Prediction of neck dissection requirement after definitive radiotherapy for head-and-neck squamous cell carcinoma

BACKGROUND

This analysis was undertaken to assess the need for planned neck dissection in patients with a complete response (CR) of involved nodes after irradiation and to determine the benefit of a neck dissection in those with less than CR by tumor site.

METHODS

Our cohort included 880 patients with T1-4, N1-3M0 squamous cell carcinoma of the oropharynx, larynx, or hypopharynx who received treatment between 1994 and 2004. Survival curves were calculated by the Kaplan-Meier Method, comparisons of rates with the log-rank test and prognostic factors by Cox's proportional hazard model.

RESULTS

Nodal CR occurred in 377 (43%) patients, of whom 365 patients did not undergo nodal dissection. The 5-year actuarial regional control rate of patients with CR was 92%. Two hundred sixty-eight of the remaining patients (53%) underwent neck dissections. The 5-year actuarial regional control rate for patients without a CR was 84%. Those who had a neck dissection fared better with 5-year actuarial regional control rates of 90% and 76% for those operated and those not operated (p < 0.001). Variables associated with poorer regional control rates included higher T and N stage, non-oropharynx cancers, non-CR, both clinical and pathological.

CONCLUSIONS

With 92% 5-year neck control rate without neck dissection after CR, there is little justification for systematic neck dissection. The addition of a neck dissection resulted in higher neck control after partial response though patients with viable tumor on pathology specimens had poorer outcomes. The identification of that subgroup that benefits from additional treatment remains a challenge.

Early postoperative epidermal growth factor receptor inhibition: safety and effectiveness in inhibiting microscopic residual of oral squamous cell carcinoma in vivo

BACKGROUND

The local-regional failure of advanced oral squamous cell carcinoma (OSCC) after surgery results from the regrowth of residual tumor cells that may be stimulated by epidermal growth factor receptor (EGFR) ligands during the wound healing process.

METHODS

The level of EGFR ligands in human drain fluids (DFs) from OSCC resection and remote flap donor site were determined. A mouse model of microscopic residual OSCC was established and treated with cetuximab to measure tumor growth, survival, and cervical lymph node metastases. A mouse model of wound healing was also established to assess the effect of an EGFR antibody on the wound healing process.

RESULTS

EGFR ligands are found in sites from OSCC resection. EGFR targeted therapy can delay tumor regrowth in a microscopic residual disease model of OSCC without significant effects on local wound healing.

CONCLUSION

These results provide a strong rationale for clinical evaluation of this approach to treat patients with local-regionally advanced OSCC.

Sham-controlled, randomised, feasibility trial of acupuncture for prevention of radiation-induced xerostomia among patients with nasopharyngeal carcinoma

BACKGROUND

Xerostomia (dry mouth) after head/neck radiation is a common problem among cancer patients. Quality of life (QOL) is impaired, and available treatments are of little benefit. This trial determined the feasibility of conducting a sham-controlled trial of acupuncture and whether acupuncture could prevent xerostomia among head/neck patients undergoing radiotherapy.

METHODS

A sham controlled, feasibility trial was conducted at Fudan University Shanghai Cancer Center, Shanghai, China among patients with nasopharyngeal carcinoma undergoing radiotherapy. To determine feasibility of a sham procedure, 23 patients were randomised to real acupuncture (N=11) or to sham acupuncture (N=12). Patients were treated three times/week during the course of radiotherapy. Subjective measures were the Xerostomia Questionnaire (XQ) and MD Anderson Symptom Inventory for Head and Neck Cancer (MDASI-HN). Objective measures were unstimulated whole salivary flow rates (UWSFR) and stimulated salivary flow rates (SSFR). Patients were followed for 1 month after radiotherapy.

RESULTS

XQ scores for acupuncture were significantly lower than sham controls starting in week 3 and lasted through the 1-month follow-up (all P's <0.001 except for week 3, which was 0.006), with clinically significant differences as follows: week 6 - RR 0.28 [95% confidence interval, 0.10, 0.79]; week 11 - RR 0.17 [95%CI, 0.03, 1.07]. Similar findings were seen for MDASI-HN scores and MDASI-Intrusion scores. Group differences for UWSFR and SSFR were not found.

CONCLUSIONS

In this small pilot study, true acupuncture given concurrently with radiotherapy significantly reduced xerostomia symptoms and improved QOL when compared with sham acupuncture. Large-scale, multi-centre, randomised and placebo-controlled trials are now needed.

A phase II study of gefitinib for aggressive cutaneous squamous cell carcinoma of the head and neck

PURPOSE

To determine the disease control rate and toxicity of treating patients with aggressive cutaneous squamous cell carcinoma (CSCC) with neoadjuvant gefitinib.

EXPERIMENTAL DESIGN

A prospective phase II clinical trial evaluating neoadjuvant gefitinib given prior to standard treatment with surgery and/or radiotherapy. Patients with stable disease after one cycle received escalated doses. Patients who responded were given gefitinib during radiation therapy, as well as maintenance therapy after definitive treatment. We analyzed the correlation between epidermal growth factor receptor (EGFR) expression, mutation status, and gene copy number on available tissue samples and clinical response.

RESULTS

Twenty-three patients were accrued and 22 patients were evaluable for response prior to definitive local treatment; complete responses were attained by 18.2% of patients and partial responses by 27.3%. Grades 2 to 3 toxicities were observed in 59.1% of patients experiencing class-specific effects during induction therapy. After induction, 11.8% underwent surgery alone, 17.6% had definitive radiation, 11.8% were treated with radiation and concurrent gefitinib, and 47% had surgery with postoperative radiation and concurrent gefitinib. Median follow-up for the censored observations was 32 months. Two-year overall, disease-specific, and progression-free survival rates were 72.1%, 72.1%, and 63.6%, respectively. No EGFR-activating mutations were identified in tumor samples available from 10 patients. No associations between EGFR correlative studies and patient outcomes were identified.

CONCLUSIONS

Gefitinib, in the neoadjuvant setting, was active and well tolerated in patients with aggressive CSCC and did not interfere with definitive treatment. In view of the 18% complete response rate we observed, EGFR tyrosine kinase inhibitors should be further explored in the treatment of aggressive CSCC.

Concurrent chemoradiation for adenoid cystic carcinoma of the head and neck

BACKGROUND

We performed a retrospective review of patients with nonresected head and neck adenoid cystic carcinoma (ACC) treated with concurrent chemoradiation.

METHODS

Sixteen patients (nasopharynx 7, oropharynx 4, trachea 3, oral and nasal cavity 1 each) were treated at 3 tertiary care centers. Six patients received intraarterial cisplatin and 10 received intravenous cisplatin or carboplatin concurrently with radiation.

RESULTS

Thirteen patients are alive, 7 without signs of disease with a median follow-up of 61 months. Tumor progression was noted in 8 patients (50%) (distant metastasis in 5 patients and local tumor progression in 3 patients) with a median time to progression of 25 months (range, 4-52 months). Overall survival (OS), progression-free survival (PFS), and local progression-free survival (LPFS) rates at 5 years were 87%, 39%, and 61%, respectively.

CONCLUSION

Concurrent chemoradiation is a feasible treatment option and may lead to sustained locoregional tumor control in patients with nonresected ACC of the head and neck.

Randomized controlled trial of acupuncture for prevention of radiation-induced xerostomia among patients with nasopharyngeal carcinoma

BACKGROUND

Xerostomia (dry mouth) after head/neck radiation is a common problem among cancer patients, and available treatments are of little benefit. The objective of this trial was to determine whether acupuncture can prevent xerostomia among head/neck patients undergoing radiotherapy.

METHODS

A randomized, controlled trial among patients with nasopharyngeal carcinoma was conducted comparing acupuncture to standard care. Participants were treated at Fudan University Shanghai Cancer Center, Shanghai, China. Forty patients were randomized to acupuncture treatment and 46 to standard care. Patients were treated 3×/wk on the same days they received radiotherapy. Subjective measures included the Xerostomia Questionnaire and MD Anderson Symptom Inventory-Head and Neck (MDASI-HN). Objective measures were unstimulated and stimulated whole salivary flow rates. Patients were followed for 6 months after the end of radiotherapy.

RESULTS

Xerostomia Questionnaire scores for acupuncture were statistically significantly lower than for controls starting in week 3 through the 6 months (P = .003 at week 3, all other P < .0001), with clinically significant differences as follows: week 11, relative risk (RR) 0.63 (95% confidence interval [CI], 0.45-0.87); 6 months, RR 0.38 (95% CI, 0.19-0.76). Similar findings were seen for MDASI-HN scores. Group differences emerged as early as 3 weeks into treatment for saliva (unstimulated whole salivary flow rate, P = .0004), with greater saliva flow in the acupuncture group at week 7 (unstimulated whole salivary flow rate, P < .0001; stimulated whole salivary flow rate, P = .002) and 11 (unstimulated whole salivary flow rate, P < .02; stimulated whole salivary flow rate, P < .03) and at 6 months (stimulated whole salivary flow rate, P < .003).

CONCLUSIONS

Acupuncture given concurrently with radiotherapy significantly reduced xerostomia and improved quality of life.

Sonographic examination of the neck after definitive radiotherapy for node-positive oropharyngeal cancer

BACKGROUND AND PURPOSE

Radiographic determination of viable disease in cervical adenopathy following RT for head and neck cancer can be challenging. The purpose of this study was to evaluate the utility of US, with or without FNA, in regard to the postradiotherapy effects on documented metastatic adenopathy in patients with oropharyngeal cancer.

MATERIALS AND METHODS

This study included 133 patients with node-positive oropharyngeal cancer who were irradiated from 1998 to 2004. Sonographic evaluation was performed within 6 months of completion of radiation. Posttreatment US results were compared with pretreatment CT images and were recorded as the following: progression, suspicious, indeterminate, posttreatment change, or regression (positive) versus nonsuspicious or benign (negative). FNAC was classified as nondiagnostic, negative, indeterminate, or positive. Results of US and US-guided FNAC were correlated with findings at neck dissection and disease outcome.

RESULTS

Of 203 sonographic examinations, 90% were technically feasible and yielded a nonequivocal imaging diagnosis. Of 87 US-guided FNAs, 71% yielded a nonequivocal tissue diagnosis. The PPV and NPV of initial posttreatment US were 11% and 97%. Sensitivity and specificity were 92% and 28%. The PPV and NPV of US-guided FNA were 33% and 95%, and the sensitivity and specificity were 75% and 74%. On serial sonographic surveillance, of 33 patients with nonsuspicious findings, only 1 (3%) had neck recurrence. Of 22 patients with questionable findings on CT and negative findings on US, none had a neck recurrence.

CONCLUSIONS

In experienced hands, serial US is an inexpensive noninvasive reassuring follow-up strategy after definitive head and neck RT, even when CT findings are equivocal.

Sinonasal neuroendocrine carcinoma: impact of differentiation status on response and outcome

Background

The impact of tumor differentiation on the behavior and response of sinonasal neuroendocrine carcinoma is unknown.

Methods

We performed a retrospective review of the patients treated for neuroendocrine carcinoma (NEC) of the nasal cavity or paranasal sinuses from 1992 to 2008 at MDACC.

Results

The results of our study suggest that pathologic differentiation may not be a critical factor in the clinical management of patients with NEC of the sinonasal tract. This is in contrast to laryngeal and lung NEC for which pathological differentiation has traditionally guided clinical management.

Conclusion

Mutlimodality approach should be the cornerstone of treating sinonasal NEC regardless of their differentiation. Specifically, RT may provide durable local control for patients with moderately differentiated NEC if resection is not feasible or desirable, while surgical resection can benefit patients with chemo-resistant or radio-resistant disease.

Outcomes of malignant tumors of the lacrimal apparatus: the University of Texas MD Anderson Cancer Center experience

BACKGROUND

Malignant epithelial neoplasms of the lacrimal apparatus are rare and are typically treated with surgery and occasionally adjuvant radiation therapy (RT). The purpose of this study was to assess treatment outcomes by type of surgery (orbital exenteration vs eye-sparing surgery) and clarify the role of adjuvant RT for this rare disease.

METHODS

Forty-six patients with malignant epithelial neoplasms of the lacrimal apparatus were treated at a single institution from 1945 through 2008. Twenty-seven patients (59%) were treated with orbital exenteration and 19 (41%) with eye-sparing surgery; 64% of the orbital exenteration group and 83% of the eye-sparing surgery group also received adjuvant RT (median dose, 60 grays). Median follow-up time for all patients was 38 months (range, 3-460 months).

RESULTS

For the orbital exenteration and eye-sparing surgery groups, the 5-year overall survival (OS) rates were 59% and 62%, and the 5-year disease-free survival (DFS) rates were 49% and 39%, respectively (P = .56, P = .35). Tumor status (T1-2 vs T3-4) was associated with OS (P = .02), and tumor size (<3.5 vs >3.5 cm) with DFS (P = .015). Median time to locoregional recurrence was 85 months for orbital exenteration, and 123 months for eye-sparing surgery. All patients who did not receive RT experienced local recurrence, and RT extended time to locoregional recurrence (median 460 vs 30 months, P = .009). Seven grade ≥3 complications were experienced after adjuvant RT.

CONCLUSIONS

For appropriately selected patients, an eye-sparing surgery for lacrimal apparatus tumors can achieve similar survival outcomes to those in patients treated with an orbital exenteration. Adjuvant RT should be considered for all patients presenting with these rare tumors.

Anaplastic thyroid cancer: Clinical outcomes with conformal radiotherapy

BACKGROUND

The aim of this study was to review institutional outcomes for anaplastic thyroid cancer treated with conformal 3-dimensional radiotherapy (3DRT) or intensity-modulated radiotherapy (IMRT).

METHODS

In all, 53 consecutive patients were analyzed. Thirty-one (58%) patients were irradiated with curative intent. Median radiation dose was 55 Gray (Gy; range, 4-70 Gy). Thirteen (25%) patients received IMRT to a median 60 Gy (range, 39.9-69.0 Gy). Thirty-nine (74%) patients received chemotherapy with radiation.

RESULTS

The Kaplan-Meier estimate of overall survival (OS) at 1 year for definitively irradiated patients was 29%. Patients without distant metastases receiving >or=50 Gy had superior survival outcomes; 5 such patients had no evidence of disease at last follow-up. Use of IMRT versus 3DRT did not influence toxicity.

CONCLUSIONS

Outcomes for anaplastic thyroid cancer treated with 3DRT or IMRT remain equivalent to historical results. Healthy patients with localized disease who tolerate full dose irradiation can potentially enjoy prolonged survival. Biologically targeted radiosensitization merits prioritized investigation.

Compliance with quality assurance measures in patients treated for early oral tongue cancer

BACKGROUND

The objective of this study was to identify measurable parameters that provide quality data for assessing how well cancer care adheres to accepted treatment guidelines and is delivered to any given patient with oral tongue cancer.

METHODS

A retrospective chart review included 116 patients treated for T1-T2/N0-N1 squamous cell carcinoma (SCC) of the oral tongue between 1998 and 2003. A set of quality measures considered critical for outcome included: 1) accurate TNM staging at presentation, 2) documentation of margin status, 3) appropriate referral for adjuvant radiation therapy, and 4) neck dissection for depth of invasion>4 mm. In addition, 26 clinical endpoints involving pretreatment assessment, staging, treatment, surveillance, and symptom control were analyzed.

RESULTS

Patients comprised 73 men and 43 women (median age, 57 years). Forty-one (35.3%) patients presented with stage I disease, 61 (52.6%) with stage II, and 14 (12.1%) with stage III. The overall 5-year survival rate for all patients was 68.6%. There was a 90.5% compliance with TNM staging at presentation, 99.1% for documentation of margin status, 98.2% for adequate referral to radiation therapy, and 88.7% for appropriate neck dissection based on depth of invasion. Compliance with clinical endpoints was variable and ranged from 100% for endpoints related to radiation therapy to <40% for endpoints related to speech pathology and rehabilitation.

CONCLUSIONS

Overall compliance with documenting the 4 parameters designated as quality measures for treatment of oral tongue SCC was acceptable, thus demonstrating that it is possible to use these data for measuring effective cancer care.

Human papillomavirus and survival of patients with oropharyngeal cancer

BACKGROUND

Oropharyngeal squamous-cell carcinomas caused by human papillomavirus (HPV) are associated with favorable survival, but the independent prognostic significance of tumor HPV status remains unknown.

METHODS

We performed a retrospective analysis of the association between tumor HPV status and survival among patients with stage III or IV oropharyngeal squamous-cell carcinoma who were enrolled in a randomized trial comparing accelerated-fractionation radiotherapy (with acceleration by means of concomitant boost radiotherapy) with standard-fractionation radiotherapy, each combined with cisplatin therapy, in patients with squamous-cell carcinoma of the head and neck. Proportional-hazards models were used to compare the risk of death among patients with HPV-positive cancer and those with HPV-negative cancer.

RESULTS

The median follow-up period was 4.8 years. The 3-year rate of overall survival was similar in the group receiving accelerated-fractionation radiotherapy and the group receiving standard-fractionation radiotherapy (70.3% vs. 64.3%; P=0.18; hazard ratio for death with accelerated-fractionation radiotherapy, 0.90; 95% confidence interval [CI], 0.72 to 1.13), as were the rates of high-grade acute and late toxic events. A total of 63.8% of patients with oropharyngeal cancer (206 of 323) had HPV-positive tumors; these patients had better 3-year rates of overall survival (82.4%, vs. 57.1% among patients with HPV-negative tumors; P<0.001 by the log-rank test) and, after adjustment for age, race, tumor and nodal stage, tobacco exposure, and treatment assignment, had a 58% reduction in the risk of death (hazard ratio, 0.42; 95% CI, 0.27 to 0.66). The risk of death significantly increased with each additional pack-year of tobacco smoking. Using recursive-partitioning analysis, we classified our patients as having a low, intermediate, or high risk of death on the basis of four factors: HPV status, pack-years of tobacco smoking, tumor stage, and nodal stage.

CONCLUSIONS

Tumor HPV status is a strong and independent prognostic factor for survival among patients with oropharyngeal cancer. (ClinicalTrials.gov number, NCT00047008.)

Outcomes of patients with tonsillar carcinoma treated with post-tonsillectomy radiation therapy

BACKGROUND

Our aim was to evaluate the therapeutic outcomes of patients with squamous cell carcinoma of the tonsil that underwent tonsillectomies followed by radiotherapy.

METHODS

A search of the database maintained within the Department of Radiation Oncology at The University of Texas M. D. Anderson Cancer Center identified 120 patients with carcinoma of the tonsil who were irradiated between 1979 and 2004 following total gross removal of their disease by tonsillectomy.

RESULTS

Thirty-six patients had stage III disease and 64 patients had stage IV disease. Only 12 patients received systemic chemotherapy. With median follow-up of 51 months, the 5-year local-regional control rate, recurrence-free survival rate, and overall survival rates were 97%, 92%, and 86%, respectively.

CONCLUSION

Patients who undergo tonsillectomies resulting in total gross removal of their primary disease followed by radiation have excellent outcomes. Our common practice is to deliver 66 Gy to the tonsillar bed. This practice has resulted in extremely high local control rates.

Osteoradionecrosis of the hyoid bone: imaging findings

BACKGROUND AND PURPOSE

ORN is a postradiation complication that has been well-documented in the medical literature. Most cases in the head and neck have been described in the mandible or larynx. Only a handful of cases in the hyoid bone are documented, all in the clinical literature. Our purpose is to present the clinical and imaging features of ORN involving the hyoid bone.

MATERIALS AND METHODS

We present a case series of 13 patients with imaging findings highly suggestive of hyoid ORN after radiation therapy for head and neck cancers, in which we observed progressive features of hyoid disruption along with adjacent soft-tissue ulceration.

RESULTS

Pretreatment imaging, when available, showed a normal hyoid. Typical postradiation imaging findings included an initial tongue base ulcerative lesion with air approaching the hyoid bone, and subsequent observation of hyoid fragmentation, often with intraosseous or peri-hyoid air and the absence of associated mass-like enhancement.

CONCLUSIONS

Findings of hyoid fragmentation, cortical disruption, and soft tissue or intraosseous air in the postradiation therapy patient should strongly suggest the diagnosis of hyoid ORN. It is important recognize this entity because the diagnosis may preclude potentially harmful diagnostic intervention and allow more appropriate therapy.

Intensity-modulated radiotherapy for cervical node squamous cell carcinoma metastases from unknown head-and-neck primary site: M. D. Anderson Cancer Center outcomes and patterns of failure

PURPOSE

Conventional therapy for cervical node squamous cell carcinoma metastases from an unknown primary can cause considerable toxicity owing to the volume of tissues to be irradiated. In the present study, hypothesizing that using intensity-modulated radiotherapy (IMRT) would provide effective treatment with minimal toxicity, we reviewed the outcomes and patterns of failure for head-and-neck unknown primary cancer at a single tertiary cancer center.

METHODS AND MATERIALS

We retrospectively reviewed the records of 52 patients who had undergone IMRT for an unknown primary at M.D. Anderson Cancer Center between 1998 and 2005. The patient and treatment characteristics were extracted and the survival rates calculated using the Kaplan-Meier method.

RESULTS

Of the 52 patients, 5 presented with Stage N1, 11 with Stage N2a, 23 with Stage N2b, 6 with Stage N2c, 4 with Stage N3, and 3 with Stage Nx disease. A total of 26 patients had undergone neck dissection, 13 before and 13 after IMRT; 14 patients had undergone excisional biopsy and presented for IMRT without evidence of disease. Finally, 14 patients had received systemic chemotherapy. All patients underwent IMRT to targets on both sides of the neck and pharyngeal axis. The median follow-up time for the surviving patients was 3.7 years. The 5-year actuarial rate of primary mucosal tumor control and regional control was 98% and 94%, respectively. Only 3 patients developed distant metastasis with locoregional control. The 5-year actuarial disease-free and overall survival rate was 88% and 89%, respectively. The most severe toxicity was Grade 3 dysphagia/esophageal stricture, experienced by 2 patients.

CONCLUSION

The results of our study have shown that IMRT can produce excellent outcomes for patients who present with cervical node squamous cell carcinoma metastases from an unknown head-and-neck primary tumor. Severe late complications were uncommon.

Prospective imaging assessment of mortality risk after head-and-neck radiotherapy

PURPOSE

The optimal roles for imaging-based biomarkers in the management of head-and-neck cancer remain undefined. Unresolved questions include whether functional or anatomic imaging might improve mortality risk assessment for this disease. We addressed these issues in a prospective institutional trial.

METHODS AND MATERIALS

Ninety-eight patients with locally advanced pharyngolaryngeal squamous cell cancer were enrolled. Each underwent pre- and post-chemoradiotherapy contrast-enhanced computed tomography (CT) and (18)F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT imaging. Imaging parameters were correlated with survival outcomes.

RESULTS

Low post-radiation primary tumor FDG avidity correlated with improved survival on multivariate analysis; so too did complete primary tumor response by CT alone. Although both imaging modalities lacked sensitivity, each had high specificity and negative predictive value for disease-specific mortality risk assessment. Kaplan-Meier estimates confirmed that both CT and FDG-PET/CT stratify patients into distinct high- and low-probability survivorship groups on the basis of primary tumor response to radiotherapy. Subset analyses demonstrated that the prognostic value for each imaging modality was primarily derived from patients at high risk for local treatment failure (human papillomavirus [HPV]-negative disease, nonoropharyngeal primary disease, or tobacco use).

CONCLUSIONS

CT alone and FDG-PET/CT are potentially useful tools in head-and-neck cancer-specific mortality risk assessment after radiotherapy, particularly for selective use in cases of high-risk HPV-unrelated disease. Focus should be placed on corroboration and refinement of patient selection for imaging-based biomarkers in future studies.

Acupuncture for radiation-induced xerostomia in patients with cancer: a pilot study

BACKGROUND

This pilot study evaluated if acupuncture can alleviate radiation-induced xerostomia among patients with cancer. Secondary objectives were to assess the effects of acupuncture on salivary flow and quality of life (QOL).

METHODS

Nineteen patients received acupuncture twice a week for 4 weeks.

RESULTS

Xerostomia inventory (XI) and patient benefit questionnaire (PBQ) scores were significantly better after acupuncture on weeks 4 and 8 than at baseline (XI: p = .0004 and .0001; PBQ: p = .0004 and .0011, respectively). For QOL at weeks 4 and 8, there was a significant difference for questions related to head/neck cancer (p = .04 and .006, respectively). At week 8, there was a significant difference in physical well-being (p = .04). At weeks 5 and 8, there were significant differences in the total score (p = .04 and .03, respectively).

CONCLUSIONS

Acupuncture was effective for radiation-induced xerostomia in this small pilot study. Further research is needed.

Method comparison of automated matching software-assisted cone-beam CT and stereoscopic kilovoltage x-ray positional verification image-guided radiation therapy for head and neck cancer: a prospective analysis

We sought to characterize interchangeability and agreement between cone-beam computed tomography (CBCT) and digital stereoscopic kV x-ray (KVX) acquisition, two methods of isocenter positional verification currently used for IGRT of head and neck cancers (HNC). A cohort of 33 patients were near-simultaneously imaged by in-room KVX and CBCT. KVX and CBCT shifts were suggested using manufacturer software for the lateral (X), vertical (Y) and longitudinal (Z) dimensions. Intra-method repeatability, systematic and random error components were calculated for each imaging modality, as were recipe-based PTV expansion margins. Inter-method agreement in each axis was compared using limits of agreement (LOA) methodology, concordance analysis and orthogonal regression. 100 daily positional assessments were performed before daily therapy in 33 patients with head and neck cancer. Systematic error was greater for CBCT in all axes, with larger random error components in the Y- and Z-axis. Repeatability ranged from 9 to 14 mm for all axes, with CBCT showing greater repeatability in 2/3 axes. LOA showed paired shifts to agree 95% of the time within +/-11.3 mm in the X-axis, +/-9.4 mm in the Y-axis and +/-5.5 mm in the Z-axis. Concordance ranged from 'mediocre' to 'satisfactory'. Proportional bias was noted between paired X- and Z-axis measures, with a constant bias component in the Z-axis. Our data suggest non-negligible differences in software-derived CBCT and KVX image-guided directional shifts using formal method comparison statistics.

Early postoperative paclitaxel followed by concurrent paclitaxel and cisplatin with radiation therapy for patients with resected high-risk head and neck squamous cell carcinoma: report of the phase II trial RTOG 0024

PURPOSE

We sought to improve outcomes for patients with high-risk head and neck squamous cell cancer (HNSCC) after surgical resection by testing the feasibility and safety of early postoperative chemotherapy followed by concurrent chemoradiotherapy.

PATIENTS AND METHODS

Eligible patients had resected, stages III to IV HNSCC with positive margins, extracapsular nodal extension, or multiple positive nodes. Paclitaxel (80 mg/m(2)) was given once weekly during postoperative weeks 2, 3, and 4 and was given before radiation therapy (RT). Paclitaxel (30 mg/m(2)) and cisplatin (20 mg/m(2)) were given once weekly during the last 3 weeks of RT (60 Gy over 6 weeks, beginning 4 to 5 weeks after surgery). The primary end points were treatment safety and tolerability compared with concurrent cisplatin (100 mg/m(2) every 3 weeks) and RT, as tested in Radiation Therapy Oncology Group trial RTOG 9501.

RESULTS

The median follow-up time for the 70 patients enrolled was 3.3 years (range, 0.6 to 4.4 years) for surviving patients. Tolerability of all treatment components was comparable to that of RTOG 9501 treatment, which is the current standard of care (compliance rate, 75%; 95% CI, 63% to 85%). One patient died, and seven patients experienced grade 4 nonhematologic toxicities. Rates of locoregional control, disease-free survival, and overall survival exceeded those of RTOG 9501 after adjustment for important prognostic variables (ie, positive margins, extracapsular extension, primary site, and performance status).

CONCLUSION

Chemotherapy soon after surgery followed by concurrent chemoradiotherapy therapy was feasible; tolerance was in line with standard postoperative chemoradiotherapy; and this regimen led to excellent rates of locoregional control and disease-free survival.

Prospective risk-adjusted [18F]Fluorodeoxyglucose positron emission tomography and computed tomography assessment of radiation response in head and neck cancer

PURPOSE

[(18)F]Fluorodeoxyglucose positron emission tomography (FDG-PET)/computed tomography (CT) imaging may improve assessment of radiation response in patients with head and neck cancer, but it is not yet known for which patients this is most useful. We conducted a prospective trial to identify patient populations likely to benefit from the addition of functional imaging to the assessment of radiotherapy response.

PATIENTS AND METHODS

Ninety-eight patients with locally advanced cancer of the oropharynx, larynx, or hypopharynx were prospectively enrolled and treated with primary radiotherapy, with or without chemotherapy. Patients underwent FDG-PET/CT and contrast-enhanced CT imaging 8 weeks after completion of treatment. Functional and anatomic imaging response was correlated with clinical and pathologic response. Imaging accuracy was then compared between imaging modalities.

RESULTS

Although postradiation maximum standard uptake values were significantly higher in nonresponders compared with responders, the positive and negative predictive values of FDG-PET/CT scanning were similar to those for CT alone in the unselected study population. Subset analyses revealed that FDG-PET/CT outperformed CT alone in response assessment for patients at high risk for treatment failure (those with human papillomavirus [HPV] -negative disease, nonoropharyngeal primaries, or history of tobacco use). No benefit to FDG-PET/CT was seen for low-risk patients lacking these features.

CONCLUSION

These data do not support the broad application of FDG-PET/CT for radiation response assessment in unselected head and neck cancer patients. However, FDG-PET/CT may be the imaging modality of choice for patients with highest risk disease, particularly those with HPV-negative tumors. Optimal timing of FDG-PET/CT imaging after radiotherapy merits further investigation.

Enlargement and transformation of thyroglossal duct cysts in response to radiotherapy: imaging findings

BACKGROUND AND PURPOSE

Thyroglossal duct cyst remnants (TGDC) are a common midline neck mass that is mostly encountered in childhood. Enlargement after an upper respiratory tract infection or, rarely, cancer within TGDC, is a well-documented phenomenon. In the pediatric population, it rarely presents a diagnostic quandary. However, in an adult population, especially one treated for head and neck cancer with radiation therapy (RT), any enlarging cystic mass would be concerning and would raise the specter of metastatic disease. We propose that inflammation associated with RT results in secretory stimulation and/or obstruction of a persistent thyroglossal duct, resulting in changes within a pre-existing TGDC.

MATERIALS AND METHODS

We present a case series of 8 patients with subclinical TGDC treated with RT for various head and neck cancers, in which we radiographically observed enlargement or cystic transformation (more cystlike appearance) of the cyst.

RESULTS

In all patients there was in retrospect a small thyroglossal remnant, though not necessarily a discernible cyst, that was observed after radiotherapy to enlarge and become more cyst-like.

CONCLUSIONS

In patients with pre-existing TGDC undergoing RT to the neck, enlargement and cystic transformation may be encountered radiographically and should not be misinterpreted as a tumor. Our series bolsters a recently reported description of the same phenomenon.

Postoperative external beam radiotherapy for differentiated thyroid cancer: outcomes and morbidity with conformal treatment

PURPOSE

To review institutional outcomes for patients treated for differentiated thyroid cancer with postoperative conformal external beam radiotherapy (EBRT).

METHODS AND MATERIALS

This is a single-institution retrospective review of 131 consecutive patients with differentiated thyroid cancer who underwent EBRT between January 1996 and December 2005. Histologic diagnoses included 104 papillary, 21 follicular, and six mixed papillary-follicular types. American Joint Committee on Cancer stage distribution was Stage III in 2 patients, Stage IVa-IVc in 128, and not assessable in 1. Thirty-four patients (26%) had high-risk histologic types and 76 (58%) had recurrent disease. Extraglandular disease spread was seen in 126 patients (96%), microscopically positive surgical margins were seen in 62 patients (47%), and gross residual disease was seen in 15 patients (11%). Median EBRT dose was 60 Gy (range, 38-72 Gy). Fifty-seven patients (44%) were treated with intensity-modulated radiotherapy (IMRT) to a median dose of 60 Gy (range, 56-66 Gy). Median follow-up was 38 months (range, 0-134 months).

RESULTS

Kaplan-Meier estimates of locoregional relapse-free survival, disease-specific survival, and overall survival at 4 years were 79%, 76%, and 73%, respectively. On multivariate analysis, high-risk histologic features and gross residual disease predicted for inferior locoregional relapse-free survival, whereas high-risk histologic features, M1 disease, and gross residual disease predicted for inferior disease-specific and overall survival. The IMRT did not impact on survival outcomes, but was associated with less frequent severe late morbidity (12% vs. 2%).

CONCLUSIONS

Postoperative conformal EBRT provides durable locoregional disease control for patients with high-risk differentiated thyroid cancer if disease is reduced to microscopic burden. Patients with gross disease face significantly worse outcomes. The IMRT may significantly reduce chronic radiation morbidity, but requires additional study.

Cerebrovascular disease risk in older head and neck cancer patients after radiotherapy

PURPOSE

Cerebrovascular disease is common in head and neck cancer patients, but it is unknown whether radiotherapy increases the cerebrovascular disease risk in this population.

PATIENTS AND METHODS

We identified 6,862 patients (age > 65 years) from the Surveillance, Epidemiology, and End Results (SEER) -Medicare cohort diagnosed with nonmetastatic head and neck cancer between 1992 and 2002. Using proportional hazards regression, we compared risk of cerebrovascular events (stroke, carotid revascularization, or stroke death) after treatment with radiotherapy alone, surgery plus radiotherapy, or surgery alone. To further validate whether treatment groups had equivalent baseline risk of vascular disease, we compared the risks of developing a control diagnosis, cardiac events (myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft, or cardiac death). Unlike cerebrovascular risk, no difference in cardiac risk was hypothesized.

RESULTS

Mean age was 76 +/- 7 years. Ten-year incidence of cerebrovascular events was 34% in patients treated with radiotherapy alone compared with 25% in patients treated with surgery plus radiotherapy and 26% in patients treated with surgery alone (P < .001). After adjusting for covariates, patients treated with radiotherapy alone had increased cerebrovascular risk compared with surgery plus radiotherapy (hazard ratio [HR] = 1.42; 95% CI, 1.14 to 1.77) and surgery alone (HR = 1.50; 95% CI, 1.18 to 1.90). However, no difference was found for surgery plus radiotherapy versus surgery alone (P = .60). As expected, patients treated with radiotherapy alone had no increased cardiac risk compared with the other treatment groups (P = .63 and P = .81).

CONCLUSION

Definitive radiotherapy for head and neck cancer, but not postoperative radiotherapy, was associated with excess cerebrovascular disease risk in older patients.