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Clinical Management of Patients with Temporal Lobe Necrosis
Proceedings of the 52nd Annual ASTRO Meeting unknown primary. The initial N status was 9 (5%) N1, 150 (77%) N2 and 35 (18%) N3. On univariate analysis, older age, hypopharynx primary site, T3-4, and N2c-N3 were all predictors for PND+ (all p \ 0.05); however, only older age [hazard ratio (HR) 1.05, p = 0.01] and hypopharynx primary site (HR 4.39, p = 0.01) remained significant on multivariate analysis. In comparison to PND- patients, the PND+ cohort had diminished OS (33% vs. 77%), DFS (32% vs. 77%), and CSS (50% vs. 87%) (all p \ 0.01). The PND+ cohort had much higher DM (44% vs. 11%, p\0.01) with moderately reduced LC (86% vs. 96%, p\0.01) and similar RC (94% vs. 99%, p = 0.07). In the PND+ cohort, Margin+, LN4/5+, ECE/STD, and LVI were all adverse predictors for OS, DFS and CSS on univariate analysis (all p\0.05). However, on multivariate analysis only the presence of ECE/STD and LVI remained as significant predictors for OS, DFS, and only ECE/STD for CSS. Conclusions: Older age and hypopharynx primary site were associated more frequently than other factors examined with positive post-radiotherapy PND. PND+ was associated with diminished survival, mainly attributed to significantly increased DM rather than reduced LC and RC. The presence of ECE/STD and LVI was associated with reduced survival for PND+ patients. Author Disclosure: S. Huang, None; D. Goldstein, None; I. Weinreb, None; B. Perez-Ordonez, None; S. Fung, None; J. Irish, None; J. Waldron, None; J. Kim, None; B. Cummings, None; B. O’Sullivan, None.
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Clinical Management of Patients with Temporal Lobe Necrosis
T. E. Krakow1, W. Hara1, S. Yun2, S. Soltys1, S. Chang1, N. Fischbein1, B. Loo1, Q. Le1 1
Stanford University, Stanford, CA, 2Yeungnam University, Gyeongsan, Republic of Korea
Purpose/Objective(s): To evaluate the outcome and management of patients who developed temporal lobe necrosis (TLN) after radiosurgical boost for nasopharyngeal cancer (NPC)/skull base tumors. Materials/Methods: At a single institution, all patients who developed TLN after radiotherapy treatment between 09/1992 and 11/ 2006 were identified. 16 patients were identified (14 nasopharyngeal carcinoma, 1 clival chondrosarcoma, 1 nasopharyngeal adenoid cystic carcinoma, average age 49). All patients received 45-66 Gy/1.8-2.2 Gy intensity modulated radiotherapy (IMRT) followed by a stereotactic radiosurgery (SRS) boost of 8-20 Gy in 1 to 3 fractions. All patients underwent regular MRI follow-up and clinical assessment. Results: Median follow-up was 84.7 months (m), and median MRI follow-up was 75.7 m. Patients developed TLN at a median time of 39.8 m after radiotherapy, and was bilateral in 5/16 patients. While only 1 patient presented with symptoms, half developed symptoms including seizures in 3 patients, headaches in 3 patients and facial numbness in 2 patients. There were no deaths attributed to the TLN. 11 patients had progression of the TLN by 15 m (average time to progression 6 m). Of these patients, 7 eventually regressed (average time to regression was 14 m), 3 patients stabilized (average time to stabilization 12 m), and 1 patient progressed and then died of metastatic disease before stabilization was observed. 5 patients presented with TLN which remained stable, and one of these had stable TLN which then regressed at 8 m. TLN was managed with trental/vitamin E in 10, steroids in 6, hyperbaric oxygen in 6, and 4 required neurosurgical resection. Indications for surgical resection were seizures (n = 2), severe head ache (n = 1) and suspicious for recurrence (n = 1). 2 patients received no treatment, 6 received one modality, 4 received two, 3 received three and 1 patient received all four treatments. Conclusions: TLN is a serious late complication arising from radiation therapy. While symptoms at diagnosis were rare, half of our patients became symptomatic. Our limited case analysis suggested that when treated conservatively nearly all patients stabilized, and half regressed. Surgical resection can be reserved for those patients with severe symptoms or suspicious for recurrence. Author Disclosure: T.E. Krakow, None; W. Hara, None; S. Yun, None; S. Soltys, None; S. Chang, None; N. Fischbein, None; B. Loo, None; Q. Le, None.
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Surgery + Radiotherapy vs. Definitive Chemoradiotherapy for Advanced Squamous Cell Carcinoma of the Tonsil, Soft Palate and Oropharyngeal Wall
J. T. Lucas, A. J. Zauls, J. M. Watkins, A. K. Sharma MUSC, Charleston, SC Purpose/Objective(s): To analyze the patterns of failure, staging and disease outcomes following surgery with adjuvant radiotherapy (SRT) versus definitive chemoradiotherapy (CRT) in advanced squamous cell carcinoma of the tonsil, soft palate and oropharyngeal wall (SCCOP). Materials/Methods: A database composed of SCCOP patients treated from 2000-2009 was queried for patients with stage .T3, or involved lymph nodes. SRT dosage to tumor bed and high-risk regions was 60-66Gy, while CRT patients received 70Gy to gross disease using conventional fractionation schedules. Elective nodal volumes received 56Gy. Patients electing SRT were recommended chemotherapy concurrent with radiation if extracapsular extension (ECE) or close/positive margins (CPM) were found on pathologic evaluation. 33% of SRT patients underwent tonsillectomy and 62% received chemotherapy concurrently with radiation (15 ECE and 16 CPM). Staging similarities between clinical and pathologic exam were evaluated in the SRT group. Outcomes of SRT versus CRT were analyzed according to locoregional failure (LRF), and distant-metastases with/without LRF (DM) rates. Results: A total of 110 patients (34 SRT and 76 CRT) were included in the analysis with a median follow-up of 31 (SRT) and 33 (CRT) months (p = 0.64). The median age was 52 and 57 years for SRT and CRT, respectively (p = 0.004). 18% of SRT patients had . cT3 and 91% had . cN1 disease. 32% of SRT patients were . pT3 and 94% had . pN1 disease. 65% of CRT patients had . cT3 and 91% had . cN1. Pathologic evaluation resulted in a changed in T-stage in 60% (66% up- and 33% down-staged) and 26% in N-stage (62% up- and 38% down-staged) among SRT patients. Test of symmetry revealed equal propensity to assign T and N staging using clinical or pathologic staging, although the weighted kappa statistic of 0.22 and 0.20 for T and N stage demonstrated poor correlation secondary to lesions which were borderline locally or regionally advanced. A total of 9 SRT (5 LRF; 4 DM) and 20 CRT (15 LRF; 8 DM) patients had disease recurrence (p = 0.71). The three-year LRF rate was 21% (SRT) and 17.0% (CRT)(p = 0.69). Three-year OS was 73% (SRT) and 75% (CRT) (p = 0.54), with 7.5% and 4.4% of SRT deaths due to cancer and non-cancer, and 11.2% and 8.8%, cancer and non-cancer related deaths in the CRT cohort (p = 0.67, p = 0.78).
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2563
Clinical Management of Patients with Temporal Lobe Necrosis
T. E. Krakow1, W. Hara1, S. Yun2, S. Soltys1, S. Chang1, N. Fischbein1, B. Loo1, Q. Le1 1
Stanford University, Stanford, CA, 2Yeungnam University, Gyeongsan, Republic of Korea
Purpose/Objective(s): To evaluate the outcome and management of patients who developed temporal lobe necrosis (TLN) after radiosurgical boost for nasopharyngeal cancer (NPC)/skull base tumors. Materials/Methods: At a single institution, all patients who developed TLN after radiotherapy treatment between 09/1992 and 11/ 2006 were identified. 16 patients were identified (14 nasopharyngeal carcinoma, 1 clival chondrosarcoma, 1 nasopharyngeal adenoid cystic carcinoma, average age 49). All patients received 45-66 Gy/1.8-2.2 Gy intensity modulated radiotherapy (IMRT) followed by a stereotactic radiosurgery (SRS) boost of 8-20 Gy in 1 to 3 fractions. All patients underwent regular MRI follow-up and clinical assessment. Results: Median follow-up was 84.7 months (m), and median MRI follow-up was 75.7 m. Patients developed TLN at a median time of 39.8 m after radiotherapy, and was bilateral in 5/16 patients. While only 1 patient presented with symptoms, half developed symptoms including seizures in 3 patients, headaches in 3 patients and facial numbness in 2 patients. There were no deaths attributed to the TLN. 11 patients had progression of the TLN by 15 m (average time to progression 6 m). Of these patients, 7 eventually regressed (average time to regression was 14 m), 3 patients stabilized (average time to stabilization 12 m), and 1 patient progressed and then died of metastatic disease before stabilization was observed. 5 patients presented with TLN which remained stable, and one of these had stable TLN which then regressed at 8 m. TLN was managed with trental/vitamin E in 10, steroids in 6, hyperbaric oxygen in 6, and 4 required neurosurgical resection. Indications for surgical resection were seizures (n = 2), severe head ache (n = 1) and suspicious for recurrence (n = 1). 2 patients received no treatment, 6 received one modality, 4 received two, 3 received three and 1 patient received all four treatments. Conclusions: TLN is a serious late complication arising from radiation therapy. While symptoms at diagnosis were rare, half of our patients became symptomatic. Our limited case analysis suggested that when treated conservatively nearly all patients stabilized, and half regressed. Surgical resection can be reserved for those patients with severe symptoms or suspicious for recurrence. Author Disclosure: T.E. Krakow, None; W. Hara, None; S. Yun, None; S. Soltys, None; S. Chang, None; N. Fischbein, None; B. Loo, None; Q. Le, None.
2564
Surgery + Radiotherapy vs. Definitive Chemoradiotherapy for Advanced Squamous Cell Carcinoma of the Tonsil, Soft Palate and Oropharyngeal Wall
J. T. Lucas, A. J. Zauls, J. M. Watkins, A. K. Sharma MUSC, Charleston, SC Purpose/Objective(s): To analyze the patterns of failure, staging and disease outcomes following surgery with adjuvant radiotherapy (SRT) versus definitive chemoradiotherapy (CRT) in advanced squamous cell carcinoma of the tonsil, soft palate and oropharyngeal wall (SCCOP). Materials/Methods: A database composed of SCCOP patients treated from 2000-2009 was queried for patients with stage .T3, or involved lymph nodes. SRT dosage to tumor bed and high-risk regions was 60-66Gy, while CRT patients received 70Gy to gross disease using conventional fractionation schedules. Elective nodal volumes received 56Gy. Patients electing SRT were recommended chemotherapy concurrent with radiation if extracapsular extension (ECE) or close/positive margins (CPM) were found on pathologic evaluation. 33% of SRT patients underwent tonsillectomy and 62% received chemotherapy concurrently with radiation (15 ECE and 16 CPM). Staging similarities between clinical and pathologic exam were evaluated in the SRT group. Outcomes of SRT versus CRT were analyzed according to locoregional failure (LRF), and distant-metastases with/without LRF (DM) rates. Results: A total of 110 patients (34 SRT and 76 CRT) were included in the analysis with a median follow-up of 31 (SRT) and 33 (CRT) months (p = 0.64). The median age was 52 and 57 years for SRT and CRT, respectively (p = 0.004). 18% of SRT patients had . cT3 and 91% had . cN1 disease. 32% of SRT patients were . pT3 and 94% had . pN1 disease. 65% of CRT patients had . cT3 and 91% had . cN1. Pathologic evaluation resulted in a changed in T-stage in 60% (66% up- and 33% down-staged) and 26% in N-stage (62% up- and 38% down-staged) among SRT patients. Test of symmetry revealed equal propensity to assign T and N staging using clinical or pathologic staging, although the weighted kappa statistic of 0.22 and 0.20 for T and N stage demonstrated poor correlation secondary to lesions which were borderline locally or regionally advanced. A total of 9 SRT (5 LRF; 4 DM) and 20 CRT (15 LRF; 8 DM) patients had disease recurrence (p = 0.71). The three-year LRF rate was 21% (SRT) and 17.0% (CRT)(p = 0.69). Three-year OS was 73% (SRT) and 75% (CRT) (p = 0.54), with 7.5% and 4.4% of SRT deaths due to cancer and non-cancer, and 11.2% and 8.8%, cancer and non-cancer related deaths in the CRT cohort (p = 0.67, p = 0.78).
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