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While surgery (with or without radioactive iodine (RAI)) is the mainstay of locoregional control in differentiated thyroid cancer (DTC), patients with unresectable disease present a clinical challenge. Uncontrolled disease in the neck can lead to substantial morbidity and mortality in DTC and obtaining locoregional control is vital to preserving quality of life and longevity. High dose definitive radiotherapy (RT) for gross disease in DTC is understudied. This study examines the efficacy of definitive RT in this setting. From an IRB-approved registry of head and neck cancer cases treated at a tertiary care center over a period of 8 years (2014-2022), patients with incompletely resected or unresectable DTC including papillary, follicular, mixed, medullary, and poorly differentiated types were identified. All patients were treated to the neck and/or thyroid regions with visible gross disease to a definitive dose of radiation. The primary endpoint was local control within the radiated portal with a secondary endpoint of locoregional control within the neck. A total of 31 patients were identified, of whom 74.2% were Caucasian. Fourteen were female (45.2%), and 17 (54.8%) were male. The median age was 68 years (range 26-90) and the median follow-up was 31 months. Histologically, 19 (61.3%) cases were papillary, 4 (12.9%) were follicular, 2 (6.5%) were mixed, 3 (9.7%) were medullary, and 3 (9.7%) were poorly differentiated. Among patients with non-medullary DTC 18 (69.2%) received prior RAI. Twelve patients were treated with radiation at initial diagnosis, while 19 patients were treated at the time of recurrence; two patients received concurrent chemotherapy. Twenty-eight patients (90.3%) were treated with IMRT and 3 (9.7%) were treated with SBRT. The median dose to the gross disease was 66 Gy (range 30-70.4) in 32 fractions (range 5-35). Overall, 5 patients (16.1%) experienced a locoregional failure after RT and all experienced failure in the RT portal. The actuarial infield control/locoregional control of radiation therapy at 3 and 5 years was 84.8% and 74.2%, respectively. Overall survival at 3 and 5 years was 68.5% and 47.4%, respectively. Among patients who had a locoregional failure after RT, 2 patients were salvaged with systemic therapy, 2 patients with surgery, and 1 patient with SBRT re-irradiation (40 Gy/5 fractions). The patient salvaged with SBRT remains without disease 8 months post-RT. Definitive radiotherapy is a highly effective strategy to obtain durable control of unresected DTC. It should be standard for unresected disease and considered as a viable alternative for patients with borderline resectable disease for whom resection would be highly morbid. [ABSTRACT FROM AUTHOR]

Treatment of oropharyngeal cancer with definitive radiation/chemoradiation (RT/CRT) is an effective treatment and rapid regression of tumor can occur. Following treatment some patients will develop a pharyngeal ulcer which may or may not be associated with disease persistence. Data for the management of ulcers could improve post radiation care. From an IRB approved database of head and neck cancer cases at a tertiary care center, we reviewed patients with non-metastatic squamous cell carcinoma of the oropharynx treated curatively in non-operative fashion with RT/CRT between 1/1/2011 and 1/1/2022. Patients were reviewed for clinical, radiographic and laryngoscopic evidence of pharyngeal ulcer development following completion of radiation. Pharyngeal ulcer patients were evaluated for management strategy of the ulcer and associated complications and association with recurrence. A total of 45 patients with a pharyngeal ulceration following RT/CRT with a median follow up of 30.8 months were identified. The median age of patients was 60 (range 35-82) years, 80% of patients were caucasian, 82% were male, and 42% of patients were active smokers at the time of RT/CRT. 75% of patients had p16/HPV+ disease with T stages of T1/2, T3 and T4 of 44, 20 and 36% respectively. 93% of patients were treated with concurrent chemotherapy (74% cisplatin) to a median dose of 70 Gy (range 60-74 Gy). The median time to development of ulcer was 3.1 months (range 0.2-31.4 months). 19 patients (42%) underwent biopsy of their ulcer of whom 9 (47%) where found to have disease persistence. Ultimately thirteen patients (29%) had associated tumor persistence. Among the 32 patients with ulcer not associated with recurrence, 28 (87.5%) were p16/HPV+ and 90.6% has received chemotherapy. 3 ulcers (9.4%) were associated with exposed bone. Treatment of ulcers revealed 15 (46%) received antibiotics, 23 (72%) needed narcotics and 5 (16%) required feeding tube placement for pharyngeal rest. Three patients (9.4%) required surgical reconstruction to facilitate resolution. Overall, at time of last follow up 28 (88%) of ulcers not associated cancer had resolved with a median time to resolution of 3.6 months (range 1.3-75.2) months. The overall survival of the non-malignant ulcer group was 83% at 3 years compared to 28% in the patients with ulcers associated with persistent cancer. Pharyngeal ulceration is a significant potential complication of RT/CRT in oropharyngeal cancer. Ulceration is frequently identified around 3 months post treatment and when not associated with disease persistence has a high rate of resolution with conservative measures including antibiotics and pain control. Severe case may necessitate feeding tube and rarely surgical reconstruction. [ABSTRACT FROM AUTHOR]

Due to a lack of internal barriers, many radiation oncologists believe whole tongue (WT) irradiation is warranted in the adjuvant setting for oral tongue cancer. Our institutional practice is to include the resection bed and flap with a 5-10 mm margin, attempting to spare unaffected oral tongue. We hypothesize that partial tongue (PT) irradiation, when feasible, results in decreased dose to surrounding normal structures without an increased risk of local recurrence (LR). Patients with a new diagnosis of squamous cell carcinoma of the oral tongue treated with adjuvant IMRT between 2010 and 2021 were collected from an IRB approved database. PT was defined as <80% of residual tongue in the clinical target volume (CTV). Recurrence was deemed local if in the tongue or floor of mouth, and in field if within the CTV or marginal if outside of CTV. Mean dose to mandible, pharyngeal constrictors, and oral cavity were evaluated. Comparisons between groups were made using parametric one-way ANOVA. Multivariable linear regression was used to predict mean radiation dose. Local control and overall survival were estimated using Kaplan-Meier. A total of 130 patients are included with median follow up 34.1 months (IQR 13.5-64.6). Radiation dose was 48-72 Gy in 24-36 fractions, most commonly 60-66 Gy in 30-33 fractions (84.6%). All were treated to oral cavity, and neck irradiation included bilateral 96 (72%), unilateral 31 (24%), and none 3 (4%). PT sparing was feasible in 91 (70%) and 39 (30%) required WT. Primary tumor stage in PT included 20 pT1, 50 pT2, 17 pT3, and 4 pT4, and WT included 3 pT1, 8 pT2, 15 pT3, and 13 pT4. 3-year local control for PT and WT was 96% and 87%, respectively. LR occurred in 14 patients overall (10.8%), 6.6% (6) of patients treated with PT and 20.5% (8) treated with WT (p = 0.072). Of the LR for PT, stage was 2 pT1, 3 pT2, and 1 pT3, and all occurred within the radiation field. Of the LR for WT, stage was 1 each of pT1 and pT2, 2 pT3, and 4 pT4. Overall survival was 57%, regional and distant recurrence was each 17.7%. Dosimetric analysis for PT vs WT is described in Table 1, demonstrating lower mean dose when the primary tumor CTV is limited to PT. Unilateral neck irradiation also resulted in a lower mandible [-8.5 Gy (-11.2 – -5.8)], pharyngeal constrictor [-14.3 Gy (-18.1 – -10.5)], and oral cavity [-9.0 Gy (-13.0 – -5.0)] dose (all p<0.001). Limiting the primary tumor CTV to PT for adjuvant radiotherapy resulted in significant sparing of the mandible and pharyngeal constrictors, and a routinely lower oral cavity mean dose of ≥3.5 Gy. There was a low risk of LR when implementing PT, and all LR occurred in field. Given the increased sparing of normal structures, and low risk of LR outside of PT radiation field, sparing a portion of unaffected oral tongue should be considered. [ABSTRACT FROM AUTHOR]