International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Outcomes following proton therapy for pediatric esthesioneuroblastoma

BACKGROUND

Pediatric esthesioneuroblastoma (EN) can infiltrate skull base anatomy, presenting challenges due to high radiation doses and pediatric tissue sensitivity. This study reports outcomes of pediatric EN treated with proton radiotherapy (PT).

PROCEDURE

Using an IRB-approved prospective outcomes registry, we evaluated patient, tumor, and treatment-related variables impacting disease control and toxicity in pediatric nonmetastatic EN treated with modern multimodality therapy, including PT.

RESULTS

Fifteen consecutive patients (median age 16) comprising Kadish stage B (n = 2), C (n = 9), and D (n = 4) tumors were assessed, including six with intracranial involvement, four with cranial nerve deficits, and four with cervical lymphadenopathy. Before radiation, two had subtotal and 13 had gross total resections (endoscopic or craniofacial). Two underwent neck dissection. Eleven received chemotherapy before radiation (n = 5), concurrent with radiation (n = 4), or both (n = 2). Median total radiation dose (primary site) was 66 Gy/CGE for gross disease and 54 Gy/CGE (cobalt Gray equivalent) for microscopic disease. Median follow-up was 4.8 years. No patients were lost to follow-up. Five-year disease-free and overall survival rates were 86% (no local or regional recurrences). Two patients developed vertebral metastases and died. Two required a temporary feeding tube for oral mucositis/dysphagia. Late toxicities included symptomatic retinopathy, major reconstructive surgery, cataracts, chronic otitis media, chronic keratoconjunctivitis, hypothyroidism, and in-field basal cell skin cancer.

CONCLUSIONS

A multimodality approach for pediatric EN results in excellent local control. Despite the moderate-dose PT, serious radiation toxicity was observed; further dose and target volume reductions may benefit select patients. Longer follow-up and comparative data from modern photon series are necessary to fully characterize any relative PT advantage.

Impact of mandated drug monitoring on opioid use during highly conformal radiotherapy for oropharynx cancer

BACKGROUND

Prescription drug monitoring programs (PDMPs) have proliferated due to increasing opioid-related deaths. We evaluated acute opioid use changes for 64 patients treated with highly conformal radiotherapy (RT) following a state-mandated PDMP.

METHODS

Patients receiving proton therapy (PT) (n=40), intensity-modulated RT (IMRT) (n=14), or both (n=10) were divided into preintervention (n=26) and postintervention cohorts (n=38); records were reviewed retrospectively under an institutional review board (IRB)-approved tracking protocol. Dosages prescribed during acute therapy (during RT-3 months post-RT) and patient-reported pain (Defense and Veterans Pain Rating Scale) were endpoints. Dosages were treated as responses in Chi-square tests (three-level ordinal response).

RESULTS

Overall, 72% (n=46) received opioids; of which 22% (n=10) of all patients and 10% (n=2) of opioid-naive patients continued analgesic management 3 months post-RT. Median total doses were 975 and 1,025 morphine milligram equivalents (MME) in pre- and postintervention groups, with no significant differences in MME prescribed (P=0.8) or uncontrolled pain (P=0.3). Statistically significant factors were tonsil primaries (P<0.01) and alcohol use (P=0.02). Uncontrolled pain episodes during and post-RT did not vary per cohort (P=0.19).

CONCLUSIONS

PDMP use was not associated with management changes in patient-reported acute pain during RT (IMRT or PT). Following highly conformal RT, few patients remained on narcotics 3 months post-RT.

Carbon Ion Radiotherapy: An Evidence-Based Review and Summary Recommendations of Clinical Outcomes for Skull-Base Chordomas and Chondrosarcomas

Skull-base chordoma and chondrosarcoma are rare radioresistant tumors treated with surgical resection and/or radiotherapy. Because of the established dosimetric and biological benefits of heavy particle therapy, we performed a systematic and evidence-based review of the clinical outcomes of patients with skull-base chordoma and chondrosarcoma treated with carbon ion radiotherapy (CIRT). A literature review was performed using a MEDLINE search of all articles to date. We identified 227 studies as appropriate for review, and 24 were ultimately included. The published data illustrate that CIRT provides benchmark disease control outcomes for skull-base chordoma and chondrosarcoma, respectively, with acceptable toxicity. CIRT is an advanced treatment technique that may provide not only dosimetric benefits over conventional photon therapy but also biologic intensification to overcome mechanisms of radioresistance. Ongoing research is needed to define the magnitude of benefit, patient selection, and cost-effectiveness of CIRT compared to other forms of radiotherapy.

Challenging the Role of Subtotal Resection Following Proton Radiotherapy for Adenoid Cystic Carcinoma of the Head and Neck

PURPOSE/OBJECTIVE(S)

To report long-term outcomes of patients with adenoid cystic carcinoma (ACC) of the head and neck treated with proton radiotherapy.

MATERIALS/METHODS

On this IRB-approved, single institutional prospective outcomes registry, 56 patients were included with de novo, nonmetastatic adenoid carcinoma of the head and neck treated with primary (n = 9) or adjuvant proton therapy from June 2007 to December 2021. The cohort had 30 women and 26 men with a median age of 57 years (range, 10-81 years). Twenty-nine percent (n = 16) had intracranial extension, 23% (n = 13) had orbital extension, and 55% (n = 31) had clinical cranial nerve involvement at the time of radiotherapy. Thirty patients underwent gross total resection (GTR), 26 had gross disease at the time of treatment undergoing a subtotal resection (STR) (n = 17) or biopsy alone (n = 9). The median dose to the primary site was 72.6 GyRBE (range, 64-74.4 GyRBE) delivered in either once (n = 19) or twice (n = 37) daily treatments. Thirty patients received either elective nodal irradiation (ENI) in a node negative neck or concurrent chemotherapy.

RESULTS

With a median follow-up of 6.2 years (range, 0.9 - 14.7 years), the 5-year local-regional control (LRC), disease free survival (DFS), cause-specific survival (CCS) and overall survival (OS) were 88%, 85%, 89%, and 89%, respectively. Cranial extension (p = 0.003) and gross residual tumor (p = 0.0388) were factors associated with decreased LRC. While LRC for those with a GTR was 96%, those with STR or biopsy alone were 81% and 76%, respectively. T-stage (p = 0.0154), cranial extension (p = 0.0056), extent of resection (p = 0.0355), and gross residual tumor (p = 0.0094) were associated with decreased DFS. T-stage (p = 0.0099), extent of surgery (p = 0.029) and gross residual tumor (p.0071) were associated with decreased CCS. The 5-year cumulative incidence of clinically significant late grade ³3 toxicity was 15% and the crude incidence at most recent follow-up was 23% (n = 13). There was no LRC benefit with ENI (p = 0.94).

CONCLUSION

Proton therapy provides excellent disease control for head and neck ACC with acceptable toxicity. Gross residual disease at the time of treatment and intracranial involvement were significant prognostic features for worse outcomes. STR did not confer benefit over biopsy only at 5-years and may question the role of extensive and morbid operations if GTR is not technically feasible.

Low Tesla MR Imaging for Spine with Hardware

PURPOSE/OBJECTIVE(S)

Acquiring MR images with minimized susceptibility artifacts is essential for spines with medical hardware to delineate clinical target volumes (CTVs) in radiation therapy for chordomas, chondrosarcomas, and other sarcomas. Since it can be more challenging to visualize the primary structures in high-tesla MR images due to metal-induced artifacts, we optimized imaging parameters to acquire high-quality, low-tesla MR images for clinical use.

MATERIALS/METHODS

OptimalMR imaging parameters were investigated under general guidelines for artifact reduction techniques by testing several 3D spin echo and gradient echo sequences in a 0.23-T MR scanner. A customized spine phantom was developed to acquire MR images for bony materials which included, 4-6 industrial titanium screws, an aluminum plate, and a superflab bolus. While the 3D b-FFE sequence was used to acquire MR images with a high signal-to-noise ratio, the other 3D T1-FFE, THRIVE, and DTSE sequences were applied to reduce susceptible artifacts to the medical hardware. The optimized parameters determined in the phantom test were applied to the 15 clinical cases, including patients with residual spinal tumors and fusion hardware. The low-tesla MR imaging technique was also used to scan sarcomas of the extremities and re-irradiation cases of spinal metastases.

RESULTS

The optimized low-tesla MR images in the spine were noticeably useful to guide CTV delineations for patients with medical hardware, especially for residual or recurrent tumors. The imaging technique to minimize susceptibility artifacts enabled a more defined separation of each hardware component from the spinal cord and CTVs. In spine metastasis cases, pre-irradiated target volumes were determined, reflecting property changes in the bone marrow.

CONCLUSION

The MR images acquired using the optimized parameters showed minimal artifacts to scan spine patients with hardware. By using the low-tesla MR images, spinal chordoma and chondrosarcoma patients could be treated to improve tumor control probabilities with minimized complications.

Pediatric Esthesioneuroblastoma Treated with Proton Radiotherapy

PURPOSE/OBJECTIVE(S)

Given its tendency to abut and infiltrate critical skull base anatomy, pediatric esthesioneuroblastoma (EN) presents a local control challenge, particularly given the high dose of radiation historically utilized in adult patients and the sensitivity of developing pediatric normal tissue. The purpose of this study was to report the outcomes of pediatric EN treated with proton radiotherapy.

MATERIALS/METHODS

Using an IRB-approved, single institutional prospective outcomes registry, we analyzed disease control and toxicity in pediatric patients with non-metastatic EN treated with a multimodality approach, including proton radiotherapy, between March 2008 and March 2022. Of the 15 patients, 8 were female, and 7 were male. The median age was 16 years (range, 3-21 years). Patients were Kadish stage B (n = 2), C (n = 8), and D (n = 5) and Hyams low-grade (n = 9), high-grade (n = 5), and not specified (n = 1). Six patients had intracranial involvement, 4 had cranial nerve deficits, and 4 had positive cervical lymph nodes. Prior to radiation, 2 patients had a subtotal resection and 13 had a gross total resection via either endoscopic (n = 8) or craniofacial (n = 7) approaches. Two patients underwent neck dissection (one unilateral and one bilateral). A total of 11 patients received chemotherapy before (n = 5), concurrent (n = 4) with radiation, or both (n = 2). The median total radiation dose delivered to the primary site was 66 Gy/CGE (range, 59.4-72.8 Gy/CGE) for patients with gross disease and 54 Gy/CGE (range, 54-74.4 Gy/CGE) for patients with microscopic disease.

RESULTS

With a median follow-up of 4.8 years (range, 0.1-12.2 years), both the 5-year disease free and overall survival rates were 86%. There were no local or regional recurrences. Two patients with Kadish D, high grade tumors developed vertebral metastases and died with disease. Serious acute toxicity included 2 patients requiring a temporary feeding tube for oral mucositis/dysphagia. Serious late toxicity included symptomatic retinopathy (n = 3), major reconstructive surgery (n = 2), cataracts requiring intervention (n = 2), chronic otitis media (n = 2), chronic keratoconjunctivitis (n = 2), hypothyroidism (n = 2), and in-field basal cell skin cancer (n = 1).

CONCLUSION

A multimodality approach to pediatric EN results in excellent local control. Despite the use of moderate dose proton therapy, serious radiation toxicity was observed and thus select patients may benefit from further dose and target volume reduction. Longer follow-up and comparative data from modern photon series are necessary to fully characterize any relative advantage of proton therapy.

Proton Radiotherapy for Skull-Base Malignancies

Proton therapy (PT) is a form of highly conformal external-beam radiotherapy used to mitigate acute and late effects following radiotherapy. Indications for treatment include both benign and malignant skull-base and central nervous system pathologies. Studies have demonstrated that PT shows promising results in minimizing neurocognitive decline and reducing second malignancies with low rates of central nervous system necrosis. Future directions and advances in biologic optimization may provide additional benefits beyond the physical properties of particle dosimetry.

Outcomes of Patients Treated in the UK Proton Overseas Programme: Central Nervous System Group

AIMS

In 2008, the UK National Health Service started the Proton Overseas Programme (POP), to provide access for proton beam therapy (PBT) abroad for selected tumour diagnoses while two national centres were being planned. The clinical outcomes for the patient group treated for central nervous system (CNS), base of skull, spinal and paraspinal malignancies are reported here.

MATERIALS AND METHODS

Since the start of the POP, an agreement between the National Health Service and UK referring centres ensured outcomes data collection, including overall survival, local tumour control and late toxicity data. Clinical and treatment-related data were extracted from this national patient database. Grade ≥3 late toxicities were reported following Common Terminology Criteria for Adverse Events (CTCAE) v 4.0 definition, occurring later than 90 days since the completion of treatment.

RESULTS

Between 2008 and September 2020, 830 patients were treated within the POP for the above listed malignancies. Overall survival data were available for 815 patients and local control data for 726 patients. Toxicity analysis was carried out on 702 patients, with patients excluded due to short follow-up (<90 days) and/or inadequate toxicity data available. After a median follow-up of 3.34 years (0.06-11.58), the overall survival was 91.2%. The local control rate was 85.9% after a median follow-up of 2.81 years (range 0.04-11.58). The overall grade ≥3 late toxicity incidence was 11.97%, after a median follow-up of 1.72 years (0.04-8.45). The median radiotherapy prescription dose was 54 GyRBE (34.8-79.2).

CONCLUSIONS

The results of this study indicate the safety of PBT for CNS tumours. Preliminary clinical outcomes following PBT for paediatric/teen and young adult and adult CNS tumours treated within the POP are encouraging, which reflects accurate patient selection and treatment quality. The rate of late effects compares favourably with published cohorts. Clinical outcomes from this patient cohort will be compared with those of UK-treated patients since the start of the national PBT service in 2018.

Long-term outcomes of fractionated proton beam therapy for benign or radiographic intracranial meningioma

PURPOSE

Benign intracranial meningioma is one of the most common primary brain neoplasms. Proton therapy has been increasingly utilized for nonoperative management of this neoplasm, yet few long-term outcomes studies exist.

METHODS

The medical records of a total of 59 patients with 64 lesions were reviewed under a prospective outcomes tracking protocol for histologically proven or radiographically benign meningioma. The patients were treated with proton therapy at the University of Florida Proton Therapy Institute between 2007 and 2019 and given a median dose of 50.4 GyRBE at 1.8 GyRBE (relative biological effectiveness) (range 48.6-61.2 GyRBE) in once-daily treatments.

RESULTS

With a median clinical and imaging follow-up of 6.3 and 4.7 years, the rates of 5-year actuarial local progression and cumulative incidence of grade 3 or greater toxicity were 6% (95% confidence interval [CI] 1%-14%), and 2% (95% CI < 1%-15%), respectively. Two patients experienced local progression after 5 years. The 5-year actuarial overall survival rate was 87% (95% CI 74-94%).

CONCLUSION

Fractionated PBT up to 50.4 GyRBE is a safe and highly effective therapy for treating benign intracranial meningioma.

Early-stage vocal cord cancer treated with hypofractionated radiotherapy to the larynx with or without concurrent chemotherapy

BACKGROUND

We report outcomes among patients with T2 and select T3 glottic squamous cell carcinoma (SCC) treated with radiotherapy.

METHODS

We reviewed T2 and T3 (only paraglottic space invasion) N0 M0 glottic SCC patients treated with curative-intent hypofractionated larynx radiotherapy, with or without concurrent systemic therapy.

RESULTS

Of 71 patients, those who received concurrent chemotherapy (23/71; 32%) had worse prognostic factors, including impaired cord mobility (70% vs. 40%, p = 0.02) and larger median gross tumor volume (3.0 vs. 1.6 cm³ , p = 0.003). Over a median follow-up of 3.8 years, 2-year local control among patients with impaired cord mobility appeared higher for those who received chemotherapy (88% vs. 61%, p = 0.12), but the difference was not statistically significant. Acute and late toxicity rates were not higher among patients who received chemotherapy.

CONCLUSIONS

The addition of concurrent platinum-based chemotherapy to hypofractionated larynx radiotherapy among patients with early-stage glottic SCC with impaired cord mobility appears safe and worthy of additional investigation.

The incidence of brainstem toxicity following high-dose conformal proton therapy for adult skull-base malignancies

BACKGROUND

Dose escalation for skull-based malignancies often presents risks to critical adjacent neural structures, including the brainstem. We report the incidence of brainstem toxicity following fractionated high-dose conformal proton therapy and associated dosimetric parameters.

MATERIAL AND METHODS

We performed a single-institution review of patients with skull-base chordoma or chondrosarcoma who were treated with proton therapy between February 2007 and January 2020 on a prospective outcomes-tracking protocol. The primary endpoint was grade ≥2 brainstem toxicity. No patients received concurrent chemotherapy, and brainstem toxicity was censored for analysis if it coincided with local disease progression.

RESULTS

We analyzed 163 patients who received a minimum of 45 GyRBE to 0.03 cm³ of the brainstem. Patients were treated to a median total dose of 73.8 (range 64.5-74.4) GyRBE at 1.8 GyRBE per fraction with 17 patients undergoing twice-daily treatment at 1.2 GyRBE per fraction. With a median follow-up of 4 years, the 5-year cumulative incidence of grade ≥2 brainstem injury was 1.3% (95% CI 0.25-4.3%). There was one grade 2, one grade 3, and no grade 4 or 5 events, with all patients recovering function with medical management.

CONCLUSION

In delivering curative-intent radiotherapy for skull-base chordoma and chondrosarcoma in adults, small volumes of the brainstem can safely receive at least 64 GyRBE with minimal risk of serious brainstem injury.

Impact of Type of Treatment Center and Access to Care on Mortality and Survival for Skull Base Chordoma and Chondrosarcoma

Introduction In adults with skull base chordoma or chondrosarcoma, the impact of treatment center and access to care have not been well described in regard to perioperative mortality and survival.

Methods A query of the National Cancer Database (NCDB) and review of 1,102 adults—488 with chordomas and 614 with chondrosarcomas—was performed. The Kaplan–Meier's product limit method and chi-square analysis, respectively, assessed overall survival and 30-day (30D) and 90-day (90D) mortalities.

Results For 925 patients who had surgery and available mortality data, the 30D and 90D mortality rates were 0.9 and 1.5%. Lower education level (p = 0.0185) and treatment at a nonacademic facility (p = 0.016) were associated with increased risk of 90-day mortality. Median follow-up was 52 months and analysis was dichotomized by histology. For those with skull base chordoma, patients from a larger metro size (p = 0.002), age below the median 52 years (p ≤ 0.001), and private insurance (<0.001) were associated with prolonged survival, whereas for skull base chondrosarcoma, the factors were treatment at an academic medical center (p = 0.001), high-volume center (p = 0.007), age below the median 52 years (p ≤ 0.001), higher income (p = 0.043), higher education (p = 0.017), and private insurance (p ≤ 0.001). Comparing high-, medium-, and low-volume centers, high-volume centers were most likely to be academic, deliver radiotherapy, escalate doses >70 Gy, and utilize proton radiotherapy consistent across both disease subsets.

Conclusion Higher educational attainment and treatment at an academic facility were associated with decreased 90D mortality for patients with skull base chordoma and chondrosarcoma. For those with skull base chordoma, larger metro size, younger age, and private insurance were associated with prolonged survival; for those with chondrosarcoma, it was treatment at a high-volume or academic medical center, younger age, higher income or education, and private insurance.

Passively Scattered Proton Therapy for Nonmelanoma Skin Cancer with Clinical Perineural Invasion

Purpose

To report our experience with the delivery of passively scattered proton therapy in the management of nonmelanoma skin cancers with clinical perineural invasion.

Materials and Methods

We reviewed the medical records of patients who received definitive or postoperative proton therapy for nonmelanoma skin cancer with clinical perineural invasion at our institution and updated patient follow-up when possible. All patients were treated with curative intent with or without the delivery of concurrent systemic therapy. We report disease control rates and the rates of late toxicity among this cohort.

Results

Twenty-six patients treated between 2008 and 2017 were included in the analysis. Following proton therapy, the 3-year overall, cause-specific, and disease-free survival rates were 59%, 73%, and 60%, respectively. The 3-year local control, local regional control, and distant metastasis-free survival rates were 80%, 65%, and 96%, respectively. On univariate analysis, surgical resection before radiation therapy significantly improved local regional control rates at 3 years (55% versus 86%; P = .04). Grade 3+ late toxicities occurred in 13 patients (50%) and the most common toxicities included grade 3+ keratitis of the ipsilateral eye, which occurred in 4 patients (15%) and grade 3+ brain necrosis in 4 patients (15%).

Conclusion

Proton therapy is effective in the management of nonmelanoma skin cancer with clinical perineural invasion. Although disease control and complication rates compare favorably to those previously published for photon-based radiation therapy, the risk for late toxicity is significant and patients should be appropriately counseled.

Clinical Outcomes Following Dose-Escalated Proton Therapy for Skull-Base Chordoma

Purpose

To evaluate the effectiveness of external-beam proton therapy (PT) on local control and survival in patients with skull-base chordoma.

Materials and Methods

We reviewed the medical records of patients with skull-base chordoma treated with definitive or adjuvant high-dose PT and updated their follow-up when feasible. We assessed overall survival, disease-specific survival, local control, and freedom from distant metastasis. Radiotherapy toxicities were scored using the Common Terminology Criteria for Adverse Events, version 4.0.

Results

A total 112 patients were analyzed, of whom 105 (94%) received PT and 7 (6%) received combined proton-photon therapy between 2007 and 2019. Eighty-seven patients (78%) underwent a subtotal resection, 22 (20%) a gross total resection, and 3 (3%) a biopsy alone. The median radiotherapy dose was 73.8 Gy radiobiologic equivalent (GyRBE; range, 69.6-74.4). Ninety patients (80%) had gross disease at radiotherapy and 7 (6%) were treated for locally recurrent disease following surgery. Median follow-up was 4.4 years (range, 0.4-12.6); for living patients, it was 4.6 years (range, 0.4-12.6), and for deceased patients, 4.1 years (range, 1.2-11.2). At 5 years after radiotherapy, the actuarial overall survival, disease-specific survival, local control, and freedom from distant metastasis rates were 78% (n = 87), 83% (n = 93), 74% (n = 83), and 99% (n = 111), respectively. The median time to local progression was 2.4 years (range, 0.8-7). Local control and disease-specific survival by resection status was 95% versus 70% (P = 0.28) and 100% versus 80% (P = 0.06) for gross total, versus subtotal, resection or biopsy alone, respectively. There were no serious acute toxicities (grade ≥ 3) related to radiotherapy.

Conclusion

High-dose PT alone or after surgical resection for skull-base chordoma reaffirms the favorable 5-year actuarial local control rate compared with conventional techniques with acceptable late-complication–free survival. Outcomes following gross total resection and adjuvant PT were excellent. Further follow-up of this cohort is necessary to better characterize long-term disease control and late toxicities.

Long-term Outcomes from Proton Therapy for Sinonasal Cancers

PURPOSE

To report long-term disease control, survival, and toxicity after proton therapy for sinonasal cancer.

PATIENTS AND METHODS

We reviewed 143 cases of adults with nonmetastatic sinonasal cancers treated with primary (18%; n = 26) or adjuvant (82%; n = 117) proton therapy. The most common histologies were squamous cell carcinoma (29%; n = 42), olfactory neuroblastoma (23%; n = 33), and adenoid cystic carcinoma (16%; n = 23). Patients had predominantly advanced-stage disease (T3, 24%, n = 35; T4, 66%, n = 94) and high-grade histology (52%; n = 74). Surgery included endoscopic resection alone (50%) with craniotomy (10%) or open resection (40%), and 31% had gross disease present at radiotherapy. Most (91%) received high-dose (median, 73.6 Gy radiobiological equivalent [GyRBE]; 84% >70 GyRBE) passive-scatter proton therapy using accelerated hyperfractionation (1.2 GyRBE twice daily) and concurrent chemotherapy (70%). Univariate and multivariate models assessed prognostic factors. Grade 3+ toxicities were recorded per Common Terminology Criteria, version 4. Median follow-up was 3.4 years (range, 0.1-12.5 years) overall and 4.9 years (range, 0.9-12.5 years) for living patients.

RESULTS

The 5-year outcomes were as follows: local control (LC), 80%; neck control, 96%; local-regional control, 78%; freedom from distant metastases, 71%; and disease-free survival, 62%; cause-specific survival, 64%; and overall survival, 59%. Surgery improved LC, but only with gross total resection (5-year LC 87% versus subtotal resection 62.9%, and biopsy alone 55% (P < 0.001). Gross residual disease was the only significant prognostic factor for local-regional control on multivariate analysis. High-grade, T4, and local recurrence were associated with decreased overall survival. Late (G3+) toxicity occurred in 22% (32 of 143), including central nervous system necrosis and vision loss in 6% (9 of 143) and 3.5% (5 of 143), respectively.

CONCLUSION

Proton therapy after gross-total resection provides excellent long-term LC in patients with locally advanced, high-grade sinonasal cancer. Moreover, LC remains strongly associated with long-term survival. With gross disease, about 60% of patients had long-term LC with proton therapy and induction or concurrent chemotherapy.

Proton therapy for adult medulloblastoma: Acute toxicity and disease control outcomes

PURPOSE

We report disease control, survival outcomes, and treatment-related toxicity among adult medulloblastoma patients who received proton craniospinal irradiation (CSI) as part of multimodality therapy.

METHODS

We reviewed 20 adults with medulloblastoma (≥ 22 years old) who received postoperative proton CSI ± chemotherapy between 2008 and 2020. Patient, disease, and treatment details and prospectively obtained patient-reported acute CSI toxicities were collected. Acute hematologic data were analyzed.

RESULTS

Median age at diagnosis was 27 years; 45% of patients had high-risk disease; 75% received chemotherapy, most (65%) after CSI. Eight (40%) patients received concurrent vincristine with radiotherapy. Median CSI dose was 36GyE with a median tumor bed boost of 54GyE. Median duration of radiotherapy was 44 days. No acute ≥ grade 3 gastrointestinal or hematologic toxicities attributable to CSI occurred. Grade 2 nausea and vomiting affected 25% and 5% of patients, respectively, while 36% developed acute grade 2 hematologic toxicity (36% grade 2 leukopenia and 7% grade 2 neutropenia). Those receiving concurrent chemotherapy with CSI had a 38% rate of grade 2 hematologic toxicity compared to 33% among those not receiving concurrent chemotherapy. Among patients receiving adjuvant chemotherapy (n = 13), 100% completed ≥ 4 cycles and 85% completed all planned cycles. With a median follow-up of 3.1 years, 4-year actuarial local control, disease-free survival, and overall survival rates were 90%, 90%, and 95%, respectively.

CONCLUSIONS

Proton CSI in adult medulloblastoma patients is very well tolerated and shows promising disease control and survival outcomes. These data support the standard use of proton CSI for adult medulloblastoma.

Local Control After Proton Therapy for Pediatric Chordoma

PURPOSE

Due to the location and high dose required for disease control, pediatric chordomas are theoretically well-suited for treatment with proton therapy, but their low incidence limits the clinical outcome data available in the literature. We sought to report the efficacy and toxicity of proton therapy among a single-institution cohort.

METHODS AND MATERIALS

Between 2008 and 2019, 29 patients with a median age of 14.8 years (range, 3.8-21.8) received passive-scattered proton therapy for nonmetastatic chordoma. No patient received prior irradiation. Twenty-four tumors arose in the clivus/cervical spine region and 5 in the lumbosacral spine. Twenty-six tumors demonstrated classic well-differentiated histology and 3 were dedifferentiated or not otherwise specified. Approximately half of the tumors underwent specialized testing: 14 were brachyury-positive and 10 retained INI-1. Three patients had locally recurrent tumors after surgery alone (n = 2) or surgery + chemotherapy (n = 1), and 17 patients had gross disease at the time of radiation. The median radiation dose was 73.8 Gy relative biological effectivness (range, 69-75.6).

RESULTS

With a median follow-up of 4.3 years (range, 1.0-10.7), the 5-year estimates of local control, progression-free survival, and overall survival rates were 85%, 82%, and 86%, respectively. No disease progression was observed beyond 3 years. Excluding 3 patients with dedifferentiated/not-otherwise-specified chordoma, the 5-year local control, progression-free survival, and overall survival rates were 92%, 92%, and 91%, respectively. Serious toxicities included 3 patients with hardware failure or related infection requiring revision surgery, 2 patients with hormone deficiency, and 2 patients with Eustachian tube dysfunction causing chronic otitis media. No patient experienced brain stem injury, myelopathy, vision loss, or hearing loss after radiation.

CONCLUSIONS

In pediatric patients with chordoma, proton therapy is associated with a low risk of serious toxicity and high efficacy, particularly in well-differentiated tumors. Complete resection may be unnecessary for local control, and destabilizing operations requiring instrumentation may result in additional complications after therapy.

Current Role of Radiotherapy in the Management of Oral Cavity Squamous Cell Carcinoma

Study Design

Literature review.

Objective

To review the current role of radiotherapy (RT) in the management of oral cavity squamous cell carcinoma (SCC).

Methods

Review of selected literature.

Results

T1-T2N0 SCCs may be treated with either RT alone or surgery with a high likelihood of cure. The pendulum swung toward surgery with postoperative RT (PORT) added depending on the pathological findings in the mid 1980s. Patients with positive margins, extranodal extension (ENE), and/or 4 or more positive nodes receive concomitant chemotherapy (POCRT). Patients with T3-T4 and/or positive regional nodes are treated with surgery and PORT alone or POCRT. The likelihood of cure is moderate to low depending on extent of disease. The likelihood of major complications ranges from 10% to 30% depending on the method of reconstruction and the aggressiveness of postoperative PORT/POCRT. Patients with very advanced disease are treated with palliative RT, chemotherapy, or supportive care.

Conclusions

The role of RT in the management of oral cavity SCC is primarily in the postoperative setting with palliative RT being reserved for those with very advanced disease where the likelihood of cure is remote.

Clinical outcomes following proton therapy for adult craniopharyngioma: a single-institution cohort study

BACKGROUND

Craniopharyngioma is a benign tumor that commonly develops within the suprasellar region. The tumor and treatment can have debilitating consequences for pediatric and adult patients, including vision loss and pituitary/hypothalamic dysfunction. Most craniopharyngioma series focus on treatment of the pediatric population. We evaluated the outcomes of all adult craniopharyngioma patients treated at our institution using proton therapy to report outcomes for disease control, treatment-related toxicity, and tumor response.

METHODS

We analyzed 14 adult patients (≥ 22 years old). All patients had gross disease at the time of radiotherapy. Five were treated for de novo disease and 9 for recurrent disease. Patients received double-scattered conformal proton therapy to a mean dose of 54 GyRBE in 1.8 GyRBE/fraction (range 52.2-54 GyRBE). Weekly magnetic resonance imaging (MRI) helped to evaluate tumor changes during radiotherapy.

RESULTS

With median clinical and radiographic follow-up of 29 and 26 months, respectively, the 3-year local control and overall survival rates were both 100%. There were no grade 3 or greater acute or late radiotherapy-related side effects. There was no radiotherapy-related vision loss or optic neuropathy. No patients required intervention or treatment replanning due to tumor changes during radiotherapy. Two patients experienced transient cyst expansion at their first post-radiotherapy MRI. Both patients were followed closely clinically and radiographically and had subsequent dramatic tumor/cyst regression, requiring no interventions.

CONCLUSIONS

Our data support the safety and efficacy of proton therapy in the treatment of adult craniopharyngioma as part of primary or salvage treatment. We recommend early consideration of radiotherapy. This trial was registered at www.clinicaltrials.gov as #NCT03224767.

Does the Incidence of Treatment-Related Toxicity Plateau After Radiation Therapy: The Long-Term Impact of Integral Dose in Hodgkin's Lymphoma Survivors

Background

Conventional radiation therapy (RT) has produced unprecedented cure rates in patients with Hodgkin's lymphoma (HL) but exposed large volumes of nontargeted tissue to radiation (integral dose).

Objective

Our goal was to report the effects of integral radiation dose on health outcomes in patients with at least 20 years of potential follow-up time.

Methods and Materials

We reviewed the medical records of 365 patients who were treated with RT for HL between 1965 and 1995. All patients were confirmed to have received primary RT with curative intent at our institution for de novo HL. Serious adverse events were classified as HL progression or death, grade ≥3 treatment- or staging-related acute or late effects, second malignancies, or cardiovascular events.

Results

The minimum potential follow-up time was 20 years, and the actual median follow-up time 22 years (range, <1-49 years) for all patients and 27 years (range, 5-49 years) for surviving patients. The overall survival rates at 5, 10, 20, 30, and 40 years were 86%, 76%, 64%, 44%, and 27%, respectively. The observed-to-expected ratio for second malignancy was 3.6 (95% confidence interval, 2.9-4.4). Grade ≥3 cardiovascular events occurred in 31% of all patients (n = 112). At the time of the most recent follow up, serious adverse events occurred in 70% of the entire cohort (n = 256) and 58% (n = 103), 77% (n = 103), and 93% (n = 50) among those with a potential 20, 30, and 40 years of follow up, respectively.

Conclusions

With increased survivorship, the long-term impact of the integral radiation dose may result in clinically significant adverse events, which suggests the importance of surveillance and affirms advances in both chemotherapy and RT that minimize the integral dose in future patients with HL.

Proton therapy for skull-base chondrosarcoma, a single-institution outcomes study

BACKGROUND

We sought to evaluate the effectiveness of definitive or adjuvant external-beam proton therapy on local control and survival in patients with skull-base chondrosarcoma.

METHODS

We reviewed the medical records of 43 patients with a median age of 49 years (range, 23-80 years) treated with double-scattered 3D conformal proton therapy for skull-base chondrosarcomas between January 2007 and February 2016. Proton therapy-related toxicities were scored using CTCAE v4.0.

RESULTS

The median radiotherapy dose was 73.8 Gy(RBE) (range, 64.5-74.4 Gy[RBE]). Thirty-six (84%) and 7 (16%) patients underwent surgical resection or biopsy alone. Tumor grade distribution included: grade 1, 19 (44%) patients; grade 2, 22 (51%); and grade 3, 2 (5%). Forty patients had gross disease at the time of radiotherapy and 7 patients were treated for locally recurrent disease following surgery. The median follow-up was 3.7 years (range, 0.7-10.1 years). There were no acute grade 3 toxicities related to RT. At 4 years following RT, actuarial rates of overall survival, cause-specific survival, local control, and RT-related grade 3 toxicity-free survival were 95%, 100%, 89%, and 95%.

CONCLUSION

High-dose, double-scattered 3D conformal proton therapy alone or following surgical resection for skull-base chondrosarcoma is an effective treatment with a high rate of local control with no acute grade 3 radiation-related toxicity. Further follow-up of this cohort is necessary to better characterize long-term disease control and late toxicities.

Proton therapy for skull base tumors: A review of clinical outcomes for chordomas and chondrosarcomas

BACKGROUND

Skull base chordomas and chondrosarcomas are rare tumors traditionally treated by surgical resection and adjuvant radiation therapy (RT). We will discuss data evaluating clinical outcomes of proton therapy in the treatment of skull base chordomas and chondrosarcomas.

METHODS

A literature review was performed using a MEDLINE search from January 1990 to January 2017.

RESULTS

The published data suggest that the dose intensification allowed by proton therapy has resulted in good clinical outcomes and a tolerable toxicity profile.

CONCLUSION

Proton therapy is a modern RT technique that has demonstrated improved preliminary clinical outcomes in the treatment of skull base chordomas and chondrosarcomas compared to conventional radiotherapy, and comparable to other advanced photon-based RT techniques.

Implementation of depression and anxiety screening in patients undergoing radiotherapy

Anxiety and depression are disabling, underdiagnosed issues that affect the management of oncology patients. Until recently, there has been no standard protocol for screening and treating these ailments at our cancer centre. The purpose of this institutional review board-approved study was to analyse the implementation of a screening tool in our clinical workflow with the aim of screening over 90% of patients and increasing referrals to mental health services by 50%.

Knowledge and attitudes toward hookah usage among university students

OBJECTIVE

Hookah smoking is a popular form of tobacco use on university campuses. This study documented use, attitudes, and knowledge of hookah smoking among college students.

PARTICIPANTS

The sample included 943 university students recruited between February 2009 and January 2010. Respondents (M age = 20.02) included 376 males, 533 females, and 34 who did not report sex.

METHODS

An anonymous online questionnaire was completed by respondents.

RESULTS

In this sample, 42.9% of college students had tried hookah, and 40% of those individuals had used it in the past 30 days. Students perceived fewer negative consequences of hookah smoking compared with cigarette smoking. Age, sex, racial background, marijuana/cigarette use, and perceptions of side effects were significantly associated with hookah use.

CONCLUSIONS

University students are misinformed regarding the health consequences of hookah smoking. Programs aimed at education, prevention, and intervention for hookah use are needed to address this growing public health concern.