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Background: To assess the association between radiation therapy (RT) use and overall survival (OS) for patients with metastatic head and neck squamous cell carcinomas (HNSCC). Methods: We analyzed the National Cancer Database to identify patients with newly diagnosed metastatic HNSCC from 2004 to 2013 who were treated with up‐front chemotherapy. Associations between the use of RT and OS were evaluated. Results: We identified 3516 patients with metastatic HNSCC who were treated with chemotherapy; 2288 (65%) were also treated with RT. The addition of RT to chemotherapy was associated with prolonged survival (median: 13.6 vs 11.3 months, log‐rank P < .001). After adjusting for other prognostic factors in a multivariable Cox model, propensity score matching and landmark analyses limited to patients who survived at least 3, 6, and 12 months after diagnosis, the use of RT remained associated with prolonged survival. Conclusion: The addition of RT to chemotherapy in the up‐front management of metastatic HNSCC was associated with prolonged OS in this study. [ABSTRACT FROM AUTHOR]

Objective: To analyze nutritional factors and compliance with dietary recommendations for associations with overall survival (OS) and progression-free survival (PFS) in patients receiving definitive RT for laryngeal and oropharyngeal cancers.Materials/methods: We identified 352 patients with non-metastatic laryngeal (146) and oropharyngeal (206) cancer treated with definitive RT between 2004 and 2013. Disease and patient characteristics, treatment information, sarcopenia based on muscle areas at L3 level on CT, compliance with the nutritional program, and clinical outcomes data were tabulated. Descriptive statistics, Kaplan-Meier survival analysis, and log rank tests were performed, and Cox regression models were used to examine predictors of OS and PFS.Results: The median follow-up for the entire cohort was 22.86 months. The actuarial rates for OS were 91, 86, and 73% at years 1, 2, and 5, respectively. Of patients with abdominal CT prior to starting RT, 70.9% (112/158) were sarcopenic with a median muscle mass index of 48.2 (range 30.4-70.9) for males and 35.9 (range 24.6-53.2) for females. The majority (85.8%) of patients met with a dietitian during their course of RT and 62.6% of these patients were compliant with the nutritional program. Compliance with the nutritional program resulted in 27% (HR 0.73, 95% CI 0.43-1.26) protection from death (did not reach significance) and 31% (HR 0.69, 95% CI 0.50-0.94) significant protection from disease progression. Higher pretreatment BMI was associated with a lower risk of death (HR 0.94, 95% CI 0.90-0.99) and disease progression (HR 0.96, 95% CI 0.93-0.99).Conclusion: Laryngeal and oropharyngeal cancer patients treated with definitive RT who are compliant with regular dietetic counseling and contact appear to have improved outcomes.Trial Registration: Not applicable. [ABSTRACT FROM AUTHOR]

Purpose. Transoral robotic surgery (TORS) has increased in popularity in the management of squamous cell carcinoma of the head and neck. However, TORS does not address the neck or retropharyngeal nodes (RPN). In the current report, we highlight the impact of the lack of adjuvant radiotherapy on RPN recurrence after TORS. Materials and Methods. A 58-year-old Caucasian male presented with squamous cell carcinoma of the head and neck of unknown primary. He was offered radiotherapy as a definitive management for clinical stage T0N2aM0, stage IVA, but he opted to left neck dissection. Follow-up PET-CT scan revealed recurrence in the left base of tongue and right level II lymph node. He was offered radiotherapy which he declined and opted to TORS and right neck dissection. Follow-up PET-CT scan showed recurrence in left RPN for which he underwent salvage concurrent chemoradiotherapy to 70 Gy. Results. After a followup of 9 months from the date of salvage chemoradiotherapy completion, the patient is with no evidence of disease. Conclusions. TORS followed by adjuvant radiotherapy seems reasonable in the context of squamous cell carcinoma of the head and neck due to the odds of RPN involvement. Further reports are warranted to optimize post-TORS adjuvant treatment. [ABSTRACT FROM AUTHOR]

Purpose: To perform a prospective trial testing the feasibility and utility of acquiring activity data as a measure of health status during concurrent chemoradiotherapy.Methods and Materials: Ambulatory patients who were planned for treatment with concurrent chemoradiotherapy with curative intent for cancers of the head and neck, lung, or gastrointestinal tract were provided with activity monitors before treatment initiation. Patients were asked to wear the devices continuously throughout the radiation therapy course. Step count data were downloaded weekly during radiation therapy and 2 and 4 weeks after radiation therapy completion. The primary objective was to demonstrate feasibility, defined as collection of step counts for 80% of the days during study subjects' radiation therapy courses. Secondary objectives included establishing step count as a dynamic predictor of unplanned hospitalization risk.Results: Thirty-eight enrolled patients were treated with concurrent chemoradiotherapy. Primary diagnoses included head and neck cancer (n=11), lung cancer (n=13), and a variety of gastrointestinal cancers (n=14). Step data were collected for 1524 of 1613 days (94%) during patients' radiation therapy courses. Fourteen patients were hospitalized during radiation therapy or within 4 weeks of radiation therapy completion. Cox regression modeling demonstrated a significant association between recent step counts (3-day average) and hospitalization risk, with a 38% reduction in the risk of hospitalization for every 1000 steps taken each day (hazard ratio 0.62, 95% confidence interval 0.46-0.83, P=.002). Inferior quality of life scores and impaired performance status were not associated with increased hospitalization risk.Conclusion: Continuous activity monitoring during concurrent chemoradiotherapy is feasible and well-tolerated. Step counts may serve as powerful, objective, and dynamic indicators of hospitalization risk. [ABSTRACT FROM AUTHOR]

Summary: Objectives: Radiation induced cranial nerve palsy (RICNP) involving the lower cranial nerves (CNs) is a serious complication of head and neck radiotherapy (RT). Recommendations for delineating the lower CNs on RT planning studies do not exist. The aim of the current study is to develop a standardized methodology for contouring CNs IX–XII, which would help in establishing RT limiting doses for organs at risk (OAR). Methods: Using anatomic texts, radiologic data, and guidance from experts in head and neck anatomy, we developed step-by-step instructions for delineating CNs IX–XII on computed tomography (CT) imaging. These structures were then contoured on five consecutive patients who underwent definitive RT for locally-advanced head and neck cancer (LAHNC). RT doses delivered to the lower CNs were calculated. Results: We successfully developed a contouring atlas for CNs IX–XII. The median total dose to the planning target volume (PTV) was 70Gy (range: 66–70Gy). The median CN (IX–XI) and (XII) volumes were 10c.c (range: 8–12c.c) and 8c.c (range: 7–10c.c), respectively. The median V50, V60, V66, and V70 of the CN (IX–XI) and (XII) volumes were (85, 77, 71, 65) and (88, 80, 74, 64) respectively. The median maximal dose to the CN (IX–XI) and (XII) were 72Gy (range: 66–77) and 71Gy (range: 64–78), respectively. Conclusions: We have generated simple instructions for delineating the lower CNs on RT planning imaging. Further analyses to explore the relationship between lower CN dosing and the risk of RICNP are recommended in order to establish limiting doses for these OARs. [ABSTRACT FROM AUTHOR]

Purpose: Anatomic changes and positional variability during intensity-modulated radiation therapy (IMRT) for head and neck cancer can lead to clinically significant dosimetric changes. We report our single-institution experience using an adaptive protocol and correlate these changes with anatomic and positional changes during treatment. Methods and Materials: Twenty-three sequential head and neck IMRT patients underwent serial computed tomography (CT) scans during their radiation course. After undergoing the planning CT scan, patients underwent planned rescans at 11, 22, and 33 fractions; a total of 89 scans with 129 unique CT plan combinations were thus analyzed. Positional variability and anatomic changes during treatment were correlated with changes in dosimetric parameters to target and avoidance structures between planning CT and subsequent scans. Results: A total of 15/23 patients (65%) benefited from adaptive planning, either due to inadequate dose to gross disease or to increased dose to organs at risk. Significant differences in primary and nodal targets (planning target volume, gross tumor volume, and clinical tumor volume), parotid, and spinal cord dosimetric parameters were noted throughout the treatment. Correlations were established between these dosimetric changes and weight loss, fraction number, multiple skin separations, and change in position of the skull, mandible, and cervical spine. Conclusions: Variations in patient positioning and anatomy changes during IMRT for head and neck cancer can affect dosimetric parameters and have wide-ranging clinical implications. The interplay between random positional variability and gradual anatomic changes requires careful clinical monitoring and frequent use of CT- based image-guided radiation therapy, which should determine variations necessitating new plans. [ABSTRACT FROM AUTHOR]

Abstract: Intensity-modulated radiation therapy (IMRT) has been applied for treatments of primary head with neck nodes, lung with supraclavicular nodes, and high-risk prostate cancer with pelvis wall nodes, all of which require large fields. However, the design of the Varian multileaf collimator requires fields >14 cm in width to be split into 2 or more carriage movements. With the split-field technique, both the number of monitor units (MUs) and total treatment time are significantly increased. Although many different approaches have been investigated to reduce the MU, including introducing new leaf segmentation algorithms, none have resulted in widespread success. In addition, for most clinics, writing such algorithms is not a feasible solution, particularly with commercial treatment planning systems. We introduce a new approach that can minimize the number of split fields and reduce the total MUs, thereby reducing treatment time. The technique is demonstrated on the Eclipse planning system V7.3, but could be generalized to any other system. [Copyright &y& Elsevier]

Purpose: With 54° of freedom from the skull to mandible to C7, ensuring adequate immobilization for head-and-neck radiotherapy (RT) is complex. We quantify variations in skull, mandible, and cervical spine movement between RT sessions. Methods and Materials: Twenty-three sequential head-and-neck RT patients underwent serial computed tomography. Patients underwent planned rescanning at 11, 22, and 33 fractions for a total of 93 scans. Coordinates of multiple bony elements of the skull, mandible, and cervical spine were used to calculate rotational and translational changes of bony anatomy compared with the original planning scan. Results: Mean translational and rotational variations on rescanning were negligible, but showed a wide range. Changes in scoliosis and lordosis of the cervical spine between fractions showed similar variability. There was no correlation between positional variation and fraction number and no strong correlation with weight loss or skin separation. Semi-independent rotational and translation movement of the skull in relation to the lower cervical spine was shown. Positioning variability measured by means of vector displacement was largest in the mandible and lower cervical spine. Conclusions: Although only small overall variations in position between head-and-neck RT sessions exist on average, there is significant random variation in patient positioning of the skull, mandible, and cervical spine elements. Such variation is accentuated in the mandible and lower cervical spine. These random semirigid variations in positioning of the skull and spine point to a need for improved immobilization and/or confirmation of patient positioning in RT of the head and neck. [Copyright &y& Elsevier]