of 417 patients were reviewed retrospectively at tertiary oncology referral center. Total or subtotal thyroidectomy patients constituted group I (n = 225), reoperative thyroid surgery patients constituted group II (n = 106), and therapeutic neck dissection cases constituted group III (n = 86). Age, gender, thyroid functions, pathologically verified tumor type, differentiation, localization and size, multicentricity, thyroid capsule invasion, extrathyroidal soft tissue invasion, coexistence of lymphocytic thyroiditis, metastatic lymph nodes dissected, incidental parathyroidectomy, and the type of surgery were investigated. RE SULTS: Permanent hypocalcemia was seen in 32 (7.7%) patients. The incidence of permanent hypocalcemia for each group was 1.7%, 10.3% and 19.7%, respectively. Related risk factors were hyperthyroidism for group I [adjusted relative risk (RR) = 21.1, 95% confidence interval (CI) = 2.6-165, p = 0.01] incidental parathyroidectomy for group II (RR = 7.8, 95% CI = 1.9-31.0, p = 0.004), and extrathyroidal soft tissue invasion (RR = 3.1, 95% CI = 1.1-9.5, p = 0.03) for group III. Permanent hypocalcemia rate was increased with reoperative thyroid surgery and neck dissection added to total thyroidectomy. Hyperthyroidism, incidental parathyroidectomy and extrathyroidal extension were related risk factors.

Treatment Outcomes of T4 Locally Advanced Head and Neck Cancers With Soft Tissue Invasion or Bone and Cartilage Invasion

T4 locally advanced squamous cell cancers of the head and neck (SCCHN) with bone and cartilage invasion (BCI) traditionally have been treated with resection followed up with chemoradiotherapy (CRT). Because the organ preservation trials, more patients with BCI, as well as those with soft tissue invasion (STI), have been treated with definitive CRT. This is a review of our experience. We performed a retrospective review of patients who underwent definitive CRT or radical resection followed up with postoperative CRT for T4N0-3M0 locally advanced SCCHN. We analyzed outcomes based on STI/BCI and types of treatment. Radiotherapy doses ranged from 59.4 to 72 Gy. Concurrent chemotherapy was platinum based in all CRT patients. From 1995 to 2006, 101 patients with locally advanced SCCHN were treated definitively. Of these, 51 had STI and 50 had BCI. Of the 51 patients with STI, 42 were treated with CRT, 5 patients were treated with resection followed by CRT, and 4 patients were treated with radiotherapy alone. Of the 50 patients with BCI, 26 patients were treated with CRT, 20 patients were treated with radical resection followed by radiotherapy or CRT, and 4 patients were treated with radiotherapy alone. Five-year local-regional control was 51% and 43% for STI and BCI patients treated with CRT, respectively, and 44% for BCI treated with radical resection. Five-year overall survival was 23%, 51%, and 28% for STI treated with CRT, BCI treated with CRT, and BCI treated with radical resection. Outcomes were not statistically different between these groups. This study suggests similar outcomes for CRT or resection followed up with chemoradiotherapy for patients with locally advanced SCCHN with BCI. Concurrent CRT may be viable alternative to upfront resection in these patients. Further studies should be performed to validate these provocative findings.

Interstitial brachytherapy as boost for locally advanced T4 head and neck cancer

Purpose Locally advanced squamous cell cancers of the head and neck (SCCHN) with bone and cartilage invasion (BCI) or those with soft-tissue invasion (STI) have been treated with resection followedup with chemoradiotherapy (CRT) or definitive CRT. However, locoregional recurrence remained a large component of treatment failure. High-dose-rate interstitial brachytherapy (BT) has been used for dose escalation to further prevent local relapse. This is a review of our experience. Methods and Materials T4N0-3M0 locally advanced oral cavity and oropharyngeal squamous cell carcinoma (SCCA) patients underwent definitive CRT or radiotherapy (RT) followedup with brachytherapy (BT). RT doses ranged from 45 to 50.4 Gy. The patients were reassessed at this dose and if response was inadequate, patients underwent BT. BT doses ranged from 24 to 30 Gy at 3–4 Gy per fraction BID with 6 h in between fractions. Concurrent chemotherapy was platinum based. Results Twenty patients were treated with CRT or RT alone followed by BT. Thirteen patients had STI and 7 had BCI; 14 patients were treated with CRT followed by BT; and 6 patients were treated with RT alone followed by BT. Five-year locoregional control was 61%. Five-year overall survival was 29%. When we excluded the patients treated with RT alone, 5-year overall survival was 36%. Nodal status was the only prognostic factor. Conclusions This study suggests CRT followedup with BT for patients with T4 locally advanced SCCHN of the oral cavity, and oropharynx is a feasible treatment option. In patients with poor response to CRT, BT may be used for dose escalation to increase locoregional control.