Purpose/Objective(s)By emphasizing precise target volume delineation, highly conformal radiation treatment using intensity-modulated radiation therapy (IMRT) may shift the location of local disease relapse from centrally within the tumor bulk to the periphery. This study aims to evaluate patterns of local failure specifically among patients with locally-advanced head and neck squamous cells carcinoma (HNSCC) treated with IMRT and simultaneous integrated boost (SIB) technique.Materials/MethodsThe records of 24 patients presenting with primary HNSCC and treated at UCLA from July 2007 through October 2008 were reviewed. The study population included: 16 male (67%), 8 female (33%), 4 stage II (17%), 4 stage III (17%) and 16 stage IV (67%). The primary tumor sites were: oropharynx in 11 patients, larynx 4, nasopharynx 3, hypopharynx 2, oral cavity 2, paranasal sinus 1, and unknown in 1 patient. Twenty of the 24 patients (83%) received definitive RT, while the remaining 4 were treated post-operatively. Twenty-one (88%) patients received chemotherapy during the RT course. Median prescription doses for planning target volume (PTV) levels 1, 2 and 3 were 69.3 Gy, 62.7 Gy and 56.1 Gy, respectively, given simultaneously over 33 fractions.ResultsThe median follow-up duration was 22.4 months (range: 7.9 - 36.6). Disease-specific and overall survival rates at 3 years were 100%. The actuarial local control probability was 83% at 3 years. Four (17%) patients failed to achieve local control of their disease, with 3 having oropharynx and one having hypopharynx primary. All 4 recurrent tumors were detected by either imaging (2) or biopsy (2), and occurred within the planning target volumes, not outside or at the periphery. The median time from the end of RT to recurrence was only 4.8 months (range: 4.1 - 5.2), raising the possibility of persistent but inconspicuous residual disease versus true recurrences. All patients with local failure received salvage chemotherapy, with one also receiving RT and another undergoing neck dissection.ConclusionsIMRT with SIB technique for HNSCC can achieve high rates of locoregional control and does not seem to portend a tendency for geographic miss. The predominant centrally-located failure pattern calls for further need of dose escalation. Precise anatomic delineation as well as judicial use of fractionation scheme for the PTV design is critical when utilizing SIB technique. Purpose/Objective(s)By emphasizing precise target volume delineation, highly conformal radiation treatment using intensity-modulated radiation therapy (IMRT) may shift the location of local disease relapse from centrally within the tumor bulk to the periphery. This study aims to evaluate patterns of local failure specifically among patients with locally-advanced head and neck squamous cells carcinoma (HNSCC) treated with IMRT and simultaneous integrated boost (SIB) technique. By emphasizing precise target volume delineation, highly conformal radiation treatment using intensity-modulated radiation therapy (IMRT) may shift the location of local disease relapse from centrally within the tumor bulk to the periphery. This study aims to evaluate patterns of local failure specifically among patients with locally-advanced head and neck squamous cells carcinoma (HNSCC) treated with IMRT and simultaneous integrated boost (SIB) technique. Materials/MethodsThe records of 24 patients presenting with primary HNSCC and treated at UCLA from July 2007 through October 2008 were reviewed. The study population included: 16 male (67%), 8 female (33%), 4 stage II (17%), 4 stage III (17%) and 16 stage IV (67%). The primary tumor sites were: oropharynx in 11 patients, larynx 4, nasopharynx 3, hypopharynx 2, oral cavity 2, paranasal sinus 1, and unknown in 1 patient. Twenty of the 24 patients (83%) received definitive RT, while the remaining 4 were treated post-operatively. Twenty-one (88%) patients received chemotherapy during the RT course. Median prescription doses for planning target volume (PTV) levels 1, 2 and 3 were 69.3 Gy, 62.7 Gy and 56.1 Gy, respectively, given simultaneously over 33 fractions. The records of 24 patients presenting with primary HNSCC and treated at UCLA from July 2007 through October 2008 were reviewed. The study population included: 16 male (67%), 8 female (33%), 4 stage II (17%), 4 stage III (17%) and 16 stage IV (67%). The primary tumor sites were: oropharynx in 11 patients, larynx 4, nasopharynx 3, hypopharynx 2, oral cavity 2, paranasal sinus 1, and unknown in 1 patient. Twenty of the 24 patients (83%) received definitive RT, while the remaining 4 were treated post-operatively. Twenty-one (88%) patients received chemotherapy during the RT course. Median prescription doses for planning target volume (PTV) levels 1, 2 and 3 were 69.3 Gy, 62.7 Gy and 56.1 Gy, respectively, given simultaneously over 33 fractions. ResultsThe median follow-up duration was 22.4 months (range: 7.9 - 36.6). Disease-specific and overall survival rates at 3 years were 100%. The actuarial local control probability was 83% at 3 years. Four (17%) patients failed to achieve local control of their disease, with 3 having oropharynx and one having hypopharynx primary. All 4 recurrent tumors were detected by either imaging (2) or biopsy (2), and occurred within the planning target volumes, not outside or at the periphery. The median time from the end of RT to recurrence was only 4.8 months (range: 4.1 - 5.2), raising the possibility of persistent but inconspicuous residual disease versus true recurrences. All patients with local failure received salvage chemotherapy, with one also receiving RT and another undergoing neck dissection. The median follow-up duration was 22.4 months (range: 7.9 - 36.6). Disease-specific and overall survival rates at 3 years were 100%. The actuarial local control probability was 83% at 3 years. Four (17%) patients failed to achieve local control of their disease, with 3 having oropharynx and one having hypopharynx primary. All 4 recurrent tumors were detected by either imaging (2) or biopsy (2), and occurred within the planning target volumes, not outside or at the periphery. The median time from the end of RT to recurrence was only 4.8 months (range: 4.1 - 5.2), raising the possibility of persistent but inconspicuous residual disease versus true recurrences. All patients with local failure received salvage chemotherapy, with one also receiving RT and another undergoing neck dissection. ConclusionsIMRT with SIB technique for HNSCC can achieve high rates of locoregional control and does not seem to portend a tendency for geographic miss. The predominant centrally-located failure pattern calls for further need of dose escalation. Precise anatomic delineation as well as judicial use of fractionation scheme for the PTV design is critical when utilizing SIB technique. IMRT with SIB technique for HNSCC can achieve high rates of locoregional control and does not seem to portend a tendency for geographic miss. The predominant centrally-located failure pattern calls for further need of dose escalation. Precise anatomic delineation as well as judicial use of fractionation scheme for the PTV design is critical when utilizing SIB technique.

Purpose/Objective(s)The purpose of this study was to identify patient and treatment characteristics predictive of non-compliance with radiotherapy among West Los Angeles Veterans Affairs Hospital (WLAVA) patients treated for squamous cell carcinoma of the head and neck (SCCHN.) The secondary purpose was to examine the effect of missed days of radiotherapy on the survival of these patients.Materials/MethodsPatients treated with radiotherapy with curative intent for SCCHN from 2000 to 2005 were retrospectively identified. Data collected for each patient included gender, ethnicity, KPS, age, stage, smoking status, alcohol use, other substance abuse, cohabitation status, presence of a psychiatric diagnosis, distance from home to hospital, type of lodging during treatment, use of IMRT, use of chemotherapy, and primary versus adjuvant therapy. Non-compliance was measured in number of days of radiotherapy missed, excluding holidays and technical malfunction. Multivariate analysis was performed using patient variables to identify predictors of non-compliance, as well as overall survival.Results109 patients were identified as meeting the inclusion criteria. 106 patients had sufficient documentation for complete data collection and analysis. The median number of radiotherapy days missed was two. Patient variables of low KPS, advanced stage, and short distance of the patient's primary address to the hospital were identified by a stepwise multiple logistic regression analysis as predictive of missing greater than two treatment days, with performance measured by area under the ROC curve 0.73 (95% confidence interval 0.64–0.83.) Of these 106 patients, 59 were treated at least two years prior to analysis, all of whom had survival follow-up data, and these patients were included in survival analysis. Patient variables of smoking cessation, high KPS, and young age were identified as predictive of survival at 2 years, with performance measured by area under the ROC curve 0.82 (95% confidence interval 0.72–0.93.) In a supplementary analysis, non-compliance was associated with decreased survival at 2 years.ConclusionsPatient variables of low KPS, advanced stage, and short distance from home were associated with an increased likelihood of non-compliance in patients with SCCHN treated with radiotherapy at the WLAVA. These findings are especially relevant given the large proportion of WLAVA patients referred for radiotherapy from outside facilities, who have a primary address that is a long distance from the hospital. Purpose/Objective(s)The purpose of this study was to identify patient and treatment characteristics predictive of non-compliance with radiotherapy among West Los Angeles Veterans Affairs Hospital (WLAVA) patients treated for squamous cell carcinoma of the head and neck (SCCHN.) The secondary purpose was to examine the effect of missed days of radiotherapy on the survival of these patients. The purpose of this study was to identify patient and treatment characteristics predictive of non-compliance with radiotherapy among West Los Angeles Veterans Affairs Hospital (WLAVA) patients treated for squamous cell carcinoma of the head and neck (SCCHN.) The secondary purpose was to examine the effect of missed days of radiotherapy on the survival of these patients. Materials/MethodsPatients treated with radiotherapy with curative intent for SCCHN from 2000 to 2005 were retrospectively identified. Data collected for each patient included gender, ethnicity, KPS, age, stage, smoking status, alcohol use, other substance abuse, cohabitation status, presence of a psychiatric diagnosis, distance from home to hospital, type of lodging during treatment, use of IMRT, use of chemotherapy, and primary versus adjuvant therapy. Non-compliance was measured in number of days of radiotherapy missed, excluding holidays and technical malfunction. Multivariate analysis was performed using patient variables to identify predictors of non-compliance, as well as overall survival. Patients treated with radiotherapy with curative intent for SCCHN from 2000 to 2005 were retrospectively identified. Data collected for each patient included gender, ethnicity, KPS, age, stage, smoking status, alcohol use, other substance abuse, cohabitation status, presence of a psychiatric diagnosis, distance from home to hospital, type of lodging during treatment, use of IMRT, use of chemotherapy, and primary versus adjuvant therapy. Non-compliance was measured in number of days of radiotherapy missed, excluding holidays and technical malfunction. Multivariate analysis was performed using patient variables to identify predictors of non-compliance, as well as overall survival. Results109 patients were identified as meeting the inclusion criteria. 106 patients had sufficient documentation for complete data collection and analysis. The median number of radiotherapy days missed was two. Patient variables of low KPS, advanced stage, and short distance of the patient's primary address to the hospital were identified by a stepwise multiple logistic regression analysis as predictive of missing greater than two treatment days, with performance measured by area under the ROC curve 0.73 (95% confidence interval 0.64–0.83.) Of these 106 patients, 59 were treated at least two years prior to analysis, all of whom had survival follow-up data, and these patients were included in survival analysis. Patient variables of smoking cessation, high KPS, and young age were identified as predictive of survival at 2 years, with performance measured by area under the ROC curve 0.82 (95% confidence interval 0.72–0.93.) In a supplementary analysis, non-compliance was associated with decreased survival at 2 years. 109 patients were identified as meeting the inclusion criteria. 106 patients had sufficient documentation for complete data collection and analysis. The median number of radiotherapy days missed was two. Patient variables of low KPS, advanced stage, and short distance of the patient's primary address to the hospital were identified by a stepwise multiple logistic regression analysis as predictive of missing greater than two treatment days, with performance measured by area under the ROC curve 0.73 (95% confidence interval 0.64–0.83.) Of these 106 patients, 59 were treated at least two years prior to analysis, all of whom had survival follow-up data, and these patients were included in survival analysis. Patient variables of smoking cessation, high KPS, and young age were identified as predictive of survival at 2 years, with performance measured by area under the ROC curve 0.82 (95% confidence interval 0.72–0.93.) In a supplementary analysis, non-compliance was associated with decreased survival at 2 years. ConclusionsPatient variables of low KPS, advanced stage, and short distance from home were associated with an increased likelihood of non-compliance in patients with SCCHN treated with radiotherapy at the WLAVA. These findings are especially relevant given the large proportion of WLAVA patients referred for radiotherapy from outside facilities, who have a primary address that is a long distance from the hospital. Patient variables of low KPS, advanced stage, and short distance from home were associated with an increased likelihood of non-compliance in patients with SCCHN treated with radiotherapy at the WLAVA. These findings are especially relevant given the large proportion of WLAVA patients referred for radiotherapy from outside facilities, who have a primary address that is a long distance from the hospital.

Chemoradiation is increasingly becoming the standard of care for node-positive squamous cell cancer of the head and neck. Response to chemoradiation for clinically node-positive disease in the neck is often difficult to ascertain because clinical response may or may not be predictive of pathological response. This often leads to uncertainty about the necessity of a functional neck dissection after chemoradiation. In this study, we retrospectively analyzed a cohort of node-positive patients to examine pathological response as well as clinical outcome after chemoradiation with or without functional neck dissection.METHODS Using the radiation oncology records from 1993 until 2003, a population of 420 patients with squamous cell cancer of the head and neck were identified. Of these, 34 patients were clinically node positive at,the time of diagnosis and underwent chemoradiation as their primary therapy. All patients received a concurrent platinum-based regimen. Median radiation dose to gross neck disease was 68.4 Gy (range: 50.4-73.8 Gy).RESULTS Median follow-up time was 25 months (range: 4-88 months). Patients with a complete response (17/34, 50%) after receiving 50 Gy finished the full course of therapy but did not undergo functional neck dissection. Only one patient (1/17) in this observation group experienced relapse in the neck. Patients with a partial response who received 50 Gy (17/34) completed therapy and underwent functional neck dissection, regardless of response at the end of therapy. Fifty percent (3/6) with positive pathology had a regional relapse in the neck. whereas on, 1/11 patients with negative pathology relapsed in the neck. T his result compared favorably with those who were observed after chemoradiation.CONCLUSIONS Clinical response at 50 Gy can be an effective means of selecting patients for functional neck dissection. Patients with complete response at 50 Gy may be observed with a low regional recurrence rate. Those patients with a partial response should undergo adjuvant neck dissection.

PURPOSE:The purpose of this study was to understand the natural history and progression of sinonasal undifferentiated carcinoma (SNUC) to establish optimal management guidelines. Methods and materials We analyzed 8 consecutively treated patients diagnosed with SNUC between 1995 and 2002 at UCLA Medical Center. Staging was classified by the Kadish System with 7 patients presenting at stage C and 1 patient with stage B disease. Five patients received surgery. Four of these 5 patients received adjuvant radiotherapy, with 2 patients receiving it concurrently with chemotherapy (cisplatinum/5-fluorouracil). One patient received surgery alone as definitive management. Of the remaining 3 patients who did not receive surgical treatment, concurrent chemotherapy and radiation was used.RESULTS:At last follow-up, 6 of the 8 patients were still alive (overall survival 75%) with mean survival time of 20.6 months. However, only 2 of the 6 were alive and free of disease (disease-free survival 25%) with a mean disease-free survival time of 12.3 months. Locoregional recurrence occurred in 5 of the 8 patients (63%). Time to recurrence ranged from 3 to 30 months. Distant metastasis presented in 4 of the 8 patients (50%), all with disease spread to bone. Two of the 4 patients with distant metastasis were found to have locoregional disease recurrence at the same time. Time to metastasis ranged from 2 to 30 months. Results also show that the 5 patients who received surgery are still alive with a mean survival time of 23 months at last follow-up. Meanwhile, 1 of the 3 patients who received no surgical therapy is alive, with a mean survival time of 16.7 months in this group.CONCLUSIONS:SNUC has proven to have a poor prognosis. Although limited by small numbers, this study along with reported series in the past appear to suggest longer survival results with aggressive multimodality therapy, especially with the incorporation of complete surgical resection.

The role of adjuvant external-beam radiation therapy (EBRT) in well-differentiated thyroid cancer is not well delineated. Many clinicians rely solely on iodine 131 (131I) to destroy thyroid remnants following thyroidectomy. However, the lesser uptake of isotope in tumor cells suggests that 131I alone may not be sufficient to eradicate microscopic residual disease when no gross thyroid tissue remains. We conducted a retrospective study to examine the potential benefit of adjuvant EBRT in patients at high risk for microscopic residual disease following thyroidectomy. Between 1973 and 2001, 44 patients with well-differentiated papillary or follicular thyroid cancer were found to have extracapsular extension following thyroidectomy. These patients were divided into 2 groups based on the type of treatment; 11 patients had received adjuvant EBRT (with or without 131I) and 33 patients had not received EBRT (i.e., they received adjuvant 131I only). We reviewed their medical records and compiled data on local recurrence and overall survival (Kaplan-Meier analysis). Despite having a less favorable prognosis, the EBRT group experienced no local recurrences during a mean follow-up of 7.8 years; in contrast, 9 local recurrences were seen in the no-EBRT group. Also, the median survival for patients without a local recurrence was longer than that for those who had failed locally (425 vs. 317 mo). Although our population was not large enough for these differences to achieve statistical significance, our study did show that adjuvant EBRT provided excellent results. We hypothesize that a reciprocal irradiation effect between cancer cells and normal cells may be necessary in order for 131I to be tumoricidal. If so, a patient with microscopic residual disease would not have enough cancer cells to sufficiently concentrate 131I. Because EBRT does not depend on such a mechanism, it may be more effective than 131I in controlling disease in the setting of microscopic disease. Larger studies are needed to validate our results. In the meantime, we believe that adjuvant EBRT should play an important role in the treatment of patients with high-risk well-differentiated thyroid cancer.

Purpose: To determine the long term results of conservative therapy for invasive lobular carcinoma of the breast. Methods: From 1976 to 1993, 271 patients with the diagnosis of stage I or II infiltrating lobular carcinoma of the breast received breast conservative surgery and radiation therapy at our institution. 135 patients were excluded from this study (81 patients were excluded because of mixed ductal and lobular histology, 54 patients were excluded because of less than 8 years of follow-up). The study population is comprised of 136 patients who had more than 8 years of post-treatment follow-up. End points for this study include locoregional recurrence, disease-free survival, and overall survival. A comprehensive list of clinical and pathologic features was evaluated for all patients. Results: With a median follow-up of 13 years, the actuarial locoregional recurrence at 5, 8, and 12 years are 3%, 8%, and 20%, respectively. Close or positive surgical margins was the only clinicopahtologic factor found to significantly correlate with local recurrence. Salvage therapy was effective in establishing local regional control in 92% of recurrences. Disease-free survival and overall survival at 5, 8, and 12 years were 90%, 84%, 71% and 92%, 87%, and 79%, respectively. The 13 year crude contralateral breast cancer rate was 3%. Conclusion: To our knowledge, there have been few reports concerning the long term results of conservative therapy for invasive lobular carcinoma. Our findings indicate similar local regional control rates at 5 and 7 years as has been previously reported. However, in comparison to invasive ductal carcinoma, the rate of local regional relapse for invasive lobular carcinoma appears to continue to rise even after 10 years of follow-up. This may indicate a more indolent disease course or possibly new primaries. This increase in local events did not translate into a decrease in long term survial. Salvage therapy was effective in establishing local regional control in the majority of recurrences resulting in long-term survival similar to published data for invasive ductal carcinoma. This long term study suggest that breast conservation therapy is an appropriate treatment for this type of cancer when careful attention is paid to margin status. In addition, our analysis also emphasizes the importance of long term surveillance in the management of invasive lobular carcinoma.

PURPOSE To evaluate the utility of positron emission tomography (PET) fluorodeoxyglucose (FDG) imaging in the workup of unknown primary head and neck tumors. METHODS Fourteen patients with squamous cell carcinoma of cervical lymph node metastasis of unknown primary origin (clinical stage N2-N3) were studied prospectively. The patients underwent conventional workup, including physical examination, computed tomography, and random biopsies of the potentially suspected sites. If no primary site was found, 8 to 13 mCi of FDG was given intravenously, and whole-body scans with standardized uptake values were obtained. The results of FDG-PET imaging were compared with clinical, CT, and histopathologic findings. To eliminate bias, PET scans were reviewed by nuclear medicine physicians who had no previous knowledge of the other findings. RESULTS PET identified the location of primary tumor in three patients: lung hilum, base of tongue, and pyriform sinus. These lesions were pathologically confirmed. All these primary sites were not visualized on CT or physical examination, except for a pyriform sinus lesion, which was seen on CT, but initial biopsy result was negative. In one patient, the initial PET did not identify a primary tumor, but a nasopharyngeal carcinoma was identified in post-radiation therapy follow-up PET. In the remaining nine patients, a primary lesion was never found. All cervical lymph nodes detected by CT were identified by PET. DISCUSSION A previously unknown primary tumor can be identified with FDG-PET in about 21% of the patients in our prospective series. PET can be of value in guiding endoscopic biopsies for histologic diagnosis and treatment options.

Purpose: Desmoid tumors have a high propensity for local recurrence with surgical resection. There are many reports describing good responses of desmoid tumors to irradiation, but none have clearly established the indications for adjuvant radiotherapy in treating resectable desmoid tumors.Methods and Materials: A retrospective analysis was performed on 61 patients with resectable desmoid tumor(s) who were treated at our institution from 1965 to February of 1992. Five patients had multifocal disease and are analyzed separately. Fifty-six patients had unifocal disease, of which 34 had positive surgical margins. Forty-five of the 56 patients with unifocal disease were treated with surgery alone, while 11 were treated with surgery plus adjuvant radiotherapy. Median follow-up was 6 years. Local control was measured from the last day of treatment, and all cases were reviewed by our Department of Pathology.Results: Multivariate analysis of the 56 patients with unifocal disease revealed that positive margins independently predicted for local recurrence (p less than or equal to 0.01). Only 3 of 22 patients with clear margins experienced a local recurrence, with a 6-year actuarial local control of 85%. Multivariate analysis of the 34 patients with positive margins revealed that adjuvant radiotherapy independently predicted for improved local control (p = 0.01), and patients with recurrent disease had a slightly higher risk of local recurrence (p = 0.08). The 6-year actuarial local control determined by Kaplan-Meier for patients with unifocal disease and positive margins was 32% (+/- 12%) with surgery alone, and 78% (+/- 14%) with surgery plus adjuvant radiotherapy (p = 0.02). Subgroup analysis of the patients with positive margins and recurrent disease revealed that those treated with surgery alone had a 6-year actuarial local control of 0% vs. 80% for those treated with surgery plus radiotherapy (p less than or equal to 0.01). Patients with positive margins and primary disease had a trend towards improved local control with adjuvant radiotherapy, but this was not statistically significant. None of the patients treated with radiotherapy developed serious complications or a secondary malignancy.Conclusions: Margin status is the most important predictor of local recurrence for patients with resectable, unifocal desmoid tumor. Adjuvant radiotherapy is indicated in the treatment of patients with positive margins following wide excision of recurrent disease. The role of adjuvant radiotherapy in patients with positive margins following resection of primary disease is controversial, and should be based on a balanced discussion of the potential morbidity from radiotherapy compared to the potential morbidity of another local recurrence. Adjuvant radiotherapy is less likely to benefit those with clear margins due to the excellent results for these patients treated with surgery alone. The local control of desmoid tumor in the adjuvant setting is excellent with total doses ranging from 50-60 Gy, with acceptable morbidity. Field sizes should be generous to prevent marginal recurrences, and large volume MRIs of patients with extremity lesions should be used to identify those patients with multifocal disease. (C) 1997 Elsevier Science Inc.

Positron emission tomography (PET) is a biochemical-imaging tool that uses the uptake of the glucose analog 2-deoxy-2-[F-18] fluoro-D-glucose (FDG) to detect head and neck tumor proliferation. The aim of this study is to determine if quantitation of either primary tumor metabolic activity or tumor response using PET scans could predict local control and overall survival in patients with head and neck cancer undergoing primary radiotherapy. Twelve patients with squamous cell carcinomas of the head and neck underwent PET scans before and 6 weeks after completion of radiation therapy. Tumor metabolic activity was quantitated using the metabolic ratio method. Mean follow-up was 40 months (range: 18-55 months). In our series, tumors with metabolic rates greater than that of the cerebellum are associated with significantly better local control (p < 0.05) and survival. Posttreatment PET imaging was falsely positive in one patient with clinical signs of severe inflammation. Tumors with greater than 50% decrease in metabolic activity with irradiation had improved local control. Clinically, nine patients had excellent response to irradiation. These results suggest that pretreatment PET findings may have prognostic implications in determining which patients will achieve long-term local control with primary radiation therapy. This may help identify those at increased risk of recurrence that may benefit from more aggressive altered fractionation schemes or combined modality therapy.

The purpose of this study was to determine the frequency and severity of complications following pelvic irradiation in elderly women with gynecologic malignancies. A retrospective analysis was conducted of the 60 women over 65 years of age treated with pelvic radiation therapy for cervical (26), endometrial (31) or proximal vaginal (3) cancer at the UCLA Medical Center between 1978 and 1991. Acute grade 3 to 4 gastrointestinal (GI) complications, using Gynecologic Oncology Group (GOG) criteria occured in three of 60 patients (5%). Chronic complications occured in 28 of 49 patients (57%) followed for longer than 3 months after radiation therapy. The 3-year actuarial rate of chonic GI and/or genitourinary (GU) complications was 63% for any grade and 24% for grades 2, 3 or 4. Twelve of the 14 grade 2-4 chronic complications were GI. The 3-year actuarial chronic complication rate was 45% for GI compared to 17% for GU (P=0.01). The median time to occurrence for GI and GU chronic complications was 8 and 19 months, respectively. In multivariate analysis, two or more pre-existing medical problems (P=0.03) and dose of external beam radiation therapy greater than or equal to 45 Gy (P=0.07) were associated with the development of a chronic complication. We conclude that moderate to severe intestinal complications are common after pelvic irradiation of elderly women, particularly those with two or more pre-existing medical problems. Pelvic radiation therapy should be used judiciously in elderly women.

Patients with advanced malignancies who received intralymphatic injections of irradiated tumor cell suspensions (''vaccines'') were unexpectedly found to be resistant to common viral diseases; 17 patients with a documented past history of viral infections who have been observed for 48 to 148 months (median 108 months), were analyzed. The resistance to viruses was found to correlate closely with the presence, in the serum, of certain cytokines. Specifically, the interleukins, -2, -6, -8 and interferon-gamma, at low but sustained levels appeared to be possibly responsible for the nonspecific protection against viral infections obtained by intralymphatic injections of cellular material. These findings suggest that viral infections in normal or immunosuppressed individuals at particular risk might be prevented by treatments aimed at attaining very modest levels of certain cytokines.

The management for mucosal melanoma of the head and neck is controversial in view of the poor prognosis. Thirty-five patients seen from 1955 to 1991 were analyzed retrospectively. Almost all (34/35) presented with localized disease. Primary treatments included radical surgery (15), local resection (11), radiation therapy (6), or systemic treatment (2). While the rate of local recurrence was high (27/34), only 5 patients developed distant disease before local relapse. Furthermore, only 5/21 achieved successful local salvage. Patients with their disease controlled locally had significantly longer survival than those with persistent local disease (P = .0001). The 5-year disease-specific survival was 45%. The authors conclude that mucosal melanoma of the head and neck is not necessarily incurable. When local control is achieved, survival rate is significantly improved. Aggressive local treatments should be initiated at presentation of this disease.

Nasopharyngeal carcinoma recurrent following primary radiation therapy has been treated with surgery and reirradiation. Reirradiation is often limited by the tolerance of structures previously treated. Radiosurgery was used to boost the recurrent site while avoiding critical structures. Seven patients were evaluated for treatment. Three patients met requirements for treatment. The lesions invaded the parapharyngeal region, the base of skull, cavernous sinus, cranial nerves, or carotid artery. Treatment included a radiosurgery boost utilizing multiple isocenters, noncoplanar arcs, and arc weighting, to yield a plan conforming to the tumors while avoiding critical anatomical structures. The patients tolerated the procedure well with minor acute side effects. Follow-up included magnetic resonance imaging (MRI) and positron emission tomography (PET). Two lesions responded, and one had no significant change. One patient had a regional recurrence. Two patients had distance recurrence. Long term side effects include trismus, parotiditis, ear fullness, hemorrhage, and pain. Radiosurgery may improve the local control rate of such lesions, however, with the severe long term complications of single fraction radiosurgery in the head and neck region this procedure may be more beneficial if the treatment is fractionated.

Objective: To examine the effect of microscopic tumor at the margins on local recurrence after breast-conserving surgery for invasive carcinoma.Design: Retrospective review of patients treated with surgical resection followed by radiation therapy.Setting: A university-based radiation department and a community-based cancer referral center.Patients: A consecutive series of 272 women treated between 1982 and 1990.Main Outcome Measure: Local recurrence according to the histopathologic status of excised margins and the total dose of radiation.Results: During a mean follow-up period of 48 months, the overall rate of local recurrence was 6.3%. Local recurrence was more frequent (P=.0001) in patients with histologically positive margins (18.2%) than in those with unknown margins (7.1%) or negative margins (3.7%). In the 44 patients with positive margins, the local recurrence rate was 8.3% after radiation doses of 66 Gy or more compared with 21.9% following lower doses.Conclusions: Microscopic involvement of resection margins increases the risk of local recurrence following breast-conserving surgery for invasive carcinoma. Therefore, every effort should be made to achieve negative margins intraoperatively.

Background. The purpose of this study was to evaluate the utility of positron emission tomography- (PET) 2[F-18]-fluoro-2-deoxy-D-glucose (FDG) imaging in extracranial head and neck cancers.Methods. Sixty patients with biopsy-proven cancers were studied using PET-FDG. Thirty-four patients were studied before therapy (staging), of which 15 patients received primary radiotherapy and serial PET-FDG imaging (monitoring). Seven patients with advanced disease had laser excision (monitoring), and 19 patients were evaluated for recurrent disease (recurrence).Results. Four patients had unknown primary lesions. PET-FDG imaging located the primary tumor in two of four patients, and magnetic resonance imaging (MRI) in none of four. In the remaining patients (staging), PETFDG imaging detected the primary tumor in 29 of 30 patients, and MRI in 23 of 30. In the staging group, PET-FDG imaging identified the presence or absence of lymph node involvement in 32 of 34 patients, and MRI in 31 of 34.PET-FDG imaging was helpful in evaluating tumor response to radiation therapy or laser excision.Ten patients evaluated for recurrent disease had biopsy-confirmed recurrences, and 7 had no recurrence. PET-FDG imaging results were positive for primary tumor recurrence in 9 of 10 patients, and MRI results were positive in 6 of 10. MRI results were negative for lymph node disease in one of these patients with recurrent primary tumor where PET-FDG imaging and biopsy demonstrated nodal involvement. PET-FDG results were negative for recurrent disease in seven of seven patients, and MRI results were negative for recurrent disease in in four of seven.Conclusion. In this series, the authors found that PET-FDG is a useful diagnostic modality for evaluating the patient with an unknown primary, monitoring response to therapy, and in detecting recurrent tumors.

Background. Desmoplastic malignant melanoma (DMM) is a rare variant of malignant melanoma with high local recurrence rate after surgical excision. We performed a retrospective review to address the role of radiation therapy in local control of this tumor.Methods. Between 1976 and 1997, 44 patients with the pathologic diagnosis of DMM were registered at our tumor registry. Fourteen patients received postoperative RT, and one patient received preoperative RT. Three of the irradiated lesions had gross residual or positive surgical margins. Doses ranged from 44 to 66 Gy.Results. Sixty-eight percent of DMM lesions occurred in the head and neck region. Forty-eight percent (21 of 44) of patients experienced a local recurrence after initial excision (mean time to recurrence, 12 months). Local failure in head and neck was 46% (14 of 30). Clark level, primary site, and neurotropism did not predict local recurrence; the Clark level predicted distant metastasis. No viable tumor was found in the surgical specimen of the patient who received preoperative FIT. None of 15 patients who received adjuvant irradiation had any additional recurrences (mean follow-up, 64.7 months). By contrast, four of seven patients with history of recurrence who did not receive FIT had local relapse (p =.005). The incidence of distant metastasis did not reach statistical significance between the irradiated and nonirradiated groups.Conclusions. The high rate of local recurrence of DMM after surgical resection is dramatically reduced by adjuvant radiation therapy. We recommend adjuvant postoperative radiation therapy as a part of treatment of DMM. (C) 2003 Wiley Periodicals, Inc.

Earlier literature suggests a high incidence of multicentricity and bilaterality, with an overall poor prognosis, in patients with invasive lobular carcinoma of the breast. Consequently, there is considerable disagreement regarding appropriate local management of this disease. To determine the influence of invasive lobular histologic findings on local tumor control, disease-free survival, and overall survival, the authors reviewed 60 patients with Stage I and II invasive lobular breast carcinoma treated with local tumor excision and radiation therapy between 1981 and 1987 (mean follow-up, 5.5 years; range, 2.5 to 10 years). The 5-year actuarial risk of locoregional recurrence was 5%, with two of three failures occurring in the regional lymphatics. The mean time to locoregional failure was 28 months. The 5-year actuarial disease-free survival (84%) and overall survival (91%) were comparable to those seen in several large series of similarly treated patients with invasive ductal carcinoma. Contralateral breast cancer occurred at a rate of approximately 0.6% per year. This study and a review of the literature suggest that breast conservation, with local resection and radiation therapy, is appropriate therapy for invasive lobular breast cancer.

Introduction: This study was undertaken to elucidate the efficacy of external beam irradiation in the treatment of head and neck malignant melanoma, in comparison with the efficacy of surgical excision and the efficacy of surgical excision combined with external beam irradiation.