Long-term outcomes of modern multidisciplinary management of sinonasal cancers: The M. D. Anderson experience

PURPOSE

To report long-term outcomes of modern radiotherapy for sinonasal cancers.

METHODS AND MATERIALS

A retrospective analysis of patients with sinonasal tumors treated with intensity-modulated radiotherapy or proton therapy. Multivariate analysis was used to determine predictive variables of progression free survival (PFS) and overall survival (OS).

RESULTS

Three hundred and eleven patients were included, with median follow-up of 75 months. The most common histologies were squamous cell (42%), adenoid cystic (15%), and sinonasal undifferentiated carcinoma (15%). Induction chemotherapy was administered to 47% of patients; 68% had adjuvant radiotherapy. Ten-year local control, regional control, distant metastasis free survival, PFS, and overall survival rates were 73%, 88%, 47%, 32%, and 51%, respectively. Age, non-nasal cavity tumor site, T3-4 stage, neck dissection, and radiation dose were predictive of PFS, while age, non-nasal cavity tumor site, T3-4 stage, positive margins, neck dissection, and use of neoadjuvant chemotherapy were predictive of OS. There was a 13% rate of late grade ≥3 toxicities.

CONCLUSION

This cohort of patients with sinonasal cancer treated with modern radiotherapy demonstrates favorable disease control rate and acceptable toxicity profile.

Therapeutic approaches and outcomes in patients with larynx or hypopharynx high-grade neuroendocrine carcinoma: A single-center retrospective analysis

BACKGROUND

High-grade neuroendocrine carcinoma of the larynx (HG-NECL) is rare and aggressive with limited data regarding response to systemic therapy. We evaluated clinicopathological features, therapeutic approaches, and outcomes in patients with laryngeal or hypopharyngeal HG-NECL.

METHODS

Data were retrospectively collected through 1997-2020. Median disease-free (mDFS), progression-free (mPFS), and overall survival (mOS) were estimated using the Kaplan-Meier method.

RESULTS

Fifteen patients were identified; most had locoregional (N = 7) or metastatic disease (N = 5). The main curative-intent treatment was chemoradiation concurrent with platinum-based chemotherapy; the rate of complete response was 78%. Most patients (80%) developed recurrence; the mDFS was 13.1 months. For the first-line palliative therapy, the ORR and mPFS were 50% and 3.1 months, respectively. For all patients, the mOS was 17.8 months, and 8.6 months for metastatic disease.

CONCLUSION

Laryngeal HG-NEC is associated with high relapse rates and dismal prognosis for those with recurrent/metastatic disease. Novel therapeutic strategies are needed.

Impact of Cancer Care Regionalization on Patient Volume

BACKGROUND

Cancer centers are regionalizing care to expand patient access, but the effects on patient volume are unknown. This study aimed to compare patient volumes before and after the establishment of head and neck regional care centers (HNRCCs).

METHODS

This study analyzed 35,394 unique new patient visits at MD Anderson Cancer Center (MDACC) before and after the creation of HNRCCs. Univariate regression estimated the rate of increase in new patient appointments. Geospatial analysis evaluated patient origin and distribution.

RESULTS

The mean new patients per year in 2006-2011 versus 2012-2017 was 2735 ± 156 patients versus 3155 ± 207 patients, including 464 ± 78 patients at HNRCCs, reflecting a 38.4 % increase in overall patient volumes. The rate of increase in new patient appointments did not differ significantly before and after HNRCCs (121.9 vs 95.8 patients/year; P = 0.519). The patients from counties near HNRCCs, showed a 210.8 % increase in appointments overall, 33.8 % of which were at an HNRCC. At the main campus exclusively, the shift in regional patients to HNRCCs coincided with a lower rate of increase in patients from the MDACC service area (33.7 vs. 11.0 patients/year; P = 0.035), but the trend was toward a greater increase in out-of-state patients (25.7 vs. 40.3 patients/year; P = 0.299).

CONCLUSIONS

The creation of HNRCCs coincided with stable increases in new patient volume, and a sizeable minority of patients sought care at regional centers. Regional patients shifted to the HNRCCs, and out-of-state patient volume increased at the main campus, optimizing access for both local and out-of-state patients.

Dyadic Yoga for Head and Neck Cancer Patients Undergoing Chemoradiation and their Family Caregivers

OBJECTIVES

Concurrent chemoradiation to treat head and neck cancer (HNC) may result in debilitating toxicities. Targeted exercise such as yoga therapy may buffer against treatment-related sequelae; thus, this pilot RCT examined the feasibility and preliminary efficacy of a yoga intervention. Because family caregivers report low caregiving efficacy and elevated levels of distress, we included them in this trial as active study participants.

METHODS

HNC patients and their caregivers were randomized to a 15-session dyadic yoga program or a waitlist control (WLC) group. Prior to randomization, patients completed standard symptom (MDASI-HN) and patients and caregivers completed quality of life (SF-36) assessments. The 15-session program was delivered parallel to patients' treatment schedules. Participants were re-assessed at patients' last day of chemoradiation and again 30 days later. Patients' emergency department visits, unplanned hospital admissions and gastric feeding tube placements were recorded over the treatment course and up to 30 days later.

RESULTS

With a consent rate of 76%, 37 dyads were randomized. Participants in the yoga group completed a mean of 12.5 sessions and rated the program as "beneficial." Patients in the yoga group had clinically significantly less symptom interference and HNC symptom severity and better QOL than those in the WLC group. They were also less likely to have a hospital admission (OR = 3.00), emergency department visit (OR = 2.14), and/or a feeding tube placement (OR = 1.78).

CONCLUSION

Yoga therapy appears to be a feasible, acceptable, and possibly efficacious behavioral supportive care strategy for HNC patients undergoing chemoradiation. A larger efficacy trial is warranted.

Longitudinal changes in the carotid arteries of head and neck cancer patients following radiation therapy: Results from a prospective serial imaging biomarker characterization study

INTRODUCTION

We prospectively evaluated morphologic and functional changes in the carotid arteries of patients treated with unilateral neck radiation therapy (RT) for head and neck cancer.

METHODS

Bilateral carotid artery duplex studies were performed at 0, 3, 6, 12, 18 months and 2, 3, 4, and 5 years following RT. Intima media thickness (IMT); global and regional circumferential, as well as radial strain, arterial elasticity, stiffness, and distensibility were calculated.

RESULTS

Thirty-eight patients were included. A significant difference in the IMT from baseline between irradiated and unirradiated carotid arteries was detected at 18 months (median, 0.073 mm vs -0.003 mm; P = 0.014), which increased at 3 and 4 years (0.128 mm vs 0.013 mm, P = 0.016, and 0.177 mm vs 0.023 mm, P = 0.0002, respectively). A significant transient change was noted in global circumferential strain between the irradiated and unirradiated arteries at 6 months (median difference, -0.89, P = 0.023), which did not persist. No significant differences were detected in the other measures of elasticity, stiffness, and distensibility.

CONCLUSIONS

Functional and morphologic changes of the carotid arteries detected by carotid ultrasound, such as changes in global circumferential strain at 6 months and carotid IMT at 18 months, may be useful for the early detection of radiation-induced carotid artery injury, can guide future research aiming to mitigate carotid artery stenosis, and should be considered for clinical surveillance survivorship recommendations after head and neck RT.

Intensive radiation therapy concurrent with up to 7-week continuous-infusion paclitaxel for locally advanced solid tumors: phase I studies

Patients with locally advanced solid tumors of the lung, head and neck, and malignant astrocytomas usually succumb to their disease despite aggressive standard therapy. Laboratory data suggest that the addition of 1.0 to 10 nmol/L paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ), a microtubule stabilizing drug, to radiation therapy may result in significant radiation sensitization, perhaps due to accumulation of cells at G2/M. Relatively low concentrations (1.0 to 10 nmol/L) appear to be optimal for direct cytotoxicity and radiosensitization in vitro. Within this dose range, more prolonged exposure seems to result in higher response rates. The phase I trials reported here are designed to test the combination of paclitaxel, administered by continuous intravenous infusion (24 hours a day, 7 days a week), and standard, curative-intent radiation therapy. The ultimate goal of this study is to improve local and systemic control and survival for patients with these three tumor types. To date, 39 evaluable patients are enrolled in this study; there has been no dose-limiting toxicity up to 6.5 mg/m2/d. Observed toxicities include anemia, lymphopenia, mucositis, and cutaneous toxicities.

Local recurrence in head and neck cancer: relationship to radiation resistance and signal transduction

PURPOSE

Locoregional recurrence is the dominant form of treatment failure in head and neck (H&N) cancer. The epidermal growth factor receptor (EGFR) is frequently amplified in this disease (<or=80%) and can lead to activation of phosphatidylinositol-3-kinase (PI3K), both directly and indirectly through Ras. We have shown previously that radioresistance could be conferred via the Ras-PI3K pathway. Here we investigate the contribution of EGFR to this pathway and its impact on treatment outcome.

EXPERIMENTAL DESIGN

In a series of 38 H&N cancer patients, overexpression of EGFR by immunohistochemical staining was assessed. PI3K signaling was evaluated by staining for phosphorylated Akt (P-Akt), a downstream target of PI3K. Both EGFR and P-Akt were then related to outcome. Radiation survival was determined in the SQ20B cell line, a radioresistant squamous cell line derived from a recurrent laryngeal cancer, after pharmacological blockade of EGFR with Iressa, of Ras by the FTI L744,832, or of PI3K by LY294002.

RESULTS

A significant association was found between P-Akt staining and local control in the patient series. Two-year local control was 100% for patients staining 0-1+ for P-Akt as compared with 70.6% for patients staining 2-3+ (P = 0.04). In our series of 38 H&N cancers, 30 (78.9%) of the specimens were strongly (3+) positive for EGFR, whereas 25 (65.8%) were moderately to strongly (2-3+) positive for P-Akt. Pharmacologically inhibiting EGFR, Ras, and PI3K led to radiosensitization of SQ20B cells.

CONCLUSIONS

Evaluation of PI3K activation by Akt phosphorylation might be a prognostic marker for response to therapy, and PI3K could be a useful target for therapy. These results also suggest that signaling from EGFR to PI3K can lead to radioresistance.

Reinterpretation of cross-sectional images in patients with head and neck cancer in the setting of a multidisciplinary cancer center

BACKGROUND AND PURPOSE

Patients referred to tertiary care centers frequently arrive with images obtained at outside institutions; these images require reinterpretation. We assessed the clinical value of reinterpreting cross-sectional imaging studies of patients with head and neck cancer, in the setting of a multidisciplinary cancer center.

METHODS

Outside CT and MR images of 136 patients with known or presumed head and neck cancer were reinterpreted by a neuroradiologist. Clinical history and findings on physical examination were available. Reinterpretation was performed before review of outside reports, which were subsequently compared with those generated at the cancer center. Changes in interpretation were noted, and their effects on TNM staging, patient care, and prognosis were assessed. Reliability and statistical significance of rates of change in diagnosis were analyzed with 95% confidence intervals (CIs) and the sign test, respectively. Verification of change in diagnosis was confirmed by pathologic analysis (75%), characteristic radiologic findings (18%), or clinical and imaging follow-up (7%).

RESULTS

Change in interpretation occurred in 56 patients (41%) (95% CI: 33-49%, P <.001). Forty-six patients (34%) had a change in T, N, and/or M staging (26-42%, P <.001). Change in T stage occurred in 27 cases (20%) (13-27%, P <.001) (upstaged in 22, downstaged in five), and a change in N stage in 26 cases (19%) (12-26%, P <.001) (upstaged in 20, downstaged in six). Two patients (1.5%) had missed systemic metastases. Three patients with an initial diagnosis of cancer were found to be cancer-free, and six patients had a diagnosis of new second primary cancers that were missed at original interpretation. One patient had a missed middle cerebral artery aneurysm. Changes in image interpretation altered treatment in 55 (98%) of 56 patients and affected prognosis in 53 patients (95%) (P <.001).

CONCLUSION

Reinterpretation of cross-sectional images in the setting of a multidisciplinary cancer center has a significant effect on staging, management, and prognosis in patients with head and neck cancer.

Changes in Apparent Diffusion Coefficient (ADC) in Serial Weekly MRI during Radiotherapy in Patients with Head and Neck Cancer: Results from the PREDICT-HN Study

Background: The PREDICT-HN study aimed to systematically assess the kinetics of imaging MR biomarkers during head and neck radiotherapy. Methods: Patients with intact squamous cell carcinoma of the head and neck were enrolled. Pre-, during, and post-treatment MRI were obtained. Serial GTV and ADC measurements were recorded. The correlation between each feature and the GTV was calculated using Spearman’s correlation coefficient. The linear mixed model was used to evaluate the change in GTV over time. Results: A total of 41 patients completed the study. The majority (76%) had oropharyngeal cancer. A total of 36 patients had intact primary tumours that can be assessed on MRI, and 31 patients had nodal disease with 46 nodes assessed. Median primary GTV (GTVp) size was 14.1cc. The rate of GTVp shrinkage was highest between pre-treatment and week 4. Patients with T3-T4 tumours had a 3.8-fold decrease in GTVp compared to T1-T2 tumours. The ADC values correlated with residual GTVp. The median nodal volume (GTVn) was 12.4cc. No clinical features were found to correlate with GTVn reduction. The overall change in ADC for GTVn from pre-treatment was significant for 35th−95th percentiles in weeks 1−4 (p < 0.001). Conclusion: A discrepancy in the trajectory of ADC between primary and nodal sites suggested that they exhibit different treatment responses and should be analysed separately in future studies.

Patterns of failure for recurrent head and neck squamous cell carcinoma treated with salvage surgery and postoperative IMRT reirradiation

Purpose/Objectives

The purpose of this study was to evaluate patterns of locoregional recurrence (LRR) after surgical salvage and adjuvant reirradiation with IMRT for recurrent head and neck squamous cell cancer (HNSCC).

Materials/Methods

Patterns of LRR for 61 patients treated consecutively between 2003 and 2014 who received post-operative IMRT reirradiation to ≥ 60 Gy for recurrent HNSCC were determined by 2 methods: 1) physician classification via visual comparison of post-radiotherapy imaging to reirradiation plans; and 2) using deformable image registration (DIR). Those without evaluable CT planning image data were excluded. All recurrences were verified by biopsy or radiological progression. Failures were defined as in-field, marginal, or out-of-field. Logistic regression analyses were performed to identify predictors for LRR.

Results

A total of 55 patients were eligible for analysis and 23 (42 %) had documented LRR after reirradiation. Location of recurrent disease prior to salvage surgery (lymphatic vs. mucosal) was the most significant predictor of LRR after post-operative reirradiation with salvage rate of 67 % for lymphatic vs. 33 % for mucosal sites (p = 0.037). Physician classification of LRR yielded 14 (61 %) in-field failures, 3 (13 %) marginal failures, and 6 (26 %) out-of-field failures, while DIR yielded 10 (44 %) in-field failures, 4 (17 %) marginal failures, and 9 (39 %) out-of-field failures. Most failures (57 %) occurred within the original site of recurrence or first echelon lymphatic drainage. Of patients who had a free flap placed during salvage surgery, 56 % of failures occurred within 1 cm of the surgical flap.

Conclusion

Our study highlights the role of DIR in enhancing the accuracy and consistency of POF analysis. Compared to traditional visual inspection, DIR reduces interobserver variability and provides more nuanced insights into dose-specific and spatial parameters of locoregional recurrences. Additionally, the study identifies the location of the initial recurrence as a key predictor of subsequent locoregional recurrence after salvage surgery and re-IMRT.

Feasibility of Mobile and Sensor Technology for Remote Monitoring in Cancer Care and Prevention

Objectives. Remote monitoring (RM) of health-related outcomes may optimize cancer care and prevention outside of clinic settings. CYCORE is a software-based system for collection and analyses of sensor and mobile data. We evaluated CYCORE's feasibility in studies assessing: (1) physical functioning in colorectal cancer (CRC) patients; (2) swallowing exercise adherence in head and neck cancer (HNC) patients during radiation therapy; and (3) tobacco use in cancer survivors post-tobacco treatment (TTP). Methods. Participants completed RM: for CRC, blood pressure, activity, GPS; for HNC, video of swallowing exercises; for TTP, expired carbon monoxide. Patient-reported outcomes were assessed daily. Results. For CRC, HNC and TTP, respectively, 50, 37, and 50 participants achieved 96%, 84%, 96% completion rates. Also, 91-100% rated ease and self-efficacy as highly favorable, 72-100% gave equivalent ratings for overall satisfaction, 72-93% had low/no data privacy concerns. Conclusion. RM was highly feasible and acceptable for patients across diverse use cases.

Phase I study of Paclitaxel given by seven-week continuous infusion concurrent with radiation therapy for locally advanced non-small cell lung cancer

BACKGROUND

Paclitaxel is active in non-small-cell lung cancer (NSCLC) and is a radiosensitizer with a dose-response relationship that depends more on duration of exposure than peak concentration. A continuous infusion prolongs exposure and may maximize the drug-radiation interaction. The goal of this National Cancer Institute-sponsored phase I study was to determine the feasibility and toxicity of a continuous infusion paclitaxel (24 hours/day, 7 days/week, 7 weeks total) concurrent with standard radiation therapy (RT) for locally advanced NSCLC.

METHODS

Eligible patients had locally advanced (T4, N1-3, M0 or Tany, N2-3, M0) NSCLC, performance status less than or equal to 2, and adequate hematological, hepatic, renal, and pulmonary function. RT was given to a total dose of 64.8 Gy at 1.8 Gy/day. Paclitaxel was delivered by infusion beginning 48 hours before and then continuously throughout the 7 weeks of RT. The paclitaxel concentration was escalated in sequential dose cohorts ranging from 0.5 to 17 mg/m/d, and each contained at least three patients in a standard phase I design.

RESULTS

Twenty-nine patients were enrolled. Significant grade 3+ toxicity was observed in one patient, who experienced grade 3 pneumonitis at the 6.5-mg/m/day dose level. This cohort was expanded, but none of four additional patients experienced significant toxicity. Three patients completed the 15-mg/m/day dose level without serious or dose-limiting toxicity. The two patients entered at the 17-mg/m/day dose level had grade 4 neutropenia requiring a delay in therapy of more than 1 week. The median survival of all patients was 12 months; however, 4 of 27 patients (15%) survived longer than 60 months (mean 63.4 months).

CONCLUSION

The maximally tolerated and recommended phase II paclitaxel dose delivered by protracted continuous infusion is 15 mg/m/day when combined with thoracic RT. This schedule allows for the delivery of more total paclitaxel than other published regimens and may have less esophagitis than weekly paclitaxel regimens. This regimen has the potential to achieve a radiosensitizing serum concentration of paclitaxel continuously for 7 weeks without exceeding levels associated with neutropenia or neurotoxicity. There were four long-term survivors in this phase I study. These data suggest that continuous paclitaxel infusion with concurrent RT is safe and should be of interest to explore in combination with other cytotoxic or targeted therapies.

Risk factors for osteonecrosis in patients with type 1 Gaucher's disease

This study investigated 51 patients with Type 1 Gaucher's disease clinically and radiographically for the presence of osteonecrosis. Twenty-five female and 26 male patients with a mean age of 37 years were evaluated retrospectively for osteonecrosis of the proximal and distal femur, proximal tibia, and proximal humerus. All patients were examined before enzyme replacement therapy. Gender, age at diagnosis, prior splenectomy, hematocrit, platelet count, acid phosphatase level, radiographs of the long bones, and magnetic resonance quantitative chemical shift imaging of the spine were analyzed to see if any of these values or findings were associated with the presence of osteonecrosis. Splenectomy was an independent risk factor for the presence of osteonecrosis in three of the four major sites and was a multivariate risk factor for osteonecrosis of the proximal femur and tibia. Male gender was the other significant multivariate risk factor for osteonecrosis of the humerus and distal femur when all sites were taken into account.

Longitudinal diffusion and volumetric kinetics of head and neck cancer magnetic resonance on a 1.5T MR-Linear accelerator hybrid system: A prospective R-IDEAL Stage 2a imaging biomarker characterization/ pre-qualification study

Objectives

We aim to characterize the serial quantitative apparent diffusion coefficient (ADC) changes of the target disease volume using diffusion-weighted imaging (DWI) acquired weekly during radiation therapy (RT) on a 1.5T MR-Linac and correlate these changes with tumor response and oncologic outcomes for head and neck squamous cell carcinoma (HNSCC) patients as part of a programmatic R-IDEAL biomarker characterization effort.

Methods

Thirty patients with pathologically confirmed HNSCC who received curative-intent RT at the University of Texas MD Anderson Cancer Center, were included in this prospective study. Baseline and weekly Magnetic resonance imaging (MRI) (weeks 1-6) were obtained, and various ADC parameters (mean, 5 th , 10 th , 20 th , 30 th , 40 th , 50 th , 60 th , 70 th , 80 th , 90 th and 95 th percentile) were extracted from the target regions of interest (ROIs). Baseline and weekly ADC parameters were correlated with response during RT, loco-regional control, and the development of recurrence using the Mann-Whitney U test. The Wilcoxon signed-rank test was used to compare the weekly ADC versus baseline values. Weekly volumetric changes (Δvolume) for each ROI were correlated with ΔADC using Spearman's Rho test. Recursive partitioning analysis (RPA) was performed to identify the optimal ΔADC threshold associated with different oncologic outcomes.

Results

There was an overall significant rise in all ADC parameters during different time points of RT compared to baseline values for both gross primary disease volume (GTV-P) and gross nodal disease volumes (GTV-N). The increased ADC values for GTV-P were statistically significant only for primary tumors achieving complete remission (CR) during RT. RPA identified GTV-P ΔADC 5 th percentile >13% at the 3 rd week of RT as the most significant parameter associated with CR for primary tumor during RT (p <0.001). Baseline ADC parameters for GTV-P and GTV-N didn't significantly correlate with response to RT or other oncologic outcomes. There was a significant decrease in residual volume of both GTV-P & GTV-N throughout the course of RT. Additionally, a significant negative correlation between mean ΔADC and Δvolume for GTV-P at the 3 rd and 4 th week of RT was detected (r = -0.39, p = 0.044 & r = -0.45, p = 0.019, respectively).

Conclusion

Assessment of ADC kinetics at regular intervals throughout RT seems to be correlated with RT response. Further studies with larger cohorts and multi-institutional data are needed for validation of ΔADC as a model for prediction of response to RT.

Fractionated Stereotactic Radiotherapy in the Management of Dural Recurrence of Olfactory Neuroblastoma

PURPOSE/OBJECTIVE(S)

Treatment protocols for dural recurrence among esthesioneuroblastoma patients have not been standardized. We assess the outcomes of fractionated stereotactic radiotherapy (FSR) for patients with olfactory neuroblastoma (ONB) dura-based recurrences.

MATERIALS/METHODS

We identified ONB patients with dura-based recurrences treated with FSR after prior radiotherapy who were enrolled between 2013 and 2022 in our prospective head and neck reirradiation and skull base registries. In-field tumor control (within 2 cm of prescribed radiotherapy volume) and out-of-field tumor control (non-contiguous or contralateral dura, nodal, or distant metastases) were analyzed.

RESULTS

Thirteen patients with 28 dural lesions were included in this analysis. All patients were initially treated with surgery to their primary paranasal sinus disease; 69% with a craniofacial approach followed by adjuvant radiotherapy to a median dose of 63 Gy (range 60-72.4 Gy) prescribed to the resected tumor bed. Patients re-presented with dural recurrence at median 58.3 months (range 35.0 - 163.0 months) from completion of their initial treatment. Two patients underwent dural resections. On presentation of recurrence, 4 patients had 1 lesion treated, with a median of 2 lesions treated (range 1-4 lesions). All dural based tumors were treated with FSR to a median dose of 27 Gy in 3 fractions delivered QOD. 68Ga-DOTATATE PET/CT was utilized for FSR treatment planning in 31% of cases. The median follow up from FSR was 23.3 months (range: 13.1 - 51.6 months). The 1-year overall survival and progression free survival was 75% and 38%, respectively. The 1- and 2-year in-field control rate was 85% and 75%, respectively. Among treated lesions, 25 of 28 (89%) responded or remained stable following FSR. Two patients (3 lesions) had evidence of in-field radiographic progression at 17 and 9 months, respectively. Five patients (38%) experienced progression in the contralateral or non-contiguous dura, and 5 patients (38%) developed distant metastases. The overall out-of-field progression rate was 58% at 1 year. There was no grade 3 or higher toxicity observed. Three patients (23%) developed asymptomatic changes on MRI consistent with brain necrosis, all of which occurred in a previously irradiated region.

CONCLUSION

In the largest single institution study of FSR reirradiation for ONB dural recurrence to date, high local control rates with minimal toxicity are attainable. However, subsequent out-of-field dural recurrences and/or distant metastases remain problematic.

Longitudinal Changes in the Carotid Arteries of Head and Neck Cancer Patients Following Radiation Therapy: Results from a Prospective Serial Imaging Biomarker Characterization Study

INTRODUCTION

We prospectively evaluated morphologic and functional changes in the carotid arteries of patients treated with unilateral neck radiation therapy (RT) for head and neck cancer.

METHODS

Bilateral carotid artery duplex studies were performed at 0, 3, 6, 12, 18 months and 2, 3, 4, and 5 years following RT. Intima media thickness (IMT); global and regional circumferential, as well as radial strain, arterial elasticity, stiffness, and distensibility were calculated.

RESULTS

Thirty-eight patients were included. A significant difference in the IMT from baseline between irradiated and unirradiated carotid arteries was detected at 18 months (median, 0.073mm vs -0.003mm; P =0.014), which increased at 3 and 4 years (0.128mm vs 0.013mm, P =0.016, and 0.177mm vs 0.023mm, P =0.0002, respectively). A > 0.073mm increase at 18 months was significantly more common in patients who received concurrent chemotherapy (67% vs 25%; P =0.03). A significant transient change was noted in global circumferential strain between the irradiated and unirradiated arteries at 6 months (median difference, -0.89, P =0.023), which did not persist. No significant differences were detected in the other measures of elasticity, stiffness, and distensibility.

CONCLUSIONS

Functional and morphologic changes of the carotid arteries detected by carotid ultrasound, such as changes in global circumferential strain at 6 months and carotid IMT at 18 months, may be useful for the early detection of radiation-induced carotid artery injury, can guide future research aiming to mitigate carotid artery stenosis, and should be considered for clinical surveillance survivorship recommendations after head and neck RT.

Detection of Alteration in Carotid Artery Volumetry Using Standard-of-care Computed Tomography Surveillance Scans Following Unilateral Radiation Therapy for Early-stage Tonsillar Squamous Cell Carcinoma Survivors: A Cross-Sectional Internally-Matched Carotid Isodose Analysis

Purpose

Radiation induced carotid artery disease (RICAD) is a major cause of morbidity and mortality among survivors of oropharyngeal cancer. This study leveraged standard-of-care CT scans to detect volumetric changes in the carotid arteries of patients receiving unilateral radiotherapy (RT) for early tonsillar cancer, and to determine dose-response relationship between RT and carotid volume changes, which could serve as an early imaging marker of RICAD.

Methods and Materials

Disease-free cancer survivors (>3 months since therapy and age >18 years) treated with intensity modulated RT for early (T1-2, N0-2b) tonsillar cancer with pre- and post-therapy contrast-enhanced CT scans available were included. Patients treated with definitive surgery, bilateral RT, or additional RT before the post-RT CT scan were excluded. Pre- and post-treatment CTs were registered to the planning CT and dose grid. Isodose lines from treatment plans were projected onto both scans, facilitating the delineation of carotid artery subvolumes in 5 Gy increments (i.e. received 50-55 Gy, 55-60 Gy, etc.). The percent-change in sub-volumes across each dose range was statistically examined using the Wilcoxon rank-sum test.

Results

Among 46 patients analyzed, 72% received RT alone, 24% induction chemotherapy followed by RT, and 4% concurrent chemoradiation. The median interval from RT completion to the latest, post-RT CT scan was 43 months (IQR 32-57). A decrease in the volume of the irradiated carotid artery was observed in 78% of patients, while there was a statistically significant difference in mean %-change (±SD) between the total irradiated and spared carotid volumes (7.0±9.0 vs. +3.5±7.2, respectively, p<.0001). However, no significant dose-response trend was observed in the carotid artery volume change withing 5 Gy ranges (mean %-changes (±SD) for the 50-55, 55-60, 60-65, and 65-70+ Gy ranges [irradiated minus spared]: -13.1±14.7, -9.8±14.9, -6.9±16.2, -11.7±11.1, respectively). Notably, two patients (4%) had a cerebrovascular accident (CVA), both occurring in patients with a greater decrease in carotid artery volume in the irradiated vs the spared side.

Conclusions

Our data show that standard-of-care oncologic surveillance CT scans can effectively detect reductions in carotid volume following RT for oropharyngeal cancer. Changes were equivalent between studied dose ranges, denoting no further dose-response effect beyond 50 Gy. The clinical utility of carotid volume changes for risk stratification and CVA prediction warrants further evaluation.

Advanced External Beam Stereotactic Radiotherapy for Skull Base Reirradiation

BACKGROUND/OBJECTIVES

Stereotactic body radiation therapy (SBRT) for skull base reirradiation is particularly challenging, as patients have already received substantial radiation doses to the region, and nearby normal organs may have approached their tolerance limit from prior treatments. In this study, we reviewed the characteristics and capabilities of four advanced external beam radiation delivery systems and four modern treatment planning systems and evaluated the treatment plan quality of each technique using skull base reirradiation patient cases.

METHODS

SBRT plans were generated for sixteen skull base reirradiation patients using four modalities: the GK plan for the Elekta Leksell Gamma Knife Perfexion/ICON, the CyberKnife (CK) plan for the Accuray CyberKnife, the intensity-modulated proton therapy (IMPT) plan for the Hitachi ProBeat-FR proton therapy machine, and the volumetric-modulated arc therapy (VMAT) plan for the Varian TrueBeam STx. These plans were evaluated and compared using two novel gradient indices in addition to traditional dosimetry metrics for targets and organs at risk (OARs). The steepest border gradient quantified the percent prescription dose fall-off per millimeter at the boundary between the target and adjacent critical structures. This gradient index highlighted the system's ability to spare nearby critical OARs. The volume gradient assessed the extent of dose spread outside the target toward the patient's body.

RESULTS

All plans achieved comparable target coverage and conformity, while IMPT and VMAT demonstrated significantly better uniformity. The GK plans exhibited the highest border gradient, up to 20.9%/mm, followed by small-spot-size IMPT plans and CK plans. Additionally, IMPT plans showed the benefit of reduced dose spread in low-dose regions and the lowest maximum and mean doses to the brainstem and carotid artery.

CONCLUSIONS

The advanced external beam radiotherapy modalities evaluated in this study are well-suited for SBRT in skull base reirradiation, which demands precise targeting of tumors with highly conformal doses and steep dose gradients to protect nearby normal structures.

Clinical presentation of alveolar soft-part sarcoma

Alveolar soft-part sarcomas are rare and seldom considered in the differential diagnosis of a soft-tissue mass. Thus, early clinical recognition can be elusive. The authors have identified several clinical and radiographic features of alveolar soft-part sarcoma, emphasizing the importance of magnetic resonance imaging in the preoperative diagnostic and staging workup. Accurate diagnosis and treatment of this unusual tumor requires clinical suspicion and clinicopathologic correlation with appropriate radiographic studies. If the clinical or radiographic interpretation is equivocal, early biopsy is essential to differentiate alveolar soft-part sarcoma from arteriovenous malformation.

Cross-Cultural Brain Activity Differences Between True and Sham Acupuncture for Xerostomia During Head and Neck Cancer Radiotherapy

Background:

A prior phase III, multicenter (United States and China), clinical trial found true acupuncture (TA) resulted in lower xerostomia scores 12 months after radiotherapy than that of a standard care control group. This small pilot study examined brain function changes comparing TA to sham acupuncture (SA) in US and Fudan patients undergoing head and neck radiotherapy.

Methods:

To determine cerebral activity during TA versus SA acupuncture, patients underwent electroencephalogram evaluation (EEG) immediately prior, during and after both conditions. Acupuncture occurred during weeks 3 to 5 of radiotherapy, with patients receiving either TA or SA, followed 2 to 3 days later by the other treatment in a counterbalanced manner.

Results:

In the TA minus SA condition (N = 14 Fudan; N = 13 US), most changes were in the delta (0.5-3.5 Hz) and alpha (8-12 Hz) bandwidths. Delta was present in the frontal gyrus and parahippocampal gyrus. Alpha was present in the anterior and posterior cingulate, lingual gyrus, amygdala, precuneus, medial frontal gyrus, fusiform gyrus, and superior frontal gyrus. Maximal cortical differences in the Fudan cohort between TA and SA were in areas previously shown to be associated with (TA). In the US cohort, maximal differences between TA and SA were associated with areas which are usually decreased in TA conditions.

Conclusions:

There were distinct differences in brain function between those receiving TA and SA and there were clear differences between cultures, helping to explain the lack of placebo effect in the Fudan participants and strong placebo effect in the US patients.

Radiological imaging for the diagnosis of bone metastases

Primary neoplasms of the skeleton are rare, but metastatic involvement is, unfortunately, a common occurrence. This is particularly true for certain primary tumors. Skeletal metastases are clinically significant because of associated symptoms, complications such as pathological fracture and their profound significance for staging, treatment and prognosis. Detection of bone metastases is, thus, an important part of treatment planning. The frequency with which metastases are detected varies considerably with the type of primary tumor and with the methodology utilized for detection. Four main modalities are utilized clinically: plain film radiography, CT scan, nuclear imaging and magnetic resonance imaging. In this discussion, we will review literature on the radiology of skeletal metastases with respect to lesion detection, assessment of response to treatment and possible therapeutic implications. The bulk of the discussion will focus on MRI and nuclear studies since most of the recent advances have been made in these areas.

Using hypnosis to accelerate the healing of bone fractures: a randomized controlled pilot study

CONTEXT

Hypnosis has been used in numerous medical applications for functional and psychological improvement, but has been inadequately tested for anatomical healing.

OBJECTIVE

To determine whether a hypnotic intervention accelerates bodily tissue healing using bone fracture healing as a site-specific test.

DESIGN

Randomized controlled pilot study.

SETTING

Massachusetts General Hospital, Boston, Mass, and McLean Hospital, Belmont, Mass.

PATIENTS

Twelve healthy adult subjects with the study fracture were recruited from an orthopedic emergency department and randomized to either a treatment (n = 6) or a control group (n = 6). One subject, randomized to the treatment group, withdrew prior to the intervention.

INTERVENTION

All 11 subjects received standard orthopedic care including serial radiographs and clinical assessments through 12 weeks following injury. The treatment group received a hypnotic intervention (individual sessions, audiotapes) designed to augment fracture healing.

MAIN OUTCOME MEASURES

Radiological and orthopedic assessments of fracture healing 12 weeks following injury and hypnotic subjects' final questionnaires and test scores on the Hypnotic Induction Scale.

RESULTS

Results showed trends toward faster healing for the hypnosis group through week 9 following injury. Objective radiographic outcome data revealed a notable difference in fracture edge healing at 6 weeks. Orthopedic assessments showing trends toward better healing for hypnosis subjects through week 9 included improved ankle mobility; greater functional ability to descend stairs; lower use of analgesics in weeks 1, 3, and 9; and trends toward lower self-reported pain through 6 weeks.

CONCLUSION

Despite a small sample size and limited statistical power, these data suggest that hypnosis may be capable of enhancing both anatomical and functional fracture healing, and that further investigation of hypnosis to accelerate healing is warranted.