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Study Design: Retrospective cohort study. Objective: To evaluate the outcomes of conventionally-fractionated external beam radiation therapy (cEBRT) in the treatment of prostate cancer spinal metastases (PCSM). Methods: Patients who received palliative cEBRT for PCSM in our institution between 2008 and 2018 were included. Our outcomes were local progression-free survival (LPFS), overall survival (OS), pain response and toxicities graded using CTCAE version 4.03. Univariable and multivariable Cox proportional hazard regressions were performed to identify predictors for LPFS and OS. Results: A total of 100 patients with 132 sites of PCSM were identified, with a median follow-up of 54 months. Fourteen-percent of patients underwent surgical intervention before receiving cEBRT. Eighteen spinal segments (13.6%) had local progression, with a median time to local progression of 8 months. The median LPFS and OS were 7.8 and 9.0 months, respectively. The complete and partial pain response rates were 57% and 39% respectively. The incidence of grade ≥3 acute toxicities was 11%. Better ECOG performance status (0 to 1), castration-sensitive disease, spinal surgery and use of novel antiandrogen agent were identified as significant predictors for improved OS on multivariable analysis. Conclusions: In our prostate cancer cohort, cEBRT is an effective treatment modality for local palliation of spinal metastases. More aggressive treatment approach should be considered for patients with excellent performance status and castration-sensitive disease in light of their expected longer survival. Further studies are warranted to identify the predictors for radiotherapy response in this population.

Previous non-randomised studies comparing dosimetric outcomes between advanced techniques such as IMRT and VMAT reported conflicting findings. We thus sought to perform a systematic review and meta-analysis to consolidate the findings of these studies.We searched PUBMED and EMBASE for eligible studies from their time of inception to 10 March 2022. A random effects model was used to estimate the pooled mean differences (MDs) and their 95% confidence intervals(CIs) for target volume coverage, organ-at-risk(OAR) doses, monitor units(MUs) and treatment delivery times. We also performed a subgroup analysis to evaluate if different treatment planning systems (TPS) (Eclipse, Monaco and Pinnacle) used affected the pooled mean differences.A total of 17 studies (383 patients) were eligible to be included. The pooled results showed that dual arc VMAT reduced D2% of PTV (MD=0.71Gy,95%CI=0.14-1.27,P=0.01), mean left cochlea dose (MD=2.6Gy,95%CI=0.03-5.16,P=0.05), mean right cochlea dose (MD=3.4Gy,95%CI=0.7-6.1,P=0.01), MUs (MD=554.9,95%CI=245.8-863.9,P=0.0004), treatment delivery times (MD=6.7mins,95%CI=4.5-8.9,P0.0001) and integral dose (MD=0.97Gy,95%CI=0.28-1.67,P=0.006). None of the other indices were significantly better for the IMRT plans. The subgroup analysis showed that the integral dose was significantly lower only for Eclipse (MD=0.88Gy, 95%CI=0.14-1.63, P=0.02). The total MUs was significantly lower only for Eclipse (MD=1035.2, 95%CI=624.6-1445.9, P0.0001) and Pinnacle (MD=293, 95%CI=15.6-570.5, P=0.04). Similarly, delivery time was also significantly lower only for Eclipse (MD=6.1mins, 95%CI=5.7-6.5, P0.0001) and Pinnacle (MD=4.9mins, 95%CI=2.6-7.2, P0.0001). The subgroup analysis however showed that target coverage was superior for the IMRT plans for both Pinnacle (MD=0.48Gy, 95%CI=0.31-0.66, P0.0001) and Monaco (MD=0.12Gy, 95%CI=0.07-0.17, P0.0001).Dual-arc VMAT plans improved OAR doses, MUs and treatment times as compared to IMRT plans. The different TPS used may modify dosimetric outcomes.

To compare the efficacy and safety of stereotactic body radiation therapy (SBRT) and conventional external beam radiation therapy (cEBRT) in patients with previously unirradiated painful bone metastases (BM).We searched biomedical databases for eligible randomized controlled trials (RCTs). The outcomes of interest were pain response, local progression, overall survival (OS) and adverse events. We used established tools to assess the quality of the individual trials and certainty of the pooled evidence. We performed meta-analyses using random effects models.Six RCTs were identified. SBRT improved complete pain response rates at 3 months (OR, 3.38; 95% CI, 1.88-6.07; high certainty), reduced local progression rates (OR, 0.19; 95% CI, 0.06-0.62; high certainty) and increased pain flare rates. There were no differences for other outcomes.Among patients with previously unirradiated painful BM, SBRT significantly improved complete pain response rates at 3 months, delayed local progression and increased pain flare rates.

Our study seeks to describe our surgical technique of the use of a tissue expander and a pelvic sling in order to perform high-dose pelvic irradiation without incurring radiation toxicity to the small bowel. High-dose radiation therapy for pelvic tumours comes at a risk of radiation toxicity to the small bowel. Our study discusses our novel surgical technique of compartmentalising the abdomen and the pelvis through the use of a tissue expander and pelvic sling to avoid small bowel radiation toxicity. We present a patient with an unresectable sacral chordoma. We describe our surgical technique incorporating both a tissue expander and an absorbable pelvic mesh sling to successfully compartmentalise the abdomen from the pelvis. The patient underwent an uneventful surgical procedure to place the tissue expander within the pelvis and deploy the pelvic mesh sling. Following surgery, a separation of at least 8 cm was achieved between bowel loops and the tumour. A dose of 70 Gy delivered over 35 fractions using intensity modulated radiotherapy (IMRT) was administered to the sacral chordoma, whilst managing to constrain the maximum bowel dose to 35.7 Gy. Surgery to remove the tissue expander was uneventful. The patient has not suffered any small bowel irradiation toxicity. Our technique to exclude small bowel from the pelvis is effective and safe. This technique not only can be applied in the setting of unresectable sacral chordomas but also may be applicable to other pelvic cancers which require radiation therapy.

Introduction: Childhood radiation exposure is a known risk factor for thyroid malignancy and dysfunction. However, local data are limited and there is no consensus on the modality and frequency of screening in this high-risk group. Methods: Retrospective analysis study evaluating patients with childhood radiation exposure in 2006–2016 and minimum of 1-year follow-up. Results: Of the 132 childhood cancer survivors in the study, thyroid malignancy was detected in 2 cases (1.5%) and thyroid nodules in 13 (9.8%). The earliest thyroid malignancy was detected 5 years post-radiotherapy via ultrasound. Of the 84 patients who had screening thyroid function test, 26 (31.0%) were detected with abnormal test results post-radiation, majority being subclinical hypothyroidism. Conclusion: Regular screening via clinical examination for thyroid nodules should be performed at least annually. Where feasible and if resources permit, consideration should be given to using ultrasound for thyroid nodule(s) and malignancy screening at 5 years post-radiation therapy. Screening for thyroid dysfunction can be considered from 6–12 months post-radiotherapy. Keywords: Childhood post-radiotherapy complications, post-radiotherapy secondary malignancies, thyroid cancer, thyroid dysfunction, thyroid nodules

Background and ObjectivesWe aim to determine the risk of stroke and death within 30 days after stroke in nasopharyngeal cancer (NPC) survivors.MethodsWe conducted a population-based cohort study of patients diagnosed with NPC from January 1, 2005, to December 31, 2017. Using the cancer and stroke disease registries and the Singapore general population as the reference population, we report the age-standardized incidence rate differences (SIRDs) ratios (SIRs) and the cumulative incidence of stroke and the standardized mortality rate differences (SMRDs) and ratios (SMRs) for all causes of death within 30 days after stroke for NPC survivors.ResultsAt a median follow-up of 48.4 months (interquartile range 19.8–92.9 months) for 3,849 patients diagnosed with NPC, 96 patients developed stroke. The overall SIRD and SIR for stroke were 3.12 (95% confidence interval [CI] 2.09–4.15) and 2.54 (95% CI 2.08–3.10), respectively. The SIRD was highest for the age group 70 to 79 years old (8.84 cases per 1,000 person-years, 95% CI 0.46–17.21), while the SIR was highest for the age group 30 to 39 years old (16.41, 95% CI 6.01–35.82). The SIRD and SIR for stage 1 disease were (6.96 cases per 1000 person-years, 95% CI 2.16–11.77) and (4.15, 95% CI 2.46–7.00), respectively. The SMRD and SMR for all cause deaths within 30 days of stroke were (3.20 cases per 100 persons, 95% CI −3.87 to 10.28) and (1.34, 95% CI 0.76–2.37), respectively.DiscussionThe overall risk of stroke was markedly elevated in survivors of NPC, especially in stage 1 disease, compared to the general population. The risk of death within 30 days of stroke was not significantly higher for NPC survivors.Classification of EvidenceThis study provides Class II evidence of the increased risk of stroke in survivors of NPC compared to the general population.

In this review, we will outline the role of percutaneous interventional radiological management of recurrent head and neck (H&N) cancer in the context of a multidisciplinary setting which consists of surgery, radiation therapy, as well as established and evolving systemic therapies that may impact current practice. Management of recurrent H&N cancer is complex, with attention to the preservation of function and minimal treatment-related morbidity. The favored treatment modalities in local recurrence previously treated with radiotherapy are surgical resection, and if unresectable, for chemotherapy as definitive treatment, or as a prelude to resection if there is good tumor response. Unfortunately, some of these patients are too frail for major surgery or to withstand the toxicity of chemotherapy. There is a gap for effective local therapy without the morbidity of surgery, toxicity of re-irradiation, and systemic side effects of chemotherapy. Percutaneous interventions have the potential to bridge that gap as well as provide palliative symptomatic treatment for patients that have exhausted all treatment options. In the multidisciplinary setting involving the treatment of complex recurrent H&N cancer, percutaneous management now plays a viable and effective role with a foothold in this team-based approach.

In this review, we will outline the role of percutaneous interventional radiological management of recurrent head and neck (HN) cancer in the context of a multidisciplinary setting which consists of surgery, radiation therapy, as well as established and evolving systemic therapies that may impact current practice.Management of recurrent HN cancer is complex, with attention to the preservation of function and minimal treatment-related morbidity. The favored treatment modalities in local recurrence previously treated with radiotherapy are surgical resection, and if unresectable, for chemotherapy as definitive treatment, or as a prelude to resection if there is good tumor response. Unfortunately, some of these patients are too frail for major surgery or to withstand the toxicity of chemotherapy. There is a gap for effective local therapy without the morbidity of surgery, toxicity of re-irradiation, and systemic side effects of chemotherapy. Percutaneous interventions have the potential to bridge that gap as well as provide palliative symptomatic treatment for patients that have exhausted all treatment options. In the multidisciplinary setting involving the treatment of complex recurrent HN cancer, percutaneous management now plays a viable and effective role with a foothold in this team-based approach.

PURPOSE: To determine and compare the incremental clinical benefit (ICB) and costs of induction chemotherapy (IC) when added to concurrent chemoradiotherapy (CCRT), concurrent chemotherapy (CC) when added to radiotherapy (RT), and CC plus adjuvant chemotherapy (AC) when added to RT for locally advanced nasopharyngeal cancer (LA-NPC). MATERIALS AND METHODS: We searched phase III randomized controlled trials (RCTs) that reported overall survival benefit with the use of IC, CC, and CC + AC in LA-NPC. We quantified the ICB using the ASCO and European Society for Medical Oncology (ESMO) value frameworks. We calculated the incremental drug costs in US dollars using the lowest average wholesale price reported in the Lexicomp drug database. RESULTS: We identified three RCTs on IC, three RCTs on CC, and four RCTs on CC + AC. The ICB was judged to be grade A based on the ESMO framework. The ASCO Net Health Benefit score ranged from 17.43 to 57.39. The incremental drug costs ranged from $133.46 to $626.14. There were no statistically significant differences in the mean Net Health Benefit scores (39.37 for IC v 37.61 for CC v 33.98 for CC + AC; P = .89) and costs ($383 for IC v $253 for CC v $460 for CC + AC; P = .27) between the three approaches. There was no statistically significant correlation between ICB and costs. CONCLUSION: The magnitudes of ICB and incremental drug costs of adding of IC to CCRT, CC to RT, and CC + AC to RT for LA-NPC are not significantly different.

Purpose To determine if the addition of induction chemotherapy (IC) to concurrent chemoradiation (CCRT) in locally advanced nasopharyngeal carcinoma (LA-NPC) can improve survival. Methods We performed a meta-analysis of both randomized controlled trials (RCTs) and observational studies (OBS) to compare the effects of addition of IC to CCRT versus (vs) CCRT alone on overall survival (OS), progression free survival (PFS), distant metastasis-free survival (DMFS) and adverse events (AE) in LA-NPC. We searched MEDLINE for eligible studies comparing IC plus CCRT vs CCRT for LA-NPC from Jan 1996 to May 2017. We selected RCTs and OBS that included patients with non-metastatic, LA-NPC who received IC followed by CCRT or CCRT alone. Three reviewers independently assessed the abstracts for eligibility. We assessed the methodological quality of the included studies using the MERGE criteria. We performed the meta-analysis with random effects model. We used the GRADE approach to appraise the quality of evidence from RCTs. The primary outcome was OS; secondary outcomes included PFS, DMFS and AE. Results We found six RCTs and five OBS including 2802 patients with low to moderate risk of bias in their methodological quality. There was high quality evidence from the RCTs that IC improved PFS (HR 0.69, 95% CI 0.57–0.84, P = 0.0003, I2 = 0%) and OS (HR 0.77, 95% CI 0.60–0.98, P = 0.03, I2 = 0%) significantly and was associated with more frequent AE. The estimates of IC effects from RCTs and OBS were similar (PFS HR 0.69 vs 0.71, interaction P (IP) = 0.92; OS HR 0.77 vs 0.58, IP = 0.27). Conclusions IC delays disease progression and improves survival significantly for LA-NPC treated with CCRT, and was associated with more toxicity. There were no divergent results between RCTs and OBS. IC followed by CCRT can be considered one of the standard treatment options for LA-NPC.

In December 2019, pneumonia of unknown cause was reported by China to WHO. The outbreak was found to be caused by a coronavirus which was officially named "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2), and the disease caused by it was named 'COVID-19'. The first case in Singapore was confirmed on 23rd January 2020. With lessons learnt from the SARS epidemic in 2003 and the H1N1 flu pandemic in 2009, Singapore was much better prepared to deal with the virus outbreak. The government has taken swift measures to contain and break the chain of transmission. Healthcare workers face the challenge of keeping patients and staff safe from the disease. There is a higher risk of mortality of COVID-19 in cancer patients and hence unique considerations for a radiation oncology department operating in an infectious disease outbreak. This article is the recommendations and adapted workflow from the two National Cancer Centres in Singapore with the endorsement by the working committee of the Chapter of Radiation Oncology, Academy of Medicine, Singapore. It highlights the challenges that radiation oncology departments in Singapore face and the appropriate recommended responses. This includes interventions, business continuity plans and workflow in managing a COVID-19 positive patient on radiotherapy.

Our knowledge of nasopharyngeal carcinoma (NPC) is rapidly changing. This article is a snapshot of the present state of NPC imaging in relation to the latest staging system, current standards of care, and treatment complications. The article’s emphasis on pathophysiology and important radiological anatomy will improve the interpretation of radiological findings and allow the radiologist to optimize the role of imaging in a multidisciplinary team.

Background/Aim: The aim of this study was to review the outcomes of palliative radiotherapy (RT) for hematuria treated with modern RT techniques. Patients and Methods: This was a retrospective cohort study. The primary endpoint was symptom response rate. Secondary endpoints included symptom recurrence rate, overall survival and treatment-related toxicity. Results: Median age was 82 years (range=36-98 years). Median biologically effective dose (BED) was 36 Gy. Sixty-seven percent of patients (39/58) responded to RT. The median survival duration was 5.6 months (range=0.02-47.6 months). One third (13/39) of responders had recurrence of hematuria. Competing Risk regression with death as the competing risk showed that patients treated with low BED regimen (36 Gy) (p=0.01). One patient (2%) developed grade 3 nausea and vomiting which required admission for intravenous hydration. Conclusion: BED regimens should be recommended as they are associated with a significantly lower rate of recurrent hematuria.

INTRODUCTION Glioblastoma multiforme (GBM) is the most common primary brain tumour in adults. Although the survival rate for GBM has improved with recent advancements in treatment, the prognosis remains generally poor. METHODS We conducted a retrospective review of GBM patients seen in National University Hospital, Singapore, and Tan Tock Seng Hospital, Singapore, from January 2002 to December 2011. Data on disease and treatment factors was collected and correlated with survival. RESULTS Data on a total of 107 GBM patients was analysed. Their median survival time was 15.1 months and the two-year survival rate was 23.5%, which is comparable with data published in other series. The factors associated with improved median survival time were radiotherapy dose > 50 Gy (16.1 months vs. 8.7 months, p = 0.01) and adjuvant concurrent chemotherapy (16.4 months vs. 9.2 months, p = 0.003). CONCLUSION GBM confers a poor prognosis. Adjuvant radiotherapy and chemotherapy are associated with improved survival. Ethnicity may be a contributing factor to differences in GBM incidence and prognosis.

Locally advanced, fungating breast cancer is a distressing condition that is frequently seen worldwide. Radiation is particularly useful in reducing the associated symptoms such as discharge, bleeding and pain. However, there is surprisingly limited data regarding the efficacy of radiation in controlling symptoms in patients with this condition. Records of 35 patients with fungating breast cancer were retrospectively reviewed. Study end points included tumor and symptom response (including response rates, duration of response), median survival, and treatment toxicity, which was scored using the Common Toxicity Criteria v3.0. To investigate for a dose-response relationship, patients were divided into two subgroups using the median biological effective dose (BED) of radiation. Patients in the higher BED subgroup (40 Gy10 or greater) were compared to those in the lower BED group (less than 40 Gy10) using the Fisher’s exact test. Median age was 59 years (range 40–91 years). Thirty-two patients (91 %) had tumor size larger than 5 cm and nine patients (26 %) had known distant metastatic disease at the time of treatment. Dose-fractionation regimen ranged from 20 Gy in 5 fractions to 65 Gy in 26 fractions. Median survival was 11.7 months. Actuarial 12-month survival was 58 %. There was no difference between the high-dose and the low-dose groups, and higher radiation dose was not found to be associated with a longer duration of palliation or survival. No patients experienced grade 3 or 4 toxicity. Radiotherapy is effective palliative treatment for patients with fungating breast cancer. High response rates of up to 90 % can be expected, with a median local progression-free survival of 10 months. With the advent of dose escalation techniques such as intensity-modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT), it is now technically possible to deliver high radiation doses to patients with low toxicity and risk to the adjacent normal organs. Nevertheless, whether higher doses or longer courses of radiotherapy confer better local control is a potential subject for further study.

67 Background: To determine and compare the incremental clinical benefit (ICB) and costs of induction chemotherapy (IC) when added to concurrent chemoradiotherapy (CCRT), concurrent chemotherapy (CC) added to RT and CC + adjuvant chemotherapy (AC) when added to RT for locally advanced nasopharyngeal cancer (LA-NPC). Methods: We searched phase III randomized controlled trials (RCTs) which reported overall survival (OS) benefit with the use of IC, CC and CC+AC in LA-NPC. We quantified the ICB using the ASCO and ESMO value framework. We calculated the incremental drug costs in US dollars using the lowest average wholesale price reported in the Lexicomp drug database. Results: We identified three RCTs on IC, three RCTs on CC and four RCTs on CC + AC. The ICB was judged to be Grade A based on the ESMO framework. The ASCO Net Health Benefit Score (NHBS) ranged from 17.43 to 57.39. The incremental drug costs ranged from 133.46 to 626.14. There were no statistically significant differences in the means of NHBS [39.37 (IC) vs 37.61 (CC) vs 33.98 (CC+AC), P = 0.89] and costs [383 (IC) vs 253 (CC) vs 460 (CC+AC), P = 0.27] between these three approaches. There was no statistically significant correlation between ICB and costs. Conclusions: The magnitudes of ICB and incremental drug costs of adding of IC to CCRT, CC to RT and CC + AC to RT for LA NPC are not significantly different.

Renal cell carcinoma (RCC) has been traditionally thought to be radioresistant. This retrospective cohort study aims to assess the outcomes of patients with spinal metastases from RCC treated with conventionally-fractionated external beam radiation therapy (cEBRT) in our institution. Patients diagnosed with histologically or radiologically-proven RCC who received palliative cEBRT to spinal metastases, using 3-dimensional conformal technique between 2009 and 2018 were reviewed. Local progression-free survival (PFS), overall survival (OS) and common terminology criteria for adverse events version 4.0-graded toxicity were assessed. Univariable and multivariable Cox proportional hazards regression analyses were performed to evaluate for predictors associated with survivals. Thirty-five eligible patients with forty spinal segments were identified, with a median follow-up of 7 months (range, 0–47). The median equivalent dose in 2 Gy fractions (EQD2) was 32.5 Gy 10 (range, 12–39). Thirty-seven percent of patients underwent surgical intervention. At the time of last follow-up, all but 1 patient had died. Seven patients developed local progression, with the median time to local progression of 10.2 months. The median local PFS and OS were 3.3 and 4.8 months. There was no grade 3 or higher toxicity. A higher radiation dose (equivalent dose to 2 Gy fraction

AIM Whole brain radiotherapy (WBRT) is commonly used to treat brain metastases (BM) from nonsmall cell lung cancer (NSCLC). Its utility is increasingly being questioned after a recent randomized trial (QUARTZ) showed that its omission did not significantly impact the survival or quality of life of their patients recruited from UK and Australian centers. We report the patient characteristics and survival outcomes of our local population in comparison with theirs. METHODS Medical records of patients who received WBRT in two tertiary hospitals over 18 months were reviewed. Characteristics and survival outcomes of patient with NSCLC receiving WBRT for the first time were evaluated. Patients with prior excision of BM or stereotactic radiotherapy were excluded. Treatment details including radiotherapy dose and use of tyrosine kinase inhibitors (TKIs) were recorded. RESULTS Between January 2015 and June 2016, 116 patients with NSCLC received WBRT for their BM. Their median age was 65 years (range, 36-85) and median follow-up duration was 110 days (range, 14-840). A total of 102 (88%) patients had their driver mutation tested of which 59 (58%) were epidermal growth factor receptor (EGFR) mutants. Factors predicting for better survival were female gender (P

Supplemental Digital Content is available in the text, Rationale: Spontaneous regression of non-small cell lung cancer is exceptionally rare. Patient concerns: Treatment-related toxicity. Diagnoses: We report a case of a patient diagnosed with locally advanced non-small cell lung cancer. Interventions: The patient declined potentially curative treatment, and did not receive any anti-cancer treatment. Outcomes: He has survived more than two years since his initial diagnosis, maintaining his good performance status. Serial imaging with computed tomography scans showed tumour regression and near-complete resolution of his disease. Lessons: Spontaneous regression of non-small cell lung cancer, by virtue of its scarcity, has not been well-studied and is poorly understood. Further studies are required, in order to clarify the mechanisms by which spontaneous regression occurs, and possibly identify new targets for cancer treatment.

We aim to quantify the magnitude of the systematic and random setup errors at three different anatomical levels of the neck in Nasopharyngeal Carcinoma (NPC) when clivus matching is used, and recommend appropriate PTV margins for each level.Thirty-six patients undergoing image-guided radiotherapy (IGRT) each with 9 scheduled CBCTs were reviewed. The magnitude of setup errors were measured at the level of the clivus, C4 and C7 vertebrae, before and after CBCT correction. The 3D displacements, systematic and random errors were calculated for each level. The appropriate PTV expansion was determined using Van Herk's formula.Mean 3D displacement was 1.88, 2.66 and 3.35 mm at the clivus, C4 and C7 before correction. The differences were statistically significant (p0.05). The PTV margin required without correction was 2.33, 4.33 and 6.52 mm respectively. These were reduced to 1.20, 3.72 and 6.08 mm after CBCT corrections.Variability is seen in setup errors at the clivus, C4 and C7 vertebral levels. A variable planning margin approach with reduced margin at the clivus is recommended. Use of daily CBCT allows the PTV expansion to be reduced to 1.2 mm.

Background The purpose of this study was to characterize the clinical course of hearing loss in patients with nasopharyngeal carcinoma (NPC) and the clinical factors affecting its severity. Methods The time course of hearing loss in patients with NPC was assessed using threshold shift from baseline and Common Terminology Criteria for Adverse Events (CTCAE) grade. Results In the chemoradiotherapy (CRT) groups, the threshold shift was significantly higher from 3 months at 4 kHz (P = 2.30 × 10-9 , concurrent CRT only) but not within 2 years posttreatment in the radiotherapy (RT) group. The CRT groups had worse CTCAE grades than the RT group (percentage of latest CTCAE grade ≥1: 64.9% vs 29.0%, respectively). Cumulative cisplatin dose and cochlear RT dose significantly affects threshold shifts, especially at high frequencies. Conclusion Although cisplatin led to high frequency hearing impairment from about 3 months posttreatment, RT conferred no significant hearing impairment in the first 2 years.

Temporal lobe necrosis as result of radiation for nasopharyngeal cancer (NPC) occurs up to 28% of NPC patients. The only effective mitigation is by strict adherence to temporal lobe dose tolerances during radiotherapy planning, which in turn hinges on accurate temporal lobe delineation. We a

e17573 Background: Multiple randomized trials (RCTs) reported that concurrent chemotherapy (CCT) with or without adjuvant chemotherapy (AC) improves survival in stage II-IVB nasopharyngeal carcinoma (NPC) compared to radiation therapy alone. However, it is unclear if similar benefits can be observed in routine practice as patients included in RCTs could be very different from patients in routine practice. The aim of this study is to compare the effects of CCT with or without AC as estimated from observational studies (OBS) with findings from RCTs. Methods: We searched MEDLINE for eligible studies determining the effect of addition of CCT with or without AC in stage II-IVB NPC. Outcome of interest was overall survival (OS). We performed the meta-analysis with random effects model to estimate the pooled hazard ratios (HR), confidence intervals (CI), and I squared statistic (I2) for both RCTs and OBS and compared them using Altman interaction test. Results: We found nine RCTs and 19 OBS including 6523 patients. Eight RCTs and 14 OBS had at least 75% of its patients with stage III-IVB NPC while only one RCT and five OBS had at least 75% of its patients with stage II NPC. The survival benefit associated with chemotherapy was similar in both RCTs and OBS focusing on stage III-IVB NPC (RCTs HR 0.67, 95% CI 0.56 – 0.81, I2 = 48% vs OBS HR 0.71 95% CI 0.62 – 0.82, I2 = 4%, interaction P (IP) = 0.67). Similarly, there was no significant difference in OS for RCT and OBS focusing on stage II NPC (RCTs HR 0.34, 95% CI 0.17 to 0.66, I2 = non-applicable due to single study vs OBS HR 0.61, 95% CI 0.37 to 1.02, I2 = 0%, IP = 0.17). Conclusions: Patients with stage II and stage III-IVB nasopharyngeal carcinoma treated in routine practice received similar survival benefits associated with concurrent chemotherapy with or without adjuvant chemotherapy as patients treated in randomized trials.

e17552 Background: To determine if addition of neoadjuvant chemotherapy (NACT) to concomitant chemoradiation (CCRT) for patients with locoregionally advanced nasopharyngeal carcinoma (NPC) improves overall survival. Methods: We searched MEDLINE for eligible studies comparing NACT plus CCRT versus (vs) CCRT alone for locoregionally advanced NPC. We assessed the methodological quality of the included studies using the MERGE criteria. We performed the meta-analysis with random effects model using Revman 5.3 to estimate the pooled hazard ratios (HR), confidence intervals (CI), P values (P) and I squared statistic (I2). The primary outcome was overall survival (OS); secondary outcomes include progression-free survival (PFS) and adverse events (AE). We used the GRADE approach to appraise the quality of evidence from randomized trials. Results: We found four randomized and five retrospective comparative studies including 2178 patients with low to moderate risk of bias in their methodologic quality. Pooled estimates from both randomized and retrospective studies demonstrated a benefit in PFS (HR 0.78, 95% CI 0.66 to 0.93, P = 0.006, I2 = 0%) and OS (HR 0.77, 95% CI 0.61 to 0.96, P = 0.02, I2 = 0%) with NACT. In the randomized trials, there was moderate quality evidence that NACT improved PFS significantly (HR 0.73, 95% CI 0.57 to 0.93, P = 0.01, I2 = 0%); trend towards OS benefit (HR 0.76, 95% CI 0.56 to 1.03, P = 0.08, I2= 0%) and was associated with more frequent AE. There were no significant differences in the results between the randomized and retrospective comparative studies (PFS HR 0.73 vs 0.82, interaction P (IP) = 0.58; OS HR 0.76 vs 0.78, IP = 0.93). Conclusions: Neoadjuvant chemotherapy delays disease progression substantially and may improve survival for locoregionally advanced nasopharyngeal carcinoma. There were no divergent results between randomized and retrospective comparative studies. Future trials should test more effective and/or better tolerated agents during the neoadjuvant therapy phase.

RATIONALE FOR CASE REPORT Cutaneous Squamous Cell Carcinoma (cSCC) of the hand is uncommon and tends to have poorer outcomes. Surgical resection with wide margins around the tumor is recommended as the treatment of choice, and radiotherapy is considered second-line treatment. Nodal evaluation involves dissection necessitating some morbidity. The role of less invasive modalities of nodal evaluation is not well established. CASE PRESENTATION We report a case of locally advanced case of hand cSCC. Positron emission tomography-computed tomography (PET-CT) showed disease involving full thickness of the hand as well as the ipsilateral axillary node. To achieve adequate surgical margins would have necessitated amputation at the wrist, which the patient did not consent to. Instead, he was given a two-and-a-half week course radiotherapy to the hand without axillary radiation. With the radiotherapy treatment, he managed to achieve complete remission of disease while retaining full function of the hand, which was maintained at 22 months post-treatment. MAIN LESSONS CSCC of the hand is uncommon and challenging to treat. Radiotherapy is a highly effective treatment modality which is able to achieve functional preservation. Care should be taken when evaluating nodal status using PET-CT.