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Treatment planning for breast cancer has been traditionally based on clinical landmarks. The Radiation Therapy Oncology Group (RTOG) published consensus guidelines on contouring target volumes (TV) for the breast/chest wall and draining lymphatics. The effect of these guidelines on dosimetric parameters in surrounding organs at risk (OAR) and TVs is unknown. Fourteen patients treated with clinically derived plans from 2007-2011 (Group I) and fourteen patients treated with target volume-based plans from 2011-2012 were selected for comparison (Group II). Treatment plans were constructed based on clinical landmarks (Group I) or TVs (Group II) to a median dose of 50.4 Gy to the breast/chest wall, axilla (Ax), supraclavicular (SCV), and internal mammary (IMN) lymph nodes. The RTOG TVs were then contoured in Group I patients by a single investigator blinded to the dose distributions. Dose-volume histograms (DVH) were computed for the RTOG TVs and OARs in both groups, and DVH parameters were compared. In Group II, coverage improved for the SCV (V90 = 78.0% versus 93.6%, p = 0.02) and intact breast (V95 = 95.6% versus 99.3%, p = 0.007). The dose to the cord, the lung (V20Gy and V30Gy), and contralateral breast (V5Gy) were the same. Finally, the low dose to the heart and lung was decreased in Group II (heart V5Gy= 48.7% versus 27.3%, p= 0.02, heart V10Gy = 33.5% vs. 17.5%, p = 0.01, and ipsilateral lung V5Gy = 84.5% vs. 69.3%, p = 0.001). Overall, our study supports that treatment planning using the RTOG consensus guidelines can improve coverage to certain target volumes compared to treatments based solely on clinical landmarks. Additionally, treatment planning using these target volumes does not increase dose to the contralateral breast, cord, heart, or lungs. Longer follow-up is needed to determine if using these target volumes will affect clinical outcomes.

Summary: Purpose: Current standard therapy for nasopharyngeal carcinoma (NPC) is concurrent chemoradiation based on randomized data. However, limited randomized data exist to support the addition of induction chemotherapy (ICT). Methods: 58 Patients with NPC were treated from 1990 to 2010. All patients received platinum-based ICT. All 58 patients were treated with chemoradiation, 57 in a week-on/week-off (WOWO) fashion. Concurrent chemotherapy included hydroxyurea/5-fluorouracil for all patients. Median radiation dose was 70Gy. No patient received adjuvant chemotherapy. Results: AJCC 2009 stage was II=13, III=21, IVa=13, and IVb=11. Median follow-up for surviving patients was 66months. Response to ICT was complete response (CR) 17% and partial response (PR) 64%. The CR rate after chemoradiation was 96%. Five-year actuarial freedom from local failure (FFLF), freedom from distant failure (FFDF), cause-specific survival (CSS), and overall survival (OS) was 98%, 90%, 90%, and 76%, respectively. Analysis of pediatric patients (n =9) demonstrated 5-year actuarial FFLF, FFDF, CSS, and OS of 100%, 88%, 80%, and 80%, respectively. Conclusions: ICT followed by concurrent chemoradiation demonstrates excellent FFLF, FFDF, CSS, and OS with tolerable toxicity. Induction chemotherapy followed by concurrent chemoradiation for patients with NPC should be explored further in a randomized setting. [ABSTRACT FROM AUTHOR]

Up to 50% of patients with head and neck cancer (HNC) may recur after initial treatment, which often includes a combination of surgery, chemotherapy, and radiation. Reirradiation is an effective treatment option with high rates of local control. Hypofractionated regimens may be desirable due to high biologically effective doses, however they can be complicated by high rates of toxicity. Intensity-modulated proton therapy (IMPT) plans have dosimetric advantages compared to standard photon plans. We sought to review initial patient tolerance and treatment outcomes of proton-based stereotactic body radiotherapy (SBRT) for reirradiation of HNC. A single institution retrospective review of HNC patients treated with proton-based SBRT for reirradiation in the head and neck from July 2020 to December 2022 was performed. Acute and late toxicities were prospectively recorded. Patient reported outcomes were assessed prior to and at completion of treatment using the MD Anderson Symptom Inventory (MDASI) and EQ-5D5L visual analogue score (VAS). Planning outcomes and dosimetry parameters, including GTV volume, conformity (CI and R50), and PTV coverage were evaluated. Local control and overall survival were estimated using the Kaplan-Meier method. Paired t-test was used to compare continuous variables. 9 patients were treated with proton SBRT to 10 lesions in the head and neck. Most patients had squamous cell carcinoma histology (89%). All patients received a biologically effective dose of at least 58.5 Gy at initial course. Patients were reirradiated at median time of 2 years following prior head and neck radiotherapy (range 0.4, 15.8). The most commonly used dose and fractionation for reirradiation was 40 Gy (range 34, 40) in 5 fractions. Three patients received immunotherapy during treatment. Average gross target volume (GTV) was 9.1 cc (1.7, 28.6). The mean conformity index was 1.0 (0.6, 1.1) and mean R50% was 4.0 (2.3, 6.7). PTV V100% was 86.0% on average (54.9% – 96.2%). No patients developed a new grade 3 or greater toxicity during treatment or at last follow up. Comparing pretreatment to end of treatment timepoints, there was no significant increase in the mean VAS (55 to 62, p = 0.10), with no significant change in the mean MDASI symptom (2.5 to 2.4, p = 0.77) or interference (3.7 to 3.2, p = 0.63) scores. Local control was 100% at last follow up or death. Median overall survival was 0.8 years. Proton-based SBRT for reirradiation of HNC is well tolerated with high rates of local control and median overall survival consistent with other reports in this population. Further follow up is necessary to assess tumor control and toxicities. [ABSTRACT FROM AUTHOR]

HPV-driven oropharyngeal squamous cell cancer (OPSCC) has a high cure rate and a high burden of treatment-related toxicities. Transoral robotic surgery (TORS) is a treatment option for patients with early-stage disease. Most patients will be recommended adjuvant RT. ECOG 3311 was a phase 2 trial demonstrating that patients with intermediate pathologic risk factors treated with 50 Gy of adjuvant RT had similar survival as those receiving the current standard 60 Gy of adjuvant RT. However, 50 Gy is still associated with meaningful toxicity, specifically with respect to impaired swallowing function. Circulating tumor HPV DNA (ctHPVDNA) is a sensitive marker of tumor recurrence. We posit that HPV-driven OPSCC patients with intermediate pathologic risk factors and an undetectable post-operative ctHPVDNA are a subset of patients with particularly excellent prognosis that are candidates for further de-escalation of therapy. We initiated a trial treating those patients with 36 Gy of adjuvant RT based on the hypothesis that swallow function (as measured by the MD Anderson Dysphagia Inventory (MDADI)) will be improved at one year compared to historical controls from ECOG 3311. We opened a single institution study (NCT05387915) including patients with pT1-2, N0-1, M0 HPV-related OPSCC who had TORS resection of their primary site and neck dissection. Inclusion criteria include patients with <10 pack-year smoking history or a <30 pack-year smoking history if >10 years since last tobacco consumption. Pathologic criteria include a set of intermediate risk factors (close margin (1-4 mm), perineural invasion, 2-4 positive lymph nodes or a single lymph node >3 cm, and no ENE). Patients must have a detectable pre-operative ctHPVDNA. A ctHPVDNA is drawn 7-14 days post-operatively; if negative, patients receive 36 Gy of adjuvant RT in 2.4 Gy daily fractions; if positive, they receive care per the discretion of the treating radiation oncologist. If the final surgical margin at the the primary site is >2mm, patients are eligible to have the primary tumor site omitted from the radiation volume. Our primary endpoint is 1-year composite MDADI score. Secondary endpoints include overall/progression-free survival and other quality of life metrics. The study is powered to detect an 8.5-point improvement in MDADI composite score at one year over the historical control from ECOG 3311 Arm B. With an alpha of 0.05 and a power of 0.90 we require 27 evaluable patients. Accounting for dropout, we aim to enroll 33 total patients. We have been open for approximately one year at a single institution and have enrolled 13 patients thus far. We have plans to open at two additional sites.. This ongoing study of ctHPVDNA-guided adjuvant RT in patients with HPV-driven OPSCC continues to accrue well. [ABSTRACT FROM AUTHOR]

Advanced radiotherapy techniques (ART), including intensity-modulated radiotherapy (IMRT) and proton beam therapy (PBT), offer enhanced conformality, can reduce acute and late toxicities from radiotherapy for head and neck cancers (HNC), and are considered standard-of-care by consensus guidelines. This study aims to characterize implementation of ART and corresponding patterns of care in the United States since 2004. Data for patients treated with external beam radiotherapy for primary HNC (any histology) were extracted from the National Cancer Database (2004-2017). Cases with metastatic disease and early stage glottic larynx cancer (Tis-T2,N0) were excluded. ART was defined as radiotherapy delivery with either IMRT or PBT, while non-ART encompassed 2D or 3D-conformal techniques. Sociodemographic, facility-specific, and clinical associations with receipt of ART were assessed by logistic regression. 177,373 patients with HNC were eligible for analysis; 94.2% received ART (IMRT: 93.3%, PBT: 0.9%), and 5.8% received non-ART. ART utilization increased substantially from 3,317 (78.0%) in 2004 to 14,088 (96.0%) in 2012 (p<0.001), largely driven by adoption of IMRT (77.0% to 95.7%). Use of ART increased slightly between 2012 and 2017 (96.0% to 96.9%; p<0.001), driven by growth in PBT (0.3% to 2.7%; p<0.001). On multivariable logistic regression, black patients were less likely to receive ART (OR 0.87; 95%CI 0.80-0.94), as were older patients (continuous OR 0.95; 95%CI 0.93-0.96), the uninsured (OR 0.70; 95%CI 0.63-0.78), and those with Medicaid (OR 0.80; 95%CI 0.74-0.87). Patients undergoing care at treatment facilities in the Northeast or Midwest, of non-academic affiliation, and with lower HNC volume were also less likely to receive ART. Census-tract level measures of income and educational attainment were directly correlated with receipt of ART. Likewise, nasopharyngeal or oropharyngeal primary site, advanced T- or N-classification, and receipt of chemotherapy or surgery were each independently associated with receipt of ART. ART utilization has increased since the early 2000's, driven initially by IMRT and more recently by PBT. Despite the near-ubiquity of ART today, we identified racial, socioeconomic, and geographic disparities in their adoption, potentially exposing disadvantaged patients to preventable toxicity and quality-of-life insults from non-ART. [ABSTRACT FROM AUTHOR]