Conventional methods that have been developed to immobilize the mouth and tongue for radiotherapy (RT) in head and neck cancer (HNC) treatment have been unsatisfactory. We, therefore, developed three-dimensional (3D), customizable, silicone bite blocks and examined their clinical feasibility. For HNC patients, before RT, the 3D printed bite blocks were fabricated based on primary computed tomography (CT) simulation images. The placement of the 3D bite blocks was followed by a secondary CT simulation before RT planning was finalized. Dosimetric parameters and positioning verification achieved with the propose bite blocks were compared with conventional universal oral corks. The 3D printed bite blocks were conformal to the occlusal surface, ensuring immobilization of the tongue without eliciting a gag reflex, and an elastic and firm texture that supports opening of the mouth, with a smooth surface with tolerable intraoral tactility. The dosimetry of patients using the proposed bite blocks showed better coverage of the planning target volume and surface of a tumour bed along with reduction in normal tissue doses. Good concordance of positioning by 3D printed bite blocks during the RT course was verified. The 3D printed bite blocks with silicone might be a customizable, safe, and practical advanced technology in RT for HNC.

Rationale: The diagnosis of anaplastic lymphoma kinase (ALK)-negative inflammatory myofibroblastic tumors (IMT) remains challenging because of their morphological resemblance with spindle cell sarcoma with myofibroblastic characteristics. Patient concerns: A 69-year-old female patient presented with loco-regional recurrent IMT several times within 8 years after primary treatment and neck lymph node metastasis 3.5 years after last recurrence. Diagnosis: The primary, recurrence, and lymph node metastasis lesions were diagnosed as ALK-negative IMTs based on the histopathological features. Interventions: Biopsy samples were obtained during repeated surgeries and evaluated for genomic alterations during first and recurrent presentations. The evaluation was done using pathway-driven massive parallel sequencing, and genomic alterations between primary and recurrent tumors were compared. Outcomes: Copy number gains and overexpression of mouse double minute 2 homolog (MDM2) and cyclin dependent kinase 4 (CDK4) were observed in the primary lesion, and additional gene amplification of Discoidin Domain Receptor Tyrosine Kinase 2 (DDR2), Succinate Dehydrogenase Complex II subunit C (SDHC), and thyroid stimulating hormone receptor (TSHR) Q720H were found in the recurrent tumors. Metastases to the neck lymph node were observed 3.5 years after recurrence. Lessons: Our results indicated genetic evolution in a microscopically benign condition and highlighted the importance of molecular characterization of fibro-inflammatory lesions of uncertain malignant potential.

Purpose This study integrated clinical outcomes and radiomics of advanced thoracic esophageal squamous cell carcinoma patients receiving neoadjuvant concurrent chemoradiotherapy (NACCRT) to establish a novel constraint model for predicting radiation pneumonitis (RP). Patients and methods We conducted a retrospective review for thoracic advanced esophageal cancer patients who received NACCRT. From 2013 to 2018, 89 patients were eligible for review. Staging workup and response evaluation included positron emission tomography/computed tomography (PET/CT) scans and endoscopic ultrasound. Patients received RT with 48 Gy to gross tumor and 43.2 Gy to elective nodal area in simultaneous integrated boost method divided in 24 fractions. Weekly platinum-based chemotherapy was administered concurrently. Side effects were evaluated using CTCAE v4. Images of 2-fluoro-2-deoxyglucose PET/CT before and after NACCRT were registered to planning CT images to create a region of interest for dosimetry parameters that spatially matched RP-related regions, including V 10 , V 20 , V 50% , V 27 , and V 30 . Correlation between bio-physic parameters and toxicity was used to establish a constraint model for avoiding RP. Results Among the investigated cohort, clinical downstaging, complete pathological response, and 5-year overall survival rates were 59.6%, 40%, and 34.4%, respectively. Multivariate logistic regression analysis demonstrated that each individual set standardized uptake value ratios (SUVRs), neither pre- nor post-NACCRT, was not predictive. Interestingly, cutoff increments of 6.2% and 8.9% in SUVRs (delta-SUVR) in registered V 20 and V 27 regions were powerful predictors for acute and chronic RP, respectively. Conclusion Spatial registration of metabolic and planning CT images with delta-radiomics analysis using fore-and-aft image sets can establish a unique bio-physic prediction model for avoiding RP in esophageal cancer patients receiving NACCRT.

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