Ultimate Local Control Research Articles

Definitive hypofractionated radiotherapy for early glottic carcinoma: experience of 55Gy in 20 fractions.

IntroductionA wide variety of fractionation schedules have been employed for the treatment of early glottic cancer. The aim is to report our 10-year experience of using hypofractionated radiotherapy with 55Gy in 20 fractions at 2.75Gy per fraction.MethodsPatients treated between 2004 and 2013 with definitive radiotherapy to a dose of 55Gy in 20 fractions over 4 weeks for T1/2 N0 squamous cell carcinoma of the glottis were retrospectively identified. Patients with prior therapeutic minor surgery (eg. laser stripping, cordotomy) were included. The probabilities of local control, ultimate local control (including salvage surgery), regional control, cause specific survival (CSS) and overall survival (OS) were calculated.ResultsOne hundred thirty-two patients were identified. Median age was 65 years (range 33–89). Median follow up was 72 months (range 7–124). 50 (38 %), 18 (14 %) and 64 (48 %) of patients had T1a, T1b and T2 disease respectively. Five year local control and ultimate local control rates were: overall - 85.6 % and 97.3 % respectively, T1a - 91.8 % and 100 %, T1b - 81.6 and 93.8 %, and T2 - 80.9 % and 95.8 %. Five year regional control, CSS and OS rates were 95.4 %, 95.7 % and 78.8 % respectively. There were no significant associations of covariates (e.g. T-stage, extent of laryngeal extension, histological grade) with local control on univariate analysis. Only increasing age and transglottic extension in T2 disease were significantly associated with overall survival (both p <0.01). Second primary cancers developed in 17 % of patients. 13 (9.8 %) of patients required enteral tube feeding support during radiotherapy; no patients required long term enteral nutrition. One patient required a tracheostomy due to a non-functioning larynx on long term follow up.ConclusionsHypofractionated radiation therapy with a dose of 55Gy in 20 fractions for early stage glottic cancer provides high rates of local control with acceptable toxicity.

Identifying outcome predictors of transoral laser cordectomy for early glottic cancer.

The purpose of this study was to determine the predictors of outcomes in patients with early glottic cancer treated by transoral laser cordectomy. This was an inception cohort study of 201 patients with early glottic cancer who were treated by transoral laser cordectomy. Five-year Kaplan-Meier analyses were realized. Patients with anterior commissure involvement (n = 75) had a significantly lower disease-free survival (DFS) rate (54.6% vs 79.8%; p = .0004), ultimate local control with laser alone rate (71.0% vs 95.7%; p < .0001), laryngeal preservation rate (91.6% vs 100%; p = .0003), and disease-specific survival (DSS) rate (90.8% vs 99.0%; p = .03). There was no significant difference in overall-survival (OS) rates (76.9% vs 88.5%; p = .29). Surgical margin status was not found to be a significant predictor of outcomes in this series. Although anterior commissure involvement has a significant impact on outcomes, laser cordectomy remains a valuable option considering its high organ preservation and survival rates. In cases of local recurrence, all standard further treatment options remain available. © 2015 Wiley Periodicals, Inc. Head Neck 38: E406-E411, 2015.

IMRT for Nasal Tumors – Local Control and Cosmetic Outcome

Background: To evaluate local control and cosmetic outcome in patients with cancer in the nasal cavity/vestibule treated with intensity-modulated radiotherapy (IMRT). Methods: From 06/2008 – 11/2012 15 consecutive patients presenting nasal cavity (n=5), ala of the nose (n=5) or nasal vestibule tumors (n=5) were treated in our institution either postoperatively (n=8) or as definitive treatment (n=7). Results: Mean/median follow-up (FU) was 30/22 months (range 17-62). Two patients suffered from a local relapse. As a salvage therapy an ablatio nasi was carried out in curative intention in both patients. Thereafter no failure was reported. Local control rate, ultimate local control and overall survival after 2 years were 87%, 100% and 100%, respectively. None of the patients developed grade II or higher late sequels. Cosmetic outcome after RT was very satisfying so far. Conclusion: IMRT for nasal tumors is effective and well tolerated. Radical surgical procedures can be saved for curative salvage treatment.

Supracricoid Partial Laryngectomy for Primary and Recurrent Laryngeal Cancer

Supracricoid partial laryngectomy (SCPL) is an essential technique in the armamentarium of modern laryngeal organ preservation surgery. OBJECTIVE, DESIGN, SETTING: Retrospective case series to review the oncologic outcomes following SCPL in a large US-based cohort treated by a single surgeon in a tertiary-care university hospital. A total of 96 consecutive patients with primary or recurrent squamous cell carcinoma of the larynx undergoing SCPL from 1992 to 2010. Supracricoid partial laryngectomy surgery. Five-year local control and laryngeal preservation, using the Kaplan-Meier method. There were 54 primary laryngeal carcinomas and 42 previously treated with radiation to the larynx; 23% were supraglottic or transglottic tumors (n = 22). The overall 5-year local control rate for the series was 94%. For T2 and T3 primary tumors, the 5-year local control was 100% and 96%, respectively. In patients previously treated with radiation, the 5-year local control was 89%, with an 89% laryngeal preservation rate. Among stage III or IV primary laryngeal tumors for which concurrent chemoradiation was a treatment alternative, the 5-year local and locoregional control was 96% and 83%, respectively, and the 5-year larynx preservation was 91%. Ultimate local control was achieved for all patients in the series. A significant postoperative complication occurred in 19% (n = 18) and 1 anesthesia-related perioperative death occurred. No total laryngectomies were performed for laryngeal dysfunction. This series demonstrates excellent local control for both primary and recurrent laryngeal cancers, with functional larynx preservation. In appropriately staged and selected patients with T2 or T3 primary laryngeal cancer or laryngeal cancer following prior radiation treatment, SCPL should be considered as a treatment alternative to non-surgical treatment or total laryngectomy.

Radiotherapy in the Management of Giant Cell Tumor of Bone

To evaluate the long-term treatment outcomes for patients with giant cell tumor of bone (GCTB) treated with radiotherapy with or without surgical resection. This retrospective review includes 34 patients with GCTB treated with megavoltage radiotherapy between January 1973 and January 2008 at the University of Florida. Patients' ages ranged from 16 to 85 years (median, 29). Tumor sizes ranges from 2.5 to 12 cm (median, 4.8 cm) in the maximum dimension. Twenty-one patients received radiation for gross disease, either de novo (22 patients) or recurrent (12 patients). Thirteen patients were treated with postoperative radiation after gross total resection. The median dose was 45 Gy in both the definitive and adjuvant settings. The median follow-up was 16.8 years. The 5- and 10-year local-control (LC) rates were 85% and 81%, respectively. Six patients developed an isolated local recurrence (2/13 treated postoperatively and 4/21 who were treated for gross disease). All 6 patients who developed a local recurrence were successfully salvaged with surgery; therefore, the ultimate LC rate was 100%. Both the 5- and 10-year freedom from distant metastasis rates were 91%. Three patients developed lung metastases, including 1 patient who experienced GCTB transformation into a high-grade sarcoma. The 5- and 10-year progression-free survival rates were both 78%. Moderate-dose radiotherapy for GCTB provides a long-term LC >80%, justifying its role as an alternative to morbid surgery.

Definitive radiation therapy for treatment of laryngeal carcinoma

The purpose of this work was to evaluate outcome after radiotherapy (RT) for laryngeal carcinoma and investigate effects of local relapse on ultimate disease control, including surgical salvage procedures. In all, 435 patients with laryngeal carcinoma (cT1-cT4a) treated with primary RT were retrospectively analyzed. Uni- and multivariate analyses were performed to identify prognostic factors for local relapse-free survival and overall survival. Median follow-up was 38 months (range 1-144 months). The cumulative frequency of local recurrence was dependent on T stage: cT1 tumors 10%, cT2 18%, cT3 23%, and cT4 36% (p<0.001). Salvage surgery for local persistent/recurrent disease was performed in 59 of 78 patients (76%). The ultimate local control rates at 5 years (including salvage therapy) were 98, 98, 87, and 68% for cT1, cT2, cT3, and cT4 tumors (p<0.001), respectively. For the patients who developed local recurrence, the 5-year ultimate local control rates were 80, 88, 55, and 26% (p<0.001), respectively. Overall survival at 5 years was 68% for patients without local relapse and 50% for patients experiencing local failure (p<0.001). In univariate analysis, cT stage, cN stage, and tumor volume were statistically significant associated with local relapse-free survival. In multivariate analysis for the cT3-4 tumors, only tumor volume remained statistically significant (HR 1.017, p=0.001) for local relapse-free survival. Local control rates for cT1-2 laryngeal carcinomas are favorable and in concordance with previous reports and most recurrences are salvaged. For cT3-4 tumors treated with RT alone, initial local control rates are moderate, and in 60% of recurring cases salvage surgery is attempted, with ultimate local control being achieved in only a subset. For voluminous, locally advanced laryngeal tumors, more aggressive treatment modalities should be considered, including upfront laryngectomy or radiochemotherapy.

Re-irradiation of locally recurrent soft tissue sarcoma

The incidence of local recurrence after wide local excision and radiation of soft tissue sarcoma (STS) ranges from 5％ to 20％.The optimal management of locally recurrent STS must be individualized.Approaches for retreatment include wide local re-excision followed by a variety of radiation which include external-beam radiation,brachytherapy and intraoperative electron radiotherapy.Following retreatment,the likelihood of ultimate local control ranges from 37％ to 100％.However,each radiation technique could produce severe side effects,and so for selected patients,repeat irradiation may be unnecessary. Key words: Neoplasm recurrence, local ; Sarcoma ; Radiotherapy

Transoral laser microsurgery for early glottic cancer as one‐stage single‐modality therapy

A study was undertaken to determine the oncologic outcomes in a consecutive series of early glottic carcinomas treated with transoral CO₂ laser microsurgery (TLM) as a one-stage single-modality therapy, without any postoperative radiation therapy or retreatment with laser. We further evaluated correlations between the oncologic outcomes and clinicopathologic factors including tumor location and surgical margin. Retrospective analysis of medical records. The medical records of 118 consecutive patients with early stage (T1, T2) glottic carcinoma who underwent TLM by a single surgeon as an initial treatment from 1997 to 2011 were retrospectively reviewed. The oncologic outcomes were evaluated, and correlations to clinicopathologic factors were analyzed. The 5-year disease-free survival, ultimate local control with laser alone, disease-specific survival, overall survival, and organ preservation rates were 87.9%, 94.2%, 99.0%, 92.2%, and 96.2%, respectively. Neither the reported surgical margin nor the extension of tumor to the anterior commissure, arytenoid, subglottis, and ventricle showed any significant impact on local control or survival. Transoral CO₂ laser microsurgery as one-stage single-modality therapy resulted in a high rate of local control and a high survival rate in selected cases of early glottic carcinoma, regardless of the location of tumor and histopathology report on the surgical margin.

Salvage Transoral Laser Supraglottic Laryngectomy after Radiation Failure: A Report of Seven Cases

We evaluated the oncological and functional outcomes of salvage transoral laser supraglottic laryngectomy after radiation failure. In addition, we demonstrated the usefulness of laser surgery in patients with recurrent supraglottic cancer. Between December 1999 and May 2011,7 patients (6 men and 1 woman) underwent transoral laser supraglottic laryngectomy after radiation failure. We conducted 4 different types of endoscopic supraglottic laryngectomy. In the cases with lymph node metastasis, we performed neck dissection at the time of laser surgery. All patients had recurrent squamous cell carcinoma confirmed on the surgical specimen. Two patients were classified as having T1 disease, 2 as having T2 disease, and 3 as having T3 disease with preepiglottic space involvement. The 2- and 5-year overall survival rates were 85.7% and 68.6%, respectively. There was a recurrence at 8 months of followup after laser surgery in 1 patient; he underwent successful salvage total laryngectomy. The ultimate local control rate was 100%, and the laryngeal preservation rate was 85.7%. The hospitalization times ranged from 2 to 32 days (mean, 15.6 days). The mean decannulation time was 10.7 days (range, 5 to 30 days). All patients started oral feeding within 1 to 3 days after surgery. Salvage transoral laser supraglottic laryngectomy following radiation failure seems a feasible and oncologically safe procedure in recurrent supraglottic cancers ranging from T1 to selected T3 with minimal preepiglottic space involvement. It can be an option for minimally invasive organ preservation surgery with lesser morbidity for recurrent supraglottic cancer.

Early glottic carcinoma treated by radiotherapy: Defining a population for surgical salvage

Not all patients with early Glottis squamous cell carcinoma will be cured by radiotherapy. This is an audit of a single center's experience with those patients who fail by this approach. This retrospective study was approved by the IRB (Institutional Review Board); eligibility criterion was patients treated between 1967 and December 2006, T(IS), T(1), T(2) N(0) SCC glottic carcinoma, with analysis occurring in 2009, and with a minimum follow-up of 2 years. The eligibility criteria for this ethics-approved study was that all patients started a course of radiotherapy for early glottic laryngeal SCC. Data included in the Larynx Cancer database includes information from the Radiation Oncology Department notes, referral letters, and follow-up information. This is categorized into patient, disease, and treatment factors. Of 522 patients who commenced radiotherapy, local failure occurred in 105 patients; a salvage procedure was performed in 89, with surgery only in 83. For these 89 patients, the ultimate local control was 67%, with a larynx preservation procedure in 34%. Nodal failure occurred in 20 of the 522 patients (4%). There was a much higher failure rate in patients unfit for surgery (10/26-38%). Laryngectomy was the main salvage procedure in 55 patients. Early recognition of local failure following radiotherapy for early glottic carcinoma may avoid laryngectomy as a salvage procedure.

Radiation therapy for squamous cell carcinoma of the subglottic larynx

This study aims to summarize our institution’s experience in treating patients with primary subglottic squamous cell carcinoma (SCC) with radiotherapy (RT) and to define the optimal treatment plan for these patients. We retrospectively reviewed the medical records of 18 patients with subglottic SCC curatively treated with RT between 1977 and 2009. T1 and T2 cancers were considered early disease; T3 and T4 lesions were considered advanced disease. Patients were stratified according to whether they received RT alone or RT and surgery. Patients treated surgically tended to have more advanced disease and required a total laryngectomy. Patients were excluded if they had distant metastasis at diagnosis or if their tumor was glottic in origin and extended inferiorly into the subglottis. Twelve patients (67 %) had advanced disease, and six patients (33 %) had early disease. Local control was achieved in 100 % of the patients with early disease, regardless of treatment group. Of the patients with advanced disease, local control was achieved in five of the seven patients (71 %) treated with RT alone and in four of the five (80 %) treated with surgery and RT. Ultimate local control was achieved in six of the seven patients (86 %) with advanced disease treated with RT alone. Overall local control was 83 % at 5 years, with a 5-year cause-specific survival of 66 % and a 5-year overall survival of 44 %. Local-regional control mirrored that of local control, with an overall local-regional control rate of 83 %. No patient suffered a severe acute or late complication or acute toxicity during the treatment process. Patients with SCC of the subglottic larynx have a high likelihood of local-regional control after undergoing RT along or combined with surgery. Those with T1–T2 and low volume T3–T4 cancers have high probability of local control with voice preservation after definitive RT.

Prognostic factors for supraglottic laryngeal carcinoma: Importance of the unfit patient

The purpose of this study was to define prognostic factors for supraglottic laryngeal cancer that may influence management. This ethics-approved study captured information on patients who presented with supraglottic laryngeal cancer between 1967 and 2008. Endpoints were local/ultimate failure and cancer-specific survival (CSS). Analysis was performed using chi-square, Fisher exact test, and logistic regression. Kaplan-Meier and Cox regression analysis were used to describe time-to-event data. Three hundred sixty-nine patients were analyzed. Two hundred seventeen patients received radiotherapy, 30 were treated with surgery, and 122 were treated with radiotherapy and surgery. The 5-year ultimate local control and CSS rates were 79.5% and 62.8%. Treatment type was a univariate predictor for outcome; however, it was not an independent predictor for ultimate local control or CSS. This study highlights the fact that by documenting information it is possible to define prognostic factors. It also shows the importance of adjusting for clinical predictors such as patients being unfit for surgery.

Definitive radiation therapy for squamous cell carcinoma of the pharyngeal wall

PurposeTo analyze the results of definitive radiation therapy (RT) for squamous cell carcinoma of the pharyngeal wall. Methods and MaterialsBetween 1964 and 2009, 170 patients were treated with definitive RT; all living patients had a 1.7-year minimum follow-up. ResultsThe 5-year rates of local control and ultimate local control were the following: T1, 93% and 93%; T2, 84% and 91%; T3, 60% and 62%; and T4, 44% and 44%. Multivariate analysis revealed stage I-II tumors, female gender, and altered fractionation were associated with improved local-regional control. The 5-year cause-specific and overall survival rates were the following: I, 88% and 50%; II, 89% and 57%; III, 49% and 31%; IV, 35% and 21%; and overall, 50% and 31%, respectively. Fatal complications occurred in 9 patients (5%). ConclusionsLocal-regional control and survival are related to extent of disease and treatment technique. Although outcomes have improved in recent years, the morbidity of treatment is significant and a substantial proportion of patients die due to cancer.

CO2 laser surgery in elderly patients with glottic carcinoma: Univariate and multivariate analyses of results

There are limited data on the role of laser-assisted surgery for early glottic cancer in elderly patients. This retrospective study was conducted on a series of 130 consecutive cases of early glottic carcinoma occurring in elderly patients (>65 years old) treated with CO(2) laser surgery. The overall and disease-specific survival rates were 87.7% and 99.2%, respectively. The rates of local disease control after primary laser surgery, ultimate local control with laser alone, and laryngeal preservation were 84.6%, 93.8%, and 96.9%, respectively. A shorter disease-free survival (DFS) was associated with the involvement of 1 or more specific laryngeal regions (arytenoids, ventricle, anterior commissure, vocal muscle, subglottis) (p = .01) and the status of the surgical margins (p = .002); on multivariate analysis, only the latter remained prognostically significant vis-à-vis the DFS (p = .002). Even in elderly patients with early glottic carcinoma, endoscopic laser surgery is an effective treatment.

Predictors of radiotherapy outcome in patients with T2 supraglottic carcinoma

The decision regarding treatment of early supraglottic carcinoma remains controversial. Single institution clinical data of patients with T2 supraglottic carcinoma treated exclusively with radiotherapy in terms of prognostic factors and treatment results were analyzed. Patient-related factors that would potentially by useful for optimal therapeutic decision to be undertaken were especially investigated. Between 1994 and 2004, 78 patients with T2 supraglottic carcinoma underwent radiotherapy (RT) in Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Gliwice Branch, Poland. There were 54 (69%) males and 24 (31%) females in the median age of 61 years. There were 17 (22%) patients with N+. Median body mass of patients before (BM0) and after RT (BM1) was 74 kg (range 45.2-130 kg) and 72.9 kg (range 49.9-122.5 kg), respectively. Median hemoglobin concentrations before (Hb0) and after (Hb1) RT were 14.3 and 13.4 g/dl, respectively. Median change of Hb concentration during RT (dHb) was -0.8 g/dl. All were treated up to total doses (TD) ranged from 62.5 to 72 Gy. The overall treatment time (OTT) ranged from 30 to 70 days. Estimates of local control (LC), ultimate local control (uLC), and overall survival (OS) were calculated using the Kaplan-Meier method. Log rank statistics, Cox proportional hazard model and step-wise Cox regression hazard model were employed to identify prognostic factors for LC, uLC, and OS in univariate and multivariate analyses. The 5-year LC, RC, uLC and OS rates were 85, 92, 88, and 56%, respectively. In multivariate analysis N+ (p = 0.01) and prolonged OTT (p = 0.03) significantly decreased LC. Females (p = 0.02), higher BM0 (p = 0.03), and HB0 (p = 0.006) significantly prolonged OS. Patient-related factors like gender, hemoglobin concentration, and body mass may predict treatment outcome. Radiotherapy is effective for T2 supraglottic carcinoma of the larynx unless higher dose intensity is provided. Involved regional lymph nodes significantly deteriorate locoregional cure.

Glottic laser surgery: outcomes according to 2007 ELS classification

The aim of the present investigation was to analyze the oncological results of a series of early stage glottic carcinomas treated with CO(2) laser-assisted endoscopic surgery. We focused on prognosis factors with significant impact on local control and disease-free survival (DFS). This retrospective study was conducted on a series of 177 consecutive patients with pT1-T2 glottic carcinomas treated with CO(2) laser-assisted endoscopic surgery in the period 2000-2007. All considered patients had at least a 24-month follow-up period (mean follow-up 49.1±23.0months). The overall survival and the disease-specific survival rates were respectively 90.8 and 98.8%. The rates of local control with primary laser surgery, ultimate local control with laser alone, and laryngeal preservation were 86.3, 94.3, and 97.7%, respectively. Arytenoids (p=0.006) and limited subglottic involvements (p=0.0002) have a significant impact on DFS. Endoscopic laser surgery is the gold standard in the treatment of early glottic carcinoma because of high local control rates with laser alone, day surgery modality, very low morbility, good post-operative voice quality in most of the cases, and low costs.

Definitive Radiotherapy for T1–2 Hypopharyngeal Cancer: A Single-Institution Experience

To analyze the outcome in T1-2 hypopharyngeal cancer (HPC) patients treated with definitive radiotherapy (RT). A total of 103 patients with T1-2 hypopharyngeal squamous cell carcinoma treated with radical RT between March 2000 and June 2008 at our institution were analyzed. Pre-RT neck dissection (ND) was performed in 26 patients with advanced neck disease. Chemotherapy was used concurrently with RT in 14 patients. Sixty patients were associated with synchronous or metachronous malignancies. The median follow-up for surviving patients was 41 months. The 3-year overall and cause-specific survival rates were 70% and 79%, respectively. The 3-year local control rates were 87% for T1 and 83% for T2 disease. The ultimate local control rate was 89%, including 7 patients in whom salvage was successful. The ultimate local control rate with laryngeal preservation was 82%. Tumors of the medial wall of the pyriform sinus tended to have lower control rates compared with tumors of the lateral or posterior pharyngeal wall. Among patients with N2b-3 disease, the 3-year regional control rates were 74% for patients with pre-RT ND and 40% for patients without ND. The 3-year locoregional control rates were as follows: Stage I, 100%; Stage II, 84%; Stage III, 67%; Stage IVA, 43%; Stage IVB, 67%. Forty-two patients developed disease recurrence, with 29 (70%) patients developing recurrence within the first year. Of the 103 patients, 6 developed late complications higher than or equal to Grade 3. Definitive RT accomplished a satisfactory local control rate and contributed to organ preservation.

Sequential chemoradiotherapy (SCRT) for larynx preservation (LP): Results of the randomized phase II TREMPLIN study.

5501 Background: Induction chemotherapy (ICT) followed by concurrent chemoradiotherapy or by concurrent bioradiotherapy (BRT) is under evaluation in locally advanced head and neck squamous cell carcinoma (SCC). The TREMPLIN study assesses SCRT specifically for LP. Methods: Previously untreated patients (pts) with stage III-IV larynx/hypopharynx SCC and candidates for total laryngectomy were eligible. Pts received 3 ICT cycles (docetaxel and cisplatin both 75 mg/m² day 1 and 5-FU 750 mg/m²/day on days 1-5). Pts responding < 50% had surgery. In case of response > 50 %, pts were randomized to arm A: RT (70 Gy) with cisplatin (100 mg/m² on days 1, 22 and 43 of RT) or arm B: RT (70 Gy) with cetuximab (400 mg/m² loading dose before RT and 250 mg/m² on the first day of the 7 weeks of RT). Primary endpoint, LP 3 months after treatment, did not differ between arms but with better compliance to BRT, secondary endpoints included larynx function preservation (LFP) at 18 months after treatment, survival, feasibility of salvage surgery and tolerance to treatment. Results: 153 pts were enrolled; 116 pts could be randomized after ICT (60 in arm A, 56 in arm B). In intent to treat evaluation, 52 pts (86 %) in arm A and 46 pts (82 %) in arm B had LFP 18 months after treatment or at death (p= .41). Overall survival was respectively 85 % and 86 %. With a mean follow-up of 32 months local failures occurred in 5 pts in arm A (none were salvaged) and in 12 pts in arm B (7 were salvaged) for a similar ultimate local failure rate of 5 pts in each arm. Late toxicity (any grade) occurred more often in arm A (p= 0.111). Conclusions: LFP and survival were similar in both arms, acute and late toxicity were more common in arm A. Local failures occurred more often in arm B, but salvage surgery was only feasible in this arm resulting in similar ultimate local control. Additional research on LP is warranted.

NORMAL TISSUE TOXICITIES OF STEREOTACTIC BODY RADIATION THERAPY FOR THORACIC MALIGNANCIES

Purpose: Stereotactic body radiation therapy (SBRI) is a novel radiotherapeutic technique used to deliver a potent, locally ablative dose to deep-seated tumors in the body. In the last decade, it has emerged as a safe and effective treatment modality in the management of lung malignancies. However, data regarding the toxicities of such treatment regimens continues to evolve. We aim to evaluate the acute and chronic toxicities of patients treated with SBRT to the lung using the Novalis system at our institution. Materials: Between April 2006 and December 2009, we treated a total of 89 separate lung lesions in 78 patients with SBRT at Loyola University Chicago. Of these, 68 were primary lesions, 16 were metastatic disease and 6 were local recurrences. Sixteen tumors were considered central based on RTOG guidelines. A hypofractionated regimen was used with a median dose of 50 Gy (range 24-60) in 5 fractions (range 3-10) and median isocenter dose of 10.5 Gy (range 4-18 Gy). BodyFix (Medical Intelligence, Germany) patient immobilization was utilized during simulation and treatment. An lTV (internal target volume) approach was used with GTVs (gross tumor volumes) contoured on tidal volume inspiration and expiration CT scans and combined. For treatment planning, a uniform PTV (planning target volume) margin of 3-8mm (median 4 mm) was added to the lTV. Daily image guidance was performed using ExacTrac X-ray 6D Robotics (Brainlab, Germany). Isocenter verification was performed immediately prior to and at least once during the treatment course using conventional portal imaging. All treatment plans were available for review. Results: The mean follow-up for all patients is 13 months (range 2-41 months). Thirty-three patients had follow-up beyond 20 months. The estimated 2 year local control rate for lung tumors is 88%. For all plans, the median conformality index at the prescription dose was 1.32 with the prescription dose covering 98% of the PTV. The mean GTV and lTV for lung tumors were 24 cc and 34 cc. The median ipsilateral lung V20, V10 and V5 were 5, 10 and 18%, respectively. The mean D(1 cc) to the chest wall for peripheral lung lesions was 53 Gy. Among all lung patients treated, 9 experienced some form of acute lung toxicity six with a grade 1 cough and two with a grade 2 pneumonitis. Unfortunately, one patient experienced a lethal grade 5 acute pneumonitis complicated by an infectious process. Five patients developed acute esophageal toxicity, four with grade 1 and a single patient with grade 2 dysphagia. Fourteen patients experienced Grade 1-2 fatigue. Long term toxicity data was available for 75 patients. The SBRT treatment course was well-tolerated by the vast majority of patients. Eighteen patients experienced some degree of chronic lung toxicity with only 4 patients developing grade 2 symptoms and the remaining toxicities limited to grade 1 radiographic changes. Two patients developed chronic grade 1 chest wall toxicity. There was no incidence of rib fractures among treated patients. Each of the patients with chest wall toxicity had peripheral lung lesions with the PTV abutting or involving the chest wall. There were no observed long-term toxicities of the spinal cord, esophagus or skin in this cohort. Conclusions: In our experience with Novalis-based SBRT for lung tumors, patients have tolerated highly conformal hypofractionated regimens well, with minimal morbidity. Prior radiation therapy, central vs. peripheral tumor location and volume of irradiated tissues playa role in predicting for toxicity. Our rates of acute and chronic toxicity compare favorably to similar published series. We believe this may be in part due to our standard prescription method, 50 Gy in 5 fractions to the 90+% isodose line. Long-term follow-up is necessary to assess ultimate local control, survival and long term toxicity.

Retained role of surgery for olfactory neuroblastoma

Olfactory neuroblastoma is a rare paranasal sinus malignancy. The traditional approach was craniofacial resection (CFR) and then postoperative radiotherapy until 1998. This review will chart development of a new protocol. This ethics-approved audit evaluated the number of new patients diagnosed with olfactory neuroblastoma, with information relating to patient, disease, and treatment factors noted. There were 24 eligible patients, 16 men, 8 women, 7 Kadish stage B, 17 stage C. The planned treatment was: chemotherapy (cisplatin/etoposide) and determine treatment dependent on response in 6 patients, surgery and radiotherapy in 16 patients, and single-modality treatment only (surgery, radiotherapy 1) in 2 patients. Surgery to radiotherapy occurred in 17 patients. With salvage treatment ultimate local control was 79%. There was a higher local control in those patients who had surgery; abandoning this may carry a higher risk of local failure. The use of response to chemotherapy to determine local treatment remains experimental.