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Assessment of Morbidity and Arm Function Following Radial Forearm Free Flap in Head and Neck Cancer Patients
Volume 94 Number 4 2016 Author Disclosure: S. Samuels: None. A. Eisbruch: None. K.A. Vineberg: None. C. Lee: None. M.M. Matuszak: None. R.K. Ten Haken: None. K.K. Brock: None.
139 WITHDRAWN
140 Selectively Sparing the Submandibular Gland When Level IB Lymph Nodes Are Included in the Radiation Target Volume: A Safety and Toxicity Analysis in Cancers of the Oropharynx and Oral Cavity J.F. Greskovich, Jr,1 N.P. Joshi,2 A. Juloori,3 M.C. Ward,2 H. Qu,2 E. Murray,2 J. Potter,2 A. Dorfmeyer,2 P. Xia,2 and S. Koyfman2; 1 Cleveland Clinic Florida, Weston, FL, 2Cleveland Clinic Foundation, Cleveland, OH, 3Cleveland Clinic, cleveland, OH Purpose/Objective(s): Submandibular gland metastases are extremely rare in head and neck cancer, even in the presence of level Ib lymph node (LN) involvement. In recent years, we have contoured the submandibular gland (SMG) and selectively attempted to limit its dose exposure even in patients in whom the level Ib LN station is targeted. This study reports our preliminary feasibility and safety experience with selective submandibular gland sparing and its dosimetric impact. Materials/Methods: We identified 174 patients with squamous cell cancer (SCC) of the oral cavity or oropharynx, with T1-2, N0-3, M0 disease in whom at least a single-level Ib lymph node region was included in the target volume. All patients were treated from 2009 to 2014 with definitive or postoperative intensity modulated radiation therapy with or without chemotherapy. Patients with recurrent disease, or who were treated with reirradiation or a split course technique were excluded. Patient, tumor, and treatment-related factors were abstracted from the medical record. The treatment plans for each patient were reviewed and verified for level Ib targeting (unilateral vs bilateral) as well as if the submandibular gland was excluded from the target volume and sparing was attempted during planning. Mean doses were calculated for each submandibular gland and the oral cavity. Results: A total of 174 patients met criteria for inclusion. Patients had a median age of 59 years and median KPS of 90 at diagnosis. One hundred and forty seven patients had SCC of the oropharynx, and 27 patients had SCC of the oral cavity. One hundred and thirty-four patients were treated definitively while 40 were treated postoperatively. Of the 174 included patients, 142 were treated with concurrent chemotherapy. Among the 190 level Ib LN stations that were deliberately targeted in the clinical treatment volume, 32 submandibular glands were contoured, excluded from the target volume and avoided during treatment planning. Mean doses to the spared submandibular glands were able to be reduced by 12% (66.9 Gy vs 58.9 Gy). In a subgroup analysis of 26 patients who had bilateral level Ib LN targeted, we compared the dosimetric outcomes of 4 patients in whom bilateral submandibular glands were avoided with those of 22 patients in whom bilateral submandibular glands were included in the target volumes. In addition to a 12% reduction in mean submandibular dose (66.3 Gy vs 58.2 Gy), mean oral cavity dose was reduced by 14.5% (43.4 Gy vs 37 Gy). None of these patients experienced any level Ib LN failures. Conclusion: Selective sparing of the submandibular gland when targeting the level Ib nodes in oral cavity and oropharynx cancer is feasible, reduces the mean doses to submandibular glands and oral cavity, and does not result in increased level Ib nodal failure rates. Future studies with larger numbers are needed to validate this preliminary finding and examine the impact of this technique on functional outcomes. Author Disclosure: J.F. Greskovich: None. N.P. Joshi: None. A. Juloori: None. M.C. Ward: None. H. Qu: None. E. Murray: None. J. Potter: None. A. Dorfmeyer: None. P. Xia: None. S. Koyfman: None.
Posters
887
141 Assessment of Morbidity and Arm Function Following Radial Forearm Free Flap in Head and Neck Cancer Patients Y. Patil1 and A. Mincara2; 1University of Cincinnati Medical Center/ University of Cincinnati College of Medicine Cincinnati, OH, 2University of Cincinnati, Cincinnati, OH Purpose/Objective(s): The objective of this study is to evaluate the presence of postoperative arm (donor site) dysfunction by assessing disability following surgical reconstruction using radial forearm free flap (RFFF) in head and neck cancer patients. Three clinically validated questionnaires including a general, disease-specific, and site-specific survey were administered: Short Form 36 Health Survey (SF-36), Short Musculoskeletal Function Assessment Questionnaire (SMFA), and Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire, respectively. There are currently no retrospective or prospective studies assessing the presence of postoperative disability in RFFF patients. No studies are available on the correlation of the general, disease-specific, and site-specific disability surveys. This study will help to guide the head and neck cancer surgeon in microvascular free flap selection as well as guide postoperative therapy. Materials/Methods: Patients who met study enrollment criteria (including no previous neck surgery, arm surgery, shoulder surgery, neuromotor disorders, congenital anatomical abnormalities, or systemic disorders) completed the questionnaires, which measured various aspects of function including function index, bothersome index, physical component score, mental component score, and other important quality of life outcomes. Postoperative patient scores for each survey were compared to normative data in the general U.S. population. Results: The cohort consisted of 23 individuals with an average age of 659.5 years; 56.5% were male and 43.5% were female. One-sample z tests were performed to compare the means of the cohort to the general population. The cohort observed a significantly higher mean score, compared to the general U.S. population, for the DASH (13.24 vs 10.1, PZ.04) and Bothersome Index of the SMFA (21.47 vs 13.77, PZ.05), indicating that the cohort observed a greater disability compared to the general population. In addition, the cohort observed a significantly lower mean score, compared to the general U.S. population, for the PCS of the SF-36 (39.38 vs 50, P<.01), indicating greater disability. Conclusion: Since the validated SF-36 questionnaire detected a significant difference between patients and age- and sex-controlled population norms, RFFF does cause disability of the donor site in head and neck cancer patients. SF-36, DASH, and SMFA all showed physical disability following a RFFF. Shorter and more concise questionnaires, such as the SF-36 physical component score subset, are equally valid in evaluating donor site morbidity. This can serve as a concise and efficient clinical tool in evaluating the present of donor site disability and the need for postoperative physical therapy. Author Disclosure: Y. Patil: None. A. Mincara: None.
142 Initial Clinical Outcomes From a Prospective Phase 1 Trial of Hypofractionated Stereotactic Body Radiation Therapy for EarlyStage Glottic Larynx Cancer D.L. Schwartz,1 S.G. Chun,2 C. Ding,1 A. Sosa,1 L.A. Nedzi,1 J.S. Yordy,3 S.A. Chen,4 R.D. Timmerman,1 and B. Sumer1; 1The University of Texas Southwestern School of Medicine, Dallas, TX, 2The University of Texas MD Anderson Cancer Center, Houston, TX, 3Valley Radiation Therapy Group, Anchorage, AK, 4Pacific Radiation Oncology, Honolulu, HI Purpose/Objective(s): The primary objective of this trial is to confirm safety and feasibility of hypofractionated stereotactic body radiation therapy (SBRT) for early-stage glottic laryngeal cancer and to determine the most rapid fractionation scheme tolerated without dose-limiting toxicity (DLT). Materials/Methods: Seventeen consecutive patients with a diagnosis of carcinoma in situ, or cT1a-T2N0M0 carcinoma of the glottic larynx
139 WITHDRAWN
140 Selectively Sparing the Submandibular Gland When Level IB Lymph Nodes Are Included in the Radiation Target Volume: A Safety and Toxicity Analysis in Cancers of the Oropharynx and Oral Cavity J.F. Greskovich, Jr,1 N.P. Joshi,2 A. Juloori,3 M.C. Ward,2 H. Qu,2 E. Murray,2 J. Potter,2 A. Dorfmeyer,2 P. Xia,2 and S. Koyfman2; 1 Cleveland Clinic Florida, Weston, FL, 2Cleveland Clinic Foundation, Cleveland, OH, 3Cleveland Clinic, cleveland, OH Purpose/Objective(s): Submandibular gland metastases are extremely rare in head and neck cancer, even in the presence of level Ib lymph node (LN) involvement. In recent years, we have contoured the submandibular gland (SMG) and selectively attempted to limit its dose exposure even in patients in whom the level Ib LN station is targeted. This study reports our preliminary feasibility and safety experience with selective submandibular gland sparing and its dosimetric impact. Materials/Methods: We identified 174 patients with squamous cell cancer (SCC) of the oral cavity or oropharynx, with T1-2, N0-3, M0 disease in whom at least a single-level Ib lymph node region was included in the target volume. All patients were treated from 2009 to 2014 with definitive or postoperative intensity modulated radiation therapy with or without chemotherapy. Patients with recurrent disease, or who were treated with reirradiation or a split course technique were excluded. Patient, tumor, and treatment-related factors were abstracted from the medical record. The treatment plans for each patient were reviewed and verified for level Ib targeting (unilateral vs bilateral) as well as if the submandibular gland was excluded from the target volume and sparing was attempted during planning. Mean doses were calculated for each submandibular gland and the oral cavity. Results: A total of 174 patients met criteria for inclusion. Patients had a median age of 59 years and median KPS of 90 at diagnosis. One hundred and forty seven patients had SCC of the oropharynx, and 27 patients had SCC of the oral cavity. One hundred and thirty-four patients were treated definitively while 40 were treated postoperatively. Of the 174 included patients, 142 were treated with concurrent chemotherapy. Among the 190 level Ib LN stations that were deliberately targeted in the clinical treatment volume, 32 submandibular glands were contoured, excluded from the target volume and avoided during treatment planning. Mean doses to the spared submandibular glands were able to be reduced by 12% (66.9 Gy vs 58.9 Gy). In a subgroup analysis of 26 patients who had bilateral level Ib LN targeted, we compared the dosimetric outcomes of 4 patients in whom bilateral submandibular glands were avoided with those of 22 patients in whom bilateral submandibular glands were included in the target volumes. In addition to a 12% reduction in mean submandibular dose (66.3 Gy vs 58.2 Gy), mean oral cavity dose was reduced by 14.5% (43.4 Gy vs 37 Gy). None of these patients experienced any level Ib LN failures. Conclusion: Selective sparing of the submandibular gland when targeting the level Ib nodes in oral cavity and oropharynx cancer is feasible, reduces the mean doses to submandibular glands and oral cavity, and does not result in increased level Ib nodal failure rates. Future studies with larger numbers are needed to validate this preliminary finding and examine the impact of this technique on functional outcomes. Author Disclosure: J.F. Greskovich: None. N.P. Joshi: None. A. Juloori: None. M.C. Ward: None. H. Qu: None. E. Murray: None. J. Potter: None. A. Dorfmeyer: None. P. Xia: None. S. Koyfman: None.
Posters
887
141 Assessment of Morbidity and Arm Function Following Radial Forearm Free Flap in Head and Neck Cancer Patients Y. Patil1 and A. Mincara2; 1University of Cincinnati Medical Center/ University of Cincinnati College of Medicine Cincinnati, OH, 2University of Cincinnati, Cincinnati, OH Purpose/Objective(s): The objective of this study is to evaluate the presence of postoperative arm (donor site) dysfunction by assessing disability following surgical reconstruction using radial forearm free flap (RFFF) in head and neck cancer patients. Three clinically validated questionnaires including a general, disease-specific, and site-specific survey were administered: Short Form 36 Health Survey (SF-36), Short Musculoskeletal Function Assessment Questionnaire (SMFA), and Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire, respectively. There are currently no retrospective or prospective studies assessing the presence of postoperative disability in RFFF patients. No studies are available on the correlation of the general, disease-specific, and site-specific disability surveys. This study will help to guide the head and neck cancer surgeon in microvascular free flap selection as well as guide postoperative therapy. Materials/Methods: Patients who met study enrollment criteria (including no previous neck surgery, arm surgery, shoulder surgery, neuromotor disorders, congenital anatomical abnormalities, or systemic disorders) completed the questionnaires, which measured various aspects of function including function index, bothersome index, physical component score, mental component score, and other important quality of life outcomes. Postoperative patient scores for each survey were compared to normative data in the general U.S. population. Results: The cohort consisted of 23 individuals with an average age of 659.5 years; 56.5% were male and 43.5% were female. One-sample z tests were performed to compare the means of the cohort to the general population. The cohort observed a significantly higher mean score, compared to the general U.S. population, for the DASH (13.24 vs 10.1, PZ.04) and Bothersome Index of the SMFA (21.47 vs 13.77, PZ.05), indicating that the cohort observed a greater disability compared to the general population. In addition, the cohort observed a significantly lower mean score, compared to the general U.S. population, for the PCS of the SF-36 (39.38 vs 50, P<.01), indicating greater disability. Conclusion: Since the validated SF-36 questionnaire detected a significant difference between patients and age- and sex-controlled population norms, RFFF does cause disability of the donor site in head and neck cancer patients. SF-36, DASH, and SMFA all showed physical disability following a RFFF. Shorter and more concise questionnaires, such as the SF-36 physical component score subset, are equally valid in evaluating donor site morbidity. This can serve as a concise and efficient clinical tool in evaluating the present of donor site disability and the need for postoperative physical therapy. Author Disclosure: Y. Patil: None. A. Mincara: None.
142 Initial Clinical Outcomes From a Prospective Phase 1 Trial of Hypofractionated Stereotactic Body Radiation Therapy for EarlyStage Glottic Larynx Cancer D.L. Schwartz,1 S.G. Chun,2 C. Ding,1 A. Sosa,1 L.A. Nedzi,1 J.S. Yordy,3 S.A. Chen,4 R.D. Timmerman,1 and B. Sumer1; 1The University of Texas Southwestern School of Medicine, Dallas, TX, 2The University of Texas MD Anderson Cancer Center, Houston, TX, 3Valley Radiation Therapy Group, Anchorage, AK, 4Pacific Radiation Oncology, Honolulu, HI Purpose/Objective(s): The primary objective of this trial is to confirm safety and feasibility of hypofractionated stereotactic body radiation therapy (SBRT) for early-stage glottic laryngeal cancer and to determine the most rapid fractionation scheme tolerated without dose-limiting toxicity (DLT). Materials/Methods: Seventeen consecutive patients with a diagnosis of carcinoma in situ, or cT1a-T2N0M0 carcinoma of the glottic larynx