Long-term complications and reconstruction failures in previously radiated breast cancer patients receiving salvage mastectomy with autologous reconstruction or tissue expander/implant-based reconstruction.

Salvage mastectomy (SM) is the standard of care for patients with local recurrence (LR) after breast conservation therapy (BCT), often with immediate reconstruction. Complications of reconstruction are a concern for these patients, and long-term data are limited. We sought to compare rates of complications requiring re-operation (CRR) and reconstruction failure (RF) between autologous reconstruction (AR) and tissue expander/implant reconstruction (TE/I). Patients with locally recurrent breast cancer after BCT, treated with SM and immediate AR or TE/I between 2000 and 2008, were identified. CRR was defined as unplanned return to operating room for wound infection, dehiscence, necrosis (including flap, skin, or fat), hematoma, or hernia (for AR) and extrusion, leak, or capsular contracture (for TE/I). RF was defined as conversion to another reconstruction technique or to flat chest wall. This study included 103 patients with 107 reconstructions. Median follow-up was 6.6 years. CRR and RF were significantly higher with TE/I (n = 34) compared to AR (n = 73) at 5 years (50.9% vs 25.5%; P = 0.02) and (42.1% vs 5.8%; P < 0.001). On univariate analysis (UVA), TE/I (HR = 2.14; P = 0.02) and diabetes (HR = 5.10; P = 0.007) were significant predictors for CRR. On UVA, TE/I (HR = 7.30; P < 0.001) and older age at reconstruction (HR = 1.03; P = 0.003) were significant predictors for RF. In this population of previously irradiated patients, TE/I was associated with significantly higher CRR and RF. Complications continue to occur up to 10 years after TE/I. AR should be considered in appropriately selected patients, though TE/I may remain a reasonable option in patients without high-risk factors for surgical complications.

Ten-Year Outcomes of Moderately Hypofractionated (70 Gy in 28 fractions) Intensity Modulated Radiation Therapy for Localized Prostate Cancer.

PURPOSE: Long-term outcomes with hypofractionated radiation therapy for prostate cancer are limited. We report 10-year outcomes for patients treated with intensity modulated radiation therapy (IMRT) for localized prostate cancer with 70 Gy in 28 fractions at 2.5 Gy per fraction. METHODS AND MATERIALS: The study included 854 consecutive patients with localized prostate cancer treated with moderately hypofractionated IMRT and daily image guidance at a single institution between 1998 and 2012. Patients with a single intermediate risk factor were considered to have favorable intermediate-risk (FIR) disease, and those with multiple intermediate risk factors were considered unfavorable (UIR). Biochemical relapse-free survival, clinical relapse-free survival, and overall survival were analyzed using Kaplan-Meier analysis. Prostate cancer-specific mortality (PCSM) was analyzed using competing risk regression. All grade ≥3 genitourinary (GU) and gastrointestinal (GI) toxicities were recorded using Common Terminology Criteria for Adverse Event version 4.03, and cumulative incidence rates of GU and GI toxicity were calculated. RESULTS: The median follow-up was 11.3 years (maximum, 19 years). For patients with low-risk (LR), FIR, UIR, and high-risk (HR) disease, the 10-year biochemical relapse free survival rates were 88%, 78%, 71%, and 42%, respectively, (P < .0001). The 10-year clinical relapse free survival were 95%, 91%, 85%, and 72% for patients with LR, FIR, UIR, and HR, respectively, (P < .0001). For all patients, the 10-year actuarial overall survival rate was 69% (95% confidence interval, 66%-73%), and the 10-year PCSM was 6.8% (95% confidence interval, 5.1%-8.6%) overall. For patients with LR, FIR, UIR and HR disease, the 10-year PCSM rates were 2%, 5%, 5%, and 15%. Long-term grade ≥3 GU or GI toxicity remained low with 10-year cumulative incidences of 2% and 1%, respectively. CONCLUSIONS: High-dose moderately hypofractionated IMRT with daily image guidance for localized prostate cancer demonstrates favorable 10-year oncologic outcomes with a low incidence of toxicity. This fractionation schedule appears to be acceptable for patients across all risk groups.

Long-Term Outcomes After Autologous or Tissue Expander/Implant-Based Breast Reconstruction and Postmastectomy Radiation for Breast Cancer.

PURPOSE: The toxicity profile of breast reconstruction with postmastectomy radiation therapy (PMRT) varies by technique and timing, and long-term data are limited. We compared rates of complications requiring reoperation (CRR) and reconstruction failure (RF) between immediate autologous reconstruction (I-AR), immediate tissue expander/implant reconstruction (I-TE/I), delayed autologous reconstruction (D-AR), and delayed tissue expander/implant reconstruction (D-TE/I) in patients receiving PMRT. METHODS AND MATERIALS: Patients who received autologous reconstruction (AR) or tissue expander/implant reconstruction (TE/I) and PMRT between 2000 to 2008 were included. Reconstruction was immediate if performed on the same day as mastectomy followed by PMRT (I-AR or I-TE/I) or delayed if after PMRT (D-AR and D-TE/I). CRR was defined as an unplanned return to the operating room for infection, dehiscence, necrosis, hematoma, or hernia (with AR) and extrusion, leak, or contracture (with TE/I). RF was defined as unplanned conversion to another reconstruction technique or to flat chest wall. Cumulative incidence of CRR and RF was calculated using Kaplan-Meier and compared using the log-rank test. Logistic regression was used to identify variables associated with CRR and RF. RESULTS: Two hundred four patients were included. Median follow-up was 8 years. There were 127 AR cases (63%) and 77 TE/I cases (38%). At 5 years, CRR was 18%, 38%, 34%, and 70% (P = .010) and RF was 4%, 22%, 7%, and 56% (P < .0001) for I-AR, I-TE/I, D-AR, and D-TE/I, respectively. On multivariate analysis, TE/I (hazard ratio [HR] 2.0; P = .011), body mass index ≥30 (HR 3.9; P = .002), and smoking (HR 2.7; P = .001) were significant predictors for CRR, and TE/I (HR 6.6; P < .0001), diabetes (HR 4.1; P = .044), and hypertension (HR 3.5; P = .005) were significant for RF. When excluding RF because of infection, the rate of RF was not significantly different among the 4 groups (P = .23). CONCLUSIONS: With PMRT, TE/I reconstruction in the immediate and delayed setting is associated with higher CRR and RF compared with AR. Patient factors should guide selection of technique. Efforts to reduce rates of RF with TE/I should focus on minimizing risks for infection.

Predictors of distant metastasis in human papillomavirus-associated oropharyngeal cancer.

BACKGROUND: Human papillomavirus (HPV)-positive oropharyngeal cancer is associated with favorable outcomes, prompting investigations into treatment deintensification. The purpose of this study was for us to present the predictors of distant metastases in patients with HPV-positive oropharyngeal cancer treated with cisplatin-based chemoradiotherapy (CRT) or cetuximab-based bioradiotherapy (bio-RT). METHODS: In patients with stage III to IVb HPV-positive oropharyngeal cancer, the Kaplan-Meier analysis was used to calculate distant metastases rates. Univariate analysis (UVA) and multivariate analysis (MVA) were used to identify factors associated with distant metastases. RESULTS: Increased distant metastases rates were noted in active smokers versus never/former smokers (22% vs 5%), T4 vs T1 to T3 (15% vs 6%), and cetuximab-based bio-RT versus CRT (23% vs 5%). All remained significant on MVA. CONCLUSION: T4 tumors and active smokers have substantial rates of distant metastases, and trials investigating intensified systemic therapies may be considered. Higher rates of distant metastases observed with concurrent cetuximab are hypothesis generating, but further data are needed. © 2017 Wiley Periodicals, Inc. Head Neck 39: 940-946, 2017.

Applicant Interview Experiences and Postinterview Communication of the 2016 Radiation Oncology Match Cycle.

PURPOSE: To characterize applicant interview experiences at radiation oncology residency programs during the 2016 match cycle and to assess applicant opinions regarding postinterview communication (PIC) after recent attention to gamesmanship noted in prior match cycles. METHODS AND MATERIALS: An anonymous, institutional review board-approved, 29-question survey was deployed following the rank order list deadline to all 2016 radiation oncology residency applicants applying to a single institution. RESULTS: Complete surveys were returned by 118 of 210 applicants, for a 56% response rate. Regarding possible match violation questions, 84% of respondents were asked at least once about where else they were interviewing (occurred at a median of 20% of program interviews); 51% were asked about marital status (6% of interviews); and 22% were asked about plans to have children (1% of interviews). Eighty-three percent of applicants wrote thank-you notes, with 55% reporting fear of being viewed unfavorably if such notes were not communicated. Sixty percent of applicants informed a program that they had ranked a program highly; 53% felt this PIC strategy would improve their standing on the rank order list, yet 46% reported feeling distressed by this obligation. A majority of applicants stated that they would feel relieved if programs explicitly discouraged PIC (89%) and that it would be preferable if programs prohibited applicants from notifying the program of their rank position (66%). CONCLUSIONS: Potential match violations occur at a high rate but are experienced at a minority of interviews. Postinterview communication occurs frequently, with applicants reporting resultant distress. Respondents stated that active discouragement of both thank-you notes/e-mails and applicants' notification to programs of their ranking would be preferred.

Adjuvant versus neoadjuvant androgen deprivation with radiotherapy for prostate cancer: does sequencing matter?

INTRODUCTION/BACKGROUND: Androgen deprivation therapy (ADT) is typically provided neoadjuvantly and concurrently with radiotherapy (RT) in the management of intermediate and high-risk prostate cancer. Our objective was to compare outcomes between patients who received adjuvant ADT (ADJ), ie, immediately after the completion of RT, to those who received a neoadjuvant and concurrent regimen (NEO). MATERIALS AND METHODS: From 1995 to 2002, 515 patients with prostate cancer were definitively treated with RT and ADT. NEO was provided 2 to 3 months before the start of RT (n = 311). ADJ was initiated immediately after the completion of RT (n = 204). Kaplan-Meier analysis was used to calculate biochemical relapse-free survival (bRFS), distant metastasis-free survival (DMFS), and overall survival (OS). Cox proportional hazards regression was used to examine the impact of ADT timing on outcomes. RESULTS: Ten-year bRFS, DMFS, and OS rates were 61%, 80%, and 66%, respectively. Ten-year bRFS rates for ADJ versus NEO were 63% versus 60% (P = .98). Ten-year DMFS rates for ADJ versus NEO were both 80% (P = .60). Ten-year OS rates for ADJ versus NEO were 65% versus 67% (P = .98). CONCLUSION: There was no significant difference in bRFS, DMFS, or OS between neoadjuvant versus adjuvant ADT in the setting of dose-escalated RT for localized prostate cancer. This suggests that the synergy between RT and androgen deprivation is independent of the sequencing of both modalities and that the initiation of RT does not need to be delayed for a course of neoadjuvant ADT.