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Background: This study was done to determine if pre-radiotherapy (pre-RT) dental extractions reduce the risk of osteoradionecrosis (ORN)., Methods: Between 1987 and 2004, 413 patients with oropharyngeal carcinomas were treated with definitive RT at the University of Florida. Dentate patients underwent pretreatment dental evaluation. Teeth in the RT field were usually extracted if thought to have poor long-term prognosis from dental disease. The endpoint was > or = grade 2 ORN using a modified staging system. Patients were excluded for local recurrence, additional RT above the clavicles, or head and neck surgery besides neck dissection., Results: ORN rates were as follows: edentulous, <1%; teeth in-field with pre-RT extractions, 15%; and teeth in-field without pre-RT extractions, 9%. Patients with poor in-field teeth and pre-RT extractions had a higher 5-year incidence of ORN than those who did not have pre-RT extractions (16% vs 6%, p = .48). Likewise, for those with in-field teeth in good condition and pre-RT extractions, the 5-year ORN incidence was higher than for those who did not undergo extractions (15% vs 2%, p = .42). Multivariate analysis revealed increased ORN risk with doses of >70 Gy, once-daily fractionation, or brachytherapy., Conclusion: Pre-RT extractions do not appear to reduce the risk of ORN., ((c) 2007 Wiley Periodicals, Inc. Head Neck, 2007.)

Background and Objectives: Utilization of personal digital assistants (PDAs) in residency education is common, but information about their use and how residents are trained to use them is limited. Better understanding of resident and faculty PDA use and training is needed., Methods: We used a cross-sectional survey of 598 residents and faculty from the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) Family Medicine Residency Network regarding PDA usage and training., Results: Use of PDAs is common among residents (94%) and faculty (79%). Ninety-six percent of faculty and residents report stable or increasing frequency of use over time. The common barriers to PDA use relate to lack of time, knowledge, and formal education. Approximately half of PDA users (52%) have received some formal training; however, the majority of users report being self-taught. Faculty and residents prefer either small-group or one-on-one settings with hands-on, self-directed, interactive formats for PDA training. Large-group settings in lecture, written, or computer program formats were considered less helpful or desirable., Conclusions: PDAs have become a commonly used clinical tool. Lack of time and adequate training present a barrier to optimal application of PDAs in family medicine residency education.

Purpose: Review of the University of Florida experience in treating advanced squamous cell carcinomas of the head and neck with concurrent intraarterial cisplatin and radiotherapy (RADPLAT)., Patients and Methods: Thirty-five patients with Stage III or IV head and neck squamous cell carcinomas were treated between November 2000 and October 2001 with 3 to 4 cycles of weekly intraarterial cisplatin (150 mg/m2) and a rapid infusion of the neutralizing agent sodium thiosulfate (9 g/m2), followed by a continuous infusion of sodium thiosulfate (12 g/m2), with concomitant radiotherapy (RT). The primary site was treated with 70 Gy in 35 fractions with 6 MV photons, and the low neck received 50 to 70 Gy depending on nodal involvement. Median follow-up for all patients was 4.06 years; median follow-up for living patients was 4.34 years., Results: The 4-year outcomes were: local-regional control, 78%; distant metastasis-free survival, 83%; cause-specific survival, 65%; and survival, 57%. The majority of patients with recurrent disease failed at the primary site (73%); the remaining 27% of patients with recurrent disease failed only in distant sites. Nine patients required a neck dissection after chemoradiation because of suspected residual disease; 2 of 9 patients had residual tumor in the neck nodes. Severe osteoradionecrosis occurred in 26% of patients, and 9 of 35 patients (26%) required a permanent gastrostomy., Conclusions: RADPLAT results in excellent local-regional control and survival in patients with advanced squamous cell carcinomas of the head and neck. Outcomes from the University of Florida are comparable to those reported by other institutions. However, in our limited experience, the likelihood of osteoradionecrosis and permanent gastrostomy may be higher than what might be anticipated after RT alone or combined with intravenous chemotherapy.

Background: This study investigates the effect of full-thickness versus superficial closure of the breast parenchyma on the likelihood of subsequent infection and local recurrence after lumpectomy for early-stage breast cancer. In patients undergoing breast-conserving therapy (BCT), operative closure technique has been largely influenced by expected cosmetic outcome. However, the common practice of promoting postoperative fluid collection raises concerns about potential bacterial colonization, tumor cell migration, and impaired post-BCT surveillance., Methods: From 1985 through 2004, operative closure technique was determined in 516 breasts in 580 women with stage T0-2N0-1 breast cancers undergoing BCT. Medical records were reviewed to determine closure technique, incidence of postoperative infection, and local recurrence characteristics., Results: Median follow-up was 6.4 years from the completion of radiotherapy. The rate of acute infection was higher with the superficial closure technique: 11.7% (27/230) versus 5.2% (15/286) (P = .009). In T1-2 patients, there was no difference in the rate of local recurrence based on closure type: 5.6% (11/195) versus 3.5% (8/231) (P = .348). On multivariate analysis, acute infections and margin status were associated with increased local recurrence. Superficial closure was associated with larger recurrences less likely to be detected on mammogram. In stage T0-T2 patients, 80% of recurrent tumors after superficial closures were greater than 1 cm compared with no recurrent tumors greater than 1 cm after full-thickness closures (P = .005). In patients with superficial closure, 29% of recurrences in the tumor bed were initially detected on mammogram versus 100% in patients with deep closure (P = .003)., Conclusions: Closure method was not predictive of local recurrence. Our findings regarding infection and post-treatment surveillance suggest, however, that full-thickness closure may be the preferred technique in BCT patients.

Purpose: The purpose of this study was to evaluate the prognostic significance of paraglottic space invasion determined with pretreatment computed tomography (CT) for patients with T2N0 glottic carcinoma treated with radiotherapy (RT)., Methods: Eighty patients with T2N0 glottic squamous cell carcinomas treated with definitive RT between 1983 and 2002 who had pretreatment CT information available regarding paraglottic space invasion were analyzed. Follow up ranged from 0.14 to 18 years (median, 7.1 years). No patient was lost to follow up., Results: Five-year outcomes were: local control, 78%; local control with larynx preservation, 80%; relapse-free survival, 71%; and cause-specific survival, 91%. Multivariate analyses of various parameters (including vocal cord mobility, paraglottic space invasion, supraglottic invasion, and subglottic extension) showed that only subglottic extension significantly influenced the probability of cure., Conclusion: Paraglottic space invasion is likely associated with increased tumor volume and, by itself, is not necessarily associated with poorer outcome after definitive RT.

Purpose: The purpose of this study was to report the outcomes after external-beam radiotherapy (RT) for selected T3 and T4 vocal cord squamous cell carcinomas., Methods and Materials: One hundred nine patients with previously untreated T3 and T4 squamous cell carcinomas of the glottic larynx were treated with curative intent in this Institutional Review Board-approved outcome study using continuous-course RT alone (106 patients) or followed by a planned neck dissection (3 patients) between September 1966 and June 2002. Patients selected for such treatment had relatively low-volume, unilateral disease. Patients were staged according to the recommendations of the American Joint Committee on Cancer (AJCC) as follows: T3N0, 68 patients (62%); T3N1, 14 patients (13%); T3N2B, 5 patients (5%); T4N0, 17 patients (16%); T4N1, 4 patients (4%); and T4N2B, 1 patient., Results: The 5-year outcomes after treatment were: local control for stage T3 and T4, 78% and 81%; locoregional control for AJCC stage III and IVa, 62% and 78%; distant metastasis-free survival for AJCC stage III and IVa, 97% and 100%; cause-specific survival for AJCC stage III and IVa, 84% and 87%; and overall survival for AJCC stage III and IVa, 52% and 67%, respectively. Severe complications occurred in 13 patients (12%)., Conclusions: The results of this retrospective study compare favorably with those published elsewhere in the literature for T3 and T4 vocal cord carcinomas. Local control and ultimate cure probabilities will hopefully improve further with the addition of concomitant chemotherapy to RT for larger tumors.

Purpose: To report the long-term outcome after radiotherapy with curative intent for Stage IIIB and IVA carcinoma of the cervix., Methods and Materials: We retrospectively reviewed 91 patients treated with radiotherapy with curative intent at the University of Florida between January 1980 and December 2003 for Stage IIIB (84 patients) or IVA (7 patients) carcinoma of the cervix., Results: The median follow-up of the surviving patients was 8.8 years. The 5- and 10-year estimates of local control, regional control, locoregional control, relapse-free survival, and overall survival were 53% and 53%, 55% and 47%, 34% and 29%, 30% and 26%, and 29% and 21%, respectively. Ninety percent of the recurrences occurred within 2 years of treatment. Of these, 60% of all failures were local, 29% were regional, and 11% were distant failures alone. Also, 17% of the failures were in the paraaortic nodes with no evidence of failure in the pelvis. Univariate and multivariate analyses were conducted with the endpoint of relapse-free or overall survival. No factor was statistically significant. Complications from therapy were scored using the Radiation Therapy Oncology Group grading system; the overall severe late complication rate was 13% (Grade 3-5)., Conclusion: This series is one of the most mature of published reports. With long-term follow-up, approximately one-third of patients with Stage IIIB or IVA carcinoma of the cervix were cured, with a 13% complication rate.

Purpose: To determine the long-term outcome of a consistent treatment approach with electron beam postmastectomy radiation therapy (PMRT) in breast cancer patients with > or =10 positive nodes treated with combined-modality therapy., Methods and Materials: TSixty-three breast cancer patients with > or =10 positive lymph nodes were treated with combined-modality therapy using an electron beam en face technique for PMRT at the University of Florida. Patterns of recurrence were studied for correlation with radiation fields. Potential clinical and treatment variables were tested for possible association with local-regional control (LRC), disease-free survival (DFS), and overall survival (OS)., Results: TAt 5, 10, and 15 years, OS rates were 57%, 36%, and 27%, respectively; DFS rates were 46%, 37%, and 34%; and LRC rates were 87%, 87%, and 87%. No clinical or treatment variables were associated with OS or DFS. The use of supplemental axillary radiation (SART) (p = 0.012) and pathologic N stage (p = 0.053) were associated with improved LRC. Patients who received SART had a higher rate of LRC than those who did not. Moderate to severe arm edema developed in 17% of patients receiving SART compared with 7% in patients not treated with SART (p = 0.28)., Conclusions: TA substantial percentage of patients with > or =10 positive lymph nodes survive breast cancer. The 10-year overall survival in these patients was 36%. The addition of SART was associated with better LRC.

Purpose: To investigate the incidence of radiation-induced ototoxicity according to the total dose delivered to specific parts of the auditory system, fractionation, and chemotherapy., Methods and Materials: Records of 325 patients treated for primary extracranial head and neck tumors with curative intent who received radiotherapy between 1964 and 2000 (median follow-up, 5.4 years) were retrospectively reviewed. Reconstructions of the treatment plans were generated to estimate the doses received by components of the auditory system., Results: Radiotherapy-induced morbidity developed in 41.8% of patients (external ear, 33.2%; middle ear, 28.6%; and inner ear, 26.8%). Univariate/multivariate analyses indicate that total dose received by parts of the auditory system seem to be significant, though fractionation and chemoradiation may contribute to the incidence of ototoxicities. Sensorineural hearing loss (SNHL) was observed in 49 patients (15.1%). Univariate and multivariate analyses indicated that age (p = 0.0177 and p = 0.005) and dose to cochlea (p < 0.0001 and p < 0.0001) were significant, and chemoradiation (p = 0.0281 and p = 0.006) may increase the incidence of SNHL. Five-year and 10-year actuarial risk of clinically overt SNHL increased to 37% (p > 0.0001) above doses of 60.5 Gy compared to 3% at doses below 60.5 Gy. For patients treated with adjuvant chemotherapy, clinically overt SNHL increased to 30% compared to 18% in the no-chemotherapy group at 10 years (p = 0.0281)., Conclusion: Radiotherapy toxicity was observed in all parts of the auditory system with median doses for incidence varying between 60 Gy to 66 Gy. Total dose to organ seems to be a significant factor though fractionation and chemo-radiation may contribute to ototoxicities.

Objective: The Berg muscle-based categorization of axillary lymph node location (commonly referred to as levels I, II, and III) was used extensively by pathologists and surgeons to describe the extent of axillary node dissection in breast cancer patients. However, its reproducibility with different arm positions and utility in 3-dimensional radiation treatment planning hasn't been tested., Methods: Computed tomography scans were observed in 16 patients in 2 positions: historical position (HP), ipsilateral arm abducted 90 degrees to the body axis; standard position (SP), arms above head. The volume, contents, and location of Berg lymph node levels (LNL) and the location of lymph nodes, surgical clips, pectoral muscles, and vascular structures relative to reference points were compared., Results: From HP to SP there was no difference in LNL volumes. However, if measured from an anatomic landmark, the third thoracic vertebra (T3), LNL position varied: level I, an average of 23.1 mm anteriorly, P < 0.01; level II, 7.5 mm medially, P = 0.04; level III, 18.8 mm medially, P = 0.05. Using T3 as a reference: pectoralis major and minor muscles displaced medially (23.9 mm, P < 0.01 and 7.5 mm, P = 0.09) and anteriorly (18.2 mm, P < 0.01 and 11.2 mm, P < 0.01); axillary (18.0 mm, P < 0.01), subscapular (25.4 mm, P < 0.01), and lateral thoracic (8.4 mm, P < 0.01) vessels displaced anteriorly; axillary vessels displaced also medially (15.1 mm, P = 0.03). Disagreements in LN coverage with changes in arm position were observed in 60% (LNs) and 66% (clips) for level II., Conclusions: Surgeons, radiologists, and radiation oncologists should be aware that LNL coverage based on muscle boundaries varies significantly with arm position changes, making objective comparisons of information collected in different arm positions unreliable.

Purpose: To report the tolerability and efficacy of twice-daily whole-abdomen irradiation (WAI) for non-Hodgkin's lymphoma (NHL)., Methods and Materials: Of 123 patients treated for NHL with WAI, 37% received previous chemotherapy, 28% received WAI as part of comprehensive lymphatic irradiation (CLI), and 32% received WAI for palliation. The median dose to the whole abdomen was 25.0 Gy, followed by a median tumor boost of 9.8 Gy in 58 patients. Fractionation was 1.0 Gy once daily (54%) or 0.8 Gy twice daily (46%). Blood counts were measured weekly., Results: At a median follow-up of 4.3 years, local control was 72% and overall survival was 55% at 5 years. Median time of WAI was 42 days for once-daily treatment and 32 days for twice-daily treatment. Patients receiving twice-daily WAI did not have a significantly higher rate of acute side effects (e.g., nausea, diarrhea, platelet or red blood cell toxicity). Overall, acute thrombocytopenia was the most frequent side effect of treatment; 24 of 96 patients (25%) with available hematologic data had Grade 3+ toxicity. There was no acute Grade 3 gastrointestinal toxicity and no late small bowel obstruction. Multiple regression indicated that patients with four or less involved sites and disease size < or =6 cm had improved local control and overall survival., Conclusions: Twice-daily WAI using 0.8 Gy/fraction does not appear to have any greater toxicity compared with once-daily treatment using 1 Gy/fraction. Small doses per fraction (0.8-1 Gy/fx) are effective, tolerated well in the acute setting, and associated with a low rate of late toxicity.

Objective: To determine the rates of local-regional control, survival, and complications for patients treated with postoperative radiation for squamous carcinomas of the larynx, hypopharynx, and oropharynx., Methods: There were 295 patients with previously untreated squamous cell carcinomas of the larynx (n = 199), hypopharynx (n = 80), and oropharynx (n = 16) treated postoperatively with radiotherapy (RT)., Results: Five-year local-regional control rates according to site and pathologic American Joint Committee on Cancer (AJCC) stage were: stage III larynx, 89% versus stage IVA larynx, 85% (P = 0.33); stage III oropharynx/hypopharynx, 76% versus stage IVA oropharynx/hypopharynx, 79% (P = 0.72). Local-regional control rates steadily declined as the number of indications for administering postoperative RT increased. Five-year absolute survival rates versus pathologic AJCC stage for the entire group were: stage III 59% and stage IVA 40% (P = 0.40)., Conclusion: Rates of local-regional control, survival, and complications support the use of postoperative radiation in selected patients. Tumor control and survival will hopefully improve further with the addition of chemotherapy to postoperative radiation.

Purpose: Delayed breast cellulitis (DBC) is characterized by the late onset of breast erythema, edema, tenderness, and warmth. This retrospective study analyzes the risk factors and clinical course of DBC., Methods and Materials: From 1985 through 2004, 580 sequential women with 601 stage T0-2N0-1 breast cancers underwent breast conserving therapy. Cases of DBC were identified according to accepted clinical criteria: diffuse breast erythema, edema, tenderness, and warmth occurring >3 months after definitive surgery and >3 weeks after radiotherapy. Potential risk factors analyzed included patient comorbidity, operative technique, acute complications, and details of adjunctive therapy. Response to treatment and long-term outcome were analyzed to characterize the natural course of this syndrome., Results: Of the 601 cases, 16%, 52%, and 32% were Stage 0, I, and II, respectively. The overall incidence of DBC was 8% (50/601). Obesity, ecchymoses, T stage, the presence and aspiration of a breast hematoma/seroma, removal of >5 axillary lymph nodes, and arm lymphedema were significantly associated with DBC. The median time to onset of DBC from the date of definitive surgery was 226 days. Ninety-two percent of DBC patients were empirically treated with antibiotics. Fourteen percent required more invasive intervention. Twenty-two percent had recurrent episodes of DBC. Ultimately, 2 patients (4%) underwent mastectomy for intractable breast pain related to DBC., Conclusion: Although multifactorial, we believe DBC is primarily related to a bacterial infection in the setting of impaired lymphatic drainage and may appear months after completion of radiotherapy. Invasive testing before a trial of antibiotics is generally not recommended.

Purpose: We sought to report the outcomes after definitive radiotherapy (RT) for nasopharyngeal carcinoma., Methods: Between March 1983 and November 2003, 82 patients were treated with curative intent and followed from 0.2 to 22 years (median, 5 years). Follow-up on living patients ranged from 2.8 to 22 years (median, 10.8 years). Thirty-two patients (39%) were treated once daily, 45 patients (55%) were treated with hyperfractionation, and 5 patients (6%) were treated with the concomitant boost technique. Eight patients (10%) received intensity-modulated radiotherapy. Thirty-one patients (38%) received induction (17 patients) or concomitant (14 patients) chemotherapy. Fourteen patients (17%) underwent a planned neck dissection., Results: The 5-year outcomes after treatment were: local control, 78%; regional control, 90%; local-regional control, 76%; distant metastasis-free survival, 80%; cause-specific survival, 66%; and survival, 57%. The impact of T-stage, N-stage, overall stage, World Health Organization class, fractionation schedule, and adjuvant chemotherapy were evaluated in a multivariate analysis of various outcomes. Only N-stage and World Health Organization class impacted regional control., Conclusions: The likelihood of cure after RT is relatively high. Although the likelihood of cure diminished with increasing stage, none of the parameters evaluated significantly influenced outcomes aside from N-stage and WHO class.

Purpose: Our aim was to report the control rate of radiographically positive retropharyngeal (RP) nodes with radiation therapy (RT) and to correlate posttreatment imaging with clinical outcome., Methods and Materials: Sixteen patients treated with definitive RT for head-and-neck cancer had radiographically positive RP nodes (size >1 cm in largest axial dimension, or presence of focal enhancement, lucency, or calcification), and both pre-RT and post-RT image sets available for review. An additional 21 patients with unconfirmed radiographically positive RP nodes had post-RT imaging, which consisted of computed tomography (CT) at a median of 4 weeks after completing RT. Patients with positive post-RT RP nodes underwent observation with serial imaging., Results: Of 16 patients with pre-RT and post-RT images available for review, 9 (56%) had a radiographic complete response, and of 21 patients with unconfirmed positive RP nodes with post-RT images available for review, 14 (67%) had a radiographic complete response. In all, 14 patients with incomplete response on post-RT imaging experienced control of their disease with no further therapy, and no RP node or neck failures were noted during a median follow-up of 2.8 years. Six patients with positive post-RT RP nodes had serial imaging available for review, and none demonstrated radiographic progression of disease., Conclusions: Radiographic response at 4 weeks may not accurately reflect long-term locoregional control, as RP nodes may continue to resolve over time. The highest index of suspicion should be reserved for patients with progressive changes in size, focal lucency, or focal enhancement on serial imaging after RT.

Purpose: To examine locoregional control after adjuvant radiotherapy (RT) for cutaneous melanoma and compare outcomes between conventional fractionation and hypofractionation., Methods and Materials: Between January 1980 and June 2004, 56 patients with high-risk disease were treated with adjuvant RT. Indications for RT included: recurrent disease, cervical lymph node involvement, lymph nodes >3 cm, more than three lymph nodes involved, extracapsular extension, gross residual disease, close or positive margins, or satellitosis. Hypofractionation was used in 41 patients (73%) and conventional fractionation was used in 15 patients (27%)., Results: The median age was 61 years (21->90). The median follow-up among living patients was 4.4 years (range, 0.6-14.4 years). The primary site was located in the head and neck in 49 patients (87%) and below the clavicles in 7 patients (13%). There were 7 in-field locoregional failures (12%), 3 out-of-field regional failures (5%), and 24 (43%) distant failures. The 5-year in-field locoregional control (ifLRC) and freedom from distant metastases (FFDM) rates were 87% and 43%, respectively. The 5-year cause-specific (CSS) and overall survival (OS) was 57% and 46%, respectively. The only factor associated with ifLRC was satellitosis (p = 0.0002). Nodal involvement was the only factor associated with FFDM (p = 0.0007), CSS (p = 0.0065), and OS (p = 0.016). Two patients (4%) who experienced severe late complications, osteoradionecrosis of the temporal bone and radiation plexopathy, and both received hypofractionation (5%)., Conclusions: Although surgery and adjuvant RT provides excellent locoregional control, distant metastases remain the major cause of mortality. Hypofractionation and conventional fractionation are equally efficacious.

Purpose: To report the incidence of second bladder and colorectal cancers after prostate brachytherapy., Methods and Materials: This review included 125 patients treated with I-125 brachytherapy alone, and 223 patients who received supplemental external beam radiation therapy. Median follow-up was 10.5 years. Patients were followed for the development of lower genitourinary and colorectal cancers. Second malignancies arising five years after radiation therapy were defined as being potentially associated with treatment; observed rates were then compared with age-matched expected rates according to Surveillance, Epidemiology, and End Results data., Results: Five years out of treatment, there were 15 patients with a second solid tumor, including bladder cancer (n = 11), colorectal cancer (n = 3), and prostatic urethra cancer (n = 1). The incidence of second malignancy was no different in patients treated with brachytherapy alone (1.6%) vs. those receiving external beam radiotherapy (5.8%, p = 0.0623). There were more observed bladder cancers compared with those expected (relative risk, 2.34, 95% confidence interval 0.96-3.72; absolute excess risk 35 cancers per 10,000 patients). Relative risk did not significantly change over increasing follow-up intervals up to 20 years after treatment., Conclusions: There may be an increased but small risk of developing a second malignancy after radiation therapy for prostate cancer. This outcome could be related to radiation carcinogenesis, but more vigilant screening and thorough workup as a result of radiation side effects and predisposing conditions (e.g., genetic and environmental factors) in many of the patients found to have second malignancies likely contributed to the higher number of observed malignancies than expected.

Objective: To evaluate the efficacy of preoperative radiotherapy (RT) and chemoradiation (CRT) followed by transanal excision (TAE) for rectal adenocarcinoma., Methods: Thirty-two patients were treated between July 1988 and April 2004 and followed from 2 to 123 months (median, 27 months)., Results: The 3-year outcomes were: locoregional control, 79%; distant metastasis-free survival, 80%; cause-specific survival, 88%; and overall survival, 75%. Outcomes were better for patients with T1-T2 tumors and those who experienced a complete response to preoperative RT or CRT. Two patients (6%) had chronic RT proctitis after treatment., Conclusion: A select subset of patients with T2/T3 tumors will experience similar outcomes after preoperative RT or CRT and TAE compared with radical proctectomy. Reliably predictive clinicopathologic features to define this subgroup would best be elicited in the context of large prospective randomized trials, as would the optimal combination and schedule of systemic agents delivered in conjunction with preoperative RT. Patients who experience a complete response (cCR) after preoperative CRT are excellent candidates for TAE; those with less than a cCR have a less-favorable prognosis and are probably better treated with a low anterior resection or abdominal-perineal resection.

Objective: The minimum dose required to electively irradiate all of part of the low neck for squamous cell carcinoma of the oropharynx is 50 Gy in 25 fractions or its radiobiological equivalent. The purpose of our study is to determine the incidence of hypothyroidism when the thyroid is treated only in the low-neck radiotherapy (RT) field to approximately 50 Gy., Methods and Materials: 390 patients with oropharyngeal carcinoma received RT between 1990 and 2000, had no prior thyroid disease or surgery, and had RT involving the standard anterior low-neck field including the thyroid with a dose equivalent to 50 Gy at 2Gy/fx with or without a boost to a portion of the field to 60 to 70 Gy. The end point was hypothyroidism defined as thyroid stimulating hormone (TSH) above the upper limit of the normal range., Results: As we did not routinely monitor TSH during this study, it was obtained in 169 of 390 patients. Median follow-up on all 390 patients was 6.1 years. The incidence of hypothyroidism was calculated for 2 groups: 169 patients with TSH data and the total population of 390 patients. For both analyses, patients were censored at last follow-up if the TSH level was normal, or if TSH was not checked. The incidence of hypothyroidism at 5 years was 31% for all 390 patients and 54% for the subset of 169 patients with TSH data. Adjuvant chemotherapy and/or planned neck dissection may be associated with a small increased risk of hypothyroidism., Conclusions: Including the thyroid in the low-neck field to 50 Gy results in hypothyroidism in 30% to 50% of patients at 5 years, suggesting that the threshold for this complication is <50 Gy.

Purpose: To report outcomes of patients with localized intracranial germinoma treated with low-dose craniospinal irradiation (CSI) followed by a boost to the ventricular system and primary site., Methods and Materials: Thirty-one patients had pathologically confirmed intracranial germinoma and no spine metastases. Low-dose CSI was administered in 29 patients: usually 21 Gy of CSI, 9.0 Gy of ventricular boost, and a 19.5-Gy tumor boost, all at 1.5 Gy per fraction. Our neuroradiologist recorded three-dimensional tumor size on magnetic resonance images before, during, and after radiotherapy., Results: With a median follow-up of 7.0 years, 29 of 31 patients (94%) are disease free. One failure had nongerminomatous histology; the initial diagnosis was a sampling error. Of 3 patients who did not receive CSI, 1 died. No patient developed myelopathy, visual deficits, dementia, or skeletal growth problems. In locally controlled patients, tumor response according to magnetic resonance scan was nearly complete within 6 months after radiotherapy., Conclusions: Radiotherapy alone with low-dose prophylactic CSI cures almost all patients with localized intracranial germinoma. Complications are rare when the daily dose of radiotherapy is limited to 1.5 Gy and the total CSI dose to 21 Gy. Patients without a near-complete response to radiotherapy should undergo resection to rule out a nongerminomatous element.

Purpose: The purpose of this study is to update our experience with definitive radiotherapy (RT) for carcinoma of the tonsillar area., Patients and Methods: There were 503 patients treated between October 1964 and May 2003 (potential follow-up for at least 2 years). Of these, 198 patients underwent a planned neck dissection and 57 patients received induction (18 patients) or concomitant (39 patients) chemotherapy., Results: The 5-year local control rates were as follows: T1, 88%; T2, 84%; T3, 78%; and T4, 61%. Multivariate analysis revealed that local control was significantly influenced by T stage, primary site, and fractionation. Local control after RT for early stage cancers was higher for tonsillar fossa/posterior pillar tumors than for those arising from the anterior tonsillar pillar. The 5-year cause-specific survival rates were as follows: I, 100%; II, 86%; III, 84%; IVA, 73%; and IVB, 46%. Multivariate analysis revealed that cause-specific survival was significantly influenced by T stage, overall stage, neck dissection, race, and gender. The incidence of severe late complications was 9%., Conclusion: Based on our data and a review of the literature, definitive RT provides cure rates that are as good as those after surgery, and is associated with a lower rate of severe complications. Patients with lateralized tumors may be safely treated with ipsilateral field arrangements. Our limited experience with intensity modulated radiotherapy suggests that it is as efficacious as conventional RT.

Purpose: To determine if heterogeneity correction significantly affects commonly measured dosimetric parameters predicting pulmonary toxicity in patients receiving radiation for lung cancer., Methods and Materials: Sixty-eight patients treated for lung cancer were evaluated. The conformal treatment technique mostly employed anteroposterior/posterior-anterior fields and off-cord obliques. The percent total lung volume receiving 20 Gy or higher (V20) and mean lung dose (MLD) were correlated with the incidence of radiation pneumonitis. Parameters from both heterogeneity-corrected and heterogeneity-uncorrected plans were used to assess this risk., Results: Univariate analysis revealed a significant correlation between the development of radiation pneumonitis and both V20 and MLD. A best-fit line to a plot of V20 from the homogeneous plan against the corresponding V20 heterogeneous value produced a slope of 1.00 and zero offset, indicating no difference between the two parameters. For MLD, a similarly significant correlation is seen between the heterogeneous and homogeneous parameters, indicating a 4% difference when correcting for heterogeneity. A significant correlation was also observed between the MLD and V20 parameters (p < 0.0001)., Conclusions: A high degree of correlation exists between heterogeneity-corrected and heterogeneity-uncorrected dosimetric parameters for lung and the risk of developing pneumonitis. Either V20 or MLD predicts the pneumonitis risk with similar effect.

Objectives: To update our experience with definitive radiotherapy (RT) for juvenile nasopharyngeal angiofibroma (JNA)., Methods: Twenty-two patients received definitive RT for advanced JNA between June 1975 and March 2003 and were followed from 2.0 to 30.2 years (median, 12.7 years). Total dose ranged from 30 to 36 Gy., Results: Twenty of 22 patients (91%) remained locally controlled after RT; both patients who developed a local recurrence were salvaged so that the ultimate local control rate was 100%. No patient experienced a severe complication., Conclusion: Patients with advanced and/or recurrent JNA thought not to be amenable to complete resection with acceptable morbidity have a high likelihood of cure after RT with a low risk of complications.

Purpose: To determine how to use node response on computed tomography (CT) to indicate the need for neck dissection., Patients and Methods: Five hundred fifty patients with lymph node-positive head and neck cancer were treated between 1990 and 2002 with radiotherapy (RT) at a median dose of 74.4 Gy; 24% of these patients (n = 133) were treated with chemotherapy. Three hundred forty-one patients (62%) underwent planned post-RT neck dissection. Physical examination and contrast-enhanced CT were performed 30 days after completion of RT. CT images were reviewed in 211 patients for lymph node size (largest axial dimension) and presence of a focal abnormality (lucency, enhancement, or calcification). By correlating post-RT CT to neck dissection pathology, criteria associated with a low likelihood of residual disease were identified. A subset of patients who fit these criteria of radiographic response who did not undergo post-RT neck dissection was observed for recurrence., Results: Radiographic complete response (rCR) was defined as the absence of any large (> 1.5 cm) or focally abnormal lymph node. Correlation of response with neck dissection pathology indicated a negative predictive value of 77% for complete clinical response and 94% for rCR. In 32 patients (median follow-up time, 3.2 years) with rCR who did not undergo post-RT neck dissection, the 5-year ultimate neck control rate (100%) and cause-specific survival rate (72%) were not significantly different from the rates of patients with a negative post-RT neck dissection., Conclusion: Patients with rCR 4 weeks after RT can be spared from a post-RT neck dissection regardless of initial node stage.

Objective: To evaluate definitive radiotherapy (RT) for treatment of base of tongue cancer., Methods: There were 333 patients with squamous cell carcinoma of the base of tongue treated with definitive RT and had follow-up from 0.2 to 26.2 years. Follow-up on living patients ranged from 1.2 to 26.2 years (median, 6.6 years)., Results: Local control rates at 5 years were: T1, 98%; T2, 92%; T3, 82%; and T4, 53%. The 5-year rates of local-regional control rates were: I-II, 100%; III, 82%; IVA, 87%; and IVB, 58%. The rates of absolute and cause-specific survival at 5 years were as follows: I-II, 67% and 91%; III, 66% and 77%; IVA, 67% and 84%; and IVB, 33% and 45%. Severe complications developed in 52 patients (16%)., Conclusion: Our data and review of the pertinent literature reveal that the local-regional control rates and survival rates after RT were comparable to those after surgery, and the morbidity associated with RT was less.

Objective: Treating soft tissue sarcoma (STS) of the distal extremity is challenging in terms of achieving local control and avoiding complications. It is now accepted that a limb conserving approach provides equivalent survival when compared with radical amputation., Methods: Twenty-three patients with STS involving the hand-wrist or foot-ankle complex received adjuvant radiotherapy (RT) for limb conservation and were evaluated to determine if local control, survival, and functional ability were achieved. The median patient age was 64 and median time of follow-up was 11 years. The location of the sarcoma included the hand (n = 12) or foot (n = 11). Seven patients received preoperative RT (median dose, 50.40 Gy) and 16 patients received postoperative RT (median dose, 64.80 Gy). Patients treated preoperatively and 9 treated postoperatively received hyperfractionated RT at 1.2 Gy twice-daily. Seven patients treated postoperatively received conventional daily-fractionated treatment., Results: Twenty of 23 patients received RT at first presentation; 3 were treated for locally recurrent disease. The 5- and 10-year rates of local control were 91%. The 10-year rates of cause-specific and absolute survival were 96% and 91%, respectively. The 5- and 10-year rates of distant metastases-free survival were 87%. The ultimate limb-conservation rate was 91%. No patient required an amputation because of local recurrence or treatment complications. Function of the hand or foot was maintained for all of the 21 patients for whom limb-conserving treatment was achieved., Conclusions: Combined modality therapy with limb-conserving surgery and adjuvant RT achieves excellent local control (91%) and potential overall survival (91%) rates with excellent functional outcome.

Purpose: To evaluate the efficacy of external beam radiation therapy (EBRT) for differentiated thyroid carcinomas., Methods: Forty-two patients with a locally advanced or recurrent differentiated thyroid carcinoma received high-dose EBRT. Thirty-three patients had local-regional disease and 9 patients also had asymptomatic disease metastases. Twenty patients (48%) had macroscopic local-regional disease before EBRT., Results: The 5-year outcomes for the overall population and for the subset of those without distant metastases before EBRT were local-regional control (88% and 89%, respectively), cause-specific survival (80% and 86%, respectively), and overall survival (54% and 60%, respectively). Local-regional control was improved for patients with microscopic residual disease compared with macroscopic disease, those with previously untreated tumors, and for those who received more than 64 Gy., Conclusion: EBRT increases the likelihood of local-regional control for patients with locally advanced differentiated thyroid carcinoma.

Objective: To evaluate the role of postoperative radiotherapy (RT) for patients with dermatofibrosarcoma protuberans (DFSP)., Methods and Materials: Ten patients were treated with surgery and postoperative RT and had follow-up from 21 to 185 months. Nine patients had DFSP and 1 patient had a fibrosarcomatous component (DFSP-FS). No patient had gross disease at the time of RT., Results: Nine patients with DFSP remained disease free after surgery and postoperative RT. The patient with DFSP-FS experienced a local recurrence after surgery, external beam RT, and a brachytherapy boost, and died with disease. There were no severe complications., Conclusion: Postoperative RT may reduce the risk of local recurrence in patients with DFSP who have a high risk of residual disease after surgery.

Background: This study analyzed survival, locoregional recurrence, and reexcision rates after breast conserving therapy, based on the margin analysis technique used at the University of Florida, which incorporates frozen section analysis of shaved breast tissue from the lumpectomy cavity., Study Design: A retrospective review was done of 257 patients who underwent 267 consecutive lumpectomy operations and completed radiation therapy at our institution. Margins in 189 patients were assessed using frozen section analysis of shaved margins from the lumpectomy cavity., Results: Breast conserving therapy was performed for 220 (83%) patients with early breast cancer (T1 and T2 tumors) and 47 (17%) with ductal carcinoma in situ. With a median followup of 5.6 years, the crude locoregional recurrence rates for patients who had margins analyzed intraoperatively by frozen section analysis or margins analyzed by permanent analysis were 1.9% (3 of 157) and 3.1% (2 of 63), respectively, for early breast cancer and 15.6% (5 of 32) and 6.6% (1 of 15) for ductal carcinoma in situ (p=NS). Survival rates were 97% and 78%, at 5 and 10 years, respectively, for the early breast cancer patients, and 98% and 98%, respectively, for ductal carcinoma in situ patients. Permanent intraoperative frozen section analysis reexcision rates were 33.3% (26 of 78) and 5.8% (11 of 189)., Conclusions: Regardless of the technique used for margin analysis, breast conserving therapy led to low locoregional recurrence relative to national figures, pointing to the importance of the technique of radiation therapy at our institution. Reexcision rate was reduced with the use of frozen section analysis.

Background: The purpose of the current study was to determine the outcomes of patients with previously untreated Merkel cell carcinoma of the skin who were treated with curative intent., Methods: Between October 1984 and January 2002, 34 patients were treated with radiotherapy alone (2 patients) or combined with surgery (32 patients). Nine patients received adjuvant chemotherapy. Patients had follow-up for a median of 3.0 years (range, 0.3 to 18.5 yrs). Follow-up on living patients ranged from 2.2 to 18.5 years (median, 7.1 yrs)., Results: The 5-year outcomes were as follows: local control, 94%, locoregional control, 80%; freedom from distant metastases, 60%; cause-specific survival, 52%; and survival, 37%. No patient experienced a severe complication., Conclusions: Patients treated aggressively with surgery and locoregional radiotherapy have about a 50% chance of cure. Limited data suggest that definitive radiotherapy alone or after incomplete macroscopic resection may control locoregional disease in a significant subset of patients. The dominant site of failure was distant., (Copyright 2005 American Cancer Society)

The objective of this study was to evaluate the efficacy of larynx-sparing radiotherapy (RT) alone or in combination with a neck dissection for patients with squamous cell carcinomas metastatic to cervical lymph nodes from an unknown head and neck primary site. Seventeen patients were treated with curative intent between 1997 and 2002; 16 of 17 patients had follow up for at least 2 years. No patient developed a squamous cell carcinoma in a head and neck mucosal site after treatment. One patient (6%) had persistent nodal disease and 1 patient (6%) had recurrent nodal disease 1 year after completing RT. No patients experienced distant metastases. The 5-year cause-specific and overall survival rates were 88% and 82%, respectively. Based on our limited experience, larynx-sparing RT appears to result in a high likelihood of local-regional control and survival and likely reduces both acute and late toxicity.

Objective: The purpose of this article is to report our experience with neurotropic melanoma, a rare malignancy that sometimes produces neurologic symptoms because of a direct extension of the primary tumor., Methods: We report 3 consecutive patients with neurotropic melanoma of the head and neck who presented with clinical perineural invasion., Results: Two patients had incompletely resectable tumors and were treated with definitive radiotherapy (RT), and 1 patient received surgery and postoperative RT. One patient experienced recurrence in a regional lymph node 30 months after RT and underwent salvage surgery; he is disease-free at 45 months after initial treatment. The remaining 2 patients are disease-free 34 months and 14 months after treatment., Conclusions: Radiotherapy alone or combined with surgery may provide relatively long-term local control in patients who have neurotropic melanoma with clinical perineural invasion.

Purpose: To evaluate xerostomia following intensity-modulated radiation therapy (IMRT)., Materials and Methods: An institutional review board-approved study of xerostomia was conducted in 210 head and neck cancer patients who were beyond the acute recovery phase (> 1 year) after radiation therapy. Xerostomia was evaluated with the 8-question XQ developed and validated at the University of Michigan., Results: Median XQ scores (normalized so that no xerostomia = 0 and maximum xerostomia = 100) were larynx-only group, 4 points, ipsilateral radiotherapy, 34 points; bilateral radiotherapy, 64 points; IMRT with mean contralateral parotid dose more than 26 Gy, 44 points; and IMRT with mean contralateral parotid dose 26 Gy or less, 32 points (P < 0.05 for all major comparisons)., Conclusion: The XQ is an excellent tool for identifying important differences in xerostomia after radiation therapy for head and neck cancer. The authors' IMRT program decreases the severity of xerostomia symptoms compared with what is typically seen after conventional radiation therapy.

Purpose: To analyze the parameters that influence the risk of radiation-induced optic neuropathy (RION) after radiotherapy for head-and-neck tumors., Methods and Materials: Between 1964 and 2000, 273 patients with tumors of the nasopharynx, paranasal sinuses, nasal cavity, and hard palate adenoid cystic carcinomas were treated with curative intent and had radiation fields that included the optic nerves and/or chiasm. Patients were followed for at least 1 year after radiotherapy., Results: Radiation-induced optic neuropathy developed in 32 eyes of 24 patients (9%). The 5-year rates of freedom from RION according to the total dose and once- vs. twice-daily fractionation were as follows: < or =63 Gy once daily, 95%; < or =63 Gy twice daily, 98%; >63 Gy once daily, 78%; and >63 Gy twice daily, 91%. Multivariate analysis revealed that the total dose affected the risk of RION (p = 0.0047), with patient age (p = 0.0909), once-daily vs. twice-daily fractionation (p = 0.0684), and overall treatment time (p = 0.0972) were marginally significant. The use of adjuvant chemotherapy did not significantly influence the likelihood of developing RION., Conclusion: The likelihood of developing RION is primarily influenced by the total dose. Hyperfractionation may reduce the risk of experiencing this complication.

Background: The current study was performed to investigate the efficacy of carbogen (95% oxygen [O(2)] and 5% carbon dioxide [CO(2)]) breathing during definitive radiotherapy (RT) to enhance local control., Methods: Between November 1996 and November 2002, 101 patients with previously untreated T2 to T4 squamous cell carcinomas of the oropharynx, larynx, and hypopharynx were entered onto a prospective trial and randomized to receive definitive hyperfractionated RT alone or combined with carbogen breathing. Patients were stratified according to T classification and primary tumor site. Follow-up ranged from 1-91 months (median, 38 months). All living patients had follow-up for more than 2 years. Outcomes analyses were performed according to intent to treat., Results: Definitive RT alone was completed as planned in 50 of 51 patients (98%); 49 of the 50 patients (98%) who were randomized to receive carbogen breathing were able to complete the RT as planned. Three patients randomized to receive carbogen breathing declined carbogen. The 5-year outcomes after RT alone or combined with carbogen were as follows: local control, 83% versus 88% (P = 0.5155); locoregional control, 81% versus 83% (P = 0.7174); distant metastasis-free survival, 82% versus 86% (P = 0.5184); cause-specific survival, 73% versus 77% (P = 0.5866); and absolute survival, 53% versus 58% (P = 0.4856)., Conclusions: The addition of carbogen breathing to definitive RT did not appear to improve the likelihood of local control significantly. However, because of the limited size of the current study, the authors cannot definitively conclude that carbogen breathing is ineffective.

Background: The authors analyzed the outcomes of patients treated with radiotherapy (RT) alone or combined with surgery for carcinoma of the salivary glands., Methods: Between October 1964 and June 2003, 224 previously untreated patients were treated with curative intent with RT alone (n = 64) or combined with surgery (n = 160) at the University of Florida College of Medicine (Gainesville, FL). The median follow-up period was 5.0 years (range, 0.4-31.6 years)., Results: The 10-year local control rate was 75%. Multivariate analysis of local control revealed that T classification (P < 0.0001) and treatment group (P < 0.0001) impacted this end point. Patients treated with surgery and adjuvant RT had improved local control compared with patients treated with RT alone. The 10-year locoregional control rate was 68%. Multivariate analysis of locoregional control revealed that overall stage (P < 0.0001) and treatment group (P = 0.0002) significantly influenced this end point. The 10-year distant metastasis-free survival rate was 68%. Multivariate analysis of distant metastasis-free survival revealed that overall stage (P < 0.0001) significantly influenced this end point. The 10-year cause-specific and overall survival rates were 57% and 44%, respectively. Multivariate analysis of cause-specific survival revealed that overall stage (P < 0.0001) significantly impacted this end point. Twenty-three patients (10%) experienced severe complications., Conclusions: A substantial proportion of patients with salivary gland carcinoma were cured with surgery combined with adjuvant RT. RT alone was used for patients with unresectable tumors and cured approximately 20% of those with advanced-stage disease. The probability of cure was influenced by the extent of disease and treatment group., (Copyright 2005 American Cancer Society.)

Background: In the management of retroperitoneal sarcomas it is necessary to achieve local control to ensure survival. The role of adjuvant radiation therapy (RT), either pre- or postoperative, remains controversial., Methods: Outcomes for 40 patients with retroperitoneal sarcoma treated with surgery and postoperative RT (n = 25) or preoperative RT (n = 15) were analyzed for variables prognostic for local control, survival, and associated complications., Results: Patterns of failure for patients treated by resection and postoperative RT were local (n = 4), local and distant (n = 3), and distant (n = 3). The failure patterns for preoperative RT cases were local (n = 2), local and distant (n = 2); and distant (n = 4). Median time to local recurrence in the postoperative and preoperative RT series were 1 year and 2.5 years respectively. The margin status was predictive for local control (P = 0.0065) and survival (P = 0.0012), regardless of treatment sequence. Absolute 5-year survival was 12% with positive margins versus 69% if negative. Histologic grade was indicative of the risk for distant metastasis (low grade 8% vs high grade 64%; P = 0.1373), and significantly predicted 5-year absolute survival (low grade 77% vs high grade 34%; P = 0.0267). Postoperative RT was associated with significant complications (infection, hemorrhage, and bowel obstruction--2 cases each)., Conclusion: Compared with the surgery-alone series, adjuvant RT appears to improve the probability of local control. Preoperative RT may be the preferred sequence potentially to improve tumor resectability and local-regional control with less risk of complications than with postoperative RT.

Purpose: To analyze the outcomes of adult patients with head and neck soft tissue sarcomas., Methods: Review of 39 patients treated with radiotherapy (RT) alone (6 patients) or combined with surgery (33 patients) with curative intent between December 1966 and February 2003. Follow-up for living patients ranged from 1 to 21 years (median, 8.7 years)., Results: Five-year outcomes were as follows: local control, 78%; distant metastasis-free survival, 85%; cause-specific survival, 69%, and overall survival, 63%. Three of 6 patients (50%) treated with definitive RT were locally controlled compared with 27 of 33 patients (82%) treated with surgery and RT., Conclusions: Approximately two thirds of patients with head and neck soft tissue sarcomas are cured with RT alone or combined with surgery. Local recurrence is a significant mode of treatment failure. Outcome is influenced by tumor extent, histologic grade, and resectability.

Background: Treatment outcomes were analyzed for retromolar trigone squamous cell carcinoma., Methods: Between June 1966 and August 2003, 99 patients were treated with radiotherapy alone (35 patients) or radiotherapy combined with surgery (64 patients). Followup ranged from 0.2 to 23.8 years (median, 3.3 yrs). All living patients had followup for at least 1 year., Results: The 5-year local-regional control rates after definitive radiotherapy versus surgery and radiotherapy were as follows: Stages I-III, 51% and 87%; Stage IV, 42% and 62%; and overall, 48% and 71%, respectively. The 5-year cause-specific survival rates after definitive radiotherapy compared with surgery and radiotherapy were as follows: Stages I-III, 56% and 83%; Stage IV, 50% and 61%; and overall, 52% and 69%, respectively. Multivariate analyses revealed that the likelihood of cure was better with surgery and radiotherapy compared with definitive radiotherapy., Conclusions: The likelihood of cure after treatment for retromolar trigone squamous cell carcinoma was influenced by the extent of disease and treatment. Patients treated with surgery and radiotherapy had a better outcome than those treated with radiotherapy alone.

The purpose of this study was to evaluate the efficacy of radiotherapy (RT) and stereotactic radiosurgery (SRS) for neurofibromas. We studied 4 patients treated with RT (3 patients) or SRS (1 patient) and followed from 1.7 to 14.8 years. The tumor remained locally controlled in all patients. No significant complications related to treatment were observed. RT and SRS are likely to locally control neurofibromas in patients who require treatment and are not good candidates for complete resection.

The purpose of this study was to determine whether the incidence of hypothyroidism following radiotherapy (RT) to the low neck is high enough to justify the routine monitoring of thyroid function in asymptomatic patients. A retrospective study of 504 patients with head and neck cancer whose RT fields included the thyroid gland was conducted. Patients were treated either with definitive or postoperative RT. Hypothyroidism was defined as a thyroid stimulating hormone (TSH) level > or =4.5 mIU/L, regardless of whether the patient had clinical symptoms. Of the 504 total patients, 206 had a serum TSH level checked at some point posttreatment. If we assume that patients who had no data did not have hypothyroidism, the actuarial freedom from hypothyroidism in the entire group was 78% at 5 years and 51% at 10 years. Of the 206 patients who had a documented posttreatment TSH, the actuarial freedom from hypothyroidism was 58% at 5 years and 26% at 10 years. Univariate analysis and multivariate analysis confirmed treatment modality to be a significant predictive factor. Definitive initial surgery that removed part of the thyroid gland increased the risk of developing hypothyroidism. Overall stage was also predictive on multivariate analysis. Head and neck irradiation results in biochemical hypothyroidism in at least 50% of patients. Thyroid function should be tested on a regular basis following RT to the low-neck region. Serum TSH should be checked every 6 months for the first 5 years and yearly thereafter. Thyroid hormone replacement should be initiated in any patient with a TSH of more than 4.5 mIU/L.

Purpose: To determine how often initial treatment choices limit treatment options for subsequent breast cancer management in patients undergoing breast-conserving therapy (BCT), in particular with treatment of internal mammary nodes., Methods and Materials: Between January 1985 and June 2001, 464 women with pathologic Stage 0, I, and II (T0-2, N0-1) breast cancer underwent BCT at our institution. All 464 patients had computed tomography-based treatment planning. In patients with bilateral breast cancer, the planning computed tomography scans were used to determine the impact initial radiation therapy fields had on treatment options for subsequent contralateral breast cancer., Results: There were 500 breast cancers diagnosed in 464 patients. Thirty-six patients (8%) had bilateral breast cancer with 9 (2%) synchronous and 27 (6%) metachronous primaries. In 80 patients, the ipsilateral internal mammary nodes were explicitly treated. Initial breast cancer treatment choices impacted subsequent treatment decisions for the contralateral breast in only 2 of 464 patients (0.4%) in the study: 2 of 80 patients (2.5%) whose internal mammary nodes were treated, and 2 of 27 patients (7.4%) who developed metachronous bilateral breast cancer., Conclusions: Initial BCT, including internal mammary node irradiation, rarely compromised future contralateral breast-conserving therapy.

Purpose: We conducted an outcome and complications analysis of patients treated with adjuvant radiotherapy (RT) for early-stage testicular seminoma over a 35-year period at the University of Florida., Methods and Materials: All 73 patients had the classic seminoma histology. No patient received chemotherapy as initial treatment. There were 57, 14, and 2 patients with Royal Marsden stage I, IIA, and IIB disease, respectively. All received RT to the paraaortic (PAN) and pelvic fields. One-third of the patients received prophylactic RT to mediastinal/supraclavicular fields., Results: Median follow up was 15 years. Median RT dose to PAN and pelvic fields was 25 Gy. Local control and cause-specific survival at 20 years were 95% and 96%, respectively. Of the 3 recurrences, 1 was salvaged with chemotherapy. Subset analysis of 41 patients revealed 1 patient who developed peptic ulcer disease and 11 patients with gastrointestinal reflux symptoms after RT. Thirty-two patients fathered a child before or after RT. Cardiovascular complications were not greater in those treated with prophylactic RT to the mediastinal region. The rate of nontesticular second malignancy for the overall group was 8% at 15 years., Conclusions: Patients treated with adjuvant low-dose RT to the paraaortic and pelvic fields for treatment of early-stage seminoma enjoy an excellent long-term cure rate with minimal risk of late RT complications.

The purpose of this article is to review the pertinent literature and to define the optimal treatment of patients with aggressive fibromatosis. Data indicate the likelihood of local recurrence after surgery is high, particularly if margins are positive. Moderate-dose radiotherapy alone for gross disease or after a microscopically incomplete resection yields local control rates of approximately 75% to 80%. Treatment with pharmacologic agents results in objective response rates of approximately 40% to 50%; duration of response is variable. Thus, the optimal management for aggressive fibromatosis depends on tumor location and extent. Surgery is indicated if the lesion appears to be completely resectable with acceptable function and cosmesis. Radiotherapy is indicated for patients with unresectable tumors; those with positive margins after resection should be considered for adjuvant radiotherapy depending on the location and extent of the tumor. Pharmacologic treatment should be considered for patients with progressive disease after unsuccessful local-regional therapy.

The purpose of this article was to evaluate the role of radiotherapy (RT) in the treatment of pleomorphic adenoma. This is a retrospective analysis of 17 patients treated with RT alone (2 patients) or combined with surgery (15 patients). Follow up ranged from 1.8 to 27.1 years (median, 9.6 years). Local control was obtained in 8 of 10 patients (80%) with subclinical disease and 3 of 7 patients (43%) with gross disease. Overall local control was obtained in 11 of 17 patients (65%). The 5- and 10-year overall local control rates were 69% and 61%, respectively. One patient died secondary to tumor extension into the central nervous system, 1 patient had recurrence of carcinoma ex-pleomorphic adenoma and died of cancer at the primary site, 5 patients died free of disease, and 10 patients were alive at last follow up. RT is relatively effective at controlling subclinical disease in patients at high risk for developing recurrence after surgery for pleomorphic adenoma. Limited data suggest that RT may also occasionally control gross disease.

Background: : The purpose of this study was to review outcomes of young patients (age <40 years) treated with definitive radiotherapy alone for squamous cell carcinoma of the oropharynx, and larynx, and to compare these results with an older matched patient cohort., Methods: : Since 1983, 30 previously untreated young patients underwent definitive radiotherapy at the University of Florida and were matched with an older group of patients (age >45 years) with respect to primary site, stage of disease, and sex., Results: : There was no difference in cause-specific survival, locoregional control, or long-term complications between the two groups; however, there was a significant difference in overall survival favoring young patients (p = .0174). Older patients had twice as many second malignancies., Conclusion: : Young age does not confer a worse prognosis in patients treated with definitive radiotherapy for squamous cell carcinoma of the oropharynx and larynx.

Background: The objective of the current study was to correlate pretreatment computed tomography and magnetic resonance imaging studies with outcomes for patients with squamous or basal cell carcinoma of the skin and clinical perineural invasion., Methods: Between 1986 and 2002, 45 patients were treated with radiotherapy alone (21 patients) or combined with surgery (24 patients), and 4 patients received concomitant chemotherapy. Follow-up ranged from 0.85 years to 17.4 years (median, 3.8 years). Patients were stratified as follows: imaging negative, 10 patients; minimal or moderate peripheral disease, 14 patients; and central and/or macroscopic disease, 21 patients., Results: The 5-year local control rates were as follows: imaging negative, 76%; minimal or moderate peripheral disease, 57%; and central and/or macroscopic disease, 25%. The 5-year absolute and cause-specific survival rates were as follows: imaging negative, 90% and 100%, respectively; minimal or moderate peripheral disease, 50% and 56%, respectively; and central and/or macroscopic disease, 58% and 61%, respectively., Conclusions: Patients who had symptomatic but imaging-negative perineural invasion had a relatively good prognosis after receiving definitive radiotherapy alone or combined with surgery. Patients who had imaging-positive minimal or moderate peripheral disease had a better local control rate but a similar survival rate compared with patients who had central and/or macroscopic disease.

Purpose: The purpose of this study was to determine factors associated with the development of radiation retinopathy in a large series of patients with head-and-neck cancer. In particular, we addressed whether the use of hyperfractionated radiation therapy was effective in reducing the risk of retinopathy., Methods and Materials: One hundred eighty-six patients received a significant dose to the retina as part of curative radiotherapy. Primary sites included: nasopharynx, 46; paranasal sinus, 64; nasal cavity, 69; and palate, 7. Prescription doses varied depending on primary site and histology. Hyperfractionated (twice-daily) radiation was delivered to 42% of the patients in this study, typically at 1.10 to 1.20 Gy per fraction. The remainder were treated once-daily. Retinal doses were determined from computerized dosimetry plans when available. For all other patients, retinal doses were retrospectively calculated using reconstructed off-axis dosimetry taken from contours through the center of the globes. Retinal dose was defined as the minimum dose received by at least 25% of the globe. The median retinal dose was 56.85 Gy. Patients were followed for a median of 7.6 years., Results: Thirty-one eyes in 30 patients developed radiation retinopathy, resulting in monocular blindness in 25, bilateral blindness in 1, and decreased visual acuity in 4. The median time to the diagnosis of retinopathy was 2.6 years (range, 11 months to 5.3 years). The actuarial incidence of developing radiation retinopathy was 20% at both 5 and 10 years. The incidence of developing ipsilateral blindness due to retinopathy was 16% at 5 years and 17% at 10 years. Site-specific incidences varied considerably, with ethmoid sinus (9 of 25, 36%), nasal cavity (13 of 69, 19%), and maxillary sinus (6 of 35, 17%) being the most common sites associated with radiation retinopathy. Three of 72 patients (4%) receiving retinal doses less than 50 Gy developed retinopathy. Higher retinal doses resulted in a steady increase in the incidence of retinopathy, with 25 of the 30 cases occurring after 60 Gy or more. Of the patients receiving more than 50 Gy to the retina, hyperfractionation was associated with a significantly lower incidence of radiation retinopathy (37% vs. 13%; p = 0.0037). On multivariate analysis, retinal dose (p < 0.0001), fractionation schedule (p = 0.0003), age (p = 0.0365), and prolonged overall treatment time (p = 0.0213) were significant predictors of radiation retinopathy., Conclusion: The incidence of ipsilateral radiation retinopathy after treatment of nasal cavity/paranasal tumors is 20% at 5 and 10 years. Retinal dose and fractionation schedule are the strongest predictors of retinopathy. Hyperfractionated radiotherapy is associated with a significant reduction in the incidence of radiation retinopathy, especially when the retina receives more than 50 Gy.