Postoperative elective nodal irradiation for squamous cell carcinoma of the head and neck: outcome and prognostic factors for regional recurrence

BackgroundThis study describes the results of elective irradiation in the N0 neck and tries to identify prognostic factors for regional recurrence.Materials and methodsBetween 1985 and 2000, 785 cN0 or pN0 necks were treated with elective nodal irradiation in 619 head and neck squamous cell carcinoma patients.ResultsRegional control at 3 years was 94% in the cN0 (nondissected) neck compared with 97% in the pN0 (dissected) neck and 90% in the ipsilateral compared with 96% in the contralateral neck (P = 0.08 and P = 0.006, respectively). Regional control in the ipsilateral cN0 neck was 78% compared with 96% in the contralateral cN0 neck. Surgical margin of the primary tumor was an additional prognostic factor in all N0 and pN0 necks.ConclusionsNeck control rates in electively irradiated N0 necks were excellent. Regional control was worse in the cN0 neck compared with the pN0 neck and in the ipsilateral neck compared with the contralateral side. Additionally, in case of positive surgical margins of the primary tumor, elective nodal irradiation should be applied, even in case of a pN0 neck.     

Pattern of lymph node metastases in squamous cell carcinoma of the tonsil: implication for selective neck dissection

The aim of this study was to prospectively analyze the distribution of neck metastases and the outcome in patients surgically treated for tonsillar carcinoma in order to deduce implications for selective neck dissection. The criteria for inclusion in the study were (1) previously untreated, histologically proven, resectable squamous cell carcinoma of the tonsil, (2) curative surgical intent on the primary tumor and neck, (3) no history of prior head and neck cancer, (4) absence of synchronous second primary in the upper aerodigestive tract, lung and esophagus, (5) absence of distant metastases. Fifty-eight previously untreated consecutive patients with tonsillar squamous cell carcinoma were included in this prospective study. Among 22 patients with clinically negative cervical lymph nodes, 4 patients (18.2%) had metastatic lymph nodes on pathologic examination. Occult node metastases were mainly located in ipsilateral II level. No occult metastases occurred at levels I and V. Among 36 patients with clinically positive cervical lymph nodes, 3 patients (8.3%) had an occult pathologic metastatic involvement of cervical lymph nodes of ipsilateral level V. Level I was free of lymph node metastases. Clinical N category >N2a (p=0.003), nodal metastases to levels III (p=0.026) and IV (p=0.009) were significantly related to level V nodal metastases. The 2 and 5 years actuarial disease-free survival was 82.7% (95% CI 71.2-93.5%) and 58.3% (95% CI 36.7-79.9%), respectively. The actuarial recurrence-free survival was 87.9% (95% CI 78.9-96.8%) and 72.2% (95% CI 53.9-90.5%) at 2 and 5 years, respectively. Our findings support the role of a selective lateral neck dissection in the management of clinically N0 necks and in selected N+ necks (N1 and N2a disease located at level II) in patients with tonsillar carcinoma without oral involvement.     

Radiation therapy of squamous cell carcinoma of the nasal vestibule

From 1978 until 1988, 63 consecutive patients with squamous cell carcinoma of the nasal vestibule were treated by radiation therapy. Mean follow-up time was 46 months. Thirty-five patients were classified as having T1N0 tumors, 24 as T2N0; four patients were staged as T1/2N+. Treatment of the primary consisted of external radiation (n = 17), interstitial radiation (n = 37), or external radiation combined with interstitial radiation (n = 9). With respect to the N0 patients, local relapse was found in 3% (1/35) of T1 tumors and in 21% (5/24) of T2 tumors. Three out of six failures were salvaged by surgery. Elective irradiation of both sides of the neck (40 Gy) was performed in 9 T1 and in 16 T2 patients. Two regional failures occurred in the electively irradiated necks, two in the non-irradiated necks. Regarding the T1/2N+ patients, three relapsed locally and/or regionally, and one remains NED. For all 63 patients, a 5-year corrected survival of 90%, a relapse-free survival of 80%, and an overall survival of 65% were observed. In summary, for optimal local control and cosmesis we feel that for T1,2 N0 tumor stages a dose of 60 Gy for T1 and 70 Gy for T2 tumors is adequate treatment. The primary tumor is irradiated preferentially in our view, by means of interstitial techniques; furthermore, our data do not support the use of elective neck RT. Although patients rarely present with lymph node metastasis (6%), the prognosis of T1,2 N+ patients remains grim and more aggressive (surgical) treatment might be needed for this category.     

Dosimetric Evaluation of 3-D Conformal and Intensitymodulated Radiotherapy for Breast Cancer after Conservative Surgery

Background: Breast cancers are becoming more frequently diagnosed at early stages with improved longterm outcomes. Late normal tissue complications induced by radiotherapy must be avoided with new breastradiotherapy techniques being developed. The aim of the study was to compare dosimetric parameters of planningtarget volume (PTV) and organs at risk between conformal (CRT) and intensity-modulated radiation therapy(IMRT) after breast-conserving surgery. Materials and Methods: A total of 20 patients with early stage leftbreast cancer received adjuvant radiotherapy after conservative surgery, 10 by 3D-CRT and 10 by IMRT, witha dose of 50 Gy in 25 sessions. Plans were compared according to dose-volume histogram analyses in terms ofPTV homogeneity and conformity indices as well as organs at risk dose and volume parameters. Results: The HIand CI of PTV showed no difference between 3D-CRT and IMRT, V95 gave 9.8% coverage for 3D-CRT versus99% for IMRT, V107 volumes were recorded 11% and 1.3%, respectively. Tangential beam IMRT increasedvolume of ipsilateral lung V5 average of 90%, ipsilateral V20 lung volume was 13%, 19% with IMRT and3D-CRT respectively. Patients treated with IMRT, heart volume encompassed by 60% isodose (30 Gy) reducedby average 42% (4% versus 7% with 3D-CRT), mean heart dose by average 35% (495cGy versus 1400 cGywith 3D-CRT). In IMRT minimal heart dose average is 356 cGy versus 90cGy in 3D-CRT. Conclusions: IMRTreduces irradiated volumes of heart and ipsilateral lung in high-dose areas but increases irradiated volumes inlow-dose areas in breast cancer patients treated on the left side.     

Radiation therapy for cutaneous squamous cell carcinoma involving the parotid area lymph nodes: dose and volume considerations

PURPOSE: The intraparotid and periparotid lymph nodes are the most commonly involved when skin cancer of the head and neck metastasizes beyond the primary site. We sought to report the clinical outcome of patients treated with radiation therapy for parotid-area metastases from cutaneous squamous cell carcinoma of the head and neck. METHODS AND MATERIALS: The records of 36 patients treated with radiation therapy for cutaneous squamous cell carcinoma involving the parotid-area lymph nodes were reviewed. All patients had clinically N0 necks and were without evidence of distant disease. Thirty patients (83%) were treated postoperatively after gross total tumor resection. Median dose to the parotid area was 60 Gy (range, 50-72 Gy). Treatment of clinically N0 necks consisted of surgical dissection (7 patients), irradiation (15 patients), and observation (14 patients). RESULTS: The 5-year estimate of local (parotid) control was 86% in patients treated using surgery with postoperative therapy and 47% in patients treated using radiation therapy alone. Three of 4 patients with tumors that relapsed locally after surgery and postoperative radiation received a dose of less than 60 Gy. Elective neck irradiation decreased the incidence of subsequent nodal failures from 50% to 0% and significantly improved neck control (p < 0.001). The 5-year overall survival rate was 63%. CONCLUSIONS: Surgery followed by radiation therapy to doses of at least 60 Gy results in effective local control for patients with parotid area metastasis from cutaneous squamous cell carcinoma. Routine irradiation of the clinically N0 neck is recommended.     

宫颈癌术后快速旋转调强放疗和三维适形放疗计划的对比研究

目的 探讨宫颈癌术后快速旋转调强放疗（RapidArc）和三维适形放疗（3D-CRT）计划靶区及其周围危及器官（OAR）受照剂量的差异。方法 随机选择10 例宫颈癌术后患者,进行CT 扫描、靶区（PTV）和OAR的勾画,处方剂量50Gy。分别进行RapidArc和3D-CRT计划设计,计算并比较两种计划的PTV剂量均匀度指数（HI）、适形度指数（CI）、最大受照剂量（PTV Dmax）、最小受照剂量（PTV Dmin）、平均受照剂量（PTV Dmean）和OAR受照体积。结果 RapidArc计划的CI及PTV Dmean均优于3D-CRT计划;RapidArc计划对OAR（膀胱V50,直肠V40、V50,左、右股骨头V20）的保护优于3D-CRT计划（P＜0.05）。两种计划的PTV Dmax、PTV Dmin、HI和OAR受照体积（小肠V10、V20、V30、V40、V50,直肠V10、V20、V30, 膀胱V10、V20、V30、V40,左、右股骨头V10、V30、V40、V50）的差异均无统计学意义（P＞0.05）。结论 宫颈癌术后辅助放疗中,RapidArc计划在靶区CI和PTV Dmean方面均优于3D-CRT,同时RapidArc计划在正常组织保护上也有一定的优势。     

Minimising contralateral breast dose in post-mastectomy intensity-modulated radiotherapy by incorporating conformal electron irradiation

Purpose

To assess the potential benefit of incorporating conformal electron irradiation in intensity-modulated radiotherapy (IMRT) for loco-regional post-mastectomy RT.

Patients and methods

Ten consecutive patients that underwent left-sided mastectomy were selected for this comparative planning study. Three-dimensional conformal radiotherapy (3D-CRT) photon-electron dose plans were compared to photon-only IMRT (IMRT_p) and photon IMRT with conformal electron irradiation (IMRT_p/e). The planning target volume (PTV) was prescribed 50 Gy and included the chest wall and the internal mammary and supra-clavicular lymph node regions. It was attempted to minimise dose delivered to heart, lungs and contralateral breast (CB), while maintaining adequate PTV coverage.

Results

All plans complied with objectives for PTV coverage. IMRT_p/e eliminated volumes receiving ?70 Gy (V70) that were present in 3D-CRT at the junction of photon and electron beams. Both IMRT strategies reduced heart V30 significantly below 3D-CRT levels. Mean heart dose with IMRT_p/e was the lowest and was equal to that with 3D-CRT. Minimising heart dose with IMRT_p resulted in irradiated CB volumes much larger than that with 3D-CRT. With IMRT_p/e, CB dose was only slightly increased when compared to 3D-CRT. Mean lung dose values were similar for IMRT and 3D-CRT. With IMRT, lung V20 was smaller, whereas V5 values for heart, lung and CB were higher than those with 3D-CRT.

Conclusions

Incorporation of conformal electron irradiation in post-mastectomy IMRT_p/e enables a heart dose reduction which can only be obtained with IMRT_p when allowing large irradiated volumes in the contralateral breast.     

Level IIb lymph node metastasis in elective neck dissection of oropharyngeal squamous cell carcinoma

This study investigated the oncologic safety of preserving level IIb lymph nodes in ipsilateral and/or contralateral elective neck dissection (END) in patients with oropharyngeal squamous cell carcinoma (SCC). Fifty-one oropharyngeal SCC patients who underwent surgery as an initial treatment were reviewed. Twenty-one patients had clinically node negative necks (cN0) while 30 patients had ipsilateral clinically node positive necks (cN+). Of the cN0 patients, bilateral or ipsilateral END was performed in 15 and six patients, respectively. For the cN+ cases, ipsilateral therapeutic neck dissection with contralateral END was performed in 24 of 30 patients. In the cN0 patients, nodal metastasis to level IIb lymph nodes was not observed in any ipsilateral (21) or contralateral necks (15). Of the 24 cN+ patients who underwent contralateral END, two cases (8.3%) showed contralateral occult level IIb lymph node metastasis. Our data suggest that in cN0 oropharyngeal cancer patients, level IIb lymph nodes may be preserved in ipsilateral and contralateral neck dissection. However, caution is advised when preserving contralateral level IIb nodes in ipsilateral cN+ cases.     

Lymph node metastasis in maxillary sinus carcinoma

PURPOSE: To evaluate the incidence and prognostic significance of lymph node metastasis in maxillary sinus carcinoma. METHODS AND MATERIALS: We reviewed the records of 97 patients treated for maxillary sinus carcinoma with radiotherapy at Stanford University and at the University of California, San Francisco between 1959 and 1996. Fifty-eight patients had squamous cell carcinoma (SCC), 4 had adenocarcinoma (ADE), 16 had undifferentiated carcinoma (UC), and 19 had adenoid cystic carcinoma (AC). Eight patients had T2, 36 had T3, and 53 had T4 tumors according to the 1997 AJCC staging system. Eleven patients had nodal involvement at diagnosis: 9 with SCC, 1 with UC, and 1 with AC. The most common sites of nodal involvement were ipsilateral level 1 and 2 lymph nodes. Thirty-six patients were treated with definitive radiotherapy alone, and 61 received a combination of surgical and radiation treatment. Thirty-six patients had neck irradiation, 25 of whom received elective neck irradiation (ENI) for N0 necks. The median follow-up for alive patients was 78 months. RESULTS: The median survival for all patients was 22 months (range: 2.4-356 months). The 5- and 10-year actuarial survivals were 34% and 31%, respectively. Ten patients relapsed in the neck, with a 5-year actuarial risk of nodal relapse of 12%. The 5-year risk of neck relapse was 14% for SCC, 25% for ADE, and 7% for both UC and ACC. The overall risk of nodal involvement at either diagnosis or on follow-up was 28% for SCC, 25% for ADE, 12% for UC, and 10% for AC. All patients with nodal involvement had T3-4, and none had T2 tumors. ENI effectively prevented nodal relapse in patients with SCC and N0 neck; the 5-year actuarial risk of nodal relapse was 20% for patients without ENI and 0% for those with elective neck therapy. There was no correlation between neck relapse and primary tumor control or tumor extension into areas containing a rich lymphatic network. The most common sites of nodal relapse were in the ipsilateral level 1-2 nodal regions (11/13). Patients with nodal relapse had a significantly higher risk of distant metastasis on both univariate (p = 0.02) and multivariate analysis (hazard ratio = 4.5, p = 0.006). The 5-year actuarial risk of distant relapse was 29% for patients with neck control versus 81% for patients with neck failure. There was also a trend for decreased survival with nodal relapse. The 5-year actuarial survival was 37% for patients with neck control and 0% for patients with neck relapse. CONCLUSION: The overall incidence of lymph node involvement at diagnosis in patients with maxillary sinus carcinoma was 9%. Following treatment, the 5-year risk of nodal relapse was 12%. SCC histology was associated with a high incidence of initial nodal involvement and nodal relapse. None of the patients presenting with SCC histology and N0 necks had nodal relapse after elective neck irradiation. Patients who had nodal relapse had a higher risk of distant metastasis and poorer survival. Therefore, our present policy is to consider elective neck irradiation in patients with T3-4 SCC of the maxillary sinus.     

Is dissection of level IV absolutely necessary in elective lateral neck dissection for clinically N0 laryngeal carcinoma?

A prospective study of 73 previous untreated consecutive patients with clinically N0 laryngeal squamous cell carcinoma (SCC) from January 1997 to October 2002 was undertaken to determine whether level IV lymph nodes can be saved in elective lateral neck dissection (LND) performed as a treatment for the N0 neck. The incidence of pathological metastases to level IV lymph nodes was evaluated, as were the incidence of regional recurrence after elective LND, and postoperative complications such as chylous leakage and phrenic nerve paralysis. A total of 142 LNDs were enrolled in this prospective study. The mean number of harvested lymph nodes by level was as follows; 13.1 in level II, 7.1 in level III, and 9.2 in level IV. Pathologic examination revealed nodal involvement in 25 neck specimens (17.6%, 25 of 142). Five necks had lymph nodes which were positive for microscopic metastasis in level IV (3.5%, 5 of 142). These necks were all ipsilateral (6.8%, 5 of 73) and none of the 69 contralateral neck specimens had level IV lymph node metastasis (0%, 0 of 69). With regard to T stage, 3.3% (1 of 30) of ipsilateral necks of T2 tumors exhibited occult metastasis in level IV lymph nodes, 5.9% (2 of 34) for T3 tumors, and 33.3% (2 of 6) for T4 tumors. There were no cases of T1 (n = 3). Separate skip metastasis in level IV lymph nodes was observed in two necks (1.4%, 2 of 142). Four cases of regional recurrence (5.5%, 4 of 73) were observed. Postoperative chylous leakage and phrenic nerve paralysis occurred in four cases (5.5%, 4 of 73) and two cases (2.7%, 2 of 73), respectively. The results of the present study demonstrate the rare incidence of level IV occult lymph node metastasis, as well as infrequent nodal recurrence after elective LND in the treatment of clinically N0 laryngeal SCC. Therefore, dissection of level IV lymph node pads, especially in the ipsilateral neck of early T staged tumors or the contralateral neck, may be unnecessary for the treatment of laryngeal SCC patients with a clinically N0 neck.     

3D-conformal RT, fixed-field IMRT and RapidArc, which one is better for esophageal carcinoma treated with elective nodal irradiation

The purpose of this study is to compare the characteristics of 3D-conformal radiotherapy (3D-CRT), fixed-field intensity-modulated radiotherapy (IMRT) and RapidArc for esophageal squamous cell carcinoma (ESCC) treated with elective nodal irradiation (ENI). CT datasets of 20 patients with ESCC were included and plans for single and double arcs of RapidArc (RA1 and RA2), 7-field IMRT and 3D-CRT were created and optimized for each patient. The goal was to deliver 59.6?Gy to?≥95% of the planning target volume (40?Gy to electively irradiated lymph nodal regions) while meeting the same normal-tissue dose constraints. The plans were compared based on dosimetric characteristics of target and organs at risk (OARs), monitor units (MUs), and appraised beam-on time. Both RA2 and IMRT resulted in similar target coverage (V95%, 97.84±1.50% for RA2 versus 96.96±1.15% for IMRT), homogeneity index (HI, 0.11±0.02 for RA2 versus 0.10±0.01 for IMRT) and conformity index (CI, 0.81±0.03 for RA2 versus 0.79±0.04 for IMRT), which displayed slightly better than single arc (V95%=94.55±1.50%, HI=0.12±0.02, CI=0.80±0.02) and much better than 3D-CRT (V95%=91.17±2.89%, HI=0.15±0.03, CI=0.60±0.07). The total lung V20, V30 was reduced approximately from 31%, 16% (3D-CRT) to 22%, 13% (IMRT) and 20%, 12% (RA2); the heart V30, V40 from 29%, 21% (3D-CRT) to 28%, 20% (IMRT) and 27%, 18% (RA2). The maximum dose to the spinal cord was 44.26±2.60?Gy for 3D-CRT, 42.47±2.40?Gy for IMRT, and 42.79±1.81?Gy for RA2. The number of MUs per fraction reduced from 990±165 (IMRT) to 503±70 (3D-CRT) and 502±79 (RA2). Appraised beam-on time of RapidArc was 1.2-2.4?min, which was lower than IMRT with 5.4?min by average. RapidArc, especially for double arcs plan could provide slight improvements in OARs sparing and lower MUs without compromised target qualities compared with IMRT, which was much better than 3D-CRT for ESCC treated with ENI.     

Evaluation of treatment results of squamous cell carcinoma of the buccal mucosa

Of the 49 patients with squamous cell carcinoma of the buccal mucosa referred to the Rotterdam Radio-Therapeutic Institute (RRTI) and Universital Hospital Dijkzigt Rotterdam (AZD) during 1970-1984, 31 patients had an advanced stage of disease, 21 patients had clinical evidence of lymph node metastasis. Forty patients were treated with curative intention. Treatment modalities were: radiation therapy, preoperative radiation followed by surgery, and primary surgery. Eighteen of the 40 patients (45%) developed a local tumor recurrence; nearly all recurrences occurred within 2 years. The incidence was equal in all treatment groups. Of the 22 patients with initial clinically negative neck, regional relapse occurred in 3 of the 14 patients, of whom the neck was not treated electively by radiation therapy; all three in combination with a local recurrence. None of the 8 patients with electively irradiated necks developed a regional relapse. Eight of the 18 patients with initial clinically enlarged lymph nodes treated either by radiotherapy or surgery, developed a regional relapse, 5 in combination with a local recurrence. Treatment of the clinically positive neck by neck dissection was superior to radiotherapy. Local recurrence carried a poor prognosis. Almost 70% died of their disease. The overall and corrected 5-year survival was 38% and 52% respectively.     

Neck dissection: concepts, controversies, and technique

The various types of neck dissections are described. The indications for each type of neck dissection are discussed for patients with necks staged N0, N+, for the patient with an unknown primary and for the patient whose neck dissection is in conjunction with radiation. The technical aspects of modified neck dissections are addressed but not in great detail. The indications for the use of postoperative radiation are emphasized. The nodal groups at risk for metastases from various primary sites are identified and a terminology for neck dissection is suggested.     

The impact of positron emission tomography/computed tomography in edge delineation of gross tumor volume for head and neck cancers

PURPOSE: To study anatomic biologic contouring (ABC), using a previously described distinct halo, to unify volume contouring methods in treatment planning for head and neck cancers. METHODS AND MATERIALS: Twenty-five patients with head and neck cancer at various sites were planned for radiation therapy using positron emission tomography/computed tomography (PET/CT). The ABC halo was used in all PET/CT scans to contour the gross tumor volume (GTV) edge. The CT-based GTV (GTV-CT) and PET/CT-based GTV (GTV-ABC) were contoured by two independent radiation oncologists. RESULTS: The ABC halo was observed in all patients studied. The halo had a standard unit value of 2.19 +/- 0.28. The mean halo thickness was 2.02 +/- 0.21 mm. Significant volume modification (>or=25%) was seen in 17 of 25 patients (68%) after implementation of GTV-ABC. Concordance among observers was increased with the use of the halo as a guide for GTV determination: 6 patients (24%) had a 相似文献   

Incidence of isolated regional recurrence after definitive (chemo-) radiotherapy for head and neck squamous cell carcinoma

Objective

To evaluate the incidence and localization of regional recurrences after definitive (chemo-) radiotherapy for head and neck squamous cell carcinoma (HNSCC).

Methods

From May 1987 to March 2008, 368 patients with advanced HNSCC were irradiated to 66-80.5 Gray in 6-7 weeks, with (37%) or without (63%) concomitant chemotherapy (Cisplatinum 100 mg/m²) every 3 weeks. No planned neck dissections were performed. Data on clinical outcome were retrospectively reviewed, location of the original nodal disease and the regional recurrence was indicated on imaging and correlated with radiation dose.

Results

Mean follow-up was 34 months (range: 50 days-216 months). Three-year overall survival and disease-specific survival were 55% and 62%, respectively. Loco-regional, local and regional controls were 58%, 65%, and 80%, respectively. Forty-one patients (11.1%) relapsed in the neck, but only 11 patients (2.99%) developed a true isolated regional recurrence, 6 of whom could be successfully salvaged by surgery. Only 2 patients (0.54%) developed an isolated recurrence in the electively treated nodal levels.

Conclusion

Isolated nodal recurrences are uncommon and recurrences in the electively treated neck are extremely uncommon.     

Sentinel node detection in N0 cancer of the pharynx and larynx

Neck lymph node status is the most important factor for prognosis in head and neck squamous cell carcinoma. Sentinel node detection reliably predicts the lymph node status in melanoma and breast cancer patients. This study evaluates the predictive value of sentinel node detection in 50 patients suffering from pharyngeal and laryngeal carcinomas with a N0 neck as assessed by ultrasound imaging. Following 99m-Technetium nanocolloid injection in the perimeter of the tumour intraoperative sentinel node detection was performed during lymph node dissection. Postoperatively the histological results of the sentinel nodes were compared with the excised neck dissection specimen. Identification of sentinel nodes was successful in all 50 patients with a sensitivity of 89%. In eight cases the sentinel node showed nodal disease (pN1). In 41 patients the sentinel node was tumour negative reflecting the correct neck lymph node status (pN0). We observed one false-negative result. In this case the sentinel node was free of tumour, whereas a neighbouring lymph node contained a lymph node metastasis (pN1). Although we have shown, that skipping of nodal basins can occur, this technique still reliably identifies the sentinel nodes of patients with squamous cell carcinoma of the pharynx and larynx. Future studies must show, if sentinel node detection is suitable to limit the extent of lymph node dissection in clinically N0 necks of patients suffering from pharyngeal and laryngeal squamous cell carcinoma.     

Clinical dosimetric study of three radiotherapy techniques for postoperative breast cancer: Helical Tomotherapy, IMRT, and 3D-CRT

This paper is to investigate the dosimetric characteristics of Helical Tomotherapy (HT), step-and-shoot intensity-modulated radiation therapy (SaS-IMRT) and three-dimensional conformal radiation therapy (3D-CRT) for the postoperative breast cancer as well as their dosimetric comparison of the normal tissues. CT images of 10 postoperative patients with early stage breast cancer were transferred into HT, SaS-IMRT and 3D-CRT planning systems respectively after the target region and normal tissues were outlined by the same physician to assure the contour consistency. Each prescribed dose for three different modalities of plans was given to a total of 50 Gy in 25 fractions. Doses and irradiated volumes in heart, lungs, as well as conformity index (CI) and homogeneity index (HI) were evaluated for detailed comparison. All three plans showed appropriate coverage for the prescribed target dose in the dosimetric comparison. The CI in HT and SaS-IMRT as well as 3D-CRT was 0.68 ± 0.12, 0.58 ± 0.08 and 0.40 ± 0.08, respectively. The HI were 1.10 ± 0.03, 1.14 ± 0.02 and 1.17 ± 0.04, which appeared intergroup significant differences (p < 0.05). V?, V??, as well as V?? of the heart were smallest in 3D-CRT than HT and SaS-IMRT. V5 of the ipsilateral lung was the smallest in 3D-CRT than HT and SaS-IMRT (p < 0.05); However, V?? and V?? were smaller in HT and SaS-IMRT than 3D-CRT (p < 0.05). V? of the contralateral lung was the smallest in 3D-CRT than other groups, with V??~V?? were basically similar in numeric values with not obvious discrepancy. Comparing with SaS-IMRT and 3D-CRT, HT technique in treating breast cancer had the best conformity and homogeneity index as well as steepest dose gradient due to its highly modulated beamlets with rotational technique. The heart volume irradiated was the smallest in conventional 3D-CRT, with SaS-IMRT was the largest among the three techniques, as expected. The volume of the contralateral lung irradiated was the smallest in 3D-CRT than other groups. V? of the ipsilateral lung was the smallest in 3D-CRT than other two groups. V??~V?? in HT and SaS-IMRT were similar and better than 3D-CRT dosimetrically. We conclude that HT technique had advantages over SaS-IMRT and 3D-CRT based on the dosimetric comparison in this study, especially in the high dose region of ipsilateral lung, target homogeneity and dose uniformity.     

Elective nodal failures are uncommon in medically inoperable patients with Stage I non-small-cell lung carcinoma treated with limited radiotherapy fields

PURPOSE: To review the outcome for 56 Stage I non-small-cell lung cancer treated definitively with three-dimensional conformal radiotherapy (3D-CRT) and to investigate the value of elective nodal irradiation in this patient population. METHODS AND MATERIALS: Between 1992 and 2001, 56 patients were treated with 3D-CRT for inoperable Stage I histologically confirmed non-small-cell lung cancer; 31 with T1N0 and 25 with T2N0 disease. All patients were treated with 3D-CRT to a median isocenter dose of 70 Gy (range 59.94-83.85) given in daily doses of 1.8 or 2 Gy. Prognostic factors were analyzed with respect to their impact on overall survival. Twenty-two patients received radiotherapy (RT) directed to elective regional lymphatics to doses of 45-50 Gy. The remaining 33 patients were treated to limited fields confined to the primary lung cancer with a margin. The patterns of failure were reviewed. RESULTS: The median follow-up was 20 months (range 6 months to 6 years). The actuarial local control rate was 88%, 69%, and 63%, at 1, 2, and 3 years, respectively. The actuarial cause-specific survival rate was 82%, 67%, and 51% at 1, 2, and 3 years, respectively. The actuarial overall survival rate was 73%, 51%, and 34% at 1, 2, and 3 years, respectively. The actuarial metastasis-free survival rate was 90%, 85%, and 81% at 1, 2, and 3 years, respectively. The RT dose was the only factor predictive of overall survival in our analysis. No statistically significant difference was noted in cause-specific or overall survival according to whether patients received elective nodal irradiation. Two of 33 patients treated with limited fields had regional nodal failure. CONCLUSION: Many patients with medically inoperable Stage I lung cancer die of intercurrent causes. The omission of the elective nodal regions from the RT portals did not compromise either the cause-specific or overall survival rate. Elective nodal failures were uncommon in the group treated with limited RT fields. A radiation dose 70 Gy was predictive of better survival in our population. We await the results of prospective trials evaluating high-dose RT in patients treated with RT alone for Stage I lung cancer.     

The role of selective neck dissection (I-III) in the treatment of node negative (N0) neck in oral cancer

It is now possible to limit the extent of selective neck dissection for mucosal squamous cell carcinoma of the head and neck by sparing selected lymphatic levels thereby reducing the morbidity. This has been brought about by our improved understanding of the metastasis behavior of these cancers. Studies have demonstrated similar rates of neck recurrences and survival after selective neck dissection compared to modified radical neck dissection. The purpose of this study was to evaluate the efficacy of selective neck dissection (SND) in managing the N0 neck in oral cavity carcinomas. A retrospective analysis of Squamous cell carcinoma of oral cavity with N0 neck from 1998 to 2004 was performed. Statistical analysis was done using SPSS software. The chi-square test was used to compare the various proportions. The overall and disease-free survival were estimated using the Kaplan–Meier method and statistical significant difference in survival was tested by log rank test. Out of the 219 cases, 84% were in the early stage and 16% were in the late stages. Seventy two percent of the patients had primary tumors in the anterior two-thirds of the tongue. One hundred and sixty one patients were pathologically node negative. There was no statistically significant difference in the regional recurrence between the pN0 and pN+ patients. There was no difference in the regional recurrence inside and outside the surgical field. The pathological node positive patients had a worse disease-free survival (DFS) compared to the node negative patients, and the patients with nodal recurrence had a significantly worse DFS compared to patients without nodal recurrence. SND (I–III) is a sound and effective procedure in the management of clinically negative neck in squamous cell carcinoma of the oral cavity. Clinically N0 neck but pathologically N+ neck requires adjuvant radiation therapy. It probably has a therapeutic role in the selected cases of squamous cell carcinoma of the oral cavity with N1 neck, and in these cases an extension of dissection to levels IV and V is beneficial.