Advances of surgery and radiation therapy of glioblastoma and metastatic tumor

On the surgery for malignant gliomas, most cases are beyond the stage for desirable removal of tumors, because of the risk of damage to the normal function of surrounding brain tissue. The restriction of the surgical treatment has inevitably required postoperative radiation therapy. With a protocol aiming at removing tumors extensively and delivering high dose radiation to the tumor area, we treated 107 patients with cerebral glioblastoma. Wide removal of the tumor combined with intraoperative radiation therapy (IORT) was applied to expected resectable cases at the first surgery or at the second salvage surgery after conventional external radiation therapy. Thirty patients underwent extensive removal with IORT and demonstrated a 2-year survival rate of 60%. Fifty six patients were treated only by postoperative radiation therapy and a two-year survival rate was only 6.8%. The results apparently indicate that areas adjacent to the margin of almost complete removal should be irradiated with a sufficient dose to sterilize the remaining malignant remnants. As metastatic brain tumors without systemic metastasis seldom develop to multiple lesions, surgical removal followed by local radiation therapy would be ideal in order to prevent brain atrophy and dementia induced by whole brain irradiation. IORT would be also useful for its strong local effect to tumors and for shortening the hospital stay of patients.     

Preoperative radiation therapy with selective dose escalation to the margin at risk for retroperitoneal sarcoma

BACKGROUND: Retroperitoneal sarcomas (RPSs) are rare tumors with poor survival rates due to difficult resectability and high local and distant recurrence rates. Preoperative radiation therapy appears to have dosimetric advantages to utilize the tumor as a tissue expander to limit exposure of small bowel to higher radiation doses. METHODS: Between June 1999 and December 2003, 16 consecutive patients with biopsy-proven RPS were treated with preoperative radiation with selective dose escalation. This included 45 grays (Gy) in 25 fractions to the entire tumor plus margin and a boost dose of 57.5 Gy to the volume predicted as high risk for positive surgical margins. Treatment toxicity and local control were evaluated prospectively as primary endpoints. The secondary goal was the theoretical calculation of future dose escalation and feasibility. Each patient underwent laparotomy. Tumor response was judged using computed tomography (CT) scan and by necrosis on final pathology. Theoretical treatment plans evaluated the potential for additional radiation dose escalation. RESULTS: All patients completed the radiation protocol. The most common acute side effects were nausea/vomiting, which affected 4 patients (25%), with only 1 patient requiring inpatient intravenous hydration. There was no severe late postoperative morbidity or mortality. Twelve tumors (75%) decreased in maximum dimension, with a median decrease of 9.4%. Fourteen of 16 patients (88%) underwent complete macroscopic resection. With a median follow-up of 28 months (range, 7-52 months), there were only 2 local recurrences. The actuarial 2-year local control rate was 80%. Theoretical treatment plans suggest that significant dose escalation (up to 80 Gy) may be possible. CONCLUSIONS: Preoperative radiation therapy with selective dose escalation to the margin at risk is tolerable and allows higher radiation dose to the volume judged to be at greatest risk for local tumor recurrence.     

Desmoid tumors: Local control and patterns of relapse following radiation therapy

Desmoid tumors are benign neoplasms, arising from musculoaponeurotic tissues, which tend to be locally infiltrative, resulting in a high rate of local recurrence following surgical resection. Nineteen patients with desmoid tumors underwent radiation therapy at the University of California, San Francisco, between 1970 and 1980. Fifteen patients were referred with local recurrence following one or more surgical resections. Three patients were referred for initial radiation therapy with unresectable tumors, and one patient received planned postoperative irradiation following subtotal tumor resection. At the time of treatment, 8 patients had nonresectable disease measuring greater than 10 cm. Five patients had residual tumor masses measuring 4 to 6 cm, and six had only microscopic disease following resection. The majority of patients were treated to a tumor dose of 50–55 Gy at 1.6 to 1.8 Gy per fraction. With a median follow-up of 8 years, 13 patients remained free of recurrent disease following radiation therapy. The 5 year relapse free survival was 72% with 10 patients continuing to be free of disease 5 to 11 years following therapy. Local control was not related to the amount of disease present at the time of treatment. Of the 6 patients who developed recurrent disease, only 1 patient had a true in-field recurrence. Four patients recurred at the margin of the radiation field 1 to 5 years following therapy. Of these four patients, 3 were successfully salvaged while 1 died as a result of tumor extension into a major vessel. One patient with an extensive mesenteric mass did not respond to therapy and died 1 month post irradiation. The patient with the in-field recurrence and 1 patient with a marginal recurrence were successfully treated with combination chemotherapy. Moderate dose radiation therapy to desmoid tumors can result in lasting local control when surgical resection is not possible. Post operative radiation can improve the rate of local control for patients with a high risk of recurrence. As desmoid tumors tend to be locally infiltrative, fields must be very generous to prevent marginal recurrence. Systemic chemotherapy offers an alternative to ablative surgery in the event of local failure following radiation therapy.     

Intraoperative radiation therapy

The modern use of intraoperative radiation therapy (IORT) was initiated by the studies of Abe and colleagues at the University of Kyoto. This work stimulated significant laboratory and clinical investigation into the use of IORT throughout Japan, Europe, and the United States. Because of this experience, single high doses of irradiation can be safely delivered to a tumor volume in appropriate clinical situations. Most importantly, this high dose of additional radiation treatment yields improved local control of selected tumors. Treatment programs of external beam radiation therapy, surgical resection, and IORT for patients with locally advanced primary and recurrent rectal carcinoma and retroperitoneal sarcoma have yielded excellent local control and higher survival rates. The future of IORT will be in the successful integration of this therapy into multimodality treatment programs of chemotherapy, external beam irradiation, and surgery for locally advanced malignancies. Received: August 20, 2001     

Postoperative radiotherapy of primary spinal cord tumors

During the 30 year period from 1957 to 1986, 42 patients with primary tumors arising from the spinal cord or cauda equina received postoperative irradiation at the University of California, San Francisco. Twenty-one patients had ependymomas: 18 were localized to one site, and 3 diffusely involved the cord. There were 12 patients with low grade astrocytomas and 3 with highly anaplastic astrocytoma or glioblastoma multiforme. All astrocytomas were localized at presentation. In 6 cases tissue was insufficient to permit a histologic diagnosis. Thirty-nine patients (93%) received total radiation doses ranging between 45.0-54.7 Gy using standard fractionation. The 10-year actuarial disease-specific survival rate for patients with localized ependymoma was 93%; 33% of these tumors recurred locally. The corresponding rate for diffuse ependymomas was 50%; the spinal disease was controlled in all 3 patients, but one developed a cerebral metastasis despite prophylactic cranial irradiation. Low-grade astrocytoma patients had a 10-year actuarial disease-specific survival rate of 91%, with 33% of these tumors recurring locally. No patient with highly anaplastic astrocytoma or glioblastoma multiforme survived longer than 8 months; all of these tumors recurred locally, and two of the three also developed diffuse craniospinal axis metastases. Local recurrence for ependymoma was delayed as long as 12 years following treatment, while all but one astrocytoma failure occurred within 3 years of treatment. No significant dose-response relationship with respect to local control was noted for either localized ependymomas or low grade astrocytomas. One patient developed radiation myelitis after receiving 50.4 Gy with standard fractionation. These results indicate that patients who undergo postoperative irradiation for low grade spinal astrocytomas and localized spinal ependymomas achieve excellent survival. However, despite treatment with total radiation doses taken to the practical limit of spinal cord tolerance, local failure remains common.     

Strahlentherapie bei Knochentumoren

In bone sarcoma, the local treatment of choice is complete surgical resection. Only in Ewing tumors does definitive radiotherapy with conventional radiation doses achieve satisfactory local control rates. All other bone tumors need very high radiation doses, which often cannot be obtained with conventional radiotherapy. In such cases, special techniques, such as proton therapy, which allow the application of very high doses to the target are frequently used.     

Hyperthermia and radiation therapy in the treatment of recurrent Merkel cell tumors

A high incidence of local recurrence, spread to regional lymph nodes, and distant metastases has been reported after surgical excision of Merkel cell tumors (MCT). The use of postoperative radiation therapy and/or chemotherapy is reviewed from the literature. Despite adjuvant treatment, local tumor recurrences frequently develop. Two patients are presented with metastatic MCT recurrent in previously irradiated sites who had excellent clinical responses and local control following retreatment with local hyperthermia in conjunction with low to moderate dose radiation therapy. These patients represent the first reported use of hyperthermia in the management of MCT. The encouraging local responses described suggest a potential role for the use of hyperthermia and concomitant radiation therapy in the treatment of recurrent MCT.     

Advanced-technology radiation therapy for bone sarcomas.

BACKGROUND: Bone sarcomas are rare primary tumors. Radiation therapy (RT) can be useful in securing local control in cases where negative surgical margins cannot be obtained or where tumors are not resected. Recent technical advances in RT offer the opportunity to deliver radiation to these tumors with higher precision, thus allowing higher doses to the tumor target with lower doses to critical normal tissues, which can improve local tumor control and/or reduce treatment-related morbidity. METHODS: The authors conducted a survey of recent technical developments that have been applied to the RT for bone sarcomas. RESULTS: RT techniques that show promise include intensity-modulated photon radiation therapy, 3-D conformal proton RT, intensity-modulated proton RT, heavy charged-particle RT, intraoperative RT, and brachytherapy. All of these techniques permit the delivery of higher radiation doses to the target and less dose to normal tissue than had been possible with conventional 3-D conformal radiation techniques. Protons deliver substantially less dose to normal tissues than photons. CONCLUSIONS: Data from clinical studies using these advanced radiation techniques suggest that they can improve the therapeutic ratio (the ratio of local control efficacy to the risk of complications). This is expected to improve the treatment outcome for these challenging tumors.     

Treatment of locally advanced rectal cancer with external beam radiation, surgical resection, and intraoperative radiation therapy

To try to improve the local control and survival of patients with locally advanced rectal cancer we have used a combination of high-dose pre-operative radiation therapy to 5,040 cGy followed by surgical resection and intraoperative electron beam radiation therapy (IORT) when there was visible or palpable residual disease, microscopically positive surgical margins, or persisting tumor adherence. A total of 75 patients were taken to surgery for resection +/- IORT who did not have distant metastases. Of the 49 patients with primary tumors, 11 did not have IORT as the tumor was thought to be completely resected. Of these 11, there were two local recurrences and a 3-year survival of 71%. Thirty-six patients with primary tumors had resection (20 complete, 16 partial) plus IORT, with a 3-year survival of 58% and three local failures. Twenty-six additional patients were treated for locally advanced recurrence of whom four could not receive IORT because of pelvic size or the extent of tumor. Of the 22 who received IORT, 7/9 with complete resection, 2/8 with partial resection, and 1/5 with no resection had local control with an overall 3-year actuarial survival of 32%. The local control and survival results in the primary tumors appear favorable compared to other series in the literature and suggest benefit to the use of IORT. For patients treated for local recurrence, local control and long-term survival can be obtained, but the results are not as encouraging as for the primary tumors.     

Fistula formation after postoperative radiation treatment for paranasal sinus cancer

Postoperative radiation is frequently used in the treatment paradigm for paranasal sinus tumors. The development of 3-dimensional conformal radiation treatment and intensity modulated radiotherapy (IMRT) has facilitated the delivery of high doses required for local control of these lesions while simultaneously decreasing toxicity. At Memorial Sloan-Kettering Cancer Center, a radiation dose of 70 Gy is routinely prescribed to gross tumor, and 59.4 Gy is prescribed to a clinical target volume at high risk for subclinical disease and 54 Gy is delivered to a clinical target volume at low risk for subclinical disease. Fistula formation can occur with the delivery of postoperative radiation treatment despite the use of IMRT. Prosthesis fabrication can be used in the short-term management of this unfortunate complication with an acceptable cosmetic result. Patients should be aware of this potential toxicity, which can develop in spite of appropriate management and acceptable dosimetry. Nonetheless, combined modality therapy is recommended for aggressive treatment of paranasal sinus tumors to inhibit local progression. This report describes the clinical scenario and management of the rare incidence of fistula formation after radiation for paranasal sinus malignancy.     

Squamous cell carcinoma of the supraglottic larynx without clinically detectable lymph node metastases: problem of local relapse and influence of overall treatment time

From January 1965 until December 1979, 203 patients with squamous cell carcinoma of the supraglottic larynx were treated with curative intent. The mean follow-up time was 10 years. The policy was to try to aim for cure by radiation therapy (RT) only, reserving surgery (S) for radiation therapy failures. For 193 patients the treatment consisted of a first series of radiation therapy to a total dose of 40 Gy; if a good response to radiation therapy was obtained, the treatment was continued to a full course of 60-70 Gy (RT-I, n = 132). Patients with tumors considered to have responded poorly to the first series of radiation therapy but who refused surgery or were found medically unfit for operation, were also carried to a full dose of 60-70 Gy (RT-II, n = 33). Surgery was performed in 33 cases; 23 patients had a laryngectomy because of a poor response to radiation therapy and 10 were treated with surgery upfront because of severe respiratory distress. This paper focuses on the local control and survival in the defined treatment groups. In summary, with advancing T-stage a lower survival and higher local relapse rate was found; that is, a 5-year relapse-free survival (RFS) of 53% and corrected survival (CS) of 83% for T2 tumors vs 39% (RFS) and 52% (CS) for T4 tumors. Age more than 60 was associated with a 2.2 times higher risk of dying due to laryngeal cancer. A lower relapse-free survival (T3,4: 43% vs 61%) but a comparable corrected survival (T3,4: 64% vs 69%) for RT-I patients compared to the surgery treated patients was found, due to salvage of the radiation therapy failures. Although the relapse-free survival of RT-I and RT-II was similar (43% vs 38%), the corrected survival for the RT-II patients was worse (44% vs 69%). No influence of dose (Gy) per se on the local relapse rate was observed; however, a positive association between local relapse rate with overall treatment time was found. Death from intercurrent disease was almost twice as high as might have been expected for the normal Dutch population. More than half of the patients who died of intercurrent disease developed a second primary tumor.     

Radiation therapy in the management of medically inoperable carcinoma of the lung: results and implications for future treatment strategies.

Surgery is the treatment of choice for resectable non-small cell lung carcinoma. For patients who are medically unable to tolerate a surgical resection or who refuse surgery, radiation therapy is an acceptable alternative. We reviewed the records of 152 patients with medically inoperable non-small cell lung carcinoma treated at our institution between 1982 and 1990. Patients with metastatic disease, mediastinal lymph node involvement or unresectable tumors were excluded. The actuarial overall survival at 2 and 5 years was 40% and 10%, respectively. The disease-free survival at 2 and 5 years was 31% and 15%. The disease-free survival for patients with T1 tumors was 55% at 2 years, versus 20 and 25% for T2 and T3 lesions, respectively (p = .0006). Increasing tumor dose was also associated with increasing disease-free survival (p = .0143). Overall, 66% percent of the patients were considered to have failed. Of these, 70% showed a component of local failure and 45% failed distantly. Patients with T1 tumors experienced a lower probability of failing locally or distantly than did patients with T2 or T3 tumors. A reduced risk of local and distant failure was seen for patients treated to doses of greater than 65 Gray, especially for T1 tumors. We conclude that radical radiation therapy is an effective treatment for small tumors when treated to doses of 65 Gray or more. Since local failure is the prominent pattern of relapse in patients with large tumors, new therapeutic strategies should be considered for this patient group.     

Malignant astrocytic gliomas in children

Between 1957 and 1980, 54 children less than 20 years of age with a diagnosis of glioblastoma multiforme or malignant astrocytoma were treated. All patients had a minimum follow-up period of 5 years. Twenty-seven patients had glioblastoma multiforme and 27 had malignant astrocytoma. The median age was 8 years for glioblastoma multiforme patients and 10 years for malignant astrocytoma patients. All patients received radiation therapy, but two died of postoperative complications and did not complete the treatment. The Kernohan Grading System was more useful in distinguishing glioblastoma multiforme and malignant astrocytoma in terms of prognosis than was the Nelson criterion of tumor necrosis. Glioblastoma multiforme (IV) patients had survivals of 44% at 1 year, 26% at 2 years, 4% at 5 years, and 0% at 10 years. Malignant astrocytoma (III) patients had 74% survival at 1 year, 56% at 2 years, 36% at 5 years, and 32% at 10 years, (all P less than 0.05). The tumor dose and tumor location affected survival significantly. Patients with hemispheric malignant astrocytoma who received 54-60 Gy had a 60% 5-year survival rate compared to 14% for doses of 35-50 Gy. Glioblastoma multiforme patients with noncentral tumors had a 9% 5- year survival with 54-60 Gy versus 0% with 35-50 Gy. Cerebral and cerebellar hemispheric tumors did better than central tumors. There were no 5-year survivors among patients with central tumors. Noncentral tumors, on the other hand, resulted in a 44% 5-year survival for malignant astrocytoma and 5% for glioblastoma multiforme. Radiation therapy was well tolerated during the acute period. Only one patient developed a late neurologic deficit attributable to therapy. The patient had hearing loss after two courses of 50 Gy each to a temporal lobe tumor. However, six of the 11 patients who survived for 5 years or longer had intellectual, emotional, or endocrine dysfunction.     

Definitive irradiation in multidisciplinary management of localized Ewing sarcoma family of tumors in pediatric patients: outcome and prognostic factors

PURPOSE: To assess the effect of radiation dose on local tumor control of the Ewing sarcoma family of tumors in 79 patients with localized disease treated at a single institution. METHODS AND MATERIALS: Thirty-seven patients received vincristine, actinomycin D, cyclophosphamide, and doxorubicin, and 42 received vincristine, actinomycin D, and cyclophosphamide, with alternating cycles of ifosfamide and etoposide; all underwent definitive radiotherapy (median dose, 37.5 Gy) with either low-dose (<40 Gy) or standard dose (> or =40 Gy) radiation delivered according to the protocol. We calculated the cumulative incidence of local treatment failure, disease recurrence, and overall survival and analyzed the effect of known prognostic factors and radiation dose. RESULTS: The cumulative incidence of local treatment failure at 10 years was 30.4% and that of disease recurrence was 40%. The overall survival rate was 64.5%. Patient age > or =14 years and tumor size > or =8 cm were adverse prognostic factors for local treatment failure; patient age > or =14 years was also associated with worse survival. Although the radiation dose alone did not predict for local treatment failure, the cumulative incidence of local failure at 10 years was 19% when tumors <8 cm were treated with <40 Gy, and no patient treated with standard doses (> or =40 Gy) developed local recurrence (p = 0.084). CONCLUSION: Tumor size and patient age predict for local tumor control in patients with Ewing sarcoma family of tumors treated with systemic therapy and definitive radiotherapy. Patients treated with reduced-dose radiotherapy experienced unacceptably high rates of local recurrence.     

Results of adjuvant radiation therapy in cancer of the rectum. Thomas Jefferson University Hospital experience

From 1972 to 1981, 174 patients with cancer of the rectum surgically staged as B2 or C disease, underwent surgical resection of the tumors for cure. Eighty-eight patients received surgery only with no further adjuvant therapy, and the remaining 86 patients were treated with a combination of radiation and surgery. Twenty-nine patients received low-dose preoperative radiation (500 rad in one fraction); 26 patients received postoperative radiation (4500 rad in 5 weeks); and 31 patients received combined low-dose preoperative radiation (500 rad) and postoperative radiation (4500 rad in 5 weeks). This experience was analyzed to determine the patterns of failure and the impact of adjuvant therapy on survival. Patients undergoing surgery alone had a 26% incidence of local failure in the pelvis and a 57% incidence of distant metastasis. Patients receiving low-dose preoperative radiation had a reduction in the rate of distant metastasis (24%), but no effect on local failure (34%). On the other hand, patients receiving postoperative radiation had a reduction in the local failure rate (11%), with no effect on distant metastasis (50%). Patients who received the combined preoperative and postoperative treatment had a reduction in both the local recurrence rate (7%), and the rate of distant metastasis (13%), and these patients also had a substantial improvement in survival over surgery alone. Survival of patients undergoing surgery alone was 34% at 5 years and was not substantially different for patients undergoing low-dose preoperative irradiation (48%), or for patients receiving postoperative irradiation (29%). Survival in patients receiving combined preoperative and postoperative irradiation was substantially better (78%) than the other groups of patients.     

Ectopic Recurrence of Skull Base Chordoma after Proton Therapy

Simple SummaryChordoma are very rare tumors of the spine and skull base. Due to close proximity of crucial organs, like the brain stem, complete removal can often not be achieved, and tumor tissue, either macroscopic or microscopic, remains in situ. Local recurrence up to 88% occurs in 10 years. Ectopic recurrence as an early sign of treatment failure is considered rare. We retrospectively reviewed five patients with ectopic recurrence as a first sign of treatment failure after treatment with surgery and proton therapy, and studied the applied treatment strategies and imaging follow-up. We found 18 ectopic recurrences in these five patients, of which 17 (94%) could be related to prior surgical tracts. Our theory is that these relapses occur due to microscopic tumor spill during surgery. These cells did not receive a therapeutic radiation dose. Advances in surgical possibilities and adjusted radiotherapy target volumes might improve local control and survival.AbstractBackground: Chordoma are rare tumors of the axial skeleton. The treatment gold standard is surgery, followed by particle radiotherapy. Total resection is usually not achievable in skull base chordoma (SBC) and high recurrence rates are reported. Ectopic recurrence as a first sign of treatment failure is considered rare. Favorable sites of these ectopic recurrences remain unknown. Methods: Five out of 16 SBC patients treated with proton therapy and surgical resection developed ectopic recurrence as a first sign of treatment failure were critically analyzed regarding prior surgery, radiotherapy, and recurrences at follow-up imaging. Results: Eighteen recurrences were defined in five patients. A total of 31 surgeries were performed for primary tumors and recurrences. Seventeen out of eighteen (94%) ectopic recurrences could be related to prior surgical tracts, outside the therapeutic radiation dose. Follow-up imaging showed that tumor recurrence was difficult to distinguish from radiation necrosis and anatomical changes due to surgery. Conclusions: In our cohort, we found uncommon ectopic recurrences in the surgical tract. Our theory is that these recurrences are due to microscopic tumor spill during surgery. These cells did not receive a therapeutic radiation dose. Advances in surgical possibilities and adjusted radiotherapy target volumes might improve local control and survival.     

Conservative management of rectal cancer with local excision and adjuvant therapy

The standard surgical treatment of distal, resectable, invasive rectal cancers is an abdominoperineal resection or a low anterior resection. Given the morbidity associated with these standard treatments and the frequent need for postoperative adjuvant therapy, the use of a more conservative approach, such as local excision with adjuvant therapy as primary therapy for selected cases of rectal cancer is appealing. Data from single-institution series as well as recent data from prospective, multi-institutional studies, suggest that local excision with adjuvant therapy is a reasonable alternative to radical surgery in selected patients. Local excision alone is acceptable treatment only for T1 tumors without adverse pathologic features, while local excision with adjuvant therapy is an alternative treatment for T1 tumors with adverse pathologic features and T2 tumors. Some series suggest that preoperative therapy with local excision may be a possible treatment for selected T3 tumors; however, the high local failure rates seen in T3 tumors treated with local excision and postoperative therapy cautions against this approach. Functional results with local excision are generally good, and postoperative morbidity and mortality is acceptable. In summary, the results of local excision and radiation therapy are encouraging. Randomized trials are needed to determine whether this approach has local control and survival rates comparable to those of radical surgery.     

The optimal radiation volume after first-line chemotherapy in Hodgkin lymphoma

Radiation therapy has evolved from extended-field radiation therapy (EFRT) to involved-field radiation therapy (IFRT), reducing toxicity while maintaining high cure rates. Recent publications recommend a further reduction to involved-nodal radiation therapy (INRT); however, this has not been clinically validated. The need for irradiation or optimal radiation volume after chemotherapy are not defined. The treatment results of 296 Hodgkin's disease patients receiving ABVD or BEACOPP-21 chemotherapy with consequent EFRT demonstrate CR/PR > or = 80% and 99% local disease control rate. Beam therapy with EFRT is possible to use if dose levels don't exceed 30 Gy. Higher doses demands reduction of volume of radiating target. In our opinion the optimum program of beam therapy involves 2 stages with maximal possible dose level EFRT followed by additional INRT. Those approaches offer perspectives for Hodgkin's disease treatment.     

Radiation therapy for patients with locally advanced pancreatic cancer: Evolving techniques and treatment strategies

Despite ongoing efforts, patients with locally advanced pancreatic cancer (LAPC) continue to have a dismal prognosis. Such tumors are unresectable, and optimal treatment with chemotherapy and/or radiation therapy is still not established. While chemotherapy is conventionally aimed at preventing metastatic spread of disease, radiation therapy acts locally, improving local control which can potentially improve overall survival and most importantly quality of life. Here, we aim to review the primary literature assessing the role of diverse radiation therapy strategies for patients with LAPC.Many radiation regimens can be considered, and no standard treatment has demonstrated a clear improvement in clinical outcomes. We advise that the modality of choice be dependent on the availability of equipment, the dose and fractionation of treatment, as well as the dose received by normal tissue. Moreover, a candid discussion with the patient concerning treatment goals is equally as essential. Three notable strategies for LAPC are intensity-modulated radiation therapy, volumetric modulated arc therapy, and proton. These radiation modalities tend to have improved dose distribution to the target volumes, while minimizing the radiation dose to surrounding normal tissues. Stereotactic body radiation therapy can also be considered in LAPC patients in cases where the tumor does not invade the duodenum or other neighboring structures. Because of the high doses delivered by stereotactic body radiation therapy, proper respiratory and tumor motion management should be implemented to reduce collateral radiation dosing. Despite improved clinical outcomes with modern radiation modalities, evolving techniques, and more accurate planning, future studies remain essential to elucidate the optimal role for radiation therapy among patients with LAPC.     

Are postoperative complications more frequent and more serious after irradiation for laryngeal and hypopharyngeal cancer?

In order to improve local cure rates and survival in patients with head and neck cancer, combinations of radiotherapy and surgery are used. Most reports on such treatment results indicate an improvement with combined therapy. However, it is not clear whether it is best to irradiate before or after surgery. There is disagreement in the literature, whether postoperative complications are more frequent when the irradiation is given prior to surgery. The incidence of postoperative complications was studied in 213 patients who had a laryngectomy for laryngeal or hypopharyngeal cancer. The incidence of major complications was 8.5% after a preoperative dose of 40 or 50 Gy. After rescue surgery for radiation failure this percentage was 32%. In our experience, the incidence of postoperative complications after doses up to 50 Gy/5 weeks is comparable to what can be expected after surgery alone. When higher doses are given, these complications are more frequent. In designing treatment plans, such considerations should be kept in mind.