Need For Adjuvant Radiotherapy Research Articles

A phase II trial of neoadjuvant nivolumab, docetaxel, and cisplatin followed by surgery and radiation therapy for resectable high-grade salivary gland carcinoma.

e18061 Background: High-grade resectable salivary gland carcinomas, typically treated with surgery and adjuvant therapies, often recur. This study explores combining an immune checkpoint inhibitor (ICI) with chemotherapy as neoadjuvant therapy to improve outcomes in high-risk, operable cases. Methods: This trial enrolled high-grade SGC patients with clinically positive lymph nodes. Participants received three cycles of nivolumab in conjunction with docetaxel and cisplatin every three weeks. The primary response was assessed three weeks post-treatment, and surgery followed at seven weeks in cases deemed operable. The pathologic outcomes determined the need for adjuvant radiotherapy, administered at 59.4Gy (R0) or 66.0Gy (R1 or R2). The study's primary endpoint was the major pathologic response rate (MPR). We aimed to recruit 50 patients. Herein, we present an interim analysis (NCT05727410). Results: Since November 2022, 19 patients have enrolled; predominantly male (89.5%) with a median age of 62 (range 42-75). Histologic analysis identified various subtypes, primarily salivary duct carcinoma (68.4%). Other histologies included high-grade adenocarcinoma (10.5%), mucoepidermoid carcinoma (10.5%), basaloid squamous cell carcinoma (5.3%), and secretary carcinoma (5.3%). At the time point of analysis, surgery was performed on 16 patients, and 3 patients are still under neoadjuvant therapy. Complete resection (R0) was achieved in 87.5% (n=14) of the cases, with one patient having R1 and another R2 resection. Pathologic analysis showed 12.5% (n=2) achieving pathological complete response and 18.8% (n=3) achieving MPR. Tumor viability varied, with 37.5% (n=6) presenting with 10% to 50% viability and 31.3% (n=5) presenting with 50% or higher viability. A patient with salivary duct carcinoma histology with tumor viability of 20% after neoadjuvant treatment experienced recurrence after 4.1 months from surgery. Notably, throughout the neoadjuvant treatment phase, no patients discontinued due to toxicity or intolerance, indicating a favorable tolerance profile for the combination therapy. An ongoing exploratory biomarker study includes PD-L1 expression and genomic profiling. Conclusions: The preliminary findings of this study demonstrate that the neoadjuvant combination of immune checkpoint inhibitor with chemotherapy significantly reduces tumor burden in salivary gland carcinoma, as evidenced by the high rate of complete resections (R0) and favorable pathologic responses. This treatment strategy not only facilitates surgical outcomes but also exhibits an acceptable safety profile, with no instances of treatment discontinuation due to toxicity or intolerance. These promising results underscore the potential of ICI combination therapy in the management of SGC and warrant further detailed investigations. Clinical trial information: NCT05727410 .

Neo-Adjuvant Therapy for Metastatic Melanoma.

Melanoma treatment is leading the neo-adjuvant systemic (NAS) therapy field. It is hypothesized that having the entire tumor in situ, with all of the heterogeneous tumor antigens, allows the patient's immune system to have a broader response to the tumor in all its shapes and forms. This translates into a higher clinical efficacy. Another benefit of NAS therapy potentially includes identifying patients who have a favorable response, which could offer an opportunity for the de-escalation of the extent of surgery and the need for adjuvant radiotherapy and/or adjuvant systemic therapy, as well as tailoring the follow-up in terms of the frequency of visits and cross-sectional imaging. In this paper, we will review the rationale for NAS therapy in resectable metastatic melanoma and the results obtained so far, both for immunotherapy and for BRAF/MEKi therapy, and discuss the response assessment and interpretation, toxicity and surgical considerations. All the trials that have been reported up to now have been investigator-initiated phase I/II trials with either single-agent anti-PD-1, combination anti-CTLA-4 and anti-PD-1 or BRAF/MEK inhibition. The results have been good but are especially encouraging for immunotherapies, showing high durable recurrence-free survival rates. Combination immunotherapy seems superior, with a higher rate of pathologic responses, particularly in patients with a major pathologic response (MPR = pathologic complete response [pCR] + near-pCR [max 10% viable tumor cells]) of 60% vs. 25-30%. The SWOG S1801 trial has recently shown a 23% improvement in event-free survival (EFS) after 2 years for pembrolizumab when giving 3 doses as NAS therapy and 15 as adjuvant versus 18 as adjuvant only. The community is keen to see the first results (expected in 2024) of the phase 3 NADINA trial (NCT04949113), which randomized patients between surgery + adjuvant anti-PD-1 and two NAS therapy courses of a combination of ipilimumab + nivolumab, followed by surgery and a response-driven adjuvant regimen or follow-up. We are on the eve of neo-adjuvant systemic (NAS) therapy, particularly immunotherapy, becoming the novel standard of care for macroscopic stage III melanoma.

Outcomes of dogs with apocrine gland anal sac adenocarcinoma treated via modified closed anal sacculectomy (2015-2022).

To evaluate the postoperative complication rate and local recurrence rate of apocrine gland anal sac adenocarcinoma (AGASACA) in dogs surgically treated with a modified closed anal sacculectomy technique between 2015 and 2022. Observational clinical retrospective study. Forty-seven client-owned dogs histologically diagnosed with AGASACA. Medical records were evaluated for patient demographics and history, physical examination findings, diagnostic imaging, incidence of concurrent neoplasia, postoperative complications, and incidence and time to local recurrence. Dogs with at least 150 days of follow-up were included in evaluation of local recurrence. Two dogs were euthanized at 4 and 11 days after surgery. Forty-five dogs were included for long-term local recurrence evaluation, with a median of 364 days of follow-up (range 156-2156 days). Only one dog (2.2%) developed local recurrence with a time to recurrence of 90 days. Postoperative complications were reported in 15 dogs (31.9%) and were considered minor in 14 dogs (93.3%) and major in one dog (6.7%). Mean survival time for the 20 dogs that were deceased as of November 1, 2022 was 521 days (range 156-1409 days) and the median survival time was 388 days. The modified closed anal sacculectomy technique resulted in a lower AGASACA local recurrence rate than previously reported in the veterinary literature with a comparable postoperative complication rate. Given the low recurrence rate found in this study, the modified closed anal sacculectomy technique may reduce the need for adjuvant radiation therapy and potentially chemotherapy in AGASACA patients.

A Descriptive Study of Quality of Life Following Neoadjuvant Chemotherapy and Transoral Robotic Surgery for Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma.

Patients with oropharyngeal squamous cell carcinoma (OPSCC) treated with radiation-based therapy suffer from short- and long-term toxicities that affect quality of life (QOL). Transoral robotic surgery (TORS) has an established role in the management of early OPSCC but adjuvant treatment is often indicated postoperatively due to the high incidence of nodal metastasis associated with advanced human papillomavirus (HPV)-related OPSCC. To overcome the need for adjuvant radiation therapy (RT), neoadjuvant chemotherapy followed by TORS and neck dissection (ND) is proposed. This study aimed to assess if QOL in HPV-associated OPSCC receiving neoadjuvant chemotherapy followed by TORS and ND returns to baseline within 12 months of completing treatment. A 12 month longitudinal study was carried out at McGill University Health Centre in Montreal, Canada, among a convenience sample of patients with American Joint Committee on Cancer Seventh Edition stage III and IVa HPV-related OPSCC who were treated with neoadjuvant chemotherapy followed by TORS and ND. QOL data were obtained pretreatment and at 1, 3, 6, and 12 months following treatment completion using the European Organisation for Research and Treatment of Cancer Core and Head and Neck extension modules. Paired t tests and mixed models for repeated measures analysis were used to assess changes in QOL from baseline to 12 months postoperatively and over time, respectively. Nineteen of 23 patients (median age 58 years) who received the study treatment fulfilled the eligibility criteria. OPSCC subsites were palatine tonsil (n = 12) and base of tongue (n = 7). All 19 patients were treated per protocol and none required adjuvant RT as per pathology review and protocol requirements at a postoperative multidisciplinary team tumor board discussion. No significant differences were found when comparing 12 month QOL follow-up scores to pretreatment scores in measures that would likely be affected by RT [eg, swallowing (P = .7), social eating (P = .8), xerostomia (P = .9)]. In HPV-related OPSCC, neoadjuvant chemotherapy followed by TORS and ND as definitive treatment is associated with excellent QOL outcomes. Postoperative QOL scores returned to baseline by 3 months and were maintained for all measures, indicating a return to normal function.

Abstract PO-066: Complete pathological response following neoadjuvant chemotherapy and recurrence free survival in patients with p16-positive oropharyngeal cancer

Abstract Introduction: Locoregionally advanced p16+ squamous cell carcinoma of the oropharynx (OPSCC) is most often treated either with primary chemoradiation (CRT) or surgery followed by adjuvant treatment. Surgery alone is often insufficient treatment as adverse features such as extranodal extension, close or positive margins, lymphovascular invasion, or multiple positive lymph nodes are often identified, resulting in the need for adjuvant radiation or CRT. Primary surgery is often not pursued in more advanced cases since surgical pathology may show adverse features requiring adjuvant CRT, resulting in "triple therapy", the effects of which may worsen risk of long-term treatment toxicity. Our institution has demonstrated excellent oncologic and quality of life outcomes using a neoadjuvant chemotherapy (NAC) regimen of cisplatin and docetaxel prior to surgical treatment with TORS and neck dissection. Due to high rates of clinical-to-pathologic downstaging, adjuvant treatment is often avoided entirely. Here, we explore whether the development of a complete pathologic (pCR) response following NAC associates with 2-year recurrence free survival. Methods: A retrospective cohort study of patients receiving neoadjuvant doublet cisplatin and docetaxel followed by surgery (NAC+S) at a single institution between October 2015 and March 2023 was performed and pathologic responses and 2-year recurrence free survival was recorded following IRB exemption. Results: Fifty-four patients with p16+ OPSCC treated with NAC+S were identified. 49 patients (91%) received three cycles of NAC; 5 patients (9%) received two cycles. Comparing clinical staging to pathologic analysis of surgical specimens, 40 of 54 patients (68%) experienced clinical-to-pathologic downstaging after NAC. A pCR was identified in 23 of 54 patients (43%). Of patients that did not develop a pCR, 9 of 31 patients (29%) received adjuvant treatment due to the identification of high-risk pathologic features. Of patients that developed a pCR, 1 of 23 (4%) developed disease relapse within 2 years. Of patients that did not develop a pCR but did not require adjuvant treatment, 2 of 22 (9%) developed disease relapse within 2 years. Of patients that did not develop a pCR but did require adjuvant treatment, 2 of 9 (22%) developed disease relapse within 2 years. A trend toward reduced risk of disease relapse was observed in patients that develop a pCR following NAC compared to those that do not but did not reach statistical significance (1 of 23 relapses with pCR, 4 of 31 relapses without pCR; P>0.05, two-sided Chi-square test). Conclusion: High rates of pCR following NAC were observed in this small retrospective cohort of patients with newly diagnosed p16+ OPSCC despite 84% of patients avoiding any adjuvant treatment. Patients that develop a pCR after NAC trend toward reduced risk of recurrence compared to those that do not. The development of pCR after NAC may be a suitable short-term clinical outcome measure in prospective clinical trials of NAC for patients with newly diagnosed p16+ OPSCC. Citation Format: Alisha R. Pershad, Maxwell Madani, Timothy B. Shaver, Arjun Joshi, Clint T. Allen, Joseph F. Goodman. Complete pathological response following neoadjuvant chemotherapy and recurrence free survival in patients with p16-positive oropharyngeal cancer [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Innovating through Basic, Clinical, and Translational Research; 2023 Jul 7-8; Montreal, QC, Canada. Philadelphia (PA): AACR; Clin Cancer Res 2023;29(18_Suppl):Abstract nr PO-066.

P11.85.B LONG-TERM OUTCOME AFTER INCOMPLETE RESECTION OF INTRAMEDULLARY GRADE II EPENDYMOMAS WITHOUT ADJUVANT RADIOTHERAPY

Abstract BACKGROUND Ependymomas are the most frequent intramedullary tumors in adults. While gross total resection is the aim of surgery, tumor infiltration might limit resection. In case of subtotal removal, the adjuvant management remains unclear. The aim of our study was to assess the need for adjuvant radiotherapy after incomplete resection of grade II intramedullary ependymomas (IME-II). MATERIAL AND METHODS We retrospectively reviewed all cases of IME-II operated in a single tertiary neurosurgical center from 2009 to 2018. Patients with anaplastic or myxopapillary ependymomas, and patients with a follow-up of less than 3 years were excluded. RESULTS We included 46 patients: 19 (41.3%) had gross total resection, 21 (45.7%) had subtotal resection and 6 (13%) had partial resection. None of the patients underwent adjuvant radiotherapy. Over a median follow-up of 79 months (range = 36-186), 7 patients presented a radiological tumor progression with a mean delay of 50.9 months (range =18-85), of which 2 were symptomatic (4.3%). Progression-free survival (PFS) was 90.1% at 5 years and 76.8% at 10 years. Extent of resection was the only significant risk factor for secondary tumor progression (p=0.012). 4 of the 7 patients with recurring IME-II were treated: 3 patients had a second surgery, leading to 2 GTR and 1STR, followed by radiotherapy in one case, and 1 patient underwent radiotherapy alone. CONCLUSION In this study, the rate of symptomatic progression and retreatment after incomplete resection of IME-II without adjuvant radiotherapy was low, supporting a conservative approach in such cases.

Long-Term Outcomes after Incomplete Resection of Intramedullary Grade II Ependymomas: Is Adjuvant Radiotherapy Justified?

Ependymomas are the most common intramedullary tumors in adults. While gross total resection is the aim of surgery, tumor infiltration might limit resection. In cases of subtotal removal, the necessary adjuvant management remains unclear. The aim of our study was to assess the need for adjuvant radiotherapy after an incomplete resection of grade II intramedullary ependymomas (IME-II). We retrospectively reviewed all cases of IME-II operated upon at a single tertiary neurosurgical center from 2009 to 2018. Patients with anaplastic or myxopapillary ependymomas, and patients with a follow-up of less than three years, were excluded. We included 46 patients: 19 (41.3%) had a gross total resection; 21 (45.7%) had a subtotal resection; and 6 (13%) had a partial resection. None of the patients underwent adjuvant radiotherapy. Over a median follow-up of 79 months (range = 36-186), seven patients presented a radiological tumor progression with a mean delay of 50.9 months (range = 18-85), of which two were symptomatic (4.3%). Progression-free survival (PFS) was 90.1% at 5 years and 76.8% at 10 years. The extent of the resection was the only significant risk factor for secondary tumor progression (p = 0.012). Four of the seven patients with recurring IME-II were treated: three patients had a second surgery, leading to two GTR and one STR, followed by radiotherapy in one case, and one patient underwent radiotherapy alone. In this study, the rate of symptomatic progression and retreatment after incomplete resection of IME-II without adjuvant radiotherapy was low, suggesting a conservative approach in such cases.

Surgical resection based on ontogenetic cancer field theory for cervical cancer: 10-year updated results of the MMR study.

5539 Background: Previously published findings from our center suggest that carcinoma of the cervix propagates within ontogenetic cancer fields, tissue compartments defined by staged morphogenesis. In the MMR study we aimed to determine whether surgical treatment that accounts for stage-associated, ontogenetic cancer fields and their associated lymphoid tissues results in locoregional tumor control without the need for adjuvant radiotherapy. Methods: The Leipzig School Mesometrial Resection Study (MMR study) is an ongoing, prospective, single-center, observational cohort study including patients with primary cervical cancer. All study participants undergo either total or extended mesometrial resection (TMMR or EMMR) and therapeutic lymph node dissection. Because this treatment strategy enables surgical removal of all locoregional at-risk tissues, no adjuvant radiotherapy is necessary, even in the presence of established risk factors. The trial is registered at the German Clinical Trials Register, number DRKS00015171. For this updated analysis, we identified patients in our institutional study database with primary cervical cancer staged IB1 – IIA2 according to the 2009 International Federation of Gynecology and Obstetrics staging system. Using the Kaplan-Meier estimator, we calculated recurrence free and overall survival. Results: Between October 16, 1999, and December 16, 2020, 420 patients were treated per protocol and followed up for a median of 136 months (IQR 77-190). The median age was 42 years (IQR 36-51). 329 patients (78.3%) had stage IB1, 58 (13.8%) stage IB2, 24 (5.7%) stage IIA1 and 9 (2.1%) stage IIA2 disease. Patients had either squamous cell (n = 297, 70.7%), adenocarcinoma (n = 104, 24.8%), adenosquamous (n = 18, 4.3%) or other (n = 1, 0.24%) histology. The nodal status was pN0 in 349 (83.1%) patients and pN1 in 71 (16.9%) of the cases. Clinically occult parametrial involvement was present in 47 (11.2%) patients. 10-year overall survival was 90.2% (95% confidence interval [CI] 87.1-93.4) and recurrence-free survival was 90.6% (95% CI 87.8-93.6). Stratified for lymph node status 10-year overall survival was 91.7% (95% confidence interval [CI] 88.5-95) for pN0 and 83.2% (95% confidence interval [CI] 74.6-92.9) for pN1. Recurrence-free survival was 93.8% (95% CI 91.2-96.5) for pN0 and 75.4% (95% CI 65.9-86.3) for pN1. Conclusions: Despite dispense of adjuvant radiotherapy, patients treated with total or extended mesometrial resection with therapeutic lymph node dissection have excellent survival outcomes. Additional multicenter studies are needed to further investigate and confirm our results. Clinical trial information: DRKS00015171 .

FACIAL BASAL CELL CARCINOMA- CLINICAL VARIANTS, MANAGEMENT AND CLINICAL OUTCOME EXPERIENCE AT OUR CENTRE

Background: Basal cell carcinoma (BCC) is the most common type of skin cancer and it constitutes more than three quarters of skin cancers of the face. Any lesion in the face above the line joining the tragus and the angle of mouth are considered as high risk lesions for recurrence. The gold standard surgical treatment is Mohs micrographic surgery (MMS) or surgical excision with intraoperative histological and margin assessment. Radiation therapy (RT) has always played an essential role in the management of BCC. To retrospectively analyse the presentation, risk Aim: factors, most common histopathology variant, margin status, ap reconstruction, need for adjuvant RT and recurrence of BCC in the face in a tertiary centre. Methods: Retrospective analysis of 16 cases of BCC over the face treated at out centre was done from 2018 to 2020.All were BCC above the line joining tragus to angle of mandible. All cases presented bet Results: ween the age 34 to 67, mean age of 54. Of the total 16 cases, 12 were males and 4 females. 12 cases were primary and 4 were recurrent operated outside. All lesions excised with 2-4mm margin and reconstructed with local faciocutaneous aps in rst setting. All aps healed well with no complictaions except for 2 which had minor wound breakdown. Post op Radiation given in 5 cases (4 recurrent and 1 primary). All patient had acceptable cosmesis after the completion of treatment. All patients were followed up for 2 years. In our experience high risk BCC in the face can be excised wit Conclusion: h negative margins using intraoperative frozen section and ap reconstruction can be done in rst setting only. Those that are recurrent and with high risk features , adjuvant therapy has to be given

A comparative evaluation of radical prostatectomy using laparoscopic and open method in view of surgical margins.

A positive surgical margin (PSM) in the radical prostatectomy (RP) specimen is associated with biochemical recurrence (BCR) and the need for adjuvant radiation therapy, and is an analysis of surgical procedure quality. We present data describing the identification, anatomy, and management of PSM after RP performed via an open operation and laparoscopically. The aim of the study was to compare assessment of RP (open vs. laparoscopic) in terms of analysis of PSM in postoperative histopathological tissue. Patients with pT1 to pT3b prostate cancer with detailed surgical margin parameters and BCR status were analysed. The patients were divided into groups depending on the stage of neoplastic disease and the choice of operative procedure. In total, we obtained data from 140 PC patients. Positive surgical margins were confirmed in 11 cases treated with open surgery and in 7 cases treated with laparoscopic procedure. There was no statistically significant (p >0.05) relationship between the frequency of positive margins and the type of procedure. There was no statistically significant (p >0.05) relationship between the frequency of positive margins and the type of procedure in subgroups according to the Gleason score. There was a statistically significant (p <0.05) relationship between the clinical stage of the tumor and the type of margin. This particularly refers to tumours with stage T3b (more numerous in the group of open surgeries) and T2c (more numerous in the laparoscopic group). There was no statistically significant correlation between the type of surgery and the incidence of a positive surgical margin.

A pilot study of neoadjuvant cemiplimab with platinum-doublet chemotherapy and cetuximab in patients with resectable, locally advanced head and neck squamous cell carcinoma (HNSCC).

TPS6109 Background: Definitive treatment of locally advanced HNSCC can require radical surgery and reconstruction often resulting in unacceptable functional consequences. Radiotherapy, often with concurrent chemotherapy, is administered postoperatively to achieve the best chance for cure. Induction chemotherapy has previously been shown to reduce the extent of surgical resection and need for adjuvant radiation (RT). The purpose of this trial is to evaluate if an induction regimen combining cytotoxic chemotherapy, EGFR targeting, and immune checkpoint blockade can pathologically downstage resectable HNSCC sufficiently to decrease surgical morbidity and justify omission of adjuvant RT-based therapy. Compared to standard docetaxel, cisplatin, and 5-FU (TPF), docetaxel, cisplatin, and cetuximab (TPC) has been shown to be a therapeutic alternative with a more favorable toxicity profile. Targeting PD-1 alone can induce significant pathologic responses in resectable HNSCC patients. Combining PD-1 inhibitors with cetuximab has shown promising activity in incurable HNSCC; cetuximab may optimize the tumor immune microenvionment for PD-1 therapy by stimulating IFN-gamma secretion to increase dendritic cell maturation and CD8 T cell expression of PD1. Based on this rationale, we are evaluating the novel induction regimen of platinum, docetaxel, cetuximab plus cemiplimab (anti-PD1 antibody). Methods: This is a 10-patient pilot study for locally advanced, resectable HNSCC patients for whom standard management requires adjuvant RT +/- chemotherapy. Patients will receive neoadjuvant treatment with a loading dose of cetuximab and cemiplimab followed by 3 cycles of cisplatin or carboplatin, docetaxel, cetuximab and cemiplimab followed by definitive surgical resection of the primary site +/- neck dissection(s). Post-operative RT +/- radiosensitizing agent(s) will be administered per standard of care (SOC) based on pathologic staging (rather than clinical staging at presentation). If the pathologic stage following induction and surgery is ypT0-2N0 without adverse features, adjuvant RT will not be administered and 6 months of adjuvant cemiplimab will be given. Otherwise, patients will receive SOC adjuvant RT-based treatment. The primary endpoint is safety and tolerability. Secondary endpoints include feasibility assessed by the number of patients whose definitive surgery was delayed due to toxicity and quantifying the number in whom clinical to pathologic downstaging is achieved and the planned surgery and/or need for adjuvant-RT based therapy is modified. Exploratory endpoints include evaluating the association between biomarkers in the tumor microenvironment and peripheral blood with pathologic response. 8 of 10 patients have been enrolled. Clinical trial information: NCT04722523.

Adjunctive Benefit of High-Field 3 Tesla MRI Guidance in Endoscopic Transsphenoidal Resection of Pituitary Adenoma

Abstract Introduction Pituitary adenomas (PAs) although benign, are difficult to resect intracranial tumors and their residues are associated with morbidity and reduced quality of life. Thus, gross total resection (GTR) is the goal for all PAs. Role of various modalities for better intraoperative visualization and thus improve resection of adenoma have been tested and each have their pros and cons. The aim of this paper is to analyze adjunctive benefit of high-field 3 Tesla intraoperative magnetic resonance imaging (iMRI) in PAs resection by endoscopic transnasal transsphenoidal surgery (eTSS). Materials and Methods A total of 50 patients who underwent iMRI-guided eTSS were included. MRI findings in preoperative, intraoperative, and 3 months postoperative stage were compared. Adjunctive value of iMRI in improving resection rates of adenoma, postoperative endocrinological outcomes, need for adjuvant radiotherapy, and postoperative cerebrospinal fluid leak rates was assessed. Results High-field 3 Tesla iMRI helped us to detect residues in 24 (48%) patients and iMRI-guided second look surgery increased our GTR rates from initial 52 to 80% and also helped us to identify and achieve 100% GTR in intrasellar residues and parasellar residues that were medial to medial carotid tangential line. With better resection rates, need for adjuvant radiotherapy was also reduced and only 2% received adjuvant radiotherapy. Average increase in surgical time with the use of iMRI was 38.78 minutes without any side effects pertaining to prolonged surgery. Conclusion High-field iMRI is a useful adjunct in assessment and improvement in extent of resection of PA by endoscopic transsphenoidal surgery. Also, it was found beneficial in preserving normal anatomical gland and, thus, reducing the need for postoperative adjuvant hormonal and radiation therapy.

Current Issues in Treatment of Parotid Gland Cancer and Advanced Surgical Technique of Robotic Parotidectomy.

This paper analyzed previous research data to identify the most important issues to be considered during treatment of parotid gland cancer (PGC) and reviewed recent advancements in techniques in parotid surgery. For successful treatment of PGC, a preoperative surgical plan should be designed with consideration of the histologic characteristics and anatomical complexity of the tumor, and the functional and anatomical integrity of the facial nerve should be carefully inspected during surgery and damage to the nerve minimized. The need for adjuvant radiotherapy should be determined based on intraoperative findings and pathologic findings of the specimen after surgery. Surgery and radiotherapy are the main treatment options for PGC. To optimize treatment outcomes for PGC, the extent of surgery should be decided according to histologic characteristics and extent of tumor resection, and use of adjuvant radiotherapy should be considered based on risk stratification.

Controversy in the Surgical Extent of Parotidectomy, Neck Treatment, and Adjuvant Treatment of Parotid Gland Cancer

This paper analyzed previous research data to identify the most important issues to be considered during treatment of parotid gland cancer (PGC) and reviewed recent advancements in techniques in parotid surgery. For successful treatment of PGC, a preoperative surgical plan should be designed with consideration of the histologic characteristics and anatomical complexity of the tumor, and the functional and anatomical integrity of the facial nerve should be carefully inspected during surgery and damage to the nerve minimized. The need for adjuvant radiotherapy should be determined based on intraoperative findings and pathologic findings of the specimen after surgery. To optimize treatment outcomes for PGC, the extent of surgery and adjuvant radiotherapy should be decided according to histologic characteristics and risk stratification.

The Outcome of Locally Advanced Cervical Cancer in Patients Treated with Neoadjuvant Chemotherapy Followed by Radical Hysterectomy and Primary Surgery.

Background: In recent years, before radical hysterectomy, neoadjuvant chemotherapy (NACT) has been administered to patients with locally advanced cervical cancer to shrink large tumors. It has been reported that this treatment significantly reduces the need for radiotherapy after surgery. The current study aimed to assess the outcome (survival, recurrence, and the need for adjuvant radiotherapy) of locally advanced cervical cancer in patients treated with NACT followed by radical hysterectomy and primary surgery.Methods: In a retrospective cohort study, the records of 258 patients with cervical cancer (stage IB2, IIA, or IIB), who referred to Imam Khomeini Hospital (Tehran, Iran) from 2007 to 2017 were evaluated. The patients were assigned into two groups; group A (n=58) included patients, who underwent radical hysterectomy and group B (n=44) included those, who underwent a radical hysterectomy after NACT. The outcome measures were the recurrence rate, five-year survival rate, and the need for adjuvant radiotherapy.Results: The median for overall survival time in group A and B was 113.65 and 112.88 months, respectively (P=0.970). There was no recurrence among patients with stage IB2 cervical cancer in group B, while the recurrence rate in group A was 19.5% with a median recurrence time of 59.13 months. Lymph node involvement was the only factor that affected patients’ survival. The need for postoperative adjuvant radiotherapy in group B was lower than in group A (P=0.002).Conclusion: NACT before the hysterectomy was found to reduce the need for postoperative radiotherapy in patients with locally advanced cervical cancer according to disease stages. As a direct result, adverse side effects and the recurrence rate were reduced, and the overall survival rate of patients with stage IIB cervical cancer was increased.

Extended surgical interventions in children with retinoblastoma invasion into the optic nerve

Introduction. Standard eye enucleation (EE) may not always guarantee a sufficient length of resection of the optic nerve (ON) so that the tumor cells do not spread along the optic nerve at the intersection line. Surgical access and the scope of surgical intervention are determined by the spread and localization of the tumor, as well as the qualification of the operating team.Purpose— to evaluate the role of extended surgical interventions in the spread of extraocular tumors on the ON.Materials and methods. The study included 9 patients with retinoblastoma (RB) and macroinvasion of the ON during primary magnetic resonance imaging (MRI) and/or micromorphological invasion of the ON resection line after EE. 4 of the 9 patients were treated with primary/secondary EE, induction chemotherapy (CT) and high-dose CT (HDCT), radiation therapy (RT). 5 out of 9 patients underwent secondary extended surgical interventions: exenteration of the orbit (n = 1), osteoplastic lateral orbitotomy with precanal resection of the ON (n = 2) in combination with EE in one case, subfrontal craniotomy (n = 1) and orbitozygomatic craniotomy (n = 1) with prechiasmal resection of the ON and EE with adjuvant RT (excluding the latter case) and CT, without HDCT.Results. It should be noted that the overall survival (OS) of 5 patients with complete microscopic resection (R0) after extended secondary operations was 75 ± 0.217 % with an average follow-up period of 77.25 ± 18.8 months, while in 4 patients with R1 (n = 4) without secondary extended operations with HDCT reached only 50 ± 0.25 % with an average follow-up period of 57 ± 24.8 months.Conclusion. MRI is mandatory for the primary diagnosis of RB, especially when there is a risk of the tumor spreading through the ON. Secondary surgery with R0-resection has a positive effect on survival. The need for adjuvant RT and CT after surgery should be discussed.

Mohs surgery for early-stage Merkel cell carcinoma (MCC) achieves local control better than wide local excision ± radiation therapy with no increase in MCC-specific death.

Merkel cell carcinoma (MCC) of the skin is most commonly treated with wide local excision (WLE) with or without adjuvant radiation therapy (RT). Mohs micrographic surgery (MMS) as monotherapy may offer an alternative treatment modality. The purpose of this study is to describe outcomes of patients with primary Stage I/II MCC treated with MMS alone and no RT. A retrospectively collected sample of 56 MCCs treated with MMS was studied over an 18-year period. Tumor and treatment characteristics were described, and follow-up was assessed. A total of 56 primary Stage I/II MCCs in 53 patients were treated with MMS as monotherapy from April 2001 through July 2019. Patients were followed for an average of 4.6 years (median 2.7 years, range 0.8 to 16.9 years), of which 19 (33.9%) had follow-up of 5 years or more. There were no local recurrences due to inadequate excision. The 5-year Kaplan-Meier MCC-specific survival for AJCC8 Stage I and AJCC8 Stage IIA were 91.2% and 68.6%, respectively. In comparison to historical controls, Mohs surgery offers a survival that is at least as good as WLE +/- RT, with the added benefits of no need for adjuvant RT or the need for further surgery for treatment of local recurrence.

Current indications for adjuvant treatment following transoral laser microsurgery of early and intermediate laryngeal cancer.

This review summarizes the information in the literature on the indications for adjuvant therapy after transoral laser microsurgery (TLM) for early/intermediate stage laryngeal cancer. A high rate of 'nonevaluable' margins after TLM significantly complicates decision-making concerning adjuvant therapy. However, consensus grows that second-look TLM in patients with multiple superficial and deep positive margins is more sensible than sending these patients systematically for adjuvant radiotherapy (RT). The classical adagium: 'Failure to achieve negative margins indicates need for adjuvant RT' does not translate automatically to patients with glottic cancer treated by TLM. Rather, specifically patients with multiple superficial positive margins and positive deep margins after TLM need careful judging what constitutes the best additional adjuvant treatment. Second-look resection is nowadays regarded as the preferred adjuvant treatment for many of these patients whereas RT is reserved for those in whom a second look TLM is judged unlikely to result in 'true negative margins.' Additionally, when the pathology of the re-resection reveals multiple foci of residual disease or suggests again a resection with positive margins, adjuvant postoperative RT is likely to result in a better local control. If this strict selection of patients for adjuvant RT is adhered to carefully, oncological and functional results will be optimal.

Dose homogeneity analysis of adjuvant radiation treatment in surgically resected brain metastases: Comparison of IORT, SRS, and IMRT indices

PurposeAlthough surgery remains a treatment option for symptomatic brain metastases, the need for adjuvant radiation after surgery is widely accepted as standard. Despite a multitude of randomized trials aimed at identifying the ideal radiation treatment plan for surgically resected metastases, the development of new delivery regiments necessitates a periodic re-evaluation of dosimetric performance/outcome. Here, we compare the homogeneity index (HI) across three platforms: single-session stereotactic radiosurgery (SRS), multisession stereotactic radiotherapy, and intraoperative radiotherapy (IORT). Methods and MaterialsPatients treated with IORT after surgical resection of brain metastases were identified and dosimetric parameters collected from the dose-volume histograms based on the development of conformal plans for adjuvant radiation using Gamma Knife-SRS (GK-SRS), linear accelerator based intensity-modulated radiation therapy, and IORT. HIs were calculated using four established methods and compared across platforms within the patient cohort. Statistical analyses were performed using analysis of variance. ResultsThe mean maximal doses for the GK-SRS and IMRT plans were 30 Gy and 29 Gy with margin prescription doses of 16 Gy and 24 Gy, respectively. The IORT dose was 30 Gy to the applicator surface. HIs varied based on calculation methods, but maintained consistency when comparing across platforms with IORT having the lower mean HI value (0.56; 95% confidence interval (CI) 0.55–0.60) in single-fraction treatment, compared with GK-SRS (0.77; 95% CI 0.76–0.80). The mean multisession IMRT HI was lower than both single-fraction treatment modalities at 0.41 (95% CI 0.40–0.42). ConclusionsWhen using the HI as the primary dosimetric parameter for adjuvant radiation plans after surgical resection of brain metastases IORT offers improved dose homogeneity compared with GK-SRS in single-fraction treatment, whereas fractionated LINAC-based IMRT was superior with respect to the HI in comparison among all three methods.

The V-Y gluteal fold advancement flap: Outcomes following radical surgery for vulvar malignancies.

To evaluate the feasibility and complication rate of the V-Y gluteal fold flap in surgery for vulvar cancer. From June 2015 to June 2018, 62 patients surgically treated for vulvar cancer were included in the study. Twenty-three (37.1%) underwent plastic reconstructive surgery with V-Y advancement flaps. The mean surgical time was longer for patients undergoing V-Y flap surgery. The margins were positive in six patients (9.7%), close (<8mm) in 10 (16.1%), and adequate (>8mm) in 46 (74.2%). Six (9.7%) patients had dehiscence and two (3.2%) patients suffered from necrosis. In patients undergoing V-Y flap reconstruction, two (8.7%) had a wound dehiscence, no patients had necrosis. In patients undergoing direct closure, four (10.3%) had wound dehiscence and two (5.1%) had necrosis. V-Y gluteal fold advancement technique is a safe procedure, performed in a single surgical session with minimal increase in surgical time and low wound healing complications. Use of this technique was correlated with an increased rate of adequate surgical margins (<8mm) and reduced need for adjuvant radiotherapy.