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Summary Objectives To report the results of a standardized program using positron emission tomography (PET)–computed tomography (CT) approximately 12 weeks after primary radiotherapy to determine the need for a planned neck dissection in patients with radiographic N2 squamous cell carcinoma (SCC) of the oropharynx. Methods Fifty consecutive patients with T1–4 and hemineck radiographic stage N2A–B SCC of the oropharynx for whom the only indication for planned neck dissection was a positive PET–CT performed ∼12 weeks after completing primary treatment with radiotherapy. Results Results of PET–CT to identify residual neck disease were as follows: sensitivity and positive predictive value, 0%; specificity, 89%; negative predictive value, 91%; potential neck recurrence from using this 12-week PET–CT program, 2%. The time between negative PET–CT and detection of neck recurrence was 0.5, 0.6, 1.2, and 2.0 years. The rate of successful (>1 year) salvage of neck recurrence was 25% (1/4). Conclusions PET–CT approximately 12 weeks after radiotherapy for oropharyngeal cancer is an excellent way to identify patients who do not need neck dissection. Approximately half of neck recurrences present over 1 year after negative PET–CT and the chance of successful salvage is low.

Purpose To evaluate the long-term effectiveness of radiotherapy (RT) in the treatment of sinonasal undifferentiated carcinoma (SNUC). Materials and methods The medical records of 23 patients treated with definitive or postoperative RT between 1992 and 2010 at the University of Florida were retrospectively reviewed. Fifteen patients (65%) received primary surgery and postoperative RT. Radiation doses ranged from 59.0 to 74.8 Gy (median, 70.2 Gy). The median follow-up time for all patients was 3.0 years (range, 0.9–19.9), and for living patients was 7.7 years (range, 2.5–19.9). Results The actuarial 5-year survival outcomes were as follows: progression-free survival, 42%; cause-specific survival, 43%; and overall survival, 32%. Actuarial 5-year disease control rates were as follows: local control (infield or marginal), 74%; local-regional control (excluding leptomeningeal spread), 58%, regional control 78%, freedom from leptomeningeal recurrence, 72%, and distant metastasis-free survival, 73%. Five of the 8 (62.5%) patients treated with definitive RT died with disease, and 6 of the 15 patients (40%) treated with primary surgery and postoperative RT died with disease. Three patients (13%) experienced severe complications including unilateral eye removal, osteoradionecrosis of the maxilla requiring hyperbaric oxygen and surgery, and brain necrosis. One patient died due to an infected bone graft and brain abscess. Conclusions A multimodal approach is best when treating SNUC patients. The prognosis for patients treated with definitive RT ± chemotherapy is less promising than for those who receive surgery and postoperative RT ± chemotherapy. Severe complications occur in about 17% of patients due to the high dose of RT alone or combined with surgery required for acceptable disease control.

Purpose We retrospectively reviewed long-term outcomes of patients with inverted papilloma (IP) treated with radiation therapy at our institution. Methods and Materials From 1969 to 2008, 13 patients with advanced or recurrent IP (n = 12) or cylindrical papilloma (n = 1) were treated with radiation therapy. The median age at radiation therapy was 53 years old (range, 32-84). Nine patients received postoperative radiation therapy, 3 received definitive radiation therapy, and 1 received preoperative radiation therapy. Of the 10 patients treated with combined-modality treatment, 1 underwent craniofacial resection and 9 underwent open resection. Eight patients, 4 patients, and 1 patient received once-daily fractionation, twice-daily fractionation, and planned split-course radiation therapy, respectively, to a median dose of 65 Gy (range, 45.3-70.4 Gy). Results The median follow-up was 16.2 years. Actuarial 15-year overall and cause-specific survival rates were 62% and 82%. Fifteen-year actuarial local and regional control rates were 45% and 73%. Fifteen-year local-regional control rates for IP alone and IP associated with squamous cell carcinoma (IP-SCC) at the time of treatment were 80% and 16%. Fifteen-year overall survival rates for IP alone and IP-SCC were 40% and 50%. The only severe treatment complication was a grade 3 central nervous system radionecrosis. The most common grade 1-2 toxicities were mucositis (61%), pain (46%), conjunctivitis (31%), xerostomia (31%), epiphora (31%), and anorexia (31%). Conclusions While surgery is the primary treatment for IP, radiation therapy should be considered in patients with SCC, multiply recurrent IPs, and incompletely resectable IP. Radiation therapy is associated with a relatively low risk of severe complications. Despite more aggressive treatment, local failure remains a considerable challenge.

Purpose The aim of this study was to update our experience in treating pleomorphic adenoma with radiotherapy (RT). Materials and Methods This is a retrospective analysis of 25 patients treated with RT alone (2 patients) or combined with surgery (23 patients), with follow-up ranging from 1.8 to 34.9 years (median, 10.5 years). Results Local control was achieved in 13 (75%) of 16 patients with subclinical disease and 5 (56%) of 9 patients with gross disease. Overall local control was achieved in 18 (72%) of 25 patients. The 5-, 10-, and 15-year overall local control rates were 76 %, 76%, and 68%, respectively. Ten patients died of the following causes: recurrent disease, 2; malignant transformation, 2; and intercurrent disease, 6. At last follow-up, 14 patients were alive without evidence of disease, and 1 patient was alive with disease. Dental carries and transient facial nerve deficits were the most common complications. No patients developed severe complications subsequent to RT. Conclusions In patients at high risk for developing recurrent pleomorphic adenoma after surgery, RT is effective in controlling subclinical disease.

Purpose This study reports the outcomes of adults with soft tissue sarcoma (STS) of the head and neck following resection and postoperative radiotherapy (RT), and provides a framework for explaining the issues that radiation oncologists must understand to manage patients with this diverse group of tumors. Methods and Materials Twenty-four patients met the following inclusion criteria of this study: age ≥19 years, head or neck primary site, STS, with the exception of rhabdomyosarcoma, Ewing, or angiosarcoma variants, and curative-attempt treatment with gross total tumor resection followed by RT. Results All patients underwent gross total tumor resection followed by adjuvant RT at our institution during the 28-year period between June 1, 1981, and December 31, 2009. This is a mature study with a median follow-up of 11 years (range, 0.6-27 years). No patient was lost to follow-up. All recurrences were at the primary site. No patient developed an isolated regional or distant recurrence. No patient developed synchronous nodal or distant recurrences at the time of local recurrence. Half of the recurrences presented within 1 year of completing RT, but there were 2 cases where we did not detect recurrence until years 6 and 8 after RT. No recurrence was successfully salvaged. The actuarial rate of local control and relapse-free survival was 83% (95% CI [confidence interval], 63%-94%) at 5 years and 73% (95% CI, 51%-87%) at 10 years. The incidence of moderate to severe treatment complications was 4%. Conclusions Our series documents that gross total resection followed by RT cures most patients (75%) with the most common types of STS of the head and neck. All recurrences were local, meaning near the primary site in tissue that received the full RT prescription dose. For this reason, modifying the approach to treatment of the primary tumor site is the only strategy that will meaningfully improve outcomes for this group of patients.

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

Purpose To report our experience using radiotherapy alone or combined with surgery to treat adenoid cystic carcinoma of the head and neck. Materials and methods Radiotherapy alone or combined with surgery was used to treat 120 previously untreated patients with adenoid cystic carcinoma (ACC) of the head and neck from August 1966 to March 2008. Patients were treated with curative intent. American Joint Committee on Cancer stage distribution was,T0 (n = 1), T1 (n = 26), T2 (n = 25), T3 (n = 14), T4 (n = 54), N0 (n = 113), N1 (n = 2), N2a (n = 1), N2b (n = 2), and N2c (n = 2). Treatment included surgery with postoperative radiotherapy (n = 71), radiotherapy alone (n = 46), and preoperative radiotherapy and surgery (n = 3). Incidental and clinical perineural invasion was found in 41 (34%) and 35 (29%) patients, respectively. Median follow-up was 8.6 and 11.6 years overall and among living patients, respectively. Results The10-year overall, cause-specific, and distant metastasis-free survival rates, respectively, were as follows: radiotherapy alone, 37%, 46%, and 76%; surgery and radiotherapy, 57%, 71%, and 62%; and overall, 50%. The10-year local control rates were as follows: radiotherapy alone, 36%; surgery and radiotherapy, 84%; and overall, 65%. The 10-year neck control rates were as follows: elective nodal irradiation (ENI), 98%; no ENI, 89%; and overall, 95%. Conclusions Surgery and adjuvant radiotherapy offer the best chance for cure for patients with resectable adenoid cystic carcinomas of the head and neck. Some patients with advanced, incompletely resectable disease can be cured with radiotherapy alone. ENI should be considered for primary sites located in lymphatic-rich regions.

Purpose To report the long-term results after definitive radiotherapy (RT) for T1-T2 pyriform sinus squamous cell carcinoma. Patients and Methods The data from 123 patients with T1-T2 pyriform sinus squamous cell carcinoma treated with RT with or without neck dissection between November 1964 and June 2003 were analyzed. The median follow-up for all patients was 3.2 years, and the median follow-up for living patients was 10.7 years. Results The 5-year local control, locoregional control, freedom from distant metastasis, cause-specific survival, and overall survival rate was 85%, 70%, 75%, 61%, and 35%, respectively. The ultimate local control rate, including successful salvage of RT failure, for T1 and T2 cancer patients was 96% and 94%, respectively. The overall local control rate with a functional larynx was 83%. Pretreatment computed tomography tumor volume data were available for 55 patients. The median computed tomography tumor volume was 4.2 cm3 (range, 0–22.4). Local control was worse for patients with a tumor volume >6.5 cm3 compared with those with a smaller tumor volume. Of the 123 patients, 16% developed moderate to severe acute (2%), late (9%), or postoperative (5%) complications. Conclusions Local control with larynx preservation after definitive RT for T1-T2 pyriform sinus squamous cell carcinoma likely results in local control and survival similar to that after total laryngectomy or larynx-conserving surgery. Two-thirds of our living patients retained a functional larynx.

Purpose To assess the efficacy of postoperative radiotherapy (RT) in the treatment of cutaneous melanoma. Materials Between August 1981 and December 2009, 82 patients were treated with surgery and postoperative RT for cutaneous melanoma. Patients were thought to be high risk for local–regional recurrence after surgery alone because of the presence of one or more risk factors including recurrence after prior surgery, positive lymph nodes, extracapsular extension, incomplete regional node dissection, microscopically positive margins, gross residual disease, and in-transit metastases. The primary site was located in the head and neck in 64 patients and elsewhere in the remainder. Forty-two patients (47%) were treated with hypofractionated RT and the remainder with conventional fractionation. Median age was 62 years (range, 21 to > 89 years). Median follow-up overall and for survivors was 3.0 years (range, 0.1 to 17.4 years) and 6.4 years (1.6 to 17.4 years), respectively. Results The 5-year outcomes were: in-field local–regional control 82%; local–regional control, 76%; distant metastasis-free survival, 48%; cause-specific survival, 56%; and overall survival, 43%. In-field local–regional control at 5 years was 87% after hypofractionated RT and 78% after conventionally fractionated RT. Conclusions Postoperative adjuvant RT likely reduces the risk of local–regional recurrence after surgery for patients with high risk cutaneous melanoma. Hypofractionated RT is as effective as conventional fractionation and is logistically advantageous, particularly for patients with a relatively poor prognosis. The risk of RT complications is low.

The objective of this study is to determine if radiotherapy (RT) alone to the cervical lymphatics is a suitable alternative to elective neck dissection (END) in patients who undergo parotidectomy and postoperative RT for squamous cell carcinoma metastatic to the parotid area lymph nodes (PALN). We retrospectively reviewed the medical records of 107 patients consecutively treated from November 1969 to March 2012 for cutaneous squamous cell carcinoma metastatic to the PALN with a clinically node-negative neck. Primary therapy consisted of parotidectomy in all cases. We compared regional (cervical) control in two subgroups: 42 patients treated with END and RT and 65 patients treated with elective neck irradiation (ENI) alone. The median time of follow-up was 5.5 years (range 0.3-30 years) for all patients and 11 years for living patients (range 1.8-26 years). There was 1 neck recurrence in each subgroup: END and RT, 1/42 (2 %); and ENI alone, 1/65 (1.5 %). No patient experienced a complication related to neck RT. ENI to a dose of approximately 50-60 Gy is a suitable alternative to END and postoperative RT in patients with squamous cell carcinoma metastatic to the PALN.

Purpose/Objective(s): The primary purpose of this study is to evaluate the efficacy of radiation therapy (RT) alone (brachytherapy, external-beam, or a combination) or combined with surgery for the treatment of squamous cell carcinoma of the nasal vestibule treated at our institution. Materials/Methods: We retrospectively reviewed the medical records of 100 patients treated with radiation therapy for squamous cell carcinoma of the nasal vestibule at our institution between 1970 and 2013; 92 patients were treated with definitive RT and 8 patients with advanced T4 cancers were treated with combined surgery and RT. Patients were followed from 4 months to 35.9 years (mean, 9.7 years; median, 8.3 years). Follow-up on living patients ranged from 6 months to 30.4 years (mean, 9.8 years; median, 8.2 years). Four patients treated with brachytherapy were excluded because they received external-beam radiation at an outside institution. Results: The 5and 10-year outcomes respectively were as follows: local control, 88% and 82%; local-regional control, 78% and 71%; freedom from distant metastases, 95% and 95%; cause-specific survival, 91% and 86%; and overall survival, 75% and 51%. The 5and 10-year local control rates for patients treated with definitive RT were as follows: T1T2, 94% and 87%; T3-T4, 77% and 72%; and overall, 87% and 81% (p Z 0.0356). Local control was achieved in 8 of 8 patients treated with surgery and RT. A multivariate analysis was performed using overall treatment time (< vs median 46 days), dose (< vs 7000 cGy), tumor size (< vs 4 cm), T stage (T1-2 vs T4 or overall stage I-II vs III-IV), and bone invasion (yes vs no). Of these, stage III-IV predicted increased local-regional recurrences (p Z 0.0164) and bone invasion predicted increased local recurrences (p Z 0.0271) and decreased cause-specific survival (p Z 0.0005). We also compared brachytherapy alone (n Z 15), external-beam RT (n Z 40), and a combination (n Z 45). We found no statistically significant differences in local control, local-regional control, neck control, freedom from distant metastasis, cause-specific survival, or overall survival. Conclusions: RT results in a high cure rate for T1-T2 and favorable T4 tumors with acceptable toxicity. Surgery and RT result in an improved likelihood of cure for patients with extensive T4 tumors, and there is no significant difference in treatment efficacy between brachytherapy alone, external-beam RT, or a combination of the two. Author Disclosure: J.W. Wray: None. C.G. Morris: None. R.J. Amdur: None. J.W. Werning: None. W.M. Mendenhall: None.

site-specific. No patients received chemotherapy. Median follow-up was 7.0 years (range, 1.5-27.4 years). Toxicity was graded using the CTCAE, v 3.0. Results: The 5-year local control, cause-specific survival, and overall survival rates were 72%, 84%, and 78%, respectively. Six patients with tumors > 5 cm experienced a local recurrence at a median of 2.5 years (range, 0.9-5.6 years). All 3 patients with tumors of the retroperitoneum and pelvis treated with RT alone had a local recurrence, while 1 patient with a 2-cm occipital lobe tumor treated with RT alone was alive without evidence of disease at 13 years after RT. Two patients experienced a distant metastasis at 3.7 and 19.1 years after RT and died at 6.4 and 22.7 years after RT, respectively. Two other patients died of intercurrent illness at 3.8 and 24.2 years after RT. The remaining 9 patients were alive without evidence of disease at most recent follow-up. Two patients experienced > grade 2 toxicity from RT. Conclusions: Our long-term data suggest that the morbidity of aggressive surgery combined with RT is justified due to the likelihood of local recurrence and poor outcome with RT alone, particularly for tumors of the retroperitoneum and pelvis. Further studies are required to determine the efficacy of RT alone for CNS hemangiopericytoma. Author Disclosure: M. Scott: None. J.D. Reith: None. W.M. Mendenhall: None. R.B. Marcus: None. R. Zlotecki: None. C.G. Morris: None. D.J. Indelicato: None.