Objective

Prior studies have relied on CT to assess alterations in anatomy among patients undergoing radiation for head and neck cancer. We sought to determine the feasibility of using MRI-based image-guided radiotherapy to quantify these changes and to ascertain their potential dosimetric implications.

Methods

6 patients with head and neck cancer were treated with intensity-modulated radiotherapy (IMRT) on a novel tri-⁶⁰Co teletherapy system equipped with a 0.35-T MRI (VR, ViewRay Incorporated, Oakwood Village, OH) to 66-70 Gy in 33 fractions (fx). Pre-treatment MRIs on Fx 1, 5, 10, 15, 20, 25, 30 and 33 were imported into a contouring interface, where the primary gross tumour volume (GTV) and parotid glands were delineated. The centre of mass (COM) shifts for these structures were assessed relative to Day 1. Dosimetric data were co-registered with the MRIs, and doses to the GTV and parotid glands were assessed.

Results

Primary GTVs decreased significantly over the course of IMRT (median % volume loss, 38.7%; range, 29.5-72.0%; p < 0.05) at a median rate of 1.2%/fx (range, 0.92-2.2%/fx). Both the ipsilateral and contralateral parotid glands experienced significant volume loss (p < 0.05, for all) and shifted medially during IMRT. Weight loss correlated significantly with parotid gland volume loss and medial COM shift (p < 0.05).

Conclusion

Integrated on-board MRI can be used to accurately contour and analyze primary GTVs and parotid glands over the course of IMRT. COM shifts and significant volume reductions were observed, confirming the results of prior CT-based exercises. Advances in knowledge: The superior resolution of on-board MRI may facilitate online adaptive replanning in the future.

Importance

Optimal management of subglottic stenosis has not been established. Endoscopic techniques include balloon dilation, radial incisions with carbon dioxide laser or cold knife, and combinations of techniques. Adjunctive measures include mitomycin application and glucocorticoid injection.

Objective

To determine whether surgical technique or adjunctive measures are associated with duration between surgical procedures.

Design, setting, and participants

Adult patients with subglottic stenosis treated endoscopically between 1995-2015 at a quaternary academic medical center were identified. Patients with isolated subglottic (cricotracheal) stenosis 18 years and older were included. Patients with prior open surgical procedures, prior laryngeal surgical procedures, glottic stenosis, or vocal fold paralysis were excluded.

Interventions

Patients underwent endoscopic procedures including laser radial incisions, balloon dilation, or both, with some patients receiving topical mitomycin, glucocorticoid injection, or both.

Main outcomes and measures

Time interval between endoscopic treatments.

Results

A total of 101 patients (mean [SD] age, 52.3 [15.9] years; 77.2% female) were included in the analysis, with etiologies including idiopathic (47 [46.5%]), intubation (31 [30.7%]), granulomatosis with polyangiitis (9 [8.9%]), and other autoimmune diseases (6 [5.9%]). Among the 219 operations, both laser and balloon dilation were used in 117 (53.4%), while balloon dilation alone was used in 96 (43.8%) and laser alone in 6 (2.7%). Mitomycin application and steroid injection were used in 144 (65.8%) and 93 (42.5%) cases, respectively. Mitomycin application was associated with improvement in the mean interval to next procedure from 317 to 474 days (absolute difference, 157 days; 95% CI, 15-299 days). Advanced grade of stenosis, dilation technique, and steroid injection did not significantly alter the surgical intervals.

Conclusions and relevance

Endoscopic surgery for subglottic stenosis is a critical aspect of patient management. Neither surgical technique nor grade of stenosis was seen to alter the surgical intervals. Mitomycin application was associated with an extended time interval between endoscopic treatments.

Background

The long natural history of prostate cancer (CaP) limits comparisons of efficacy between radical prostatectomy (RP) and external beam radiotherapy (EBRT), since patients treated years ago received treatments considered suboptimal by modern standards (particularly with regards to androgen deprivation therapy [ADT] and radiotherapy dose-escalation]. Gleason score (GS) 9-10 CaP is particularly aggressive, and clinically-relevant endpoints occur early, facilitating meaningful comparisons.

Objective

To compare outcomes of patients with GS 9-10 CaP following EBRT, extremely-dose escalated radiotherapy (as exemplified by EBRT+brachytherapy [EBRT+BT]), and RP.

Design, setting, participants

Retrospective analysis of 487 patients with biopsy GS 9-10 CaP treated between 2000 and 2013 (230 with EBRT, 87 with EBRT+BT, and 170 with RP). Most radiotherapy patients received ADT and dose-escalated radiotherapy.

Outcome measurements and statistical analysis

Kaplan-Meier analysis and multivariate Cox regression estimated and compared 5-yr and 10-yr rates of distant metastasis-free survival, cancer-specific survival (CSS), and overall survival (OS).

Results and limitations

The median follow-up was 4.6 yr. Local salvage and systemic salvage were performed more frequently in RP patients (49.0% and 30.1%) when compared with either EBRT patients (0.9% and 19.7%) or EBRT+BT patients (1.2% and 16.1%, p<0.0001). Five-yr and 10-yr distant metastasis-free survival rates were significantly higher with EBRT+BT (94.6% and 89.8%) than with EBRT (78.7% and 66.7%, p=0.0005) or RP (79.1% and 61.5%, p<0.0001). The 5-yr and 10-yr CSS and OS rates were similar across all three cohorts.

Conclusions

Radiotherapy and RP provide equivalent CSS and OS. Extremely dose-escalated radiotherapy with ADT in particular offers improved systemic control when compared with either EBRT or RP. These data suggest that extremely dose-escalated radiotherapy with ADT might be the optimal upfront treatment for patients with biopsy GS 9-10 CaP.

Patient summary

While some prostate cancers are slow-growing requiring many years, sometimes decades, of follow-up in order to compare between radiation and surgery, high-risk and very aggressive cancers follow a much shorter time course allowing such comparisons to be made and updated as treatments, especially radiation, rapidly evolve. We showed that radiation-based treatments and surgery, with contemporary standards, offer equivalent survival for patients with very aggressive cancers (defined as Gleason score 9-10). Extremely-dose escalated radiotherapy with short-course androgen deprivation therapy offered the least risk of developing metastases, and equivalent long term survival.