Assessment of the NSQIP Surgical Risk Calculator in Predicting Microvascular Head and Neck Reconstruction Outcomes

Objective

This study evaluated the accuracy of the Surgical Risk Calculator (SRC) of the ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Program) in predicting head and neck microvascular reconstruction outcomes.

Study Design

Retrospective analysis.

Setting

Tertiary medical center.

Subjects and Methods

A total of 561 free flaps were included in the analysis. The SRC-predicted 30-day rates of postoperative complications, hospital length of stay (LOS), and rehabilitation discharge were compared with the actual rates and events. The SRC’s predictive value was examined with Brier scores and receiver operating characteristic area under the curve.

Results

A total of 425 myocutaneous, 134 osseous (84 fibula, 47 scapula, and 3 iliac crest), and 2 omental free flaps were included in this study. All perioperative complications evaluated had area under the curve values ≤0.75, ranging from 0.480 to 0.728. All but 2 postoperative complications had Brier scores >0.01. SRC-predicted LOS was 9.4 ± 2.38 days (mean ± SD), which did not strongly correlate with the actual LOS of 11.98 ± 9.30 days ( r = 0.174, P < .0001).

Conclusion

The SRC is a poor predictor for surgical outcome among patients undergoing microvascular head and neck reconstruction.

Abstract 5639: Changes in local and peripheral T cell diversity after HPV E7 antigen-expressing Listeria-based immunotherapy (ADXS11-001) prior to robotic surgery for HPV-positive oropharyngeal cancer

Human papilloma virus associated oropharyngeal cancers (HPVOPC) account for about one third of OPC and express foreign viral antigens such as the E6 and E7 oncogenes, which are suitable for immune targeting. We performed a “window of opportunity” trial of patients undergoing standard-of-care transoral surgery for HPVOPC to assess the effect of the HPV16-E7 targeting vaccine ADXS11-001 on the intratumoral and systemic immune response. We reported, in a prior abstract, that 5 of 8 ADXS11-treated patients showed increased E6 or E7-specific IFN-γ responses post-treatment and 4/8 patients demonstrated increased CD8 and CD4 tumor infiltrating lymphocytes (TILs) after vaccination. In the present study, we profiled peripheral blood immunocyte populations (PBMCs) pre-vaccination, post-vaccination and post-surgery via multicolor flow cytometry in 8 patients. Clonal expansion and diversification of PBMCs and tumor TILs post-treatment were determined via T cell receptor (TCR) DNA sequencing and correlated to HPV antigen specific immune responses determined by ELISPOT as well as tumor immune profile determined by quantitative immunofluorescence. While peripheral CD8 cytotoxic T cell (CTL) levels remained constant over the course of the study, we observed trends towards their increased expression of LAG-3 (1.6 fold, p=0.0821) and PD-1 (1.6 fold, p=0.0748) 6 weeks post-surgery, consistent with activation. We did not observe statistically significant changes in levels of CD4 T helper cells, MDSC or Tregs, although a modest trend towards decreased CD8/MDSC ratio was observed post-surgery (0.5 fold, p=0.0864). Overall TCR diversity/clonality of PBMCs and TILs did not change. However the comparison of similarity between T cell repertoires of the tumor and PBMCs (Morisita's index) demonstrated an increase of expanded clones post-vaccination limited to TILs in 5/6 patients, indicating clonal expansion in ADXS11-treated patients. When we analyzed T cell repertoire changes in individual patients, 4 of 8 patients demonstrated expansion of specific TCR clones post-vaccination. The two patients with the greatest increase in number of expanded TCR clones among both, PBMCs and TILs, also had the strongest increase of E6 or E7-specific IFN-γ responses post-treatment, and also had strongly increased CD8 TILs. Our results demonstrate that immunomodulatory effects of ADXS11-001 on the local and peripheral immune response vary among patients, with 2/8 treated patients demonstrating evidence of an integrated adaptive immune response in blood and tumor, consistent with selective clonal expansion in the context of a vaccine-induced anti-tumor T cell response. Profiling of additional patients will permit more detailed analysis of ADXS11-induced immune modulation and impact on TCR diversity.

Citation Format: Rosemarie Krupar, Ravi R. Pathak, Naoko Imai, Eric Genden, Krzys Misiukiewicz, Elizabeth G. Demicco, Jigneshkumar Patel, Falguni Parikh, Michael Donovan, Seunghee Kim-Schulze, Sven Perner, Marshall Posner, Brett Miles, Sacha Gnjatic, Andrew G. Sikora. Changes in local and peripheral T cell diversity after HPV E7 antigen-expressing Listeria-based immunotherapy (ADXS11-001) prior to robotic surgery for HPV-positive oropharyngeal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5639.

The prognostic impact of human papillomavirus status following treatment failure in oropharyngeal cancer

INTRODUCTION

Despite the human papillomavirus conferring a better prognosis in the primary treatment setting, the prognostic impact of viral status after treatment failure in oropharyngeal squamous cell carcinoma patients is poorly understood.

METHODS

We retrospectively identified 33 oropharyngeal squamous cell carcinoma (OPC) patients with local and/or distant disease recurrence post-treatment, and looked at metastatic patterns, time to failure and survival patterns by HPV status.

RESULTS

Median overall survival following local failure was not significantly different by HPV status (17 months for HPV+ vs. 14 months for HPV-, p = 0.23). However, following distant failures, HPV+ patients lived significantly longer than HPV- patients (median 42 months vs. 11 months, p = 0.004). HPV- patients were more likely to have locoregional failures as compared to HPV+ patients (p = 0.005), but the difference in distant failure between both groups was not significant (p = 0.09). HPV+ patients were more likely to develop metastases to sites other than the lung and bones.

CONCLUSION

HPV positivity predicts a favorable prognosis with the potential for long-term survival following distant, not locoregional, failures. These results have important implications for the aggressiveness of treatment and type of surveillance imaging performed.

Standard of care vs reduced-dose chemoradiation after induction chemotherapy in HPV+ oropharyngeal carcinoma patients

6069

Background: Locally advanced Human Papillomavirus (HPV) + oropharyngeal carcinoma (OPC) has a significantly better response, locoregional control and survival compared to non HPVOPC. Standard-dose chemoradiotherapy (sdCRT) results in significant side effects, leading to acute and life-threatening late morbidity. We studied whether reduced dose chemoradiation (rdCRT) after induction chemotherapy (IC) resulted in equivalent progression-free survival (PFS) compared to sdCRT + IC with decreased late morbidity. Methods: Patients with locally advanced OPC and < 20 pack years (py) smoking history were tested for p16 and then HPV by type-specific PCR. After 3 cycles of docetaxel, cisplatin and fluorouracil (TPF) IC all HPV+/p16+ subjects underwent clinical and radiographic evaluation. Clinical responders were randomized to either sdCRT (70Gy) or rdCRT (56Gy) with weekly carboplatin (AUC 1.5) at a 1:2 ratio. The primary endpoint was 2 year PFS; the secondary endpoint was 2 year overall survival (OS). Toxicity, late morbidity and swallowing were monitored. Results: 23 patients were enrolled and 20 randomized, 8 to sdCRT and 12 to rdCRT; 2 were HPV- and 1 refused further therapy after IC and were not randomized. Median age was 56.5 yrs (range 36-78); 30% were African-American, 10% were Hispanic, 5% were female; 16 were HPV 16+ and 4 were other high risk (HR) variants; 60% never smoked, 25% were < 10 py, and 15% were 10-20 py; 70% had high risk features: T4, N2c, or N3. Clinical response to TPF was 100%; 70% had a clinical complete response. As of February 1, patients have been followed for a median of 37.5 months (range 21.7 – 49.5). 2 year PFS/OS for sdCRT and rdCRT are 87.5% vs 83.3% (log-rank test p = 0.85), respectively. All 3 failures were local or regional and 2 of 3 occurred in non HPV16 HR variants. Conclusions: HPV+ OPC patients who received rdCRT after TPF IC had similar PFS/OS compared to those receiving sdCRT. These results uphold the potential clinical benefit of radiation dose reduction as a treatment option with comparable survival to the standard radiation dose. A Phase III trial comparing IC plus rdCRT to sdCRT alone or with IC is warranted in this population. Non-HPV16 HR variants may have a worse outcome. Clinical trial information: NCT01706939.

Outcomes in Adult Sinonasal Rhabdomyosarcoma

Objective To describe patient demographics, histology, treatment modalities, and survival associated with adult sinonasal rhabdomyosarcoma. Study Design Retrospective review of a national database. Setting Tertiary medical center. Subjects and Methods Patient demographics, tumor histology, treatment modalities, and survival trends were examined for patients aged ≥18 years who were diagnosed with sinonasal rhabdomyosarcoma between 2004 and 2013 with the National Cancer Database. Kaplan-Meier analysis and the log-rank tests were performed to determine the unadjusted association between overall survival and various patient and disease characteristics. Results A total of 186 patients were identified; 5-year overall survival was 28.4%. Over half of patients were between 18 and 35 years old at diagnosis (53.8%), which was associated with improved 5-year overall survival over patients >35 years old (31.9% vs 24.4%, P = .014). Alveolar sinonasal rhabdomyosarcoma was most common (66.7%). There was no statistical difference in 5-year overall survival between alveolar and embryonal subtypes (30.5% vs 41.6%, P > .05). Metastatic disease was present in 27.7% of patients and was associated with worse 5-year overall survival (14.7% vs 33.9%, P < .0001). The majority of patients were treated with chemotherapy with adjuvant radiation (49.5%). A quarter of patients were treated with surgery plus chemoradiation (25.8%). Conclusion We present the largest analysis of adult sinonasal rhabdomyosarcoma using a standardized national based database. Adult sinonasal rhabdomyosarcoma has a very poor prognosis independent of histologic subtype. The small number of surgical cases limits the ability of the analysis to accurately compare treatment with chemoradiation with and without surgery.

Development and usability testing of a web-based self-management intervention for oral cancer survivors and their family caregivers

Oral cancer (OC) survivors experience debilitating side effects that affect their quality of life (QOL) and that of their caregivers. This study aimed to develop and evaluate a dyadic, web-based intervention to improve survivor self-management and survivor/caregiver QOL. A qualitative needs assessment (semi-structured interviews) with 13 OC survivors and 12 caregivers was conducted to discern information and support needs as well as preferences regarding website features and tools. Results using Grounded Theory analysis showed that OC survivors and caregivers: (1) want and need practical advice about managing side effects; (2) want to reach out to other survivors/caregivers for information and support; and (3) have both overlapping and unique needs and preferences regarding website features. Usability testing (N = 6 survivors; 5 caregivers) uncovered problems with the intuitiveness, navigation and design of the website that were subsequently addressed. Users rated the website favourably on the dimensions of attractiveness, controllability, efficiency, intuitiveness and learnability, and gave it a total usability score of 80/100. Overall, this study demonstrates that OC survivors and caregivers are interested in using an online programme to improve QOL, and that providing tailored website content and features based on the person's role as survivor or caregiver is important in this population.

Adjuvant Therapy for Salivary Gland Carcinomas

AIM

We compared the clinical outcomes and toxicity profile among a retrospective cohort of patients with primary major salivary gland carcinomas (SGCs) treated with surgery followed by adjuvant radiation therapy (S+RT) versus surgery and adjuvant chemoradiotherapy (S+CRT).

PATIENTS AND METHODS

Twenty patients (71%) underwent S+RT and eight (29%) S+CRT at our Institution between 2006 and 2015. Microscopic positive margins were present in 54% of the patients.

RESULTS

The 3-year overall survival (OS) was 100% with S+RT and 87.5% with S+CRT (p=0.141) and locoregional control (LRC) was 95% with S+RT and 87.5% with S+CRT (p=0.383). There were no significant differences in the rate of acute (p=0.801) and late (p=0.714) toxicities.

CONCLUSION

While we await randomized data, adjuvant CRT may be considered as a viable therapeutic option for patients at high-risk of local or regional recurrence, especially in those with a positive microscopic margin where further surgery may result in functional cranial neuropathies.

External-beam radiotherapy for differentiated thyroid cancer locoregional control: A statement of the American Head and Neck Society

The use of external-beam radiotherapy (EBRT) in differentiated thyroid cancer (DTC) is debated because of a lack of prospective clinical data, but recent retrospective studies have reported benefits in selected patients. The Endocrine Surgery Committee of the American Head and Neck Society provides 4 recommendations regarding EBRT for locoregional control in DTC, based on review of literature and expert opinion of the authors. (1) EBRT is recommended for patients with gross residual or unresectable locoregional disease, except for patients <45 years old with limited gross disease that is radioactive iodine (RAI)-avid. (2) EBRT should not be routinely used as adjuvant therapy after complete resection of gross disease. (3) After complete resection, EBRT may be considered in select patients >45 years old with high likelihood of microscopic residual disease and low likelihood of responding to RAI. (4) Cervical lymph node involvement alone should not be an indication for adjuvant EBRT.

The role of HPV status in recurrent/metastatic squamous cell carcinoma of the head and neck

Although the prognostic role of human papillomavirus (HPV) in locoregionally advanced squamous cell carcinoma of the head and neck (SCCHN) is well established, its prognostic and/or predictive role in recurrent/metastatic settings remains to be defined. Despite epidemic growth of HPV-positive oropharyngeal carcinoma, a low recurrence rate in HPV-positive patients results in a small number of patients entering clinical trials for recurrent and/or metastatic SCCHN. The consequent lack of statistical power and also significant data contamination by misclassification of HPV-positive patients leads to premature study conclusions. Even emerging data from the analysis of 2 randomized trials, SPECTRUM and EXTREME, do not provide enough evidence for any HPV-based therapeutic strategy. Many upcoming studies for locally advanced disease, including the ones with de-escalated strategies, will have an increasing number of patients with HPV. Optimal HPV testing strategies for reliable patient selection and HPV-driven therapeutic approaches will be essential. Here, we comprehensively review the existing data regarding HPV status and prognostic or predictive outcomes in recurrent/metastatic settings and discuss current promising studies and future directions that may help in the design of upcoming trials.

Early detection of recurrent disease by FDG-PET/CT leads to management changes in patients with squamous cell cancer of the head and neck

OBJECTIVE

The objective of this study was to compare the efficacy of surveillance high-resolution computed tomography (HRCT) and physical examination/endoscopy (PE/E) with the efficacy of fluorodeoxyglucose (FDG)-positron emission tomography (PET)/HRCT for the detection of relapse in head and neck squamous cell carcinoma (HNSCC) after primary treatment.

METHODS

This is a retrospective analysis of contemporaneously performed FDG-PET/HRCT, neck HRCT, and PE/E in 99 curatively treated patients with HNSCC during post-therapy surveillance to compare performance test characteristics in the detection of early recurrence or second primary cancer.

RESULTS

Relapse occurred in 19 of 99 patients (20%) during a median follow-up of 21 months (range: 9-52 months). Median time to first PET/HRCT was 3.5 months. The median time to radiological recurrence was 6 months (range: 2.3-32 months). FDG-PET/HRCT detected more disease recurrences or second primary cancers and did so earlier than HRCT or PE/E. The sensitivity, specificity, and positive and negative predictive values for detecting locoregional and distant recurrence or second primary cancer were 100%, 87.3%, 56.5%, and 100%, respectively, for PET/HRCT versus 61.5%, 94.9%, 66.7%, and 93.8%, respectively, for HRCT versus 23.1%, 98.7%, 75%, and 88.6%, respectively, for PE/E. In 19 patients with true positive PET/HRCT findings, a significant change in the management of disease occurred, prompting either salvage or systemic therapy. Of the 14 curatively treated patients, 11 were alive with without disease at a median follow-up of 31.5 months.

CONCLUSION

FDG-PET/HRCT has a high sensitivity in the early detection of relapse or second primary cancer in patients with HNSCC, with significant management implications. Given improvements in therapy and changes in HNSCC biology, appropriate modifications in current post-therapy surveillance may be required to determine effective salvage or definitive therapies.