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Shih H, Huang JS, Huang TT, Wong TY, Chen MY, Chen KC. Gland-sparing neck dissection: oncological and functional outcomes in oral cancer patients. Int J Oral Maxillofac Surg 2023; 52:825-830. [PMID: 36517308 DOI: 10.1016/j.ijom.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 11/21/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022]
Abstract
This study was performed to evaluate the subjective and objective functional outcomes of patients who had undergone submandibular gland-sparing neck dissection. All data were obtained from patients treated in a single hospital. Seventy-seven patients who had undergone complete submandibular gland sparing (CSGS) were included in the study. Cancer prognosis items were recorded. The subjective outcomes included patient self-evaluation of mouth dryness and the evaluation of the presence of saliva secretion following the application of digital pressure. Saliva scintigraphy served as the objective test. Self-reported xerostomia was compared between the CSGS patients and a control group of patients who had undergone unilateral submandibular gland removal (USGR; n = 74). In the CSGS group, local recurrence occurred in 3.8% of the 80 cancer sites, and neck recurrence occurred in 5.9% of neck dissection sites. Regarding the subjective measurements, 7.0% of the CSGS patients reported xerostomia and 91.9% demonstrated saliva secretion by digital pressure. Scintigraphy revealed actively secreting glands, with 42.9% of them showing normal gland function; none of the patients had severe xerostomia. The relative risk of dry mouth was significantly higher in the USGR patients than in the CSGS patients (P < 0.001). Submandibular gland sparing during neck dissection was found to result in satisfactory saliva secretion, with a relatively small risk of local or neck recurrence.
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Affiliation(s)
- H Shih
- Department of Dentistry, Division of Oral and Maxillofacial Surgery, China Medical University Hospital, Taichung, Taiwan
| | - J-S Huang
- Division of Oral and Maxillofacial Surgery, Department of Stomatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Dentistry, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - T-T Huang
- Division of Oral and Maxillofacial Surgery, Department of Stomatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Dentistry, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - T-Y Wong
- Division of Oral and Maxillofacial Surgery, Department of Stomatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Dentistry, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - M-Y Chen
- Division of Oral and Maxillofacial Surgery, Department of Stomatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Dentistry, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - K-C Chen
- Division of Oral and Maxillofacial Surgery, Department of Stomatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Dentistry, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Biswas L, Bose S, Sharma S, Manna D, Ghorai S. A prospective study to determine the safety and efficacy of contralateral submandibular gland-sparing radiation therapy for oral cavity and oropharyngeal carcinoma. JOURNAL OF RADIATION AND CANCER RESEARCH 2022. [DOI: 10.4103/jrcr.jrcr_39_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
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Guo Q, Xiao N, Xu H, Zong J, Xiao Y, Lu T, Xu Y, Wang B, Chen B, Pan J, Lin S. Level Ib sparing intensity-modulated radiation therapy in selected nasopharyngeal carcinoma patients based on the International Guideline. Radiother Oncol 2021; 167:239-243. [PMID: 34973279 DOI: 10.1016/j.radonc.2021.12.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE To investigate the feasibility of level Ib sparing in selected nasopharyngeal carcinoma (NPC) patients during intensity-modulated radiation therapy (IMRT) based on the International Guideline. PATIENTS AND MATERIALS Patients with histologically-proven NPC who received definitive IMRT at our group were candidates for this analysis. Other eligibility criteria for analysis were designed according to the recommendation of International Guideline for selective coverage of level Ib. Survival outcomes focused on regional recurrence-free survival (RRFS) and level Ib recurrence rate were analyzed. RESULTS A total of 450 patients were included, 60 of them received level Ib-covering IMRT due to the first three principles of the International Guideline according to our protocol. Of note, patients with level Ib involvement would receive ultrasound guided puncture, only those with positive pathological results would undergo level Ib-covering IMRT. For the remaining 390 patients who only fulfilled the last two criteria and/or level Ib involvement with negative pathological results, level Ib-sparing IMRT was delivered, with a median follow-up time of 112 months (range 6 to 194 months), reported 5- and 10-year RRFS were 95.4% and 92.9%, respectively. Twenty-two patients occurred regional recurrence at censorship (median 44.5 months), only 4(4/390, 1.03%) were recorded as level Ib recurrence. CONCLUSION Level Ib-sparing IMRT should be safe and feasible for patients who only had level II involvement with ECE, and/or had a MAD of greater than 2 cm in level II, and/or level Ib involvement with negative pathological results. Further well-designed multi-center prospective trials should be conducted.
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Affiliation(s)
- Qiaojuan Guo
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China; Fujian Key Laboratory of Translational Cancer Medicine, Fuzhou, China; Key Laboratory of Systems Biomedicine (Ministry of Education), Shanghai Center for Systems Biomedicine, Shanghai Jiao Tong University, Shanghai, China
| | - Nan Xiao
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Hanchuan Xu
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Jingfeng Zong
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Youping Xiao
- Department of Radiology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Tianzhu Lu
- Department of Radiation Oncology, Jiangxi Cancer Hospital of Nanchang University, Nanchang, China
| | - Yun Xu
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Bingyi Wang
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Bijuan Chen
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Jianji Pan
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China; Fujian Key Laboratory of Translational Cancer Medicine, Fuzhou, China
| | - Shaojun Lin
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China; Fujian Key Laboratory of Translational Cancer Medicine, Fuzhou, China.
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Lee A, Chow JCH, Lee NY. Treatment Deescalation Strategies for Nasopharyngeal Cancer: A Review. JAMA Oncol 2020; 7:2774310. [PMID: 33355642 DOI: 10.1001/jamaoncol.2020.6154] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
IMPORTANCE Since the advent of modern radiotherapy techniques and incorporation of systemic chemotherapy for nasopharyngeal cancer, locoregional control has been excellent. However, the rate of treatment-related complications, many of which are irreversible, remains high. New approaches are being explored to determine whether the toxic effects of treatment can be relieved while maintaining disease control. This review presents the current state of deescalation strategies for nasopharyngeal cancer. OBSERVATIONS A review of the literature shows that deescalation approaches can be generally categorized into deescalating systemic therapy vs deescalating radiotherapy. This review discusses studies that have explored sparing chemotherapy in selected patients with stage II cancer as well as altering the chemotherapy scheduling, dosing, and agent from the current standard of care, cisplatin. Deescalating radiotherapy has involved decreasing the dose and the treatment volume. In many cases, these approaches are being guided by measuring Epstein-Barr virus DNA levels, which is a robust biomarker for screening, treatment monitoring, and surveillance. Ongoing work with various imaging modalities, such as fluorodeoxyglucose positron emission tomography and dynamic contrast-enhanced or diffusion-weighted magnetic resonance imaging sequences, have shown promise as another biomarker to safely guide practitioners toward deescalation. CONCLUSIONS AND RELEVANCE Various strategies to deescalate treatment in nasopharyngeal cancer have been explored, and outcomes have remained excellent in most approaches. Patient selection remains key, and long-term outcomes and late complications are still to be determined. Continued investigation with prospective, multi-institutional studies are needed to better elucidate how treatment for nasopharyngeal carcinoma can best be individualized and deescalated.
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Affiliation(s)
- Anna Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- now with Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - James C H Chow
- Department of Clinical Oncology, Queen Elizabeth Hospital, Kowloon, Hong Kong Special Administrative Region, People's Republic of China
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Chang CF, Ei-Sayed IH, George JR, Heaton CM, Ryan WR, Susko MS, Yom SS, Ha PK. Modified technique of submandibular gland transfer followed by intensity modulated radiotherapy to reduce xerostomia in head and neck cancer patients. Head Neck 2020; 42:2340-2347. [PMID: 32400948 DOI: 10.1002/hed.26249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 02/14/2020] [Accepted: 04/22/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Xerostomia is one of the most common long-term adverse effects of radiotherapy for head and neck cancer patients. Contralateral submandibular gland transfer (SMG-T) before radiotherapy was shown to reduce xerostomia compared to pilocarpine. We sought to evaluate a modification of this surgery preserving the ipsilateral facial artery and vein to simplify the SMG-T. METHODS Eighteen patients planned for head and neck intensity modulated radiotherapy to both necks were reviewed. Surgical complications were recorded. The grade of xerostomia was assessed after treatment completion. RESULTS There were no minor or major complications resulting from the modified SMG-T. At 24.5-months follow up, the incidence of post-treatment moderate to severe xerostomia was 16.7%. No locoregional recurrence occurred. Only one patient had distant solitary lung metastasis. CONCLUSION The modified SMG-T technique is a practical and effective method to reduce the dose of radiation to the contralateral SMG and limit post-treatment xerostomia.
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Affiliation(s)
- Chia-Fan Chang
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ivan H Ei-Sayed
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jonathan R George
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Chase M Heaton
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - William R Ryan
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Matt S Susko
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Sue S Yom
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Patrick K Ha
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
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Jackson JE, Anderson NJ, Wada M, Schneider M, Poulsen M, Rolfo M, Fahandej M, Gan H, Joon DL, Khoo V. Clinical and dosimetric risk stratification for patients at high-risk of feeding tube use during definitive IMRT for head and neck cancer. Tech Innov Patient Support Radiat Oncol 2020; 14:1-10. [PMID: 32154393 PMCID: PMC7052527 DOI: 10.1016/j.tipsro.2020.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/06/2019] [Accepted: 01/27/2020] [Indexed: 11/29/2022] Open
Abstract
Understanding feeding tube risk is critical to optimal weight maintenance during radiotherapy. T-stage, Level II lymphadenopathy risk stratify feeding tube use into 4 groups. The addition of cervical oesophagus dose can further refine these risk stratified groups.
Introduction To identify organs to which dose limitation using intensity modulated radiotherapy (IMRT) can potentially modify the incidence and duration of feeding tube use, during and immediately following therapy for head and neck cancer. Materials and methods One hundred and fourteen patients treated with definitive IMRT (± concurrent chemotherapy) head and neck mucosal cancers were included. Patients received a prophylactic feeding tube and followed up by a dietician for at least eight weeks post-radiotherapy. Salivary and swallowing organs were delineated for each patient. Tumour and dosimetric variables were recorded for all patients and analysed for incidence and duration of feeding tube use for at least 25% of dietary requirements. Results Multivariate analysis showed T-classification ≥3 and level II lymphadenopathy as independent significant predictors of incidence and duration of feeding tube use in oral cavity, pharyngeal and supraglottic primaries. Mean dose deposited in the cervical oesophagus over 36Gy further increased the incidence and duration of feeding tube use. Mean dose deposited in the base of tongue and superior pharyngeal constrictor muscles affected incidence and duration of feeding tube use, respectively. Discussion In patients treated with definitive IMRT, T-classification and Level II lymphadenopathy, combined with a mean cervical oesophagus dose over 36Gy can a stratify patients into eight distinct risk groups for using feeding tubes for at least 25% of their dietary requirements.
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Affiliation(s)
- James E. Jackson
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Victoria, Australia
- School of Medicine, Griffith University, Gold Coast, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Sciences, Monash University, Victoria, Australia
- Icon Cancer Centres, Gold Coast University Hospital, Queensland, Australia
- Corresponding authors at: ICON Cancer Care Centre, Gold Coast University Hospital, I University Boulevard, LG Block C, Southport, QLD 4215, Australia (J.E. Jackson). Principal Research Radiation Therapist, 305 Grattan Street, Melbourne, Victoria 3000, Australia (N.J. Anderson).
| | - Nigel J. Anderson
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Victoria, Australia
- Department of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Sciences, Monash University, Victoria, Australia
- Corresponding authors at: ICON Cancer Care Centre, Gold Coast University Hospital, I University Boulevard, LG Block C, Southport, QLD 4215, Australia (J.E. Jackson). Principal Research Radiation Therapist, 305 Grattan Street, Melbourne, Victoria 3000, Australia (N.J. Anderson).
| | - Morikatsu Wada
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Michal Schneider
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Sciences, Monash University, Victoria, Australia
| | - Michael Poulsen
- Icon Cancer Centres, Gold Coast University Hospital, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Maureen Rolfo
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Maziar Fahandej
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Victoria, Australia
- Department of Palliative Care, St Vincent’s Hospital, Fitzroy, Victoria, Australia
| | - Hui Gan
- Olivia Newton-John Cancer Research Institute, Austin Health, Heidelberg, Victoria, Australia
| | - Daryl Lim Joon
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Victoria, Australia
- Icon Cancer Centres, Gold Coast University Hospital, Queensland, Australia
| | - Vincent Khoo
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, Victoria, Australia
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Sciences, Monash University, Victoria, Australia
- Department of Clinical Oncology, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Chelsea, London, UK
- Department of Medicine, University of Melbourne, Victoria, Australia
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Gupta DK, Chugh R, Singh SK, Pati S. Use of the facial artery-based cutaneous island flap (melo-labial flap) for reconstruction of the neopharynx following total laryngectomy: a novel technique. BMJ Case Rep 2019; 12:12/8/e230712. [PMID: 31383687 DOI: 10.1136/bcr-2019-230712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Reconstruction of neopharynx after total laryngectomy is a challenging task. Various locoregional flaps like pectoralis major myocutaneos/ latismus dorsi flaps and free flaps have their own limitations and advantages. To overcome this, we used facial artery-based cutaneous island flap (melo-labial flap) for reconstruction of the neopharynx following total laryngectomy (DK Gupta technique). This flap is thin, pliable, without any gravitational pull and without any risk of anastomosis failure and hence has advantage of both locoregional and free flaps and eliminates the limitations of both. It is simple, reproducible and reliable reconstructive option for neopharynx. We present a case report, review of literature and this novel technique for an excellent outcome and recommend to use it as the new workhorse of neopharyngeal reconstruction.
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Affiliation(s)
| | - Rajeev Chugh
- ENT-HNS, Army Hospital Research and Referral, New Delhi, India
| | | | - Seema Pati
- ENT-HNS, Army Hospital Research and Referral, New Delhi, India
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Zeng L, Zhang Q, Ao F, Jiang CL, Xiao Y, Xie HH, Tang YQ, Gong XC, Li JG. Risk factors and distribution features of level IB lymph nodes metastasis in nasopharyngeal carcinoma. Auris Nasus Larynx 2019; 46:457-464. [PMID: 30528104 DOI: 10.1016/j.anl.2018.10.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/16/2018] [Accepted: 10/22/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The objective of this study is to investigate the risk factors and distribution features for level IB metastasis in nasopharyngeal carcinoma (NPC) and provide clinical evidence for defining the indications and clinical target volume (CTV) of prophylactic level IB irradiation. METHODS We retrospectively analyzed 798 patients with newly-diagnosed, non-metastatic and histologically confirmed NPC underwent intensity-modulated radiation therapy (IMRT). Two sides of neck in each patient have been analyzed separately. The correlations of level IB metastasis and the clinical risk factors were analyzed with Chi-square test and logistic regression model. The risk score model (RSM) of level IB metastasis was calculated by totaling up the scores of each independent variable. We divided level IB into three areas, including anterolateral space of submandibular glands, medial space of the submandibular glands and submandibular glands. RESULTS Maximal axial diameter (MAD) of level IIA nodes >20mm or extra capsular spread (ES) of level IIA nodes, anterior half of nasal cavity involvement and submandibular gland involvement/compression were independently significantly risk factors for level IB lymph nodes (LNs) metastasis at diagnosis. Two groups based on RSM were obtained: low risk (total score=0-2.5); high risk (4-8.5). The incidence of IB LNs metastasis at diagnosis of the two groups were 0.9% and 6.3%, respectively (P<0.001). The cervical lymph nodes of level IB were distributed in the anterolateral space of submandibular glands. There was no positive/negative LNs inside or medial space of the submandibular glands. CONCLUSION Level IB LNs metastasis is associated with MAD of level IIA nodes >20mm or ES of level IIA nodes, anterior half of nasal cavity involvement and submandibular gland involvement/compression in NPC patients. Omission of level IB irradiation may be feasible for patients with low-risk IB LNs metastasis at diagnosis. The submandibular gland should not be included in level IB.
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Affiliation(s)
- Lei Zeng
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, 330029, PR China
| | - Qin Zhang
- Good Clinical Practice Office, Cancer Hospital of Shantou University Medical College, Shantou, 515041, PR China
| | - Fan Ao
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, 330029, PR China
| | - Chun-Ling Jiang
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, 330029, PR China
| | - Yun Xiao
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, 330029, PR China
| | - Hong-Hui Xie
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, 330029, PR China
| | - Yi-Qiang Tang
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, 330029, PR China
| | - Xiao-Chang Gong
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, 330029, PR China.
| | - Jin-Gao Li
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, 330029, PR China.
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9
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Varra V, Ross RB, Juloori A, Campbell S, Tom MC, Joshi NP, Woody NM, Ward MC, Xia P, Koyfman SA, Greskovich JF. Selectively sparing the submandibular gland when level Ib lymph nodes are included in the radiation target volume: An initial safety analysis of a novel planning objective. Oral Oncol 2018; 89:79-83. [PMID: 30732963 DOI: 10.1016/j.oraloncology.2018.12.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 12/16/2018] [Accepted: 12/17/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Submandibular gland (SMG) metastases are extremely rare in head and neck cancer, even in the presence of level Ib lymph node (LN) involvement. In recent years, we have contoured the SMG and specifically attempted to limit its dose exposure even in patients in whom the level Ib LN station is targeted. This study reports our preliminary feasibility and safety experience with selective submandibular gland sparing. METHODS Patients with squamous cell cancer (SCC) of the oral cavity or oropharynx with T1-2, N0-3, M0 disease in whom at least a single level Ib lymph node region was included in the target volume were identified. All patients were treated from 2009 to 2014 with definitive or postoperative IMRT with or without chemotherapy. Patients with recurrent disease, previous radiation or treated palliatively were excluded. RESULTS A total of 174 patients met criteria for inclusion. Among the 185 level Ib LN stations that were deliberately targeted in the clinical treatment volume, 32 submandibular glands were contoured, excluded from the target volume and avoided during treatment planning. Mean dose to the spared SMG were reduced by 12% (66.6 Gy vs. 58.9 Gy, p < .001). None of these patients experienced any level 1b LN failures. CONCLUSION Selective sparing of the submandibular gland when targeting the level 1b nodes in oral cavity and oropharynx cancer is feasible, reduces the mean dose to submandibular glands and does not result in increased level 1b nodal failure rates. Additional studies with larger cohorts are needed to validate this preliminary observation.
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Affiliation(s)
- Vamsi Varra
- Cleveland Clinic, Department of Radiation Oncology, Cleveland, OH, United States
| | - Richard B Ross
- Cleveland Clinic, Department of Radiation Oncology, Cleveland, OH, United States
| | - Aditya Juloori
- Cleveland Clinic, Department of Radiation Oncology, Cleveland, OH, United States
| | - Shauna Campbell
- Cleveland Clinic, Department of Radiation Oncology, Cleveland, OH, United States
| | - Martin C Tom
- Cleveland Clinic, Department of Radiation Oncology, Cleveland, OH, United States
| | - Nikhil P Joshi
- Cleveland Clinic, Department of Radiation Oncology, Cleveland, OH, United States
| | - Neil M Woody
- Cleveland Clinic, Department of Radiation Oncology, Cleveland, OH, United States
| | - Matthew C Ward
- Levine Cancer Institute, Atrium Health, Charlotte, NC, United States; Southeast Radiation Oncology Group, Charlotte, NC, United States
| | - Ping Xia
- Cleveland Clinic, Department of Radiation Oncology, Cleveland, OH, United States
| | - Shlomo A Koyfman
- Cleveland Clinic, Department of Radiation Oncology, Cleveland, OH, United States.
| | - John F Greskovich
- Cleveland Clinic, Department of Radiation Oncology, Cleveland, OH, United States
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10
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Submandibular function recovery after IMRT in head and neck cancer: A prospective dose modelling study. Radiother Oncol 2018; 129:38-43. [DOI: 10.1016/j.radonc.2018.02.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 02/21/2018] [Accepted: 02/22/2018] [Indexed: 11/20/2022]
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11
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Hawkins PG, Lee JY, Mao Y, Li P, Green M, Worden FP, Swiecicki PL, Mierzwa ML, Spector ME, Schipper MJ, Eisbruch A. Sparing all salivary glands with IMRT for head and neck cancer: Longitudinal study of patient-reported xerostomia and head-and-neck quality of life. Radiother Oncol 2017; 126:68-74. [PMID: 28823405 DOI: 10.1016/j.radonc.2017.08.002] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 07/21/2017] [Accepted: 08/02/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE While parotid-sparing intensity modulated radiotherapy (IMRT) has demonstrated superiority to conventional RT in terms of observer-rated xerostomia, patient-reported outcome measures (PROMs) have only marginally improved. We investigated how sparing all salivary glands affects PROMs. MATERIALS AND METHODS Patients treated to the bilateral neck with all-gland-sparing IMRT answered xerostomia (XQ) and head-and-neck quality of life (HNQOL) questionnaires. Longitudinal regression was used to assess the relationship between questionnaire scores and mean bilateral parotid gland (bPG), contralateral submandibular gland (cSMG), and oral cavity (OC) doses. Marginal R2 and Akaike information criterion (AIC) were used for model evaluation. RESULTS 252 patients completed approximately 600 questionnaires. On univariate analysis, bPG, cSMG, and OC doses significantly correlated with XQ-summary, XQ-eating, and HNQOL-eating scores. On multivariate analysis, bPG and OC doses significantly correlated with XQ-summary, XQ-eating, and HNQOL-eating scores; and cSMG dose with HNQOL-summary. Combining doses to all three structures yielded the highest R2 for XQ-summary, XQ-rest, XQ-eating, and HNQOL-eating. In the 147 patients who received a mean cSMG dose ≤39Gy, there were no failures in contralateral level IB. CONCLUSIONS Reducing doses to all salivary glands maximizes PROMs. A cSMG dose constraint of ≤39Gy does not increase failure risk.
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Affiliation(s)
- Peter G Hawkins
- Department of Radiation Oncology, University of Michigan, Ann Arbor, United States
| | - Jae Y Lee
- Department of Radiation Oncology, University of Michigan, Ann Arbor, United States
| | - Yanping Mao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Pin Li
- Department of Biostatistics, University of Michigan, Ann Arbor, United States
| | - Michael Green
- Department of Radiation Oncology, University of Michigan, Ann Arbor, United States
| | - Francis P Worden
- Department of Internal Medicine, Division of Medical Oncology, University of Michigan, Ann Arbor, United States
| | - Paul L Swiecicki
- Department of Internal Medicine, Division of Medical Oncology, University of Michigan, Ann Arbor, United States
| | - Michelle L Mierzwa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, United States
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, United States
| | - Matthew J Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, United States; Department of Biostatistics, University of Michigan, Ann Arbor, United States
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan, Ann Arbor, United States.
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Hoyne C, Dreosti M, Shakeshaft J, Baxi S. Comparison of treatment techniques for reduction in the submandibular gland dose: A retrospective study. J Med Radiat Sci 2017; 64:125-130. [PMID: 28240447 PMCID: PMC5454328 DOI: 10.1002/jmrs.203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 11/04/2016] [Accepted: 11/05/2016] [Indexed: 11/14/2022] Open
Abstract
Introduction Recent studies have suggested reducing the dose submandibular glands receive when patients undergo head and neck radiotherapy can play a crucial role in preventing xerostomia. However, they are traditionally not spared due to concern that target coverage may be compromised. We investigated the possibility of sparing the contralateral submandibular gland (cSM) by utilising modern planning techniques. Methods 10 head and neck patients previously treated with conformal therapy at our centre were retrospectively planned using intensity modulated radiation therapy (IMRT), and volumetric modulated arc therapy (VMAT). Each patient was prescribed 70 Gy in 35 fractions to the primary volume, with 56 Gy delivered to the elective nodal areas. The primary objective was to spare the cSM gland using appropriate dose constraints. Results Mean dose to the cSM gland was reduced to an acceptable dose level (39 Gy) for all patients replanned using an IMRT or VMAT technique, without compromising planned target volume (PTV) coverage or other critical structures. VMAT was able to reduce the mean dose to 31.5 ± 5.5 Gy compared to 34.5 ± 4.8 Gy of IMRT and offered improved plan conformity. Conclusion Sparing the cSM gland is possible using IMRT and VMAT planning, whilst preserving coverage on the elective PTV. This has produced a change in protocol in our department, more focus placed on sparing the SM glands. VMAT is a viable alternative method of delivering treatment and will be utilised when required.
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Affiliation(s)
- Christopher Hoyne
- Ballarat Austin Radiation Oncology Centre, Ballarat, Victoria, Australia
| | - Marcus Dreosti
- Adelaide Radiotherapy Centre, Adelaide, South Australia, Australia
| | - John Shakeshaft
- Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Siddartha Baxi
- South West Radiation Oncology Service, Bunbury, Western Australia, Australia
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Tuomikoski L, Kapanen M, Collan J, Keyriläinen J, Saarilahti K, Loimu V, Seppälä T, Tenhunen M. Toward a more patient-specific model of post-radiotherapy saliva secretion for head and neck cancer patients. Acta Oncol 2015. [PMID: 26203929 DOI: 10.3109/0284186x.2015.1067717] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Reduction of saliva secretion is a common side effect following radiotherapy (RT) for cancer of the head and neck region. The aim of this study is to predict the post-RT salivary function for individual patients prior to treatment and to recognise possible differences in individual radiosensitivity. MATERIAL AND METHODS A predictive model for post-RT salivary function was validated for 64 head and neck cancer patients. The input parameters for the model were salivary excretion fraction (sEF) measured by 99mTc-pertechnetate scintigraphy, total stimulated salivary flow and mean absorbed dose for the major salivary glands. SEF values after RT relative to the baseline before RT (rEF) were compared among the patients using the distance ΔrEF between single gland rEF and the corresponding expected value at the dose response curve. RESULTS A significant correlation (R = 0.86, p = 0.018) was found between the modelled and the measured values of stimulated salivary flow six months after RT. The average prediction error for the saliva flow rate was 6 ml/15 min. A linear relationship between ΔrEF for the left and the right parotid glands was observed both six (R = 0.53) and 12 (R = 0.79) months after RT. The average of absolute values of ΔrEF was 0.20 for parotid glands and 0.22 for submandibular glands. CONCLUSIONS The salivary flow model was validated for 64 patients. The results imply, that one explanation for the discrepancies between the predicted and the measured salivary flow rate values and the common variations found in ΔrEF for the parotid glands may be differences in patients' individual response to radiation. However, quantitative extraction of individual radiosensitivity would require further studies in order to take it into account in predictive models.
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Affiliation(s)
- Laura Tuomikoski
- a HUCH Comprehensive Cancer Center, Department of Radiation Oncology , Helsinki University Central Hospital , Helsinki , Finland
| | - Mika Kapanen
- a HUCH Comprehensive Cancer Center, Department of Radiation Oncology , Helsinki University Central Hospital , Helsinki , Finland
- b Department of Medical Physics , Tampere University Hospital , Tampere , Finland
| | - Juhani Collan
- a HUCH Comprehensive Cancer Center, Department of Radiation Oncology , Helsinki University Central Hospital , Helsinki , Finland
| | - Jani Keyriläinen
- a HUCH Comprehensive Cancer Center, Department of Radiation Oncology , Helsinki University Central Hospital , Helsinki , Finland
- c Department of Oncology and Radiotherapy , Turku University Hospital , Turku , Finland
| | - Kauko Saarilahti
- a HUCH Comprehensive Cancer Center, Department of Radiation Oncology , Helsinki University Central Hospital , Helsinki , Finland
| | - Venla Loimu
- a HUCH Comprehensive Cancer Center, Department of Radiation Oncology , Helsinki University Central Hospital , Helsinki , Finland
| | - Tiina Seppälä
- a HUCH Comprehensive Cancer Center, Department of Radiation Oncology , Helsinki University Central Hospital , Helsinki , Finland
| | - Mikko Tenhunen
- a HUCH Comprehensive Cancer Center, Department of Radiation Oncology , Helsinki University Central Hospital , Helsinki , Finland
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Cuaron J, Rao S, Wolden S, Zelefsky M, Schupak K, Mychalczak B, Lee N. Patterns of failure in patients with head and neck carcinoma of unknown primary treated with radiation therapy. Head Neck 2015; 38 Suppl 1:E426-31. [PMID: 25581274 DOI: 10.1002/hed.24013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2015] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The purpose of this study was to examine patterns of failure and the relationship to radiation doses in patients with head and neck carcinoma of unknown primary (HNCUP). METHODS We reviewed 85 patients with HNCUP treated with curative-intent radiation therapy (RT) during 1995 to 2012. RESULTS There have been no failures in the pharyngeal axis. Relapse at initial neck sites of disease developed in 7 patients (8.2%). The median dose to these sites was 70 Gy (range, 63-70 Gy). Failure at neck sites without initial disease occurred in 4 patients (4.7%). The median dose was 54 Gy (range, 50-58.8 Gy). There were no contralateral failures in a small cohort of patients receiving unilateral treatment (n = 6). Percutaneous endoscopic gastrostomy (PEG) tube dependence at 12 months was 7.4%, and 2.5% at 3 years. Esophageal stricture developed in 5 patients (5.9%). CONCLUSION RT for HNCUP produces excellent locoregional control rates with acceptably low levels of late toxicity. Doses prescribed to sites of eventual failure did not vary significantly from those sites that were treated and remain in control. © 2015 Wiley Periodicals, Inc. Head Neck 38: E426-E431, 2016.
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Affiliation(s)
- John Cuaron
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Shyam Rao
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Michael Zelefsky
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Karen Schupak
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Borys Mychalczak
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Nancy Lee
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
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Robin TP, Gan GN, Tam M, Westerly D, Riaz N, Karam SD, Lee N, Raben D. Safety of contralateral submandibular gland sparing in locally advanced oropharyngeal cancers: A multicenter review. Head Neck 2015; 38:506-11. [PMID: 25482748 DOI: 10.1002/hed.23928] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Previous groups have shown contralateral submandibular gland sparing to improve xerostomia with safe outcomes, but primarily in early-stage disease. In this study, we present a large cohort of patients with locally advanced head and neck cancer that underwent contralateral submandibular gland-sparing radiotherapy, to demonstrate feasibility and safety specifically in patients with locally advanced disease. METHODS We retrospectively analyzed patients who were treated prospectively with contralateral submandibular gland sparing. Only patients who underwent bilateral neck radiotherapy with contralateral submandibular gland doses <39 Gy were included. RESULTS We identified 71 patients. Approximately 80% of patients had ≥N2b disease. The contralateral submandibular gland mean dose was 33 Gy and, at a median follow-up of 27.3 months, no patients experienced treatment failure in the contralateral level IB lymph nodes. CONCLUSION Xerostomia remains a significant morbidity despite parotid sparing and can be minimized further by contralateral submandibular gland sparing. These data provide important preliminary evidence that contralateral submandibular gland sparing is feasible and may be safe even in locally advanced cancers.
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Affiliation(s)
- Tyler P Robin
- Department of Radiation Oncology, University of Colorado Cancer Center, Aurora, Colorado
| | - Gregory N Gan
- Department of Radiation Oncology, University of Colorado Cancer Center, Aurora, Colorado
| | - Moses Tam
- New York University School of Medicine, New York, New York
| | - David Westerly
- Department of Radiation Oncology, University of Colorado Cancer Center, Aurora, Colorado
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Sana D Karam
- Department of Radiation Oncology, University of Colorado Cancer Center, Aurora, Colorado
| | - Nancy Lee
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - David Raben
- Department of Radiation Oncology, University of Colorado Cancer Center, Aurora, Colorado
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Gensheimer MF, Liao JJ, Garden AS, Laramore GE, Parvathaneni U. Submandibular gland-sparing radiation therapy for locally advanced oropharyngeal squamous cell carcinoma: patterns of failure and xerostomia outcomes. Radiat Oncol 2014; 9:255. [PMID: 25424729 PMCID: PMC4262974 DOI: 10.1186/s13014-014-0255-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 11/06/2014] [Indexed: 11/24/2022] Open
Abstract
Background Saliva from submandibular glands (SMG) is necessary to minimize xerostomia. It is unclear whether SMG can be safely spared in patients undergoing bilateral neck radiotherapy for locally advanced oropharyngeal cancer without increasing the risk of marginal recurrence. We evaluated the outcomes of contralateral submandibular gland (cSMG) sparing intensity-modulated radiation therapy (IMRT). Methods All patients with stage III/IV oropharyngeal squamous cell carcinoma treated with bilateral neck IMRT from 2006–2012 at our institution were included. Appropriately selected patients with favorable primary tumor characteristics and no definite contralateral neck disease were treated with cSMG-sparing IMRT. Patterns of failure and xerostomia outcomes were retrospectively analyzed. Results 114 patients were treated. 89% had stage IV disease and 89% received definitive radiation therapy. 76 patients (67%) received cSMG sparing IMRT. With a median follow-up of 30 months, there were 10 local, 9 regional, and 10 distant recurrences. 2-year overall survival was 86% and 2-year loco-regional control was 87%. In cSMG spared patients, the mean cSMG dose was 30.7 Gy. Late grade 2+ xerostomia was significantly reduced in the cSMG spared group compared to those without SMG sparing (6 months: 23% vs. 72%, 12 months: 6% vs. 41%, 24 months: 3% vs. 36%, all p < 0.0007). There were no peri-SMG marginal recurrences in the cSMG-spared cohort. Conclusions cSMG sparing IMRT did not increase marginal failures in this series of locally advanced oropharyngeal SCC patients. Xerostomia was significantly reduced in cSMG spared patients.
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Affiliation(s)
- Michael F Gensheimer
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA, USA.
| | - Jay J Liao
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA, USA.
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - George E Laramore
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA, USA.
| | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA, USA.
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Yu Y, Daly ME, Farwell DG, Luu Q, Gandour-Edwards R, Donald PJ, Chen AM. Level IB nodal involvement in oropharyngeal carcinoma: Implications for submandibular gland-sparing intensity-modulated radiotherapy. Laryngoscope 2014; 125:608-14. [DOI: 10.1002/lary.24907] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 05/27/2014] [Accepted: 08/04/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Yao Yu
- Department of Radiation Oncology; Comprehensive Cancer Center, University of California, Davis; Davis California U.S.A
| | - Megan E. Daly
- Department of Radiation Oncology; Comprehensive Cancer Center, University of California, Davis; Davis California U.S.A
| | - D. Gregory Farwell
- Department of Otolaryngology-Head and Neck Surgery; Comprehensive Cancer Center, University of California, Davis; Davis California U.S.A
| | - Quang Luu
- Department of Otolaryngology-Head and Neck Surgery; Comprehensive Cancer Center, University of California, Davis; Davis California U.S.A
| | - Regina Gandour-Edwards
- Department of Pathology; Comprehensive Cancer Center, University of California, Davis; Davis California U.S.A
| | - Paul J. Donald
- Department of Otolaryngology-Head and Neck Surgery; Comprehensive Cancer Center, University of California, Davis; Davis California U.S.A
| | - Allen M. Chen
- Department of Radiation Oncology; Comprehensive Cancer Center, University of California, Davis; Davis California U.S.A
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Sparing level Ib lymph nodes by intensity-modulated radiotherapy in the treatment of nasopharyngeal carcinoma. Int J Clin Oncol 2013; 19:998-1004. [PMID: 24337503 DOI: 10.1007/s10147-013-0650-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 11/26/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND We retrospectively investigated the patterns of locoregional relapse and survival of patients to evaluate whether sparing level Ib lymph nodes by intensity-modulated radiotherapy (IMRT) in the treatment of nasopharyngeal carcinoma was feasible. METHODS One hundred and twenty nasopharyngeal carcinoma patients received treatment with level Ib lymph nodes spared by IMRT between January 2005 and August 2008 in our center. Before treatment, each patient underwent enhanced magnetic resonance imaging of the nasopharynx and neck. Patients with negative cervical lymph nodes received radiotherapy to the nasopharynx, skull base and upper neck drainage areas, while patients with cervical lymph node involvement received treatment to the whole neck. The prescription doses were 66-70.4 Gy/30-32 fractions to the gross tumor volume of nasopharynx, 66 Gy to the positive neck nodes, 60 Gy to the high-risk clinical target volume and 54 Gy to the low-risk clinical target volume. Patients staged III, IV A/B or II also received chemotherapy. RESULTS The median follow-up of these 120 patients was 54 months. The 5-year local control, regional control, distant metastasis-free and overall survival rates were 90.7, 96.5, 84.8 and 81.4 %, respectively. Four patients suffered regional recurrence: 2, 1 and 1 experienced regional recurrence in level II, retropharyngeal and parotid lymph nodes, respectively. CONCLUSION In nasopharyngeal carcinoma patients with negative level Ib lymph nodes who are treated with level Ib-sparing IMRT, regional lymph node recurrence alone is rare. Therefore, sparing level Ib lymph nodes by IMRT is feasible in selected patients.
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Chajon E, Lafond C, Louvel G, Castelli J, Williaume D, Henry O, Jégoux F, Vauléon E, Manens JP, Le Prisé E, de Crevoisier R. Salivary gland-sparing other than parotid-sparing in definitive head-and-neck intensity-modulated radiotherapy does not seem to jeopardize local control. Radiat Oncol 2013; 8:132. [PMID: 23721062 PMCID: PMC3680304 DOI: 10.1186/1748-717x-8-132] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 05/27/2013] [Indexed: 12/25/2022] Open
Abstract
Background The objective was to analyze locoregional (LR) failure patterns in patients with head-and-neck cancer (HNC) treated using intensity-modulated radiotherapy (IMRT) with whole salivary gland-sparing: parotid (PG), submandibular (SMG), and accessory salivary glands represented by the oral cavity (OC). Methods Seventy consecutive patients with Stage I-II (23%) or III/IV (77%) HNC treated by definitive IMRT were included. For all LR failure patients, the FDG-PET and CT scans documenting recurrence were rigidly registered to the initial treatment planning CT. Failure volumes (Vf) were delineated based on clinical, radiological, and histological data. The percentage of Vf covered by 95% of the prescription isodose (Vf-V95) was analyzed. Failures were classified as “in-field” if Vf–V95 ≥ 95%, “marginal” if 20% < Vf-V95 < 95%, and “out-of-field” if Vf-V95 ≤20%. Correlation between Vf-V95 and mean doses (Dmean) in the PG, SMG, and OC was assessed using Spearman’s rank-order correlation test. The salivary gland dose impact on the LR recurrence risk was assessed by Cox analysis. Results The median follow-up was 20 months (6–35). Contralateral and ipsilateral PGs were spared in 98% and 54% of patients, respectively, and contralateral and ipsilateral SMG in 26% and 7%, respectively. The OC was spared to a dose ≤40 Gy in 26 patients (37%). The 2-year LR control rate was 76.5%. One recurrence was “marginal”, and 12 were “in-field”. No recurrence was observed in vicinity of spared structures. Vf-V95 was not significantly correlated with Dmean in PG, SMG, and OC. The LR recurrence risk was not increased by lower Dmean in the salivary glands, but by T (p = 0.04) and N stages (p = 0.03). Conclusion Over 92% of LR failures occurred “in-field” within the high dose region when using IMRT with a whole salivary gland-sparing strategy. Sparing SMG and OC in addition to PG thus appears a safe strategy.
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