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To report the percentage of resident graduates in the modern era who establish careers in academic radiation oncology 5 to 10 years after residency.The study population included 1147 radiation oncologists who completed residency between 2011 and 2017 and were practicing radiation oncologists in 2021.The percentage of 2011-2017 graduates with an academic career in 2021 (5 to 10 y after residency): Holman Pathway resident: Yes, 74% versus No, 43% (P0.05); PhD degree before residency: Yes, 67% versus No, 38% (P0.05), Doximity top-10 ranked residency program: Yes, 66% versus No, 37% (P0.05).Logistic regression multivariate analysis confirmed PhD and Doximity top-10 as strong independent predictors for all endpoints.Regarding gender, no significant differences were observed for all 4 endpoints in the percentage of women versus men establishing academic careers at the 5-year to 10-year post-residency time point.Since 2011, at least one-third (~35%) of radiation oncology residents have gone into academic medicine and are academically productive 5 to 10 years after residency. Holman Pathway, PhD degree, or Doximity top-10 residency program approximately doubles the probability of an academic career. Moreover, radiation oncology is on track to achieve gender equity in academic medicine.

In patients with well-differentiated thyroid cancer, there is controversy about the prognostic importance of a large number of positive neck nodes and the potential value of radioiodine therapy. The purpose of this study was to evaluate this issue in the group of patients for whom it is most clinically important - those with classic histology and favorable T and M stage.Twenty-five patients met the following inclusion criteria: classic histology of papillary or follicular thyroid carcinoma treated with total thyroidectomy and neck dissection followed by adjuvant I-131 treatment in our department between January 1, 2003, and December 31, 2013; adult age of21 years; and American Joint Committee on Cancer (AJCC ) stage (8The median positive node number was 10 (range, 5-31). The median adjuvant I-131 dose was 158 mCi (range, 150-219 mCi). The median follow-up in patients without recurrence after treatment was 7.3 years. The 10-year actuarial rates were favorable: overall survival, 100%; freedom from visible recurrence, 82%; and visible or biochemical recurrence, 72%.Recurrence was infrequent in our study population with ≥ 5 positive nodes following moderate-dose adjuvant I-131 treatment. These results are valuable in directing initial adjuvant therapy and follow-up intensity. Our results do not inform the question of the use of postoperative thyroglobulin (Tg) level to select N1b patients for low-dose I-131 treatment.

We evaluated outcomes in 131 patients with cutaneous melanoma (median follow-up, 3.6 years) considered at high risk of recurrence after surgery alone treated with surgery and postoperative radiotherapy. Eligible patients had one or more of the following: recurrence after surgery, positive lymph nodes, extracapsular extension, incomplete regional node dissection, microscopically positive margins, gross residual disease, or in-transit metastases. 102 patients received hypofractionated radiotherapy and 29 had conventional fractionation. 10-year outcomes were: in-field local-regional control, 87%; local regional control, 72%; distant metastasis-free survival, 48%; cause-specific survival, 44%; and overall survival, 31%. Three patients experienced acute toxicities while 6 experienced late toxicities.

Purpose There is controversy about the need to target the mucosa of the larynx and hypopharynx during radiation therapy (RT) for squamous cell carcinoma of an unknown primary site (SCCA-UP). By 1997, the policy in our department was to target only the oropharynx and nasopharynx in patients with SCCA-UP metastatic to the level II cervical nodes. The purpose of this study was to report the rate of cancer recurrence in the larynx or hypopharynx using an approach that excluded these areas from the RT target volumes. Methods and Materials The inclusion criteria for this study were RT in our department for SCCA-UP between January 1, 1997, and December 31, 2019; no history of surgery that could disrupt the cervical lymphatics; predominant adenopathy in level IIA; and neck stage N1-2c. We excluded N3 because the incidental dose to the larynx and hypopharynx is usually high in patients with a >6-cm nodal conglomerate. Results The study population was comprised of 50 patients with a median follow-up after RT of 7.1 years. No patient developed recurrent cancer in a mucosal site (0/50), 2% (1/50) developed a neck recurrence in a high-dose area with synchronous distant metastases, and 2% (1/50) developed distant metastases with no evidence of local or regional recurrence. Conclusions When delivering RT for SCCA-UP metastatic predominantly to level IIA, it is not necessary to target the mucosa of the larynx or hypopharynx. The extent to which the incidental RT dose to these areas contributes to cancer control is not evaluated in this study.

Data are scarce on the efficacy of a second radiosurgery (SRS) treatment of vestibular schwannoma that has progressed following initial treatment with SRS. We sought to report the outcome of our repeat SRS series with long-term imaging follow-up.We retrospectively analyzed 6 patients who met the following criteria: Repeat SRS at our institution between 1995 and 2018; solitary unilateral tumor; no evidence of neurofibromatosis; and magnetic resonance (MR) planning for both SRS treatments. All treatments were delivered with a linear accelerator-based system using head frame immobilization. The prescribed dose to the periphery of the tumor was 12.5 Gy in all initial and repeat SRS treatments, except for one repeat treatment to 10 Gy.Follow-up with MR scan following the second SRS treatment was a median 8.4 years. The tumor control rate (lack of progression) following the second SRS treatment was 83% (5/6). Actuarial 10-year outcomes following repeat SRS were: tumor control, 80%; absolute survival, 80%; and cause-specific survival, 100%. Of the patients with at least minimal hearing retention before initial SRS, none had ipsilateral hearing preservation after initial radiation treatment. Improvement in any pretreatment cranial nerve deficits was not seen. The only permanent grade ≥ 3 toxicity from repeat SRS was a case of infraorbital nerve deficit. No patient developed a stroke, malignant transformation, induced second tumor, or facial nerve deficit.There was excellent overall survival, tumor control, and low morbidity in our series for recurrent vestibular schwannoma submitted to repeat single-fraction SRS, supporting additional studies of this treatment strategy.

We report outcomes among patients with T2 and select T3 glottic squamous cell carcinoma (SCC) treated with radiotherapy.We reviewed T2 and T3 (only paraglottic space invasion) N0 M0 glottic SCC patients treated with curative-intent hypofractionated larynx radiotherapy, with or without concurrent systemic therapy.Of 71 patients, those who received concurrent chemotherapy (23/71; 32%) had worse prognostic factors, including impaired cord mobility (70% vs. 40%, p = 0.02) and larger median gross tumor volume (3.0 vs. 1.6 cmThe addition of concurrent platinum-based chemotherapy to hypofractionated larynx radiotherapy among patients with early-stage glottic SCC with impaired cord mobility appears safe and worthy of additional investigation.

Purpose One of the most downloaded articles in 2017 from the International Journal of Radiation Oncology, Biology, and Physics was a study suggesting that music therapy during radiation therapy (RT) simulation substantially reduces anxiety. To further evaluate the potential of music's clinical efficacy in the context of radiation therapy, we conducted a randomized trial evaluating the influence of genre-based music chosen by the study participant on anxiety during the first RT treatment session with a method that is applicable to routine clinical practice. Methods and Materials We conducted a prospective randomized trial of music versus no music during the first RT treatment for cancer. We limited the study to women because prior studies document a higher rate of anxiety in female patients with cancer. Anxiety was evaluated before and after the first RT treatment using the State-Trait Anxiety Inventory (STAI) and Symptom Distress Thermometer (SDT). Patients randomized to music had their preferred genre of music played from a web-based application while in the treatment vault. Results In the study, 102 females were enrolled (51 with and 51 without music). Baseline high anxiety score before RT was recorded in 48% of patients using the STAI and 58% using the SDT. The percent decrease in mean STAI score was 16% with music versus 10% without music (P = .2197). The mean SDT percent changes were a 13% decrease with music versus a 2% increase without music (P = .3298). Conclusions This study documents that high anxiety is common in women receiving RT for cancer and that music, as used in this study, does not reduce anxiety to a meaningful degree.

Purpose The geographic distribution of practicing radiation oncologists is of concern for multiple stakeholders within the field. Employment outcomes of graduating residents can affect that distribution, and they are of major concern to current residents. Data investigating employment outcomes of recent graduates are sparse. We aimed to analyze the employment outcomes of the radiation oncology residency class of 2019. Methods and Materials Using publicly available information, we identified the employment of 179 of 183 graduating residents in the class of 2019. For each, the place of employment, residency program, and medical school were geocoded using Google Maps. We used the rural-urban continuum code (RUCC) published by the United States Department of Agriculture to determine the rurality of each location and compared employment outcomes by RUCC and program size. Results Two thirds of graduates (66%) took a position in a county within a metropolitan area with a population greater than 1,000,000 people; only 3.4% took a position in a county outside of a metropolitan area. Graduates of smaller programs (≤6 residents) and those in smaller metropolitan areas were more likely to take positions in smaller metropolitan areas or nonmetropolitan areas. The geographic distance between location of employment and residency program did not significantly vary by program size or size of metropolitan area where a residency program was located. Conclusions Among the class of 2019, a small proportion took positions in nonmetropolitan areas. Smaller programs and those in smaller metropolitan areas may be more likely to produce graduates that practice in similar settings, but those graduates might not do so locally. We advocate for a centralized, prospective data collection of employment outcomes for graduating residents to refine these analyses and to reduce employment prospect information asymmetry for trainees.

Objectives Increasing diversity in radiation oncology with respect to sex, under-represented minorities (URMs), and people of color is a major objective of our profession. The purpose of this project is to plot diversity percentages in our residency program over the past 52 years and explain major causes for change when identified. Materials and methods Plots of the percent of residents in our program each year between 1967 and 2020 in the following categories: White male, female, URM, and people of color. Results Between 1967 and 1992 diversity percentage in our program changed little with ∼90% of residents representing White males. Between 1992 and 1995, overall diversity increased by 40 percentage points, a change maintained from 1995 to 2020. Approximate annual percentages over the past 25 years were: female, 35%; URM, 10%; and people of color, 25%.The main reason for increased diversity starting in 1992 was new leadership seeking to promote diversity. Tools that helped promote diversity were measuring our diversity profile and setting target goals. Conclusions Our experience provides a model to measure diversity and track performance over time in residency programs, departments, or practice groups. The priority to place on diversity, and specific performance goals, vary by group. For those seeking to increase diversity, our experience shows it is possible to achieve substantial diversity in all categories, but change requires leadership making diversity a priority.

The risk of serious esophageal damage from stereotactic body radiation therapy for a spine metastasis increases when the target is in the upper thoracic or cervical spine because the esophagus almost touches the anterior edge of the vertebral body at these levels. This report describes a case of severe esophageal damage from stereotactic body radiation therapy to the T-2 vertebral body, reviews pertinent literature, and suggests implications for future research and practice.

Purpose The geographic distribution of radiation oncologists determines access to care for patients and job opportunities for practicing physicians, yet available data on practicing radiation oncologists are outdated or use large geographic unit definitions precluding granular analysis. We present an updated county-level analysis of the American radiation oncology workforce. Methods and Materials We used the Area Health Resource File published by the Health Resources and Services Administration of the U.S. Department of Health and Human Services to determine the number of radiation oncologists per 100,000 people in every or equivalent area in the United States as of 2017 (the most recently published data). We then analyzed geographic distribution per U.S. Census Bureau–defined regions, subregions, and combined statistical areas. Results The Area Health Resource File reports 5338 practicing radiation oncologists for an estimated American population of 326.1 million people as of 2017, resulting in a nationwide average of 1.64 radiation oncologists per 100,000 people. Counties located outside of a metropolitan area had a lower density of radiation oncologists than those within a metropolitan area. Among combined statistical areas (representing most large cities) the variations in density of radiation oncologists are small, with the highest-density areas located in smaller communities with academic medical centers. There was no relationship between population of combined statistical areas and density of radiation oncologists. Conclusions The geographic distribution of American radiation oncologists varies widely; the primary variation exists along the urban/rural continuum, with rural areas having fewer practitioners than urban areas. This analysis informs future work in understanding how to optimize the delivery of radiation oncology services throughout the United States.

PURPOSE Plasma circulating tumor human papillomavirus DNA (ctHPVDNA) is a sensitive and specific biomarker of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC). We investigated whether longitudinal monitoring of ctHPVDNA during post-treatment surveillance could accurately detect clinical disease recurrence. METHODS AND MATERIALS A prospective biomarker clinical trial was conducted among patients with nonmetastatic HPV-associated (p16-positive) OPSCC. All patients were treated with curative-intent chemoradiotherapy (CRT). Patients underwent a 3-month post-CRT positron emission tomography/computed tomography scan and were thereafter clinically evaluated every 2-4 months (years 1-2), then every 6 months (years 3-5). Chest imaging was performed every 6 months. Blood specimens were collected every 6-9 months for analysis of plasma ctHPVDNA using a multianalyte digital polymerase chain reaction assay. The primary endpoint was to estimate the negative predictive value (NPV) and positive predictive value (PPV) of ctHPVDNA surveillance. RESULTS One hundred fifteen patients were enrolled, and 1,006 blood samples were analyzed. After a median follow-up time of 23 months (range, 6.1-54.7 months), 15 patients (13%) developed disease recurrence. Eighty-seven patients had undetectable ctHPVDNA at all post-treatment time points, and none developed recurrence (NPV, 100%; 95% CI, 96% to 100%). Twenty-eight patients developed a positive ctHPVDNA during post-treatment surveillance, 15 of whom were diagnosed with biopsy-proven recurrence. Sixteen patients had 2 consecutively positive ctHPVDNA blood tests, 15 of whom developed biopsy-proven recurrence. Two consecutively positive ctHPVDNA blood tests had a PPV of 94% (95% CI, 70% to 99%). Median lead time between ctHPVDNA positivity and biopsy-proven recurrence was 3.9 months (range, 0.37-12.9 months). CONCLUSION Detection of ctHPVDNA in two consecutive plasma samples during post-treatment surveillance has high PPV and NPV for identifying disease recurrence in patients with HPV-associated oropharyngeal cancer and may facilitate earlier initiation of salvage therapy.

Stereotactic body radiation therapy (SBRT) is commonly used to treat early-stage, node-negative primary lung cancer, but society guidelines provide limited information regarding several technical aspects of SBRT, leading to potential variation in practice. In this report, we present the technical details used by 3 academic institutions when treating a solitary primary lung tumor up to 5 cm in dimension with curative-intent SBRT. We provide specifications outlined in major active or recently completed clinical trials. Among the participating institutions, we discovered multiple divergences in treatment parameters, including, but not limited to, prescription dose and desired degree of heterogeneity within the target volume. It is unclear to what extent these differences in parameters might affect tumor control or toxicity, but updated consensus guidelines addressing the relevant SBRT prescription details may help standardize practice patterns.

To compare survival outcomes between primary surgery and primary radiation therapy (RT) in patients with human papillomavirus (HPV)-negative oropharyngeal squamous cell carcinoma (OPSCC).A retrospective observational cohort study.National Cancer Database.A National Cancer Database review was conducted of 2635 patients with HPV-negative OPSCC who underwent surgery or RT ± chemotherapy between 2010 and 2014. Univariate analysis was performed on all variables and entered into a multivariate model. The main outcome was overall survival (OS).A total of 2635 patients with HPV-negative OPSCC were organized into 4 groups based on cancer staging. In group 1 (T1-2 N0-1; n = 774), up-front surgery had significantly better 5-year OS (76.2%) than RT (56.8%; adjusted hazard ratio [aHR], 1.76; P = .009; 95% CI, 1.15-2.69) and chemoradiation therapy (CRT; 69.5%; aHR, 1.56; P = .019; 95% CI, 1.08-2.26). In group 2 (T3-4 N0-1; n = 327), no significant difference existed between surgery and CRT (5-year OS, 51.3% vs 52.4%; aHR, 0.96; P = .88; 95% CI, 0.54-1.69). In group 3a (T1-2 N2-3; n = 807), surgery with adjuvant treatment showed significantly better 5-year OS than CRT (78.6% vs 68.8%; aHR, 1.51; P = .027; 95% CI, 1.05-2.18). In group 3b (T3-4 N2-3; n = 737), surgery with adjuvant treatment was not statistically associated with better 5-year OS as compared with CRT (61.0% vs 43.7%; aHR, 1.53; P = .06; 95% CI, 0.98-2.39).Primary surgery may provide improved survival outcomes in many cases of HPV-negative OPSCCs. These data should be used in weighing treatment options and may serve as a basis to better delineate treatment algorithms for HPV-negative disease.

OBJECTIVES Increasing the percentage of academic faculty who are female and/or an under-represented minority (URM) is a goal in radiation oncology. When studying diversity changes in our University Radiation Oncology Department, we found that increases in resident diversity preceded changes in faculty diversity in every major category. To illustrate these findings, we plotted resident versus faculty diversity each year over the 52-year history of our program. MATERIALS AND METHODS Plots were generated of the percent of residents versus faculty in our program each year between 1967 and 2020 in the following categories: female, URM, and people of color. RESULTS By 1995, substantial levels of diversity were present among both residents and faculty with approximate median annual values between 1995 and 2020 of 30% female for both residents and faculty, 15% URM for both residents and faculty, and 30% persons of color for residents and 15% for faculty. In all analyses, increase in resident diversity preceded an increase in faculty diversity and, in the great majority of years, resident diversity was greater than faculty diversity. CONCLUSION Our experience suggests that it may be easier to increase resident than faculty diversity and that increases in resident diversity may facilitate increasing faculty diversity.

Respected authors recommend broadening the radiation oncology (RO) scope-of-practice by taking more responsibility for the general medical care of our patients, directing the delivery of systemic cancer treatments that avoid the high toxicity of cytotoxic chemotherapy, managing palliative care, and supervising inpatient services for brachytherapy cases and problems related to radiation toxicity. The purpose of these changes is to increase RO involvement in clinical decision making and to avoiding becoming pigeon-holed as technicians instead of oncologists. There are no data estimating the financial implications of substituting traditional radiation oncology practice with that of an expanded clinical role. We sought to fill this void with a general proof-of-principle analysis based on current benchmark data. To determine the relative value units (RVU) of a blended radiation oncology practice, we selected the specialties of general internal medicine, hospital medicine, and palliative care as these fields most closely match the scope of the broadened clinical roles, which supporters of a more diversified radiation oncology practice typically advocate. To estimate the financial implications of a blended radiation oncology practice, we retrieved salary data by specialty and academic rank from the Clinical Practice Solutions Center report of annual RVU generation and the American Association of Medical Colleges annual faculty salary survey. For an assistant professor, this simulation estimates an 11% to 15% decrease in RVU generation for the median assistant professor operating with a 20% blended practice which, in turn, translates to a 7% to 9% decrease in total salary. The calculations for full professor demonstrate a similar decrease in total salary of approximately 8% to 9%.

Background The aim of the study was to update our experience treating patients with glottic carcinoma in situ (CIS) with curative radiotherapy (RT). Methods Fifty patients received continuous-course RT using once-daily fractionation. Twenty-eight (56%) had recurrent or persistent CIS after resection. Median total dose was 63.0 Gy; median dose per fraction was 2.25 Gy. Median follow-up was 9.6 years for all patients and 8.4 years for survivors. Results After RT, 5 patients (10%) recurred locally; salvage surgery was performed in 4 (1 refused). Five-year outcomes were as follows: local control, 91%; ultimate local control (including patients successfully salvaged after local recurrence), 100%; ultimate local control with larynx preservation, 93%; local-regional control, 91%; ultimate local-regional control, 100%; distant metastases-free survival, 100%; cause-specific survival, 100%; and overall survival, 81%. No patient experienced a severe complication. Conclusion RT is an excellent treatment for patients with CIS recurrent after transoral excision and those with previously untreated CIS who are unsuitable for partial laryngectomy.

Background Larynx preservation with chemoradiotherapy (CRT) is used frequently in the treatment of locally advanced hypopharyngeal/laryngeal squamous cell carcinoma (LSCC). Multiple large retrospective analyses have shown that CRT is associated with worse overall survival (OS) compared to total laryngectomy (TL) in patients with T4a disease. Burgeoning evidence suggests HPV status may play a prognostic role in patients with LSCC. We aimed to determine if HPV status influences OS among patients with T4a LSCC, and, if so, if it may be useful in selecting patients for CRT. Methods Using the National Cancer Database (NCDB), we identified 810 patients with T4a N0-3 M0 squamous cell carcinoma of the larynx or hypopharynx with known HPV status who received either definitive CRT (to 66–81.6 Gy with any chemotherapy) or definitive TL (with the addition of 60–70 Gy of adjuvant RT). We evaluated differences in OS using the Kaplan–Meier method and Cox proportional hazards analyses. Results On multivariate analysis, HPV-negative status (HR = 1.42, p = 0.02) and receipt of CRT (HR = 1.34, p = 0.01) were associated with worse OS when compared to HPV-positive patients and patients receiving TL, respectively. Among patients receiving CRT, 5-year OS was lower among HPV-negative patients (33.4%) when compared to HPV-positive patients (50.6%). Conclusions These data suggest that HPV status may be a prognostic factor in patients with T4a LSCC. Further, it supports further investigation into the usefulness of HPV status as a selection factor for larynx preservation with CRT in these patients.

STUDY DESIGN Retrospective outcomes review. OBJECTIVE To analyze and report long-term outcomes in a cohort of patients treated with radiotherapy (RT) for symptomatic hemangioma of a vertebral body. SUMMARY OF BACKGROUND DATA Data are scarce on the rate of tumor control with long-term (>5 yr) follow-up after RT for symptomatic hemangioma of a vertebral body. METHODS We retrospectively reviewed the medical records of patients treated at our institution between 1971 and 2008 for symptomatic hemangioma of a vertebral body, updated their follow-up, analyzed complications, and calculated the tumor control rate. Tumor control by imaging was defined as no increase in tumor size on computed tomography (CT) or magnetic resonance (MR) scan. Clinical tumor control was defined as no symptoms of recurrent tumor. RESULTS Ten patients were eligible for analysis. All patients had pain from visible hemangioma at the time of radiotherapy for which surgical resection or interventional radiology procedures were likely to result in high morbidity. Tumors were located in the lumbar (40%), thoracic (50%), or cervical (10%) areas of the spine. The mean radiotherapy dose delivered was 47 Gy.Mean imaging follow-up after completion of radiotherapy was 8.1 years; mean clinical follow-up was 21.2 years. The tumor control rate was 90% (9/10). One patient who may have developed a tumor recurrence had radiographic and clinical evidence of tumor progression 30 years after radiotherapy. The actuarial rate of tumor control was 100% at 5, 10, 20, and 25 years. There was no grade more than or equal to three treatment toxicities, no evidence of malignant transformation, and no evidence of second tumors in treatment area (with the possible exception of the one tumor recurrence). CONCLUSION RT for symptomatic hemangioma of the spine provides long-term tumor control with a low risk of serious complications. Radiotherapy is a good option when surgery or an interventional radiology procedure is high-risk. Our preferred dose is 45 Gy at 1.8 Gy/fraction. LEVEL OF EVIDENCE 4.

OBJECTIVE Chemoradiotherapy (cRT) and total laryngectomy (TL) are acceptable treatments for locally advanced laryngeal squamous cell carcinoma (LSSC). We aimed to compare the outcomes in patients receiving full-dose treatment. METHODS We identified 11,237 patients in the National Cancer Database treated 2004 to 2015 for T3-4N0-3 LSCC with either TL (with 60 to 80 Gy of adjuvant RT) or cRT (70 to 80 Gy). We evaluated differences in overall survival (OS) using Kaplan-Meier and Cox proportional hazards modeling. RESULTS For patients with T3 disease, there was no difference in OS regardless of N stage (N0: hazard ratio [HR]=0.94, P=0.38; N+: HR=0.92, P=0.19). TL was associated with improved OS in patients with T4 disease (N0: HR=1.39, P

OBJECTIVES/HYPOTHESIS Head and neck cancer pain is a prevalent problem, and the current opioid crisis has highlighted concerns raised in chronic pain management. This study assessed the characteristics of opioid use in patients undergoing treatment for oropharynx cancer and identified risk factors associated with chronic opioid use. STUDY DESIGN Retrospective cohort study. METHODS A study was conducted of 198 eligible patients who underwent radiotherapy as part of their treatment for oropharynx cancer at a single institution from 2012 to 2017. p16/human papillomavirus (HPV) status was determined by pathology report review. Opioid use was recorded. Statistical analysis was performed to assess risk factors for chronic opioid use and effect on overall survival. RESULTS The average age was 62 years, and the mean follow-up was 38 months. Eighty-three percent of patients had stage III/IV disease, and 73% received chemoradiotherapy. Sixty-nine percent were HPV/p16 positive. Fifty-seven (29%) patients had preexisting chronic pain conditions. Chronic opioid use was observed in 53% of the patients. Age ≤ 62 years (P < .0001), history of depression (P = .0356), p16 negative status (P = .0097), opioid use at pretreatment visit (P = .0021), and presence of a preexisting chronic pain condition at time of diagnosis (P = .0181) were associated with chronic opioid use using univariate analysis. On multivariate analysis, T stage and anxiety/depression were associated with chronic opioid use. Overall survival was worse for patients who had chronic opioid use, but was not significant when recurrence was taken into consideration. CONCLUSIONS More than 50% of the patients treated for oropharynx squamous cell carcinoma in this cohort were chronic opioid users after treatment. Identifying patients at greatest risk for chronic opioid use prior to treatment may help with long-term pain management in this patient population. LEVEL OF EVIDENCE 4 Laryngoscope, 129:2087-2093, 2019.

Purpose/Objective(s) Pleomorphic adenoma is the most common benign salivary gland tumor. It is primarily treated with definitive surgery. Rarely, radiation therapy can be utilized for recurrent lesions and in other scenarios such as positive margins. There are relatively few studies reporting efficacy and outcomes of pleomorphic adenoma treated with radiation therapy. The purpose of this project is to report tumor control, complications, and survival outcomes of patients treated with fractionated radiotherapy at our institution with pleomorphic adenoma. Materials/Methods This was a retrospective analysis of survival outcomes and treatment-related toxicity in patients with pleomorphic adenoma treated with fractionated radiotherapy at our institution between 1970 and 2016. We excluded patients who did not have a histologic diagnosis and those with prior unrelated head or neck radiation. We identified 35 patients who met these criteria. The Kaplan-Meier product limit method was utilized to assess time-dependent endpoints. Results Median clinical follow-up was 9.1 years and median imaging follow-up was 6.9 years. The 15-year cause-specific survival rate was 86% and the 15-year overall survival rate was 68%. The rate of 15-year local control was 64%; however, 42% of patients with local failures were ultimately successfully controlled with salvage therapies. The rate of patients who experienced grade 3 or higher CTCAE toxicity was 17%. Conclusion To the best of our knowledge, this study comprises the largest cohort of pleomorphic adenoma patients treated with fractionated radiotherapy in the last 25 years. Our data suggests that radiation therapy is efficacious and minimally toxic in this rare clinical scenario. Furthermore, in patients who do recur following radiation therapy, there is a relatively high rate of successful salvage.

Study Design: Literature review. Objective: To review the current role of radiotherapy (RT) in the management of oral cavity squamous cell carcinoma (SCC). Methods: Review of selected literature. Results: T1-T2N0 SCCs may be treated with either RT alone or surgery with a high likelihood of cure. The pendulum swung toward surgery with postoperative RT (PORT) added depending on the pathological findings in the mid 1980s. Patients with positive margins, extranodal extension (ENE), and/or 4 or more positive nodes receive concomitant chemotherapy (POCRT). Patients with T3-T4 and/or positive regional nodes are treated with surgery and PORT alone or POCRT. The likelihood of cure is moderate to low depending on extent of disease. The likelihood of major complications ranges from 10% to 30% depending on the method of reconstruction and the aggressiveness of postoperative PORT/POCRT. Patients with very advanced disease are treated with palliative RT, chemotherapy, or supportive care. Conclusions: The role of RT in the management of oral cavity SCC is primarily in the postoperative setting with palliative RT being reserved for those with very advanced disease where the likelihood of cure is remote.

Purpose Human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) treatment outcomes are re-defining management. Traditional margins, the role of extranodal extension (ENE) and adjuvant treatment intensity continue to be debated. This study aimed to determine the impact of margins, ENE and adjuvant therapy on survival following transoral robotic surgery (TORS). Methods Patients treated with TORS at an academic center were retrospectively identified (2013–2019). Survival outcomes were evaluated using Kaplan-Meier curves. Results 48 patients were included. 40 (83%) were male. Mean age was 61.2 years. 43 (90%) were stage I. 22 (45.8%) had ENE. 31 (65%) had margins >1 mm. 38 (79%) had indications for radiation therapy; 9 (24%) refused. Chemotherapy was recommended in 36 (75%) patients; 24 (67%) refused. Locoregional control was 98%, metastasis-free survival was 96%, and disease-specific survival was 100% at 5-years. Overall survival was 95%. Conclusions Given the high survival rate seen after TORS, it is likely that margins, ENE and adjuvant treatment may not significantly contribute to outcomes.

Locally recurrent head and neck malignancies after definitive radiation or chemoradiation represent challenging clinical scenarios requiring careful consideration of individualized risks and benefits before deciding upon the next best course of therapy. Herein, a case-based approach to personalized decision making highlights the expert opinions of leaders in head and neck oncology. Topics of interest include optimal candidacy for reirradiation or salvage surgical resection, the judicious use of chemotherapy as induction therapy or as a radiosensitizing agent, the incorporation of immunotherapy into the treatment paradigm for locally recurrent disease, and the impact of various treatment modalities on quality of life and functional outcomes. Interestingly, the lack of consensus among the experts on topics as fundamental as the appropriateness of offering reirradiation at all and as nuanced as target volume delineation for the reirradiated field suggests that there is no straightforward approach in this scenario. Common to all opinions is a desire to maximize the therapeutic ratio for a patient potentially facing a grim prognosis, and honest discussions about goals of care and expectations for post-treatment quality of life should be central to the clinical approach to this and similar cases.

There is no standardized format for presenting and discussing the results of a radiotherapy dosimetry comparison study. The purpose of this report is to describe a format that we have found useful in evaluating plans in our department and in reviewing studies from other groups.

OBJECTIVES Examine the utility of pretreatment computed tomography in predicting local control (LC) in squamous cell carcinoma of the supraglottic larynx treated with primary radiotherapy (RT). METHODS In total, 167 patients treated between 1983 and 2013 were reviewed. Patients had received pretreatment diagnostic computed tomographic imaging of the larynx and neck from which primary tumor volume (PrTV) was delineated. LC, larynx function at last follow-up, and RT complications were recorded. PrTV was evaluated with respect to outcome. RESULTS In this study, median age was 61 years, and mean follow-up was 96 months. In total, 43% had T1-T2, 46% had T3, and 11% had T4 disease; 49% had N0 disease. Median tumor volume, 5.1 cm (0.4 to 188 cm). Mean dose, 74 Gy; 20% received concurrent chemotherapy. Overall, 10-year LC was 78.9%. Ten-year LC stratified by tumor volume was: 0 to 4.9 cm, 90.8%; 5 to 8.9 cm, 67.3%; and >9 cm, 69.4%. Ten-year LC with preserved larynx function was: 0 to 4.9 cm, 76.7%; 5 to 8.9 cm, 61.5%; and >9 cm, 53.4%. LC and LC with preserved larynx function was significantly different between PrTV groups (P

The objective of this study is to evaluate long-term outcomes, specifically patterns of tumor recurrence, in patients with adult medulloblastoma treated with radiotherapy.We recorded outcomes of 28 (median age, 25 y) patients 18 years old or above with M0 to M3 medulloblastoma treated between 1971 and 2012. Among them, 61% had standard-risk disease. All received craniospinal irradiation with a posterior fossa boost. Median dose to the craniospinal axis was 36 Gy. Median total dose to the primary site was 55.9 Gy and 46% received chemotherapy.Median follow-up among survivors was 14.2 years. At 5 and 10 years, local control was 80% and 73%, overall survival was 71% and 59%, cause-specific survival was 71% and 63%, and freedom from progression was 68% and 59%. Tumors recurred in 11 patients (39%); median time to recurrence was 2.4 years, and 82% of recurrences developed in patients with standard-risk disease. Of the recurrences, 55% involved the primary site; 36% were bone metastases without neural axis recurrence. There were no isolated recurrences in the spinal canal or ventricular system outside of the posterior fossa.The primary site is the main site of medulloblastoma recurrence, with isolated bone metastases more common in adults than children. Our results prompt us to consider 4 modifications to our treatment approach with adults who present with medulloblastoma: (1) initial staging to include PET or bone scan; (2) radiotherapy dose to the primary site of 59.4 Gy; (3) chemotherapy during and/or following radiotherapy in medically fit patients; (4) follow-up to include PET or bone scan twice a year for 3 years.

Background Recent historical management of oropharyngeal squamous cell carcinoma typically includes radiotherapy with/without chemotherapy. Novel surgical techniques such as robotic surgery have made primary surgery more frequent; however, postoperative radiotherapy may be recommended. We aimed to assess adherence to guidelines for postoperative therapy following robotic surgery. Methods Using the National Cancer Database, we analyzed the frequency of radiotherapy following robotic surgery for cT1-3cN0-2cM0 squamous cell carcinoma of the oropharynx, specifically in the presence of widely accepted indications for postoperative radiotherapy and/or chemotherapy. Results Approximately two-thirds of patients received radiotherapy after robotic surgery for early-intermediate stage oropharyngeal cancer. One in five patients with an indication for adjuvant radiotherapy and 1/3 with an indication for adjuvant chemotherapy did not receive recommended adjuvant therapy. Conclusions A high proportion of patients require radiotherapy after robotic surgery for early-intermediate stage oropharyngeal cancer. Patients with an indication for further adjuvant therapy commonly do not receive it.

Purpose This study aimed to compare the swallowing function in patients with human papillomavirus–associated oropharyngeal squamous cell carcinoma treated with de-intensified chemoradiation therapy (6 weeks, 60 Gy) versus those receiving standard-of-care chemoradiation therapy (7 weeks, 70 Gy). Methods and materials A retrospective review was conducted of 78 patients with human papillomavirus–associated oropharyngeal squamous cell carcinoma with modified barium swallow studies pretreatment and 6 to 8 weeks posttreatment. The swallowing function was objectively scored for penetration, aspiration, and pharyngeal residue. Forty patients received de-intensified chemoradiation therapy (60 Gy image guided radiation therapy with weekly cisplatin 30 mg/m2) and 38 patients received standard-of-care chemoradiation therapy (70 Gy image guided radiation therapy with chemotherapy of the medical oncologist's choosing). Univariate and multivariate analyses were performed to detect differences between the cohorts with regard to laryngeal penetration, aspiration, and pharyngeal residue. A multivariate logistic regression was used to determine the overall effect of treatment on the swallowing function. Patient-reported swallowing outcomes in de-intensified cohort were assessed with the European Organisation for Research and Treatment of Cancer Quality of Life Module for Head and Neck Cancer and the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events questionnaires. Results Patients treated with de-intensified chemoradiation therapy were associated with a suggestion of lower risk of developing overall swallowing dysfunction (odds ratio [OR], 0.62; P = .07), laryngeal penetration (OR, 0.63; P = .12), and pharyngeal residue (OR, 0.61; P = .08). The mean pre- and 2-year post-European Organisation for Research and Treatment of Cancer Quality of Life scores pertaining to swallowing (1-4 scale, higher worse) in the de-intensified cohort were 1.4 and 1.2 for liquids; 1.2 and 1.1 for purees; 1.5 and 1.7 for solids, 1.0 and 1.3 for choked when swallowing; and 9.0 and 10.8 for composite score, respectively. The mean pre- and 2-year post-Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events swallowing difficulty scores (1-5 scale, with higher scores being worse) were 1.5 and 1.8, respectively. Conclusions Compared with 7 weeks of 70 Gy, 6 weeks of 60 Gy de-intensified chemoradiation therapy appears to better preserve the baseline swallowing function (per objective modified barium swallow assessment). Patients treated with de-intensified chemoradiation therapy reported minimal changes in swallowing function.

Background The purpose of the current study was to determine quality of life and tumor control from a prospective phase 2 clinical trial evaluating deintensified chemoradiotherapy for favorable risk, human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma. Methods Patients with T0-T3, N0-N2c, M0, p16-positive disease and a minimal smoking history were treated with 60 grays of intensity-modulated radiotherapy with concurrent weekly intravenous cisplatin (30 mg/m2 ). The primary study endpoint was the pathologic complete response rate based on biopsy of the primary site and dissection of pretreatment positive lymph node regions. The pathologic complete response rate as previously reported was 86%. Herein, the authors report secondary endpoint measures of local control, regional control, cause-specific survival, distant metastasis-free survival, and overall survival, and patient-reported outcomes (European Organization for Research and Treatment of Cancer [EORTC] Quality of Life Questionnaire [EORTC QLQ-C30] and the Patient-Reported Outcomes version of Common Terminology Criteria for Adverse Events [PRO-CTCAE]). Results A total of 44 patients enrolled with a median follow-up of 36 months (88% with ≥2 years). The 3-year local control, regional control, cause-specific survival, distant metastasis-free survival, and overall survival rates were 100%, 100%, 100%, 100%, and 95%, respectively. The mean before and 3-year after EORTC QOL scores were: global: 80 of 78; swallowing: 11 of 11; dry mouth: 16 of 41; and sticky saliva: 6 of 29. The mean before and 3-year after PRO-CTCAE scores were: swallowing: 0.4 of 0.7; and dry mouth: 0.4 of 1.4. Approximately 39% of patients required a feeding tube (median duration, 15 weeks; none were permanent). There were no ≥grade 3 late adverse events reported. Conclusions For patients with favorable-risk human papillomavirus-associated oropharyngeal squamous cell carcinoma, a substantially decreased intensity of therapy with 60 grays of intensity-modulated radiotherapy and weekly low-dose cisplatin produced better preservation of quality of life compared with standard therapies while maintaining excellent 3-year tumor control and survival. Cancer 2018;124:2347-54. © 2018 American Cancer Society.

To determine the long-term outcome after stereotactic radiosurgery (SRS) for temporal bone paragangliomas. We retrospectively reviewed the medical records of 11 patients with temporal bone paragangliomas (10 patients with a glomus jugulare tumor and 1 patient with a glomus tympanicum tumor) treated between January 1997 and July 2012 at the University of Florida with SRS to a median dose of 15 Gy in 1 fraction. Ten previously unirradiated patients received SRS as did 1 patient who received prior fractionated radiotherapy (FRT) and then received salvage SRS for a local recurrence. The major outcome endpoint was local control, meaning no further growth or shrinkage on follow-up computed tomography or magnetic resonance imaging scans. The median follow-up time was 5.3 years. Two patients developed a local recurrence after SRS, including the patient who received salvage SRS after prior FRT. The overall local control rates at 5 and 10 years were both 81%. The cause-specific survival rates at 5 and 10 years were both 88%. The distant metastasis-free survival rates at 5 and 10 years were both 100%. The overall survival rates at 5 and 10 years were both 78%. There were no severe complications. SRS for benign head and neck paragangliomas is a safe and efficacious treatment associated with minimal morbidity. SRS is suitable for patients with skull base tumors

The prevalence of patients with human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is rapidly increasing, and it is now well known that these patients have a significantly better prognosis than patients with HPV-negative OPSCC. Though standard treatments result in excellent cancer control, they are also associated with substantial long-term toxicity. There is now great interest in evaluating less intensive (ie, deintensified) treatment regimens to improve the therapeutic ratio (maintain excellent cancer control and decrease toxicity). There are many different approaches that are being studied, and each have their own caveats, with varying degrees of actual deintensification. In this article, we critically review the current landscape of emerging deintensified treatment paradigms and future direction of the treatment of HPV-associated OPSCC.