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• W4310169977 abstract "On behalf of authors of the article by Massaccesi et al. [ [1] Massaccesi M. Dinapoli N. Fuga V. Rupe C. Panfili M. Calandrelli R. et al. A predictive nomogram for trismus after radiotherapy for head and neck cancer. Radiother Oncol. 2022; 173: 231-239https://doi.org/10.1016/j.radonc.2022.05.031 Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar ] we are grateful to Topkan E. et al. [ [2] Topkan E. Somay E. Yilmaz B. In regard to recent published study of Massaccesi et al. titled ‘A predictive nomogram for trismus after radiotherapy for head and neck cancer’. (Radiother Oncol. 2022 Jun 2: S0167-8140(22)04137-8. doi: 10.1016/j.radonc.2022.05.031). Radiother Oncol. 2022; 174: 132https://doi.org/10.1016/j.radonc.2022.07.017 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar ], to whom we respond, for defining our nomogram “unarguably […] useful in routine radiation oncology”, and we add, even though it has not been externally validated yet. Indeed, we believe that the lack of external validation is not completely detrimental to the overall value of the work, simply because, usually, most of the articles referring to dosimetric and clinical results for toxicity assessment, written to a good quality standard, have an approach like ours: prospective collection of data and mostly carried out in single-center settings. This can be verified easily, for example, in the QUANTEC reviews [ [3] Deasy J.O. Moiseenko V. Marks L. Chao K.S.C. Nam J. Eisbruch A. Radiotherapy Dose-Volume Effects on Salivary Gland Function. Int J Radiat Oncol Biol Phys. 2010; : 76https://doi.org/10.1016/j.ijrobp.2009.06.090 Abstract Full Text Full Text PDF PubMed Scopus (407) Google Scholar ]. Our work focuses on dose to structures involved in mastication, and we don’t agree with the issue about heterogeneity in patients’ diagnoses because head and neck tumours are themselves very heterogeneous, and since the past, most works have often focused on patients’ populations with different diagnoses (e.g., see the references of Deasy J.O. et al. review [ [3] Deasy J.O. Moiseenko V. Marks L. Chao K.S.C. Nam J. Eisbruch A. Radiotherapy Dose-Volume Effects on Salivary Gland Function. Int J Radiat Oncol Biol Phys. 2010; : 76https://doi.org/10.1016/j.ijrobp.2009.06.090 Abstract Full Text Full Text PDF PubMed Scopus (407) Google Scholar ] itself). Heterogeneity in DVHs is a prerequisite to correlate observations of patients with positive and negative outcomes with the dose distribution itself, as we have demonstrated, finally facilitating the fit of a logistic regression model [ [4] Harrell F.E. Regression modeling strategies. Springer Verlag, New York2001 Crossref Google Scholar ]. These are the reasons why we also included patients who received low doses in some of the analysed structures. Furthermore, we want to emphasize the absence of T1-stage glottic tumours in the patients’ population, which had been hypothesized by Topkan E. et al. [ [2] Topkan E. Somay E. Yilmaz B. In regard to recent published study of Massaccesi et al. titled ‘A predictive nomogram for trismus after radiotherapy for head and neck cancer’. (Radiother Oncol. 2022 Jun 2: S0167-8140(22)04137-8. doi: 10.1016/j.radonc.2022.05.031). Radiother Oncol. 2022; 174: 132https://doi.org/10.1016/j.radonc.2022.07.017 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar ] to justify the low V42 Gy values on masseter muscles sum (V42MMS). But in detail, there is a gross error in Topkan's statement “V42MMS range of 0–72.7 Gy, as a lower range of 0 Gy suggests that the masticatory apparatus did not receive any RT doses in some individuals” [ [2] Topkan E. Somay E. Yilmaz B. In regard to recent published study of Massaccesi et al. titled ‘A predictive nomogram for trismus after radiotherapy for head and neck cancer’. (Radiother Oncol. 2022 Jun 2: S0167-8140(22)04137-8. doi: 10.1016/j.radonc.2022.05.031). Radiother Oncol. 2022; 174: 132https://doi.org/10.1016/j.radonc.2022.07.017 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar ]: the V42MMS measures the volume of masseters muscles that receives a dose of 42 Gy, and so its unit is not the Gy (as in all Vdose) but % of whole volume[ [5] ICRU ICRU 83: 3. Special Considerations Regarding Absorbed-Dose and Dose-Volume Prescribing and Reporting in IMRT. J ICRU. 2010; 10: 27-40https://doi.org/10.1093/jicru/ndq008 Crossref Google Scholar ]. This explains why it is possible to have V42MMS = 0% (as shown in an explanatory case in Fig. 1). On the role of maximum interincisal opening at baseline (MIOb): its detection underlies the definition of trismus, which may be present before treatment, but our aim was to measure the onset or persistence of trismus within six months after the end of radiotherapy so, why should we remove it from the list of covariates? We also found, in five cases showing mean V42MMS = 7%, the disappearance of the pre-treatment trismus within six months, while in pre-treatment positive persisting cases it was significantly higher (25%). Finally, looking at other investigated predictors, as chemotherapy or surgery, considering the study design and the enrolled patients’ number we could state “absence of evidence is not evidence of absence” [ [6] Alderson P. Absence of evidence is not evidence of absence. BMJ. 2004; 328: 476-477https://doi.org/10.1136/bmj.328.7438.476 Crossref PubMed Scopus (171) Google Scholar ] that is, our work doesn’t deny the potential impact of those factors (in case of surgery it was even significant in univariable analysis) but merely assesses their (relatively low) weight in the overall prediction result. In regard to recent published study of Massaccesi et al. titled ‘A predictive nomogram for trismus after radiotherapy for head and neck cancer’. (Radiother Oncol. 2022 Jun 2: S0167-8140(22)04137-8. doi: 10.1016/j.radonc.2022.05.031)Radiotherapy and OncologyVol. 174PreviewWe read the study by Massaccesi et al. [1] with great interest and are grateful for their work on this hotly contested but critically important topic in the era of contemporary radiation therapy (RT). The authors desired to create a nomogram that could more accurately predict the incidence of trismus following RT or concurrent RT (CCRT). As the distinguishing elements of the novel nomogram, it was discovered that the baseline maximum interincisal opening (MIOb) before treatment and the masseter muscle sum of V42 (V42 MMS) were the best predictors of trismus. Full-Text PDF" @default.
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• W4310169977 title "In response to Topkan E. et al. letter (Radiother Oncol. 2022;174:132. https://doi.org/10.1016/j.radonc.2022.07.017)" @default.
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