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Peter C Levendag - One of the best experts on this subject based on the ideXlab platform.

  • robotic radiosurgery vs brachytherapy as a boost to intensity modulated radiotherapy for Tonsillar Fossa and soft palate tumors the clinical and economic impact of an emerging technology
    Technology in Cancer Research & Treatment, 2007
    Co-Authors: W Nijdam, Peter C Levendag, Inge Noever, Donald Fuller, Raymond Schulz, Jeanbriac Prevost, Carin Uylde A Groot
    Abstract:

    As a basis for making decisions regarding optimal treatment for patients with Tonsillar Fossa and soft palate tumors, we conducted a preliminary investigation of costs and quality of life (QoL) for two modalities [brachytherapy (BT) and robotic radiosurgery] used to boost radiation to the primary tumors following external beam radiotherapy. BT was well established in our center; a boost by robotic radiosurgery was begun more recently in patients for whom BT was not technically feasible. Robotic radiosurgery boost treatment has the advantage of being non-invasive and is able to reach tumors in cases where there is deep parapharyngeal tumor extension. A neck dissection was performed for patients with nodal-positive disease. Quality of life (pain and difficulty swallowing) was established in long-term follow-up for patients undergoing BT and over a one-year follow-up in robotic radiosurgery patients. Total hospital costs for both groups were computed. Our results show that efficacy and quality of life at one...

  • brachytherapy versus surgery in carcinoma of Tonsillar Fossa and or soft palate late adverse sequelae and performance status can we be more selective and obtain better tissue sparing
    International Journal of Radiation Oncology Biology Physics, 2004
    Co-Authors: Peter C Levendag, W Nijdam, Inge Noever, Paul I M Schmitz, Dick Sipkema, C Braat, Maarten F De Boer, Peter P Jansen
    Abstract:

    Abstract Purpose To report on the tumor control, adverse late normal tissue sequelae, and functional performance in patients with Tonsillar Fossa and/or soft palate (SP) tumors. The aim of the study is to validate the use of a more selective clinical target volume in conjunction with highly conformal radiotherapy (RT) techniques to better spare the surrounding normal tissues. Methods and materials Between 1986 and 2001, T1-T3 Tonsillar Fossa/SP tumors were treated in the Erasmus Medical Center using external beam radiotherapy (EBRT) to 46 Gy in 2-Gy fractions to the primary tumor and neck, followed by brachytherapy (BT) to the primary. Neck dissection was performed for node-positive disease (BT group; 104 patients). If BT was not feasible, patients underwent surgery and postoperative RT (PORT) to a dose of 50–70 Gy in 2-Gy fractions (surgery group; 86 patients). Local control, regional control, disease-free survival, and overall survival were determined. Late side effects were scored using the Radiation Therapy Oncology Group criteria. Univariate and multivariate Cox regression analyses were performed for regional failure (RF), with the parameters gender, age, site, TN stage, modality, dose, and overall treatment time. Recurrences in the contralateral neck were also related to significant ipsilateral involvement of the base of tongue and/or involvement of the SP crossing the midline. To determine the performance status scale scores and degree of xerostomia, a survey was conducted among patients living with no evidence of disease and a minimum of 2 years of follow-up. For that purpose, a research nurse interviewed patients regarding eating in public, normalcy of diet, normalcy of speech, and xerostomia. Results The tumor control rates after BT vs. surgery at 5 years were 88% vs. 88% for local control; 93% vs. 85% for regional control; 57% vs. 52% for disease-free survival; 67% vs. 57% for overall survival; and 5% vs. 6% for RF. No patient had RF in the contralateral untreated N0 neck (0 of 14 vs. 0 of 15). Multivariate Cox regression analysis for RF was statistically significant for Stage T2 vs. T3 (hazard ratio 0.09) and for the dose to the neck >46 Gy (hazard ratio, 8.7; 95% confidence interval, 1.3–57.1). The significant late side effects in the BT group vs. surgery group were ulcer in 39% vs. 7% (p = 0.001) and trismus in 1% vs. 21% (p = 0.005). The performance status scale scores and response to questions regarding xerostomia for BT vs. surgery revealed no statistically significant differences for eating in public, normalcy of diet, normalcy of speech, and xerostomia. The mean visual analog score for xerostomia was 5.5 in the BT group vs. 6 in the surgery group. conclusion Excellent locoregional control was obtained in T1-T3 Tonsillar Fossa and/or SP tumors. The rate at 10 years was 84% (BT group) vs. 78% (surgery group). However, adverse late side effects were not negligible. In addition to modality-specific side effects (ulcer/trismus), both treatment groups were significantly affected by xerostomia. Only 6 recurrences (4%) were observed in the 149 electively treated contralateral necks, and no relapses were seen in the 29 untreated contralateral necks. We, therefore, suggest that it is not necessary to treat the contralateral neck, unless the tumor extends beyond the midline of the soft palate (uvula) or beyond the lateral one-third of the ipsilateral base of the tongue. Moreover, with the currently available CT-based neck level definitions, more conformal contours (i.e., tighter boundaries) around the clinical target volume can be designed. In this way, critical structures such as the temporomandibular joint and part of the pterygoid muscles can be avoided more easily. Also, when using highly conformal treatment techniques (e.g., intensity-modulated RT), one can further reduce the dose to the major salivary glands and oral mucosa. We believe these measures will lead to less trismus and less xerostomia.

  • Brachytherapy versus surgery in carcinoma of Tonsillar Fossa and/or soft palate : Late adverse sequelae and performance status: Can we be more selective and obtain better tissue sparing?
    International Journal of Radiation Oncology Biology Physics, 2004
    Co-Authors: Peter C Levendag, W Nijdam, Inge Noever, Paul I M Schmitz, Dick Sipkema, C Braat, Maarten F De Boer, Peter P Jansen
    Abstract:

    Abstract Purpose To report on the tumor control, adverse late normal tissue sequelae, and functional performance in patients with Tonsillar Fossa and/or soft palate (SP) tumors. The aim of the study is to validate the use of a more selective clinical target volume in conjunction with highly conformal radiotherapy (RT) techniques to better spare the surrounding normal tissues. Methods and materials Between 1986 and 2001, T1-T3 Tonsillar Fossa/SP tumors were treated in the Erasmus Medical Center using external beam radiotherapy (EBRT) to 46 Gy in 2-Gy fractions to the primary tumor and neck, followed by brachytherapy (BT) to the primary. Neck dissection was performed for node-positive disease (BT group; 104 patients). If BT was not feasible, patients underwent surgery and postoperative RT (PORT) to a dose of 50–70 Gy in 2-Gy fractions (surgery group; 86 patients). Local control, regional control, disease-free survival, and overall survival were determined. Late side effects were scored using the Radiation Therapy Oncology Group criteria. Univariate and multivariate Cox regression analyses were performed for regional failure (RF), with the parameters gender, age, site, TN stage, modality, dose, and overall treatment time. Recurrences in the contralateral neck were also related to significant ipsilateral involvement of the base of tongue and/or involvement of the SP crossing the midline. To determine the performance status scale scores and degree of xerostomia, a survey was conducted among patients living with no evidence of disease and a minimum of 2 years of follow-up. For that purpose, a research nurse interviewed patients regarding eating in public, normalcy of diet, normalcy of speech, and xerostomia. Results The tumor control rates after BT vs. surgery at 5 years were 88% vs. 88% for local control; 93% vs. 85% for regional control; 57% vs. 52% for disease-free survival; 67% vs. 57% for overall survival; and 5% vs. 6% for RF. No patient had RF in the contralateral untreated N0 neck (0 of 14 vs. 0 of 15). Multivariate Cox regression analysis for RF was statistically significant for Stage T2 vs. T3 (hazard ratio 0.09) and for the dose to the neck >46 Gy (hazard ratio, 8.7; 95% confidence interval, 1.3–57.1). The significant late side effects in the BT group vs. surgery group were ulcer in 39% vs. 7% (p = 0.001) and trismus in 1% vs. 21% (p = 0.005). The performance status scale scores and response to questions regarding xerostomia for BT vs. surgery revealed no statistically significant differences for eating in public, normalcy of diet, normalcy of speech, and xerostomia. The mean visual analog score for xerostomia was 5.5 in the BT group vs. 6 in the surgery group. conclusion Excellent locoregional control was obtained in T1-T3 Tonsillar Fossa and/or SP tumors. The rate at 10 years was 84% (BT group) vs. 78% (surgery group). However, adverse late side effects were not negligible. In addition to modality-specific side effects (ulcer/trismus), both treatment groups were significantly affected by xerostomia. Only 6 recurrences (4%) were observed in the 149 electively treated contralateral necks, and no relapses were seen in the 29 untreated contralateral necks. We, therefore, suggest that it is not necessary to treat the contralateral neck, unless the tumor extends beyond the midline of the soft palate (uvula) or beyond the lateral one-third of the ipsilateral base of the tongue. Moreover, with the currently available CT-based neck level definitions, more conformal contours (i.e., tighter boundaries) around the clinical target volume can be designed. In this way, critical structures such as the temporomandibular joint and part of the pterygoid muscles can be avoided more easily. Also, when using highly conformal treatment techniques (e.g., intensity-modulated RT), one can further reduce the dose to the major salivary glands and oral mucosa. We believe these measures will lead to less trismus and less xerostomia.

  • cost analysis comparing brachytherapy versus surgery for primary carcinoma of the Tonsillar Fossa and or soft palate
    International Journal of Radiation Oncology Biology Physics, 2004
    Co-Authors: W Nijdam, Peter C Levendag, Inge Noever, Carin Uylde A Groot, Michel Van Agthoven
    Abstract:

    Abstract Purpose Locoregional control rates, late normal tissue sequelae, and functional outcome scores have not been different for Tonsillar Fossa and/or soft palate tumors treated by either brachytherapy (BT) or surgery in an organ function preservation protocol. For additional prioritizing in clinical decision-making, we focused on a comparison of the full hospital costs of the different treatment options. Methods and materials Between 1986 and 2001, Tonsillar Fossa and/or soft palate tumors were treated by external beam radiotherapy (EBRT) to the primary tumor and neck, followed by fractionated BT to the primary. Neck dissection (ND) was performed for node-positive disease (BT group; 104 patients). If BT was not feasible, resection combined with postoperative EBRT was executed (surgery group; 86 patients). Locoregional control, disease-free survival, and overall survival were calculated according to the Kaplan-Meier method. The performance status scales, late side effects, and degree of xerostomia have been previously reported. This paper focused on the hospital and follow-up costs for the treatment groups EBRT and BT with or without ND compared with surgery followed by postoperative RT (PORT). Finally, these costs were also computed for future treatment strategies (e.g., better sparing of normal tissues by intensity-modulated RT [IMRT]). Results Locoregional control, disease-free survival, and overall survival rate at 5 years for patients treated with EBRT and BT with or without ND vs. surgery plus PORT was 80% vs. 78%, 58% vs. 55%, and 67% vs. 57%, respectively. The major late side effect was xerostomia. Dry mouth syndrome affected the BT group and surgery group equally. The total costs for all treatment groups were €14,262 (BT group), €16,628 (BT plus ND group), €18,782 (surgery plus PORT group), €14,532 (IMRT group), and €16,897 (IMRT plus ND group). Conclusion Excellent locoregional tumor control was observed with either modality, with no statistically significant differences in the incidence of the most noted side effect xerostomia. The total costs for BT were less than for surgery: €16,628 ($19,452) for EBRT plus BT plus ND vs. €18,782 ($22,074) for surgery plus PORT. To reduce the morbidity of xerostomia, we propose further optimizing our organ function preservation protocol by implementing IMRT as a more conformal, tissue-sparing, RT technique. This is of particular interest because the costs of IMRT plus ND (€16,897; $19,767) were not very different from those for BT plus ND (€16,628; $19,452) and were far less than the costs for surgery.

  • Cost analysis comparing brachytherapy versus surgery for primary carcinoma of the Tonsillar Fossa and/or soft palate.
    International Journal of Radiation Oncology Biology Physics, 2004
    Co-Authors: W Nijdam, Peter C Levendag, Inge Noever, Carin A. Uyl-de Groot, Michel Van Agthoven
    Abstract:

    Abstract Purpose Locoregional control rates, late normal tissue sequelae, and functional outcome scores have not been different for Tonsillar Fossa and/or soft palate tumors treated by either brachytherapy (BT) or surgery in an organ function preservation protocol. For additional prioritizing in clinical decision-making, we focused on a comparison of the full hospital costs of the different treatment options. Methods and materials Between 1986 and 2001, Tonsillar Fossa and/or soft palate tumors were treated by external beam radiotherapy (EBRT) to the primary tumor and neck, followed by fractionated BT to the primary. Neck dissection (ND) was performed for node-positive disease (BT group; 104 patients). If BT was not feasible, resection combined with postoperative EBRT was executed (surgery group; 86 patients). Locoregional control, disease-free survival, and overall survival were calculated according to the Kaplan-Meier method. The performance status scales, late side effects, and degree of xerostomia have been previously reported. This paper focused on the hospital and follow-up costs for the treatment groups EBRT and BT with or without ND compared with surgery followed by postoperative RT (PORT). Finally, these costs were also computed for future treatment strategies (e.g., better sparing of normal tissues by intensity-modulated RT [IMRT]). Results Locoregional control, disease-free survival, and overall survival rate at 5 years for patients treated with EBRT and BT with or without ND vs. surgery plus PORT was 80% vs. 78%, 58% vs. 55%, and 67% vs. 57%, respectively. The major late side effect was xerostomia. Dry mouth syndrome affected the BT group and surgery group equally. The total costs for all treatment groups were €14,262 (BT group), €16,628 (BT plus ND group), €18,782 (surgery plus PORT group), €14,532 (IMRT group), and €16,897 (IMRT plus ND group). Conclusion Excellent locoregional tumor control was observed with either modality, with no statistically significant differences in the incidence of the most noted side effect xerostomia. The total costs for BT were less than for surgery: €16,628 ($19,452) for EBRT plus BT plus ND vs. €18,782 ($22,074) for surgery plus PORT. To reduce the morbidity of xerostomia, we propose further optimizing our organ function preservation protocol by implementing IMRT as a more conformal, tissue-sparing, RT technique. This is of particular interest because the costs of IMRT plus ND (€16,897; $19,767) were not very different from those for BT plus ND (€16,628; $19,452) and were far less than the costs for surgery.

J C Mcilwain - One of the best experts on this subject based on the ideXlab platform.

  • Tonsillar Fossa obliteration and post operative pain
    Clinical Otolaryngology, 1995
    Co-Authors: V Nandapalan, J C Mcilwain
    Abstract:

    : Fifty consecutive patients over the age of 15 years undergoing tonsillectomy had one Tonsillar Fossa obliterated by 2/0 Polydioxanone (PDS II) suture. The opposite side was used as a control. Pain was assessed on a visual analogue scale from the first to tenth post-operative day. Although on the initial post-operative days the pain was more on the sutured side, 41 patients subsequently experienced significant pain relief on that side (P = 0.0001). No complications were encountered due to the Tonsillar Fossa obliteration. On the 10 day review, the 41 patients indicated in their questionnaire that Tonsillar Fossa obliteration is a useful procedure to reduce the post-operative pain and would have preferred both sides to be obliterated rather than left to heal by secondary intention.

  • Tonsillar Fossa obliteration and post‐operative pain
    Clinical Otolaryngology, 1995
    Co-Authors: V Nandapalan, J C Mcilwain
    Abstract:

    : Fifty consecutive patients over the age of 15 years undergoing tonsillectomy had one Tonsillar Fossa obliterated by 2/0 Polydioxanone (PDS II) suture. The opposite side was used as a control. Pain was assessed on a visual analogue scale from the first to tenth post-operative day. Although on the initial post-operative days the pain was more on the sutured side, 41 patients subsequently experienced significant pain relief on that side (P = 0.0001). No complications were encountered due to the Tonsillar Fossa obliteration. On the 10 day review, the 41 patients indicated in their questionnaire that Tonsillar Fossa obliteration is a useful procedure to reduce the post-operative pain and would have preferred both sides to be obliterated rather than left to heal by secondary intention.

Peter P Jansen - One of the best experts on this subject based on the ideXlab platform.

  • brachytherapy versus surgery in carcinoma of Tonsillar Fossa and or soft palate late adverse sequelae and performance status can we be more selective and obtain better tissue sparing
    International Journal of Radiation Oncology Biology Physics, 2004
    Co-Authors: Peter C Levendag, W Nijdam, Inge Noever, Paul I M Schmitz, Dick Sipkema, C Braat, Maarten F De Boer, Peter P Jansen
    Abstract:

    Abstract Purpose To report on the tumor control, adverse late normal tissue sequelae, and functional performance in patients with Tonsillar Fossa and/or soft palate (SP) tumors. The aim of the study is to validate the use of a more selective clinical target volume in conjunction with highly conformal radiotherapy (RT) techniques to better spare the surrounding normal tissues. Methods and materials Between 1986 and 2001, T1-T3 Tonsillar Fossa/SP tumors were treated in the Erasmus Medical Center using external beam radiotherapy (EBRT) to 46 Gy in 2-Gy fractions to the primary tumor and neck, followed by brachytherapy (BT) to the primary. Neck dissection was performed for node-positive disease (BT group; 104 patients). If BT was not feasible, patients underwent surgery and postoperative RT (PORT) to a dose of 50–70 Gy in 2-Gy fractions (surgery group; 86 patients). Local control, regional control, disease-free survival, and overall survival were determined. Late side effects were scored using the Radiation Therapy Oncology Group criteria. Univariate and multivariate Cox regression analyses were performed for regional failure (RF), with the parameters gender, age, site, TN stage, modality, dose, and overall treatment time. Recurrences in the contralateral neck were also related to significant ipsilateral involvement of the base of tongue and/or involvement of the SP crossing the midline. To determine the performance status scale scores and degree of xerostomia, a survey was conducted among patients living with no evidence of disease and a minimum of 2 years of follow-up. For that purpose, a research nurse interviewed patients regarding eating in public, normalcy of diet, normalcy of speech, and xerostomia. Results The tumor control rates after BT vs. surgery at 5 years were 88% vs. 88% for local control; 93% vs. 85% for regional control; 57% vs. 52% for disease-free survival; 67% vs. 57% for overall survival; and 5% vs. 6% for RF. No patient had RF in the contralateral untreated N0 neck (0 of 14 vs. 0 of 15). Multivariate Cox regression analysis for RF was statistically significant for Stage T2 vs. T3 (hazard ratio 0.09) and for the dose to the neck >46 Gy (hazard ratio, 8.7; 95% confidence interval, 1.3–57.1). The significant late side effects in the BT group vs. surgery group were ulcer in 39% vs. 7% (p = 0.001) and trismus in 1% vs. 21% (p = 0.005). The performance status scale scores and response to questions regarding xerostomia for BT vs. surgery revealed no statistically significant differences for eating in public, normalcy of diet, normalcy of speech, and xerostomia. The mean visual analog score for xerostomia was 5.5 in the BT group vs. 6 in the surgery group. conclusion Excellent locoregional control was obtained in T1-T3 Tonsillar Fossa and/or SP tumors. The rate at 10 years was 84% (BT group) vs. 78% (surgery group). However, adverse late side effects were not negligible. In addition to modality-specific side effects (ulcer/trismus), both treatment groups were significantly affected by xerostomia. Only 6 recurrences (4%) were observed in the 149 electively treated contralateral necks, and no relapses were seen in the 29 untreated contralateral necks. We, therefore, suggest that it is not necessary to treat the contralateral neck, unless the tumor extends beyond the midline of the soft palate (uvula) or beyond the lateral one-third of the ipsilateral base of the tongue. Moreover, with the currently available CT-based neck level definitions, more conformal contours (i.e., tighter boundaries) around the clinical target volume can be designed. In this way, critical structures such as the temporomandibular joint and part of the pterygoid muscles can be avoided more easily. Also, when using highly conformal treatment techniques (e.g., intensity-modulated RT), one can further reduce the dose to the major salivary glands and oral mucosa. We believe these measures will lead to less trismus and less xerostomia.

  • Brachytherapy versus surgery in carcinoma of Tonsillar Fossa and/or soft palate : Late adverse sequelae and performance status: Can we be more selective and obtain better tissue sparing?
    International Journal of Radiation Oncology Biology Physics, 2004
    Co-Authors: Peter C Levendag, W Nijdam, Inge Noever, Paul I M Schmitz, Dick Sipkema, C Braat, Maarten F De Boer, Peter P Jansen
    Abstract:

    Abstract Purpose To report on the tumor control, adverse late normal tissue sequelae, and functional performance in patients with Tonsillar Fossa and/or soft palate (SP) tumors. The aim of the study is to validate the use of a more selective clinical target volume in conjunction with highly conformal radiotherapy (RT) techniques to better spare the surrounding normal tissues. Methods and materials Between 1986 and 2001, T1-T3 Tonsillar Fossa/SP tumors were treated in the Erasmus Medical Center using external beam radiotherapy (EBRT) to 46 Gy in 2-Gy fractions to the primary tumor and neck, followed by brachytherapy (BT) to the primary. Neck dissection was performed for node-positive disease (BT group; 104 patients). If BT was not feasible, patients underwent surgery and postoperative RT (PORT) to a dose of 50–70 Gy in 2-Gy fractions (surgery group; 86 patients). Local control, regional control, disease-free survival, and overall survival were determined. Late side effects were scored using the Radiation Therapy Oncology Group criteria. Univariate and multivariate Cox regression analyses were performed for regional failure (RF), with the parameters gender, age, site, TN stage, modality, dose, and overall treatment time. Recurrences in the contralateral neck were also related to significant ipsilateral involvement of the base of tongue and/or involvement of the SP crossing the midline. To determine the performance status scale scores and degree of xerostomia, a survey was conducted among patients living with no evidence of disease and a minimum of 2 years of follow-up. For that purpose, a research nurse interviewed patients regarding eating in public, normalcy of diet, normalcy of speech, and xerostomia. Results The tumor control rates after BT vs. surgery at 5 years were 88% vs. 88% for local control; 93% vs. 85% for regional control; 57% vs. 52% for disease-free survival; 67% vs. 57% for overall survival; and 5% vs. 6% for RF. No patient had RF in the contralateral untreated N0 neck (0 of 14 vs. 0 of 15). Multivariate Cox regression analysis for RF was statistically significant for Stage T2 vs. T3 (hazard ratio 0.09) and for the dose to the neck >46 Gy (hazard ratio, 8.7; 95% confidence interval, 1.3–57.1). The significant late side effects in the BT group vs. surgery group were ulcer in 39% vs. 7% (p = 0.001) and trismus in 1% vs. 21% (p = 0.005). The performance status scale scores and response to questions regarding xerostomia for BT vs. surgery revealed no statistically significant differences for eating in public, normalcy of diet, normalcy of speech, and xerostomia. The mean visual analog score for xerostomia was 5.5 in the BT group vs. 6 in the surgery group. conclusion Excellent locoregional control was obtained in T1-T3 Tonsillar Fossa and/or SP tumors. The rate at 10 years was 84% (BT group) vs. 78% (surgery group). However, adverse late side effects were not negligible. In addition to modality-specific side effects (ulcer/trismus), both treatment groups were significantly affected by xerostomia. Only 6 recurrences (4%) were observed in the 149 electively treated contralateral necks, and no relapses were seen in the 29 untreated contralateral necks. We, therefore, suggest that it is not necessary to treat the contralateral neck, unless the tumor extends beyond the midline of the soft palate (uvula) or beyond the lateral one-third of the ipsilateral base of the tongue. Moreover, with the currently available CT-based neck level definitions, more conformal contours (i.e., tighter boundaries) around the clinical target volume can be designed. In this way, critical structures such as the temporomandibular joint and part of the pterygoid muscles can be avoided more easily. Also, when using highly conformal treatment techniques (e.g., intensity-modulated RT), one can further reduce the dose to the major salivary glands and oral mucosa. We believe these measures will lead to less trismus and less xerostomia.

  • fractionated high dose rate and pulsed dose rate brachytherapy first clinical experience in squamous cell carcinoma of the Tonsillar Fossa and soft palate
    International Journal of Radiation Oncology Biology Physics, 1997
    Co-Authors: Peter C Levendag, Paul I M Schmitz, Dick Sipkema, Peter P Jansen, Suresh Senan, W M H Eijkenboom, C A Meeuwis, Inger Karine Kolkmandeurloo, A G Visser
    Abstract:

    PURPOSE: Fractionated high-dose-rate (fr.HDR) and pulsed-dose-rate (PDR) brachytherapy (BT) regimens, which simulate classical continuous low-dose-rate (LDR) interstitial radiation therapy (IRT) schedules, have been developed for clinical use. This article reports the initial results using these novel schedules in squamous cell carcinoma (SCC) of the Tonsillar Fossa (TF) and/or soft palate (SP). METHODS AND MATERIALS: Between 1990 and 1994, 38 patients with TF and SP tumors (5 T1, 22 T2, 10 T3, and 1 T4) were treated by fr.HDR or PDR brachytherapy, either alone or in combination with external irradiation (ERT). Half of the patients were treated with fr.HDR, which entailed twice-daily fractions of > or = 3 Gy. The other 19 patients were administered PDR, which consisted of pulses of < or = 2 Gy delivered 4-8 times/day. The median cumulative dose of IRT +/- ERT series was 66 Gy (range 55-73). The results in these patients treated by brachytherapy were compared to 72 patients with similar tumors treated in our institute with curative intent, using ERT alone. The median cumulative dose of ERT-only series was 70 Gy (range 40-77). RESULTS: Excellent locoregional control was achieved with the use of IRT +/- ERT, with only 13% (5 of 38) developing local failure, and salvage surgery being possible in three of the latter (60%). Neither BT scheme (fr.HDR vs. PDR) nor tumor site (TF vs. SP) significantly influenced local control rates. The type and severity of the side effects observed are comparable to those reported in the literature for LDR-IRT. These results contrast sharply with our ERT-only series, in which 39% of patients (28 of 72) developed local failure, with surgical salvage being possible only in three patients (11%). Taking the data set of 110 patients, in a univariate analysis IRT, T stage, N stage, overall treatment time (OTT), and BEDcor10 (biological effective dose with a correction for the OTT) were significant prognostic factors for local relapse-free survival (LRFS) and overall survival (OS) at 3 years. Using Cox proportional hazard analysis, only T stage and BEDcor10 remained significant for LRFS (p < 0.001 and 0.008, respectively), as well as for OS (p < 0.001 and 0.003, respectively). With regard to the current (IRT) and historical (ERT) series, for the LRFS at 3 years, dose-response relationships were established, significant, however, only for the BEDcor10 (p = 0.03). CONCLUSION: The 3-year LRFS of approximately 90% for TF and SP tumors reported here is comparable with the best results in the literature, particularly given the fact that 30% of the patients (11 of 38) presented with T3/4 tumors. When compared with our historical (ERT-only) controls, the patients treated with IRT had superior local control. A dose-response relationship was established for the BEDcor10.

W Nijdam - One of the best experts on this subject based on the ideXlab platform.

  • robotic radiosurgery vs brachytherapy as a boost to intensity modulated radiotherapy for Tonsillar Fossa and soft palate tumors the clinical and economic impact of an emerging technology
    Technology in Cancer Research & Treatment, 2007
    Co-Authors: W Nijdam, Peter C Levendag, Inge Noever, Donald Fuller, Raymond Schulz, Jeanbriac Prevost, Carin Uylde A Groot
    Abstract:

    As a basis for making decisions regarding optimal treatment for patients with Tonsillar Fossa and soft palate tumors, we conducted a preliminary investigation of costs and quality of life (QoL) for two modalities [brachytherapy (BT) and robotic radiosurgery] used to boost radiation to the primary tumors following external beam radiotherapy. BT was well established in our center; a boost by robotic radiosurgery was begun more recently in patients for whom BT was not technically feasible. Robotic radiosurgery boost treatment has the advantage of being non-invasive and is able to reach tumors in cases where there is deep parapharyngeal tumor extension. A neck dissection was performed for patients with nodal-positive disease. Quality of life (pain and difficulty swallowing) was established in long-term follow-up for patients undergoing BT and over a one-year follow-up in robotic radiosurgery patients. Total hospital costs for both groups were computed. Our results show that efficacy and quality of life at one...

  • brachytherapy versus surgery in carcinoma of Tonsillar Fossa and or soft palate late adverse sequelae and performance status can we be more selective and obtain better tissue sparing
    International Journal of Radiation Oncology Biology Physics, 2004
    Co-Authors: Peter C Levendag, W Nijdam, Inge Noever, Paul I M Schmitz, Dick Sipkema, C Braat, Maarten F De Boer, Peter P Jansen
    Abstract:

    Abstract Purpose To report on the tumor control, adverse late normal tissue sequelae, and functional performance in patients with Tonsillar Fossa and/or soft palate (SP) tumors. The aim of the study is to validate the use of a more selective clinical target volume in conjunction with highly conformal radiotherapy (RT) techniques to better spare the surrounding normal tissues. Methods and materials Between 1986 and 2001, T1-T3 Tonsillar Fossa/SP tumors were treated in the Erasmus Medical Center using external beam radiotherapy (EBRT) to 46 Gy in 2-Gy fractions to the primary tumor and neck, followed by brachytherapy (BT) to the primary. Neck dissection was performed for node-positive disease (BT group; 104 patients). If BT was not feasible, patients underwent surgery and postoperative RT (PORT) to a dose of 50–70 Gy in 2-Gy fractions (surgery group; 86 patients). Local control, regional control, disease-free survival, and overall survival were determined. Late side effects were scored using the Radiation Therapy Oncology Group criteria. Univariate and multivariate Cox regression analyses were performed for regional failure (RF), with the parameters gender, age, site, TN stage, modality, dose, and overall treatment time. Recurrences in the contralateral neck were also related to significant ipsilateral involvement of the base of tongue and/or involvement of the SP crossing the midline. To determine the performance status scale scores and degree of xerostomia, a survey was conducted among patients living with no evidence of disease and a minimum of 2 years of follow-up. For that purpose, a research nurse interviewed patients regarding eating in public, normalcy of diet, normalcy of speech, and xerostomia. Results The tumor control rates after BT vs. surgery at 5 years were 88% vs. 88% for local control; 93% vs. 85% for regional control; 57% vs. 52% for disease-free survival; 67% vs. 57% for overall survival; and 5% vs. 6% for RF. No patient had RF in the contralateral untreated N0 neck (0 of 14 vs. 0 of 15). Multivariate Cox regression analysis for RF was statistically significant for Stage T2 vs. T3 (hazard ratio 0.09) and for the dose to the neck >46 Gy (hazard ratio, 8.7; 95% confidence interval, 1.3–57.1). The significant late side effects in the BT group vs. surgery group were ulcer in 39% vs. 7% (p = 0.001) and trismus in 1% vs. 21% (p = 0.005). The performance status scale scores and response to questions regarding xerostomia for BT vs. surgery revealed no statistically significant differences for eating in public, normalcy of diet, normalcy of speech, and xerostomia. The mean visual analog score for xerostomia was 5.5 in the BT group vs. 6 in the surgery group. conclusion Excellent locoregional control was obtained in T1-T3 Tonsillar Fossa and/or SP tumors. The rate at 10 years was 84% (BT group) vs. 78% (surgery group). However, adverse late side effects were not negligible. In addition to modality-specific side effects (ulcer/trismus), both treatment groups were significantly affected by xerostomia. Only 6 recurrences (4%) were observed in the 149 electively treated contralateral necks, and no relapses were seen in the 29 untreated contralateral necks. We, therefore, suggest that it is not necessary to treat the contralateral neck, unless the tumor extends beyond the midline of the soft palate (uvula) or beyond the lateral one-third of the ipsilateral base of the tongue. Moreover, with the currently available CT-based neck level definitions, more conformal contours (i.e., tighter boundaries) around the clinical target volume can be designed. In this way, critical structures such as the temporomandibular joint and part of the pterygoid muscles can be avoided more easily. Also, when using highly conformal treatment techniques (e.g., intensity-modulated RT), one can further reduce the dose to the major salivary glands and oral mucosa. We believe these measures will lead to less trismus and less xerostomia.

  • Brachytherapy versus surgery in carcinoma of Tonsillar Fossa and/or soft palate : Late adverse sequelae and performance status: Can we be more selective and obtain better tissue sparing?
    International Journal of Radiation Oncology Biology Physics, 2004
    Co-Authors: Peter C Levendag, W Nijdam, Inge Noever, Paul I M Schmitz, Dick Sipkema, C Braat, Maarten F De Boer, Peter P Jansen
    Abstract:

    Abstract Purpose To report on the tumor control, adverse late normal tissue sequelae, and functional performance in patients with Tonsillar Fossa and/or soft palate (SP) tumors. The aim of the study is to validate the use of a more selective clinical target volume in conjunction with highly conformal radiotherapy (RT) techniques to better spare the surrounding normal tissues. Methods and materials Between 1986 and 2001, T1-T3 Tonsillar Fossa/SP tumors were treated in the Erasmus Medical Center using external beam radiotherapy (EBRT) to 46 Gy in 2-Gy fractions to the primary tumor and neck, followed by brachytherapy (BT) to the primary. Neck dissection was performed for node-positive disease (BT group; 104 patients). If BT was not feasible, patients underwent surgery and postoperative RT (PORT) to a dose of 50–70 Gy in 2-Gy fractions (surgery group; 86 patients). Local control, regional control, disease-free survival, and overall survival were determined. Late side effects were scored using the Radiation Therapy Oncology Group criteria. Univariate and multivariate Cox regression analyses were performed for regional failure (RF), with the parameters gender, age, site, TN stage, modality, dose, and overall treatment time. Recurrences in the contralateral neck were also related to significant ipsilateral involvement of the base of tongue and/or involvement of the SP crossing the midline. To determine the performance status scale scores and degree of xerostomia, a survey was conducted among patients living with no evidence of disease and a minimum of 2 years of follow-up. For that purpose, a research nurse interviewed patients regarding eating in public, normalcy of diet, normalcy of speech, and xerostomia. Results The tumor control rates after BT vs. surgery at 5 years were 88% vs. 88% for local control; 93% vs. 85% for regional control; 57% vs. 52% for disease-free survival; 67% vs. 57% for overall survival; and 5% vs. 6% for RF. No patient had RF in the contralateral untreated N0 neck (0 of 14 vs. 0 of 15). Multivariate Cox regression analysis for RF was statistically significant for Stage T2 vs. T3 (hazard ratio 0.09) and for the dose to the neck >46 Gy (hazard ratio, 8.7; 95% confidence interval, 1.3–57.1). The significant late side effects in the BT group vs. surgery group were ulcer in 39% vs. 7% (p = 0.001) and trismus in 1% vs. 21% (p = 0.005). The performance status scale scores and response to questions regarding xerostomia for BT vs. surgery revealed no statistically significant differences for eating in public, normalcy of diet, normalcy of speech, and xerostomia. The mean visual analog score for xerostomia was 5.5 in the BT group vs. 6 in the surgery group. conclusion Excellent locoregional control was obtained in T1-T3 Tonsillar Fossa and/or SP tumors. The rate at 10 years was 84% (BT group) vs. 78% (surgery group). However, adverse late side effects were not negligible. In addition to modality-specific side effects (ulcer/trismus), both treatment groups were significantly affected by xerostomia. Only 6 recurrences (4%) were observed in the 149 electively treated contralateral necks, and no relapses were seen in the 29 untreated contralateral necks. We, therefore, suggest that it is not necessary to treat the contralateral neck, unless the tumor extends beyond the midline of the soft palate (uvula) or beyond the lateral one-third of the ipsilateral base of the tongue. Moreover, with the currently available CT-based neck level definitions, more conformal contours (i.e., tighter boundaries) around the clinical target volume can be designed. In this way, critical structures such as the temporomandibular joint and part of the pterygoid muscles can be avoided more easily. Also, when using highly conformal treatment techniques (e.g., intensity-modulated RT), one can further reduce the dose to the major salivary glands and oral mucosa. We believe these measures will lead to less trismus and less xerostomia.

  • cost analysis comparing brachytherapy versus surgery for primary carcinoma of the Tonsillar Fossa and or soft palate
    International Journal of Radiation Oncology Biology Physics, 2004
    Co-Authors: W Nijdam, Peter C Levendag, Inge Noever, Carin Uylde A Groot, Michel Van Agthoven
    Abstract:

    Abstract Purpose Locoregional control rates, late normal tissue sequelae, and functional outcome scores have not been different for Tonsillar Fossa and/or soft palate tumors treated by either brachytherapy (BT) or surgery in an organ function preservation protocol. For additional prioritizing in clinical decision-making, we focused on a comparison of the full hospital costs of the different treatment options. Methods and materials Between 1986 and 2001, Tonsillar Fossa and/or soft palate tumors were treated by external beam radiotherapy (EBRT) to the primary tumor and neck, followed by fractionated BT to the primary. Neck dissection (ND) was performed for node-positive disease (BT group; 104 patients). If BT was not feasible, resection combined with postoperative EBRT was executed (surgery group; 86 patients). Locoregional control, disease-free survival, and overall survival were calculated according to the Kaplan-Meier method. The performance status scales, late side effects, and degree of xerostomia have been previously reported. This paper focused on the hospital and follow-up costs for the treatment groups EBRT and BT with or without ND compared with surgery followed by postoperative RT (PORT). Finally, these costs were also computed for future treatment strategies (e.g., better sparing of normal tissues by intensity-modulated RT [IMRT]). Results Locoregional control, disease-free survival, and overall survival rate at 5 years for patients treated with EBRT and BT with or without ND vs. surgery plus PORT was 80% vs. 78%, 58% vs. 55%, and 67% vs. 57%, respectively. The major late side effect was xerostomia. Dry mouth syndrome affected the BT group and surgery group equally. The total costs for all treatment groups were €14,262 (BT group), €16,628 (BT plus ND group), €18,782 (surgery plus PORT group), €14,532 (IMRT group), and €16,897 (IMRT plus ND group). Conclusion Excellent locoregional tumor control was observed with either modality, with no statistically significant differences in the incidence of the most noted side effect xerostomia. The total costs for BT were less than for surgery: €16,628 ($19,452) for EBRT plus BT plus ND vs. €18,782 ($22,074) for surgery plus PORT. To reduce the morbidity of xerostomia, we propose further optimizing our organ function preservation protocol by implementing IMRT as a more conformal, tissue-sparing, RT technique. This is of particular interest because the costs of IMRT plus ND (€16,897; $19,767) were not very different from those for BT plus ND (€16,628; $19,452) and were far less than the costs for surgery.

  • Cost analysis comparing brachytherapy versus surgery for primary carcinoma of the Tonsillar Fossa and/or soft palate.
    International Journal of Radiation Oncology Biology Physics, 2004
    Co-Authors: W Nijdam, Peter C Levendag, Inge Noever, Carin A. Uyl-de Groot, Michel Van Agthoven
    Abstract:

    Abstract Purpose Locoregional control rates, late normal tissue sequelae, and functional outcome scores have not been different for Tonsillar Fossa and/or soft palate tumors treated by either brachytherapy (BT) or surgery in an organ function preservation protocol. For additional prioritizing in clinical decision-making, we focused on a comparison of the full hospital costs of the different treatment options. Methods and materials Between 1986 and 2001, Tonsillar Fossa and/or soft palate tumors were treated by external beam radiotherapy (EBRT) to the primary tumor and neck, followed by fractionated BT to the primary. Neck dissection (ND) was performed for node-positive disease (BT group; 104 patients). If BT was not feasible, resection combined with postoperative EBRT was executed (surgery group; 86 patients). Locoregional control, disease-free survival, and overall survival were calculated according to the Kaplan-Meier method. The performance status scales, late side effects, and degree of xerostomia have been previously reported. This paper focused on the hospital and follow-up costs for the treatment groups EBRT and BT with or without ND compared with surgery followed by postoperative RT (PORT). Finally, these costs were also computed for future treatment strategies (e.g., better sparing of normal tissues by intensity-modulated RT [IMRT]). Results Locoregional control, disease-free survival, and overall survival rate at 5 years for patients treated with EBRT and BT with or without ND vs. surgery plus PORT was 80% vs. 78%, 58% vs. 55%, and 67% vs. 57%, respectively. The major late side effect was xerostomia. Dry mouth syndrome affected the BT group and surgery group equally. The total costs for all treatment groups were €14,262 (BT group), €16,628 (BT plus ND group), €18,782 (surgery plus PORT group), €14,532 (IMRT group), and €16,897 (IMRT plus ND group). Conclusion Excellent locoregional tumor control was observed with either modality, with no statistically significant differences in the incidence of the most noted side effect xerostomia. The total costs for BT were less than for surgery: €16,628 ($19,452) for EBRT plus BT plus ND vs. €18,782 ($22,074) for surgery plus PORT. To reduce the morbidity of xerostomia, we propose further optimizing our organ function preservation protocol by implementing IMRT as a more conformal, tissue-sparing, RT technique. This is of particular interest because the costs of IMRT plus ND (€16,897; $19,767) were not very different from those for BT plus ND (€16,628; $19,452) and were far less than the costs for surgery.

Facs Christopher F Holsinger - One of the best experts on this subject based on the ideXlab platform.

  • a flexible single arm robotic surgical system for transoral resection of the tonsil and lateral pharyngeal wall next generation robotic head and neck surgery
    Laryngoscope, 2016
    Co-Authors: Facs Christopher F Holsinger
    Abstract:

    Objectives/Hypothesis To describe the application of a novel flexible robotic surgical system to transoral endoscopic head and neck surgery of the Tonsillar Fossa and lateral oropharyngeal wall. Study Design Preclinical anatomic study using three human cadavers. Methods Transoral resection of the lateral oropharyngeal wall with mucosal and muscular resection of the Tonsillar Fossa. Results This single-port flexible robotic system could be used to successfully perform transoral resection of this region. The optimal angle to dock the patient-side cart was at a 90-degree angle to the operating room table. The placement of the remote center of the robotic instrument arm was evaluated in three positions. When the cannula tip was placed at 10 to 15 cm, all instruments could be deployed past the first and second joggle joint settings, without collision or restriction of arm movement. Using this position and docking location, all four arms were deployed inside the oral cavity without collision or restriction of movement in all three cadavers. The Da Vinci SP (Intuitive Surgical, Inc., Sunnyvale, CA) provided sufficient access, reach, and visualization in order to complete a transoral lateral oropharyngectomy. Conclusion The first preclinical feasibility study of a novel, flexible, single-arm robotic surgical system is presented for its use in transoral endoscopic head and neck surgery. Level of Evidence N/A. Laryngoscope, 126:864–869, 2016