Neoadjuvant Radiation Treatment Research Articles

Socioeconomic Disparities in Postoperative Outcomes of Osteocutaneous Fibula Free Flaps for Head and Neck Reconstruction.

Osteocutaneous fibula free flaps (FFFs) are a fundamental component of reconstructive surgery in the head and neck region, particularly after traumatic injuries or oncologic resections. Despite their utility, FFFs are associated with various postoperative complications, such as infection, flap failure, and donor site morbidity, impacting up to 54% of cases. This study aimed to investigate the influence of socioeconomic variables, with a particular focus on median household income (MHI), on the incidence of postoperative complications in FFF reconstruction for head and neck cancer. A retrospective analysis of 80 patients who underwent FFF reconstruction for head and neck cancer at a single center from 2016 to 2022 was conducted. Demographic and patient characteristics, including race, MHI, insurance type, history of radiation therapy, and TNM (tumor, node, metastasis) cancer stage, were evaluated. Logistic regression, controlling for comorbidities, was used to assess the impact of MHI on 30-, 90-, and 180-day postoperative complications. The patient population was predominantly male (n = 51, 63.8%) and White (n = 63, 78.8%), with the majority falling within the $55,000 to $100,000 range of MHI (n = 51, 63.8%). Nearly half of the patients had received neoadjuvant radiation treatment (n = 39, 48.75%), and 36.25% (n = 29) presented with osteoradionecrosis. Logistic regression analysis revealed that the $55,000-$100,000 MHI group had significantly lower odds of developing complications in the 0- to 30-day postoperative period when compared with those in the <$55,000 group (odds ratio [OR], 0.440; 95% confidence interval [CI], 0.205-0.943; P = 0.035). This trend persisted in the 31- to 90-day period (OR, 0.136; 95% CI, 0.050-0.368; P < 0.001) and was also observed in the likelihood of flap takeback. In addition, the $100,000-$150,000 group had significantly lower odds of developing complications in the 31- to 90-day period (OR, 0.182; 95% CI, 0.035-0.940; P = 0.042). No significant difference was found in the >$150,000 group. Median household income is a significant determinant and potentially a more influential factor than neoadjuvant radiation in predicting postoperative complications after FFF reconstruction. Disparities in postoperative outcomes based on income highlight the need for substantial health care policy shifts and the development of targeted support strategies for patients with lower MHI.

Repurposing Drugs for Overcoming Therapy Resistance in Colon Cancer – A Review

Colorectal cancer is a common type of cancer worldwide. Colorectal cancer is a prevalent form of cancer that is observed globally. The survival prospects for individuals with advanced stages of this disease are notably diminished. The chance of getting colorectal cancer is 4% to 5%. Getting older, having chronic illnesses, and certain lifestyle choices raise the risk of getting colorectal cancer. Surgery, as well as neoadjuvant radiation treatment (for those affected by rectal cancer) and adjunctive chemotherapy (for stage III/IV colon cancer patients and high-risk stage II colon cancer patients), stand as the most employed therapeutic interventions. Treating CRC has improved, but the medicines are expensive and have side effects. Therefore, alternative methods that are more affordable and still effective need to be explored. The use of existing drugs to treat diseases is becoming more popular due to high attrition rates, economic burden, slow drug discovery, and development. Many methods have been proposed to find repurposed therapeutic candidates, which can save time and money. Repurposing drugs is more successful and efficient than creating new drugs for rare diseases. Using existing drugs for cancer treatment is a major priority. Non-cancer drugs should not be overlooked since they have the potential to address both identified and unidentified weaknesses in cancer. Unlike targeted therapy, old generic drugs used in multiple ways can benefit patients. This review delves into the present body of evidence regarding the utilization of established medications as a plausible therapeutic avenue for patients suffering from CRC. The focus is to illustrate the possible competitors and their complex ways of functioning, including medications that have the ability to combat malaria, parasitic infections, inflammation, high blood pressure, high cholesterol levels, and diabetes.

Patterns of Locoregional Pancreatic Cancer Recurrence after Total Neoadjuvant Therapy and Implications on Optimal Neoadjuvant Radiation Treatment Volumes

Neoadjuvant treatment for patients with localized pancreatic adenocarcinoma (PDAC) has improved survival duration. As survival increases, local disease control becomes even more important. We sought to understand the patterns of locoregional recurrence following total neoadjuvant therapy (TNT) and determine the impact of treatment volumes on recurrence. Patients with PDAC managed with neoadjuvant chemotherapy and chemoradiation (TNT) followed by surgery who developed an isolated locoregional or simultaneously locoregional and distant recurrence were identified. Locoregional recurrences were individually contoured utilizing commercially available software. When available, original neoadjuvant dose distributions were registered to the scans on which the locoregional recurrences were contoured. Recurrences where then classified as in-field (> 95% of prescription dose), marginal (50-95% of prescription dose), or out of field (< 50% of prescription dose). Target volumes were created using four commonly utilized PDAC contouring guidelines to characterize the relationship of the local recurrence to the RT dose distribution. Of 474 patients treated with TNT and surgery, 80 (17%) patients developed a locoregional recurrence with or without distant recurrence, visible on diagnostic imaging. Of the 80 patients, 56 (70%) had tumors in the pancreatic head; 46 (57.5%) were borderline resectable, 23 (28.8%) locally advanced, and 11 (13.6%) resectable. The most common initial neoadjuvant therapies were FOLFIRINOX (57.5%) and gemcitabine/nab-paclitaxel (18.8%). Chemoradiation included concurrent gemcitabine (47.5%) or 5-fluorouracil (26.3%). RT dose distributions were available for 38 patients; 22 (57.9%) had in-field failures, 9 (23.7%) marginal failures, and 7 (18.4%) out of field failures. Each published contouring atlas covered a relatively low percentage of recurrences, which are summarized in Table 1. Regions at particularly high likelihood of recurrence that were under covered on existing atlases included: aortic-diaphragmic junction, retro-pancreatic duodenal nodal basin, and the region to the right of the superior mesenteric artery (SMA). We present the largest series (to our knowledge) of mapped locoregional recurrences for patients being treated with TNT in PDAC. These recurrences differ substantially from established atlases and highlight anatomical regions of highest priority for RT coverage. A novel visual contouring volume highlighting these regions will be presented which will strive to advance the use of RT in the TNT setting.

Predictors and survival outcomes of having less than 12 harvested lymph nodes in proctectomy for rectal cancer.

Current recommendations suggest that a minimum of 12 lymph nodes (LNs) should be harvested during curative rectal cancer resection. We aimed to assess predictors and survival outcomes of harvesting < 12 lymph nodes in rectal cancer surgery. A retrospective case-control analysis of factors associated with harvesting < 12 LNs in rectal cancer surgery was conducted. Data were derived from the National Cancer Database 2010-2019. Univariate and multivariate binary logistic regression analyses were performed to determine predictors of harvesting < 12 LNs. Association between harvesting < 12 LNs and 5-year overall survival (OS) was assessed using Cox regression and Kaplan Meier statistics. 67,529 patients (60.8% male; mean age: 61.2 ± 12.5years) were included. Median number of harvested LNs was 15 (IQR: 11-20); 27.1% of patients had < 12 harvested LNs. Independent predictors of harvesting < 12 LNs were older age (OR: 1.016;p < 0.001), neoadjuvant systemic treatment (OR: 1.522;p < 0.001), neoadjuvant radiation treatment (OR: 1.367;p < 0.001), longer duration of radiation therapy (OR: 1.003;p < 0.001) and abdominoperineal resection (OR: 1.071;p = 0.017). Higher clinical TNM stage and tumor grade, pull-through coloanal anastomosis, and minimally invasive surgery were independently associated with ≥ 12 harvested LNs. < 12 harvested LNs was independently associated with lower 5-year OS (HR: 1.24;p < 0.001) and shorter mean OS (96.7 vs 102.8months;p < 0.001) than ≥ 12 harvested LNs. Older age, open resection, and neoadjuvant therapy were independent predictors of < 12 harvested LNs. Conversely, higher clinical TNM stage and tumor grade, coloanal anastomosis, and minimally invasive surgery were predictive of ≥ 12 harvested LNs. < 12 LNs harvested was associated with lower OS.

Radiotherapy and Limb-Sparing Surgery in the Management of Localized Soft Tissue Sarcomas: Tertiary Care Center Experience From Pakistan

When combined with radiotherapy, limb salvage surgery is an alternative to amputation. This study sought to determine the limb-sparing treatment outcomes in patients diagnosed with soft tissue extremity sarcomas treated at our institution. All adult patients with extremity soft tissue sarcoma treated with the radical limb salvage strategy at Shaukat Khanum Memorial Cancer Hospital and Research Canter, Lahore, Pakistan, between January 2017 and December 2019 were retrospectively assessed. A total of 122 patients were included in the study. The mean age was 42 years (range 19-82), and 64 (52.5%) were males. The majority of patients, 65 (53.3%), were diagnosed with stage III and grade III disease according to American Joint Committee on Cancer TNM classification (Eighth edition). The most common surgical modality was wide local excision that was performed in 106 (86.9%) patients. Adjuvant radiation treatment was given in 111 (91%) patients, whereas 11 (9%) patients received neoadjuvant radiation treatment. The mean dose was 58 Gy (range: 46-66 Gy). Eighty-two (67.2%) of the patients were disease-free on post-treatment radiologic scans with disease recurrence observed in 40 (32.8%) patients. The median disease-free survival was 8 months (95% CI, 5.45 to 10.55). Local recurrence and distant metastases developed in 16 (13%) and 24 (20%) patients, respectively. About two thirds of patients with extremity soft tissue sarcoma were successfully treated with limb salvage strategy, surgery, and radiation therapy. However, high rate of relapse warrants further novel strategies in this patient population.

Analysis of Pathologic Complete Response Rates Between Different Neoadjuvant Radiation Treatment Regimens for Rectal Cancer

The standard of care for rectal cancer is either long or short course radiation followed by surgery with or without adjuvant chemotherapy. Recently, total neoadjuvant therapy, an approach consisting of giving all chemotherapy and radiotherapy prior to definitive surgery, has been a promising alternative. This study aims to assess the pathologic complete response (pCR) rates among different neoadjuvant treatment regimens and determine if neoadjuvant chemotherapy improves pCR rates.Electronic medical databases were queried to identify rectal cancer patients treated with neoadjuvant therapy at our institution from 2006-2019. Patients were grouped according to neoadjuvant therapy received: long-course chemoradiation (CRT), long-course chemoradiation with chemotherapy (CRT TNT), short-course radiation (SCRT), and short-course radiation with chemotherapy (SCRT TNT). Patients without follow-up data or surgical pathology reports were excluded. pCR was defined as no evidence of disease at surgery. pCR rates were determined and compared using Chi-square analysis.A total of 249 patients were analyzed. Table 1 shows treatment characteristics in each group. There were 200 (80.3%) patients who received CRT, 26 (10.4%) who received CRT TNT, 13 (5.2%) who received SCRT, and 10 (4%) who received SCRT TNT. Initial stage was different between groups, with metastatic patients more likely to receive SCRT TNT (P < 0.001). The median time to surgery were significantly different between groups (P < 0.001). Eleven (42.3%) and 6 (60%) patients received FOLFOX, and 13 (50%) and 4 (40%) of the patients received XELOX for CRT TNT and SCRT TNT, respectively. The remaining patients (7.7%) in the CRT TNT group received Capecitabine. For CRT, 53 (26.5%) patients achieved pCR, 3 (11.5%) in CRT TNT, 1 (7.7%) in SCRT, and 2 (20%) in SCRT TNT. None of these differences were statistically different (P = 0.19). On univariate analysis, age (P = 0.13), clinical T stage (P = 0.13), clinical N stage (P = 0.95), time to surgery (P = 0.82), and presence of chemotherapy in the neoadjuvant regimen (P = 0.22) were not significant predictors for pCR.Total neoadjuvant treatment for rectal cancer did not improve pCR rates over standard chemoradiation or short course radiation alone, which is contrary to what published series suggest. These results maybe be explained in part by the fact that chemotherapy was delivered first and the time from completing radiation to the time of surgery was not significantly different between groups. These data suggest that meaningful gains in pCR rates may be achieve by sequencing chemoradiation earlier in the TNT course. Future studies are needed to investigate this hypothesis.

MRI Response to Pre-operative Stereotactic Ablative Body Radiotherapy (SABR) in Early Stage ER/PR+ HER2- Breast Cancer correlates with Surgical Pathology Tumor Bed Cellularity

ObjectiveThis study evaluates breast MRI response of ER/PR+ HER2- breast tumors to pre-operative SABR with pathologic response correlation. MethodsWomen enrolled in a phase 2 single institution trial of SABR for ER/PR+ HER2- breast cancer were retrospectively evaluated for radiologic-pathologic correlation of tumor response. These patients underwent baseline breast MRI, SABR (28.5 Gy in 3 fractions), follow-up MRI 5 to 6 weeks post-SABR, and lumpectomy. Tumor size and BI-RADS descriptors on pre and post-SABR breast MRIs were compared to determine correlation with surgical specimen % tumor cellularity (%TC). Reported MRI tumor dimensions were used to calculate percent cubic volume remaining (%VR). Partial MRI response was defined as a BI-RADs descriptor change or %VR ≤ 70%, while partial pathologic response (pPR) was defined as %TC ≤ 70%. ResultsNineteen patients completed the trial, and %TC ranged 10% to 80%. For BI-RADS descriptor analysis, 12 of 19 (63%) showed change in lesion or kinetic enhancement descriptors post-SABR. This was associated with lower %TC (29% vs. 47%, P = .042). BI-RADS descriptor change analysis also demonstrated high PPV (100%) and specificity (100%) for predicting pPR to treatment (sensitivity 71%, accuracy 74%), but low NPV (29%). MRI %VR demonstrated strong linear correlation with %TC (R = 0.70, P < .001, Pearson's Correlation) and high accuracy (89%) for predicting pPR (sensitivity 88%, specificity 100%, PPV 100%, and NPV 50%). ConclusionEvaluating breast cancer response on MRI using %VR after pre-operative SABR treatment can help identify patients benefiting the most from neoadjuvant radiation treatment of their ER/PR+ HER2- tumors, a group in which pCR to neoadjuvant therapy is rare.

Proposal for the delineation of neoadjuvant target volumes in oesophageal cancer

PurposeTo define instructions for delineation of target volumes in the neoadjuvant setting in oesophageal cancer. Materials and methodsRadiation oncologists of five European centres participated in the following consensus process: [1] revision of published (MEDLINE) and national/institutional delineation guidelines; [2] first delineation round of five cases (patient 1–5) according to national/institutional guidelines; [3] consensus meeting to discuss the results of step 1 and 2, followed by a target volume delineation proposal; [4] circulation of proposed instructions for target volume delineation and atlas for feedback; [5] second delineation round of five new cases (patient 6–10) to peer review and validate (two additional centres) the agreed delineation guidelines and atlas; [6] final consensus on the delineation guidelines depicted in an atlas.Target volumes of the delineation rounds were compared between centres by Dice similarity coefficient (DSC) and maximum/mean undirected Hausdorff distances (Hmax/Hmean). ResultsIn the first delineation round, the consistency between centres was moderate (CTVtotal: DSC = 0.59–0.88; Hmean = 0.2–0.4 cm). Delineations in the second round were much more consistent. Lowest variability was obtained between centres participating in the consensus meeting (CTVtotal: DSC: p < 0.050 between rounds for patients 6/7/8/10; Hmean: p < 0.050 for patients 7/8/10), compared to validation centres (CTVtotal: DSC: p < 0.050 between validation and consensus meeting centres for patients 6/7/8; Hmean: p < 0.050 for patients 7/10).A proposal for delineation of target volumes and an atlas were generated. ConclusionWe proposed instructions for target volume delineation and an atlas for the neoadjuvant radiation treatment in oesophageal cancer. These will enable a more uniform delineation of patients in clinical practice and clinical trials.

Retroperitoneal Liposarcoma: Treatment Outcome in Primary and Secondary Surgical Intervention

Background Approximately 30% to 40% of all retroperitoneal soft tissue tumors are sarcomas, with liposarcoma prevailing in approximately 50% of these cases. Retroperitoneal liposarcomas typically show a high rate of local recurrence and late distant metastases. The aim of our retrospective analysis was to investigate the efficacy of treatment in our patients with liposarcoma. Methods Thirty-four consecutive patients underwent surgery in our clinic between October 2004 and November 2017. Liposarcomas arising from the mesenteric or abdominal adipose tissue or the pelvis were excluded. Results Of 34 patients, 23 (67.6%) presented with primary and 11 (32.4%) with recurrent disease. In 7 of the 34 patients (20.6%), a radical resection (R0) could be achieved, and in 27 patients (76.5%) resection was marginal (R1). Time to recurrence was not affected by neoadjuvant radiotherapy. Patients who underwent systemic chemotherapy followed by radiotherapy developed earlier recurrences (P = 0.003) than patients with neoadjuvant radiotherapy only. Overall survival was significantly better in the neoadjuvant group (P 0.045) Conclusions Combining surgical resection with neoadjuvant radiation treatment showed survival benefits in primary but not recurrent disease. Repeated surgery remains a valid approach in carefully selected patients, but all patients should be referred to a center of expertise in multimodal treatment approaches for retroperitoneal liposarcomas.

Controversies in the Management of Lateral Pelvic Lymph Nodes in Patients With Advanced Rectal Cancer: East or West?

The presence of lateral pelvic lymph nodes (LPLN) in advanced rectal cancer entails challenges with ongoing debate regarding the role of prophylactic dissection vs. neoadjuvant radiation treatment. This article highlights the most recent data of both approaches: bilateral LPLN dissection in every patient with low rectal cancer (Rb) as per the Japanese guidelines, vs. the developing approach of neoadjuvant radiotherapy as per Eastern countries. In addition, we also accentuate the importance of a combined approach published by Sammour et al. where a simple “one-size-fits-all” strategy should be abandoned. Rectal cancer treatment is well-established in Western countries. Patients with advanced rectal cancer will undergo radiation ± chemo neoadjuvant therapy followed by TME. In the Dutch TME trial, TME plus radiotherapy showed that the presacral area was the most frequent site of recurrence and not the lateral pelvic wall. Supporting this data, the Swedish study also concluded that LPLN metastasis is not an important cause of local recurrence in patients with low rectal cancer. Therefore, Western approach is CRM-orientated and prophylactic LPLN dissection is not performed routinely as the NCCN guideline does not recommend its surgical removal unless metastases are clinically suspicious. The paradigm in Eastern countries differs somewhat. The Korean study demonstrated that adjuvant radiotherapy without lateral lymph node dissection was not enough to control local recurrence and LPLN metastases. The Japanese Trial JCOG 0212 demonstrated the effects of LPLN dissection in reducing local recurrence in the lateral pelvic compartment. We agree with Sammour and Chang on the fact that rather than a mutual exclusivity approach, we should claim for an approach where all available modalities are considered and used to optimize treatment outcomes, classifying patients into 3 categories of LPLN: low risk cT1/T2/earlyT3 (and Ra) with clinically negative LPLN on MRI; Moderate risk (cT3+/T4 with negative LPLN on MRI) and high risk (clinically abnormal LPLN on MRI). Treatment modality should be based on detailed pretreatment workup and an individualized approach that considers all options to optimize the treatment of patients with rectal cancer in the West or the East.

The Influence of Neoadjuvant Treatment on the Number of Lymph Nodes on the Surgical Specimen in Mid and Low Rectal Cancer - A Retrospective Single-Centre Study.

Introduction: In this study, we aim to identify the impact of neoadjuvant radiation treatment upon the number of harvested and positive lymph nodes in the surgical specimen; in addition, we tried to identify the impact of chemotherapy in association with radiotherapy on said structures. Patients and methods: In the study we included patients treated for rectal cancer within a single oncologic surgical Unit serving the north-eastern part of Romania, over a period of 5 and a half years, between May 2013 and April 2018. Firstly, we compared pathologic lymph node status to pretherapeutic staging. Secondly, we compared lymph node values in relation to the treatment scheme. Results: There was a total of 498 patients treated radically through open surgery for low and mid rectal cancer. We saw a decrease in N staging in 218 cases, 65 remaining stationary and 10 increasing their lymph node staging on the surgical specimen. We identified significant differences between the total number of lymph nodes (17.4 vs 24.2, p 0.001), the number of positive lymph nodes (1.4 vs 3.4, p 0.001) and the ratio between positive and total lymph nodes (0.08 vs 0.14, p 0.001) in patients with and without neoadjuvant treatment respectively. However, there was no statistical difference between patients with and without chemotherapy associated to radiotherapy in the neoadjuvant treatment plan (p=0.539, p=0.58, p=0.575). Conclusion: This study shows there are significant variations according to the application of neoadjuvant treatment, between the numbers of positive and total lymph nodes, as well as the positive/total lymph node ratio.

Endoscopic management of Esthesioneuroblastoma: Our experience and review of the literature

During the last two decades evolution of the endoscopic endonasal approaches (EEA) has offered the option of minimally invasive techniques in the management of esthesioneuroblastomas (ENB), either as endoscope assisted cranial resection or as pure endoscopic procedures. This study presents the use of pure EEA in the management of ENB in our center, along with a literature review. We retrospectively reviewed the clinical, radiology and pathology records of patients with ENB treated during the period July 2006 to January 2016. During the above period, ten patients with ENB were treated using pure EEA. The mean age was 47.5 years. The gender distribution was: eight males, two females. The most common presenting symptoms were nasal obstruction and discharge or epistaxis (8/10). The mean duration of symptoms was 1.5 years. All patients had preoperative confirmation of ENB by biopsy. Five patients received neoadjuvant radiation and four underwent postoperative radiation. One patient did not receive any radiotherapy and no patient received chemotherapy. Gross total resection was achieved in all patients and intraoperative microscopically negative surgical margins achieved in 9/10 (90%). No major intraoperative complications occurred. The most common postoperative complication was nasal infection. Cerebrospinal fluid leak was noted in one patient. During the follow-up period of 6–120 months (mean 74.8) two cases of neck lymph node recurrence were observed. No deaths due to the disease occurred during the follow-up period. Pure EEA offer excellent results in the management of ENB. Neoadjuvant radiation treatment is promising although more studies need to establish its role.

Wednesday, September 26, 2018 2:00 PM – 3:00 PM Improving Quality of Life for Patients with Tumors: 78. Optimal treatment strategy for newly diagnosed chordoma of the spine: results of an international survey to design a prospective cohort study

BACKGROUND CONTEXT Treatment strategies for spinal chordomas are heterogeneous and are mainly driven by institutional biases and local protocols. Surgery plays a central role in their management but the extent of surgery and the role of adjuvant therapy, particularly radiation therapy, is not standard across centers. PURPOSE The aims of this international collaborative effort are to identify the main management options for newly diagnosed chordoma of the spine, understand the variations in treatment protocols among experienced centers, and to consequently design a multicenter prospective cohort study to help determine the best multimodal treatment for this patient population. STUDY DESIGN/SETTING A survey was distributed to 39 spinal oncology specialists in neurosurgery, orthopedic surgery, and radiation oncology from 29 centers. METHODS Two clinical scenarios were presented and the preferred management strategy was queried among the respondents: (1) a newly diagnosed chordoma of the spine when en bloc resection is feasible with acceptable morbidity, and (2) when en bloc resection is not feasible as it would result in significant morbidity. Based on the results of this survey, a prospective cohort study combining centers with similar treatment strategies for newly diagnosed chordoma of the spine is proposed. RESULTS When en bloc resection is feasible with acceptable morbidity, most participants (79.5%) favored an en bloc resection without preoperative neo-adjuvant radiation treatment (RT). The main disagreement is with the role of postoperative radiation with 41% giving RT only if positive margins and 38% giving adjuvant RT to everyone irrespective of marginal status. When en bloc resection would result in significant morbidity, results were more evenly distributed and 33% of respondents preferred to do a deliberate intralesional resection followed by RT, and 33% chose to give neo-adjuvant RT prior to surgery. By combining centers with similar philosophies, three distinct treatment cohorts were identified for tumors for which en bloc resection is feasible with acceptable morbidity and 5 treatment groups for tumors in which en bloc resection would result in significant morbidity. These will constitute the distinct treatment cohorts of a prospective international cohort study. CONCLUSIONS The results of this survey allowed the design of an international collaborative prospective cohort study to uncover the best treatment strategy for patient with spinal chordomas. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Flaps for Craniofacial Reconstruction

Objective: Skull base reconstruction is one of the most challenging aspects of anterior skull base surgery, especially in the context of previous radiation treatment. The objective of the current study is to describe a novel strategy utilizing pericranial flap (PCF) and nasoseptal flap (NSF) closure following endoscopic-assisted craniofacial resection (EA-CFR) of sinus/skull base tumors. Method: Review of a prospectively collected database containing patients treated with combined PCF/NSF closure was performed between January 2008 and December 2011 at the University of Alabama at Birmingham. Demographics, pathology, surgical goals, location, technique, length of hospital stay, adjuvant treatments, and clinical status were assessed. Results: Four patients (average age 42.7 ± 5.2 years) had EA-CFRs utilizing the PCF/NSF reconstructive technique. Tumor histopathology included esthesioneuroblastoma (n = 2), mixed adenocarcinoma/esthesioneuroblastoma (n = 1), and sinonasal undifferentiated carcinoma (n = 1). Surgical goals were curative intent in all patients. The average length of stay following surgery was 3 days (range of 2-4). There were no postoperative CSF leaks or other complications. Three patients had received neoadjuvant chemo/radiation therapy. The NSF was utilized to cover the PCF at the junction of the planum sphenoidale and PCF in all patients. All patients have complete locoregional control with an average follow up of 26 months (17-41), although 1 patient is alive with metastases. Conclusion: Reconstruction of anterior skull base defects following EA-CFR utilizing the combined PCF/NSF technique resulted in effective closure in all patients in this series. Providing a double layer of vascularized tissue is a reasonable strategy particularly in the setting of neoadjuvant radiation treatment.

Primary Spindle Cell Sarcoma of the Vagina Treated With Neoadjuvant Radiation and Pelvic Exenteration

Malignant neoplasms of the vagina are rare gynecologic tumors. Primary vaginal sarcomas are even more unusual lesions, representing fewer than 2% of malignant vaginal lesions. We present a case of a primary vaginal spindle cell sarcoma, treated with neoadjuvant radiation followed by total pelvic exenteration. The patient remains without evidence of disease 2 years after surgery. The mainstay of treatment of vaginal sarcomas is surgical. Neoadjuvant radiation treatment may decrease surgical morbidity and lead to long-term cure.

Phase-2 study of neoadjuvant chemoradiation in locally advanced rectal adenocarcinoma: The Radio-Xelox study

13549 Background: Neoadjuvant Radiation treatment has been shown in many studies to decrease the incidence of loco-regional relapse in pts with locally-advanced Rectal Adenocarcinoma. Capecitabine and Oxaliplatin are both effective antineoplastic drugs in Colorectal Adenocarcinoma. They also have radiosensitizing effects. Hence,it is rational to combine these agents in association with radiotherapy,to achieve local controle and prevent systemic spread of the cancer. Methods: Thirty-eight pts with Rectal Adenocarcinoma (T3-T4 and/or N+) received radiation treatment (2.0 Gy, 5days a wk over 5 wks,total dose 50 Gy) plus oral Capecitabine at 600 mg/m2 twice a day and iv Oxaliplatin at 35 mg/m2 once weekly × 5wks. Surgery was performed 6wks post completion of XRT. Our end points were safety/feasibility and response/efficacy as demonstrable by the rate of pathologic complete remission (path-CR). Results: Seven pts (20%) acheived path-CR. Diarrhea was the most important severe adverse effect (in 25% of pts). fourteen pts (40%) showed good regression (very few cancer cells in fibronecrotic tissue Dworak grade 3). The remaining 17 pts showed less favorable regression or no significant change. Conclusions: Preoperative Radiation treatment plus chemotherapy with XELOX regimen is feasible, safe and effective with an impressive rate of path-CR in locoregionally advanced Rectal Adenocarcinoma. No significant financial relationships to disclose.

Therapy monitoring with 2-(18F)-FDG positron emission tomography after neoadjuvant radiation treatment of mouth carcinoma

Combined protocols of radiation therapy and surgical resection, as applied in advanced oral cancer, rely on objective and early assessment of treatment response to radiation therapy. Non-responders require immediate radical salvage surgery even in spite of substantial operative risks, while complete or subtotal response may give reasons for continuing the conservative approach. Therefore, we investigated radiation response by FDG-PET for early monitoring of oral cancer. In 30 patients with advanced stages of oral cancer (Table 1), FDG-PET (Siemens, ECAT EXACT 922) was performed within 4 weeks after completion of preoperative radiation therapy (36 Gy). SUV of tumor regions were compared to the histologic degree of tumor regression in complete resection specimens. Statistic evaluation included correlation analysis of SUV vs tumor regression and ROC analysis for SUV cut-off values. While low FDG accumulation was found in tumors with histological complete remission (2.3 +/- 0.4) as well as in cases of residual tumor (3.4 +/- 1.8), high FDG uptake was a rather specific indicator of vital tumor tissue (Figure 2). Significant correlation (p = 0.045) between postradiotherapeutic FDG-uptake and histological tumor regression was recognized. A SUV > 2.75 as a clinically practicable threshold value for the identification of residual vital tumor resulted in a specificity of 88%, sensitivity of 68%, a positive predictive value of 94% and a negative predictive value of 50% (Figure 3). Based on our actual follow-up data we could not confirm a significant correlation between postradiotherapeutic SUV and patients' survival. Within a standardized protocol, FDG-PET recognize treatment response to radiation therapy in oral squamous cell carcinoma with a reasonable specificity and thus provides a basis for further therapeutic decisions. An increased SUV (> 2.75) may be the rational to justify an aggressive surgical approach even when patients face substantial surgical or anesthesiological risk. However, the posttherapeutic pattern of glucose uptake varies with the applied treatment modalities and has to be explored for the protocol applied.