Improved biochemical relapse-free survival for patients with large/wide glands treated with prostate seed implantation for localized adenocarcinoma of prostate

OBJECTIVES

To analyze whether prostate size affects biochemical relapse-free survival (bRFS).

METHODS

The bRFS outcomes for 390 patients with a minimum of 2 years of follow-up were determined from a review of a prospectively maintained database. All patients were treated with iodine-125 alone as the radiotherapeutic modality and had a minimum of four posttreatment prostate-specific antigen values. None were treated with androgen deprivation. The factors examined in the univariate and multivariate analyses predicting for bRFS included gland volume, patient age, initial prostate-specific antigen value, biopsy Gleason score, clinical stage, and postimplant dosimetric variables.

RESULTS

Most patients had low-risk disease, and the median follow-up was 45 months (range 24 to 102). Using the American Society for Therapeutic Radiology Oncology definition of biochemical failure, the overall 5-year bRFS rate was 89.3%. On separate multivariate analyses, only the pretreatment prostate width and volume significantly influenced bRFS favorably (P = 0.0069 and P = 0.0255, respectively). No association was found between gland size/width and postimplant dosimetry.

CONCLUSIONS

The results of our study have shown that implantation of large/wide prostates independently confers better bRFS.

Nasopharyngeal cancer: Incidence and prognosis of human papillomavirus and Epstein-Barr virus association at a single North American institution

BACKGROUND

The prognostication of Epstein-Barr virus (EBV) and human papillomavirus (HPV) status in nasopharyngeal cancer (NPC) is unclear.

METHODS

This retrospective study analyzed NPC from 2000 to 2019.

RESULTS

Seventy-eight patients were included: 43 EBV⁺ , 12 HPV⁺ , 23 EBV^- /HPV^- , and 0 EBV⁺ /HPV⁺ . All p16⁺ tumors were also positive for HPV-CISH. Baseline characteristics were not different between groups except age, N-classification, and Karnofsky Performance Scale (KPS) (p < 0.05). For EBV⁺ , HPV⁺ , and EBV^- /HPV^- respectively, 3-year overall survival (OS) was 89.9%, 69.8%, and 52.5% (p = 0.006). EBV^- /HPV^- status was significantly associated with worse OS but not freedom from progression (FFP) on univariate analysis, and did not remain a significant predictor of OS after adjusting for KPS, age, and group stage.

CONCLUSIONS

EBV⁺ NPC tumors were seen in younger, healthier patients than HPV⁺ and EBV^- tumors, and there were no cases of coinfection. The association of viral status with OS was insignificant after adjusting for KPS and age.

Association of body mass index with prostate cancer biochemical failure

PURPOSE

The association between obesity and biochemical failure measured by prostate specific antigen after prostate cancer treatment is controversial. We determined whether there is an association between body mass index and biochemical failure in men treated for low and intermediate risk prostate cancer with various treatment modalities.

MATERIALS AND METHODS

We performed a cohort study in 2,687 patients who underwent treatment for low and intermediate risk prostate adenocarcinoma as described by National Comprehensive Cancer Network guidelines at Cleveland Clinic between January 1996 and December 2005. Univariate and multivariate analyses were done to determine the effect of multiple patient characteristics on biochemical failure.

RESULTS

There were 319 biochemical failures (11.9%). Body mass index as a continuous variable was significantly associated with biochemical failure on univariate analysis (HR 1.030, p = 0.02). There was a significant association with biochemical failure when comparing normal vs overweight and normal vs obese men but not overweight vs obese men. On multivariate analysis body mass index as a continuous or a categorical variable was not significantly associated with biochemical failure. Multivariate analysis revealed certain variables significantly associated with biochemical failure, including black race, greater initial prostate specific antigen, Gleason score 7, treatment type and more frequent prostate specific antigen screening.

CONCLUSIONS

We found a significant association between body mass index and biochemical failure on univariate analysis that did not hold true on multivariate analysis. Black race was associated with biochemical failure on multivariate analysis. The reason for this is unclear. Future studies should further characterize the relationship between race and biochemical failure.

Nutritional and metabolic features of Eubacterium suis

We studied the nutritional and metabolic features of Eubacterium suis, an anaerobic animal pathogen that causes cystitis and pyelonephritis in pigs. Peptone-yeast extract-starch (PYS) medium, which contained Trypticase (BBL Microbiology Systems), yeast extract, starch, minerals, cysteine, and sodium carbonate, was shown to support excellent growth of this organism (absorbance at 600 nm = 1.8). Growth was considerably less (absorbance at 600 nm = 0.6) when the starch in the medium was replaced by maltose. Formate, acetate, and ethanol were the major products of fermentation of starch or maltose. The organism appears to require a fermentable carbohydrate for growth since the deletion of starch from PYS resulted in a negligible amount of growth. Growth decreased by approximately 20% when CO2 was rigorously excluded from PYS minus Na2CO3. The deletion of only yeast extract from PYS resulted in a decrease in growth of about 75%, and the simultaneous deletion of both yeast extract and Trypticase resulted in negligible growth. When the yeast extract in PYS was replaced by a defined mixture of purine and pyrimidine bases, vitamins, and amino acids, growth was greater than or equal to 80% that observed in PYS. The deletion of Trypticase from this medium resulted in no detectable growth, suggesting a possible peptide requirement for E. suis growth. Good growth (absorbance at 600 nm = 1.4) was obtained when adenine and uracil were substituted for the mixture of purine and pyrimidine bases in modified PYS; the substitution of pyridoxal, riboflavin, and nicotinic acid for the vitamin mixture gave comparable growth. The nutritional requirement of E. suis apparently reflect the fact that the organism adapts to its natural niche by doing away with certain biosynthetic capabilities which it does not seem to require.

Thromboembolism in Patients with Metastatic Renal Cell Carcinoma Treated with Immunotherapy

BACKGROUND

Metastatic renal cell carcinoma (mRCC) is associated with a high risk of thromboembolism (TE).

OBJECTIVE

We investigated whether immunotherapy (IO) increases the hypercoagulable state in this high-risk population.

PATIENTS AND METHODS

Patients with mRCC treated with IO between 1 January 2015 and 31 December 2019 at the Cleveland Clinic were identified. Cumulative incidence analysis calculated TE rates over time and Gray's test determined differences in TE rates among groups. The Kaplan-Meier method estimated survival, while Cox proportional hazard regression evaluated the impact of TE on OS.

RESULTS

Of 351 patients, 75% were men with clear cell mRCC (81%) and International Metastatic Renal Cell Carcinoma (IMDC) intermediate- to poor-risk disease (77%). Patients received single-agent IO (52%), doublet IO (31%), or IO with non-IO therapy (17%). The median number of IO doses was 8 (range 1-81). At a median follow-up of 12.8 months, 12% of patients (n = 43) had a TE event (venous n = 37 [11%], arterial n = 6 [2%]). The cumulative TE incidence at 6 months was 4.4% (95% confidence interval [CI] 2.6-6.9) and 9.8% (95% CI 6.8-13.4) at 12 months. No factors, including IMDC or Khorana score, were identified to predict TE development. Seventy-two percent of TE resulted in hospitalization (9% TE-related mortality and 21% TE-related dose delay). TE (p < 0.0001), poor IMDC score (p < 0.0001), and Khorana score ≥ 2 (p < 0.0001) were associated with worse OS.

CONCLUSIONS

Patients with mRCC treated with IO had a high incidence of TE. TE was associated with risk of treatment delay, hospitalization, and mortality, while TE, IMDC poor risk, and Khorana score ≥ 2 were associated with worse survival. Further investigations into IO-associated TE are needed to identify benefit from primary thromboprophylaxis.

A National Comparison of Postoperative Outcomes in Completion Thyroidectomy and Total Thyroidectomy

OBJECTIVE

To characterize and assess the non-thyroid-specific postoperative complications of completion thyroidectomy as compared with total thyroidectomy.

STUDY DESIGN

Retrospective analysis: 2005 to 2017.

SETTING

National Surgical Quality Improvement Program database.

SUBJECTS AND METHODS

Patients aged >18 years receiving a completion or total thyroidectomy were eligible for inclusion. Patients not treated by otolaryngologists or general surgeons and with unknown demographic variables were excluded.

RESULTS

A total of 70,638 patients were analyzed, representing 64,763 total thyroidectomies and 5875 completion thyroidectomies. The 30-day mortality rate was 0.1% for both procedures (P > .05). Overall, 1.7% and 1.4% of patients undergoing total and completion thyroidectomies experienced at least 1 complication (P > .05), while 1.2% and 0.9% had a postoperative medical complication (P = .0186), respectively. On multivariable analysis, patients undergoing total thyroidectomies were significantly more likely to return to the operating room (odds ratio [OR], 1.36; 95% CI, 1.04-1.80; P = .027) and to be readmitted (OR, 1.45; 95% CI, 1.16-1.81; P = .001). Adjusted analysis also demonstrated that patients undergoing total thyroidectomies were more likely to be inpatients (OR, 1.17; 95% CI, 1.11-1.24; P < .001), be treated by nonotolaryngologists (OR, 1.36; 95% CI, 1.29-1.45; P < .001), and smoke (OR, 1.22; 95% CI, 1.13-1.33; P < .001).

CONCLUSION

National data suggest that total and completion thyroidectomies are relatively safe procedures but that completion thyroidectomies are associated with lower rates of postoperative complications. These findings may play a role in determining treatment plans for patients and optimizing risk reduction.

Management of Brain Metastasis in Patients With Pulmonary Neuroendocrine Carcinomas

Background:

The patterns of intracranial failure in patients with brain metastasis from pulmonary neuroendocrine carcinoma (PNEC) remain unknown.

Methods:

From 1998 to 2013, 29 patients with the diagnosis of PNEC were treated for brain metastasis: 16 patients (55%) underwent whole-brain radiation therapy (WBRT), 5 (17%) patients underwent WBRT with a stereotactic radiosurgery (SRS) boost, and 8 (28%) patients underwent primary SRS alone.

Results:

The median age at treatment was 61 years (range: 44-84 years) and the median follow-up was 9.6 months (0-157.4 months). Of the patients treated with SRS alone, 1 patient had radiographic local progression of disease and 1 patient had a distant intracranial failure. Of the patients treated with WBRT with or without an SRS boost, 9 patients developed intracranial progression, including 1 local failure. No differences in rates of intracranial progression or local failure between the 2 groups ( P = .94 and P = .44, respectively) were observed. The actuarial rates of distant intracranial failure at 12 months were 32.9% (95% confidence interval [95% CI] 8.9%-56.8%) and 25% (95% CI 0.0%-67.4%) in patients undergoing primary WBRT or SRS, respectively ( P = .31). The median overall survival was 15.8 months in patients treated with WBRT and 20.4 months in patients treated with primary SRS ( P = .78).

Conclusion:

Patients with brain metastasis from PNECs can be effectively treated with either WBRT or SRS alone, with a pattern of failure more consistent with non-small cell lung cancer than small cell lung cancer. In this series, there was not a statistically significant increased risk of distant intracranial failure when patients were treated with primary SRS.

The Impact of Preoperative Radiation Therapy on Locoregional Recurrence in Patients with Stage IV Rectal Cancer Treated with Definitive Surgical Resection and Contemporary Chemotherapy

PURPOSE

Definitive resection of primary rectal cancers is frequently incorporated, with or without preoperative radiotherapy and perioperative chemotherapy, in the management of selected patients with metastatic rectal adenocarcinoma. This study reviews the impact of preoperative radiotherapy and perioperative chemotherapy on locoregional recurrence and overall survival in these patients.

METHODS AND MATERIALS

This retrospective study with an Institutional Review Board (IRB) waiver included 109 patients with metastatic rectal adenocarcinoma who underwent definitive primary resection between 1998 and 2011. In addition to resection, 64 patients were treated with preoperative radiotherapy and perioperative chemotherapy and 45 patients were treated with perioperative chemotherapy alone. Radiotherapy dose was typically 50.4 Gy. Baseline variables were compared using chi-square and unpaired t tests. Overall survival was calculated using Kaplan-Meier method. Univariate and multivariate analyses were performed using Cox proportional hazards regression.

RESULTS

There were no significant baseline differences between the two groups. There was no significant difference in locoregional recurrence (10.9 vs. 11.1%; p = 0.90) or overall survival (34.5 vs. 34.8 months; p = 0.89) for patients treated with preoperative radiotherapy compared to those treated with perioperative chemotherapy alone, respectively. Patients who underwent radiotherapy were less likely to have a positive margin (10.9 vs. 20.0%; p = 0.19), lymphovascular invasion (32.8 vs. 53.3%; p = 0.03), and pathologic stage N2 disease (25.0 vs. 42.2%; p = 0.02). Grade 2 postoperative complications were more common in the preoperative radiotherapy group (32.8 vs. 15.6%; p = 0.04). Multivariate analysis demonstrated that patients with poorly differentiated tumors (HR 2.19; p = 0.009) and those that did not undergo liver-directed therapy (HR 2.20; p = 0.005) had inferior survival.

CONCLUSIONS

Locoregional recurrence is modest in patients with metastatic rectal adenocarcinoma receiving definitive primary resection, irrespective of the use of radiotherapy. Preoperative radiotherapy may enhance pathologic downstaging at the expense of increased grade 2 postoperative complications. Its use should be reserved for patients at high risk for locoregional recurrence.

Clinical Versus Pathologic Laryngeal Cancer Staging and the Impact of Stage Change on Outcomes

OBJECTIVES/HYPOTHESIS

Evaluate the impact and accuracy of clinical laryngeal cancer staging.

STUDY DESIGN

Retrospective cohort study.

METHODS

Two hundred sixty-five consecutive patients with laryngeal squamous cell carcinoma who underwent total laryngectomy from 2001 to 2017 were studied. Clinical versus pathologic tumor (T) and nodal (N) categories were compared. Logistic regression and Cox proportional hazards analyzed the association of stage change with perioperative factors and outcomes.

RESULTS

Forty-seven patients (17.7%, accuracy = 0.969 ± 0.010 [standard error]) changed between T1-2 and T3-4. Sixty-four patients (24.1%, accuracy = 0.866 ± 0.020) had inaccurate N category. Salvage patients were less likely to have stage change (downstage: odds ratio [OR] = 0.20, 95% confidence interval [CI]: 0.08-0.50, P < .001; upstage: OR = 0.41, 95% CI: 0.23-0.74, P = .003), but more likely to have inaccurate nodal category (39.8% vs. 11.7%, P < .001). Patients with stage change tended to have greater odds of positive/close margins (upstage: OR = 1.78, 95% CI: 0.91-3.5, P = .092) and chemotherapy (downstage: OR = 2.21, 95% CI: 0.80-6.14, P = .128; upstage: OR = 1.87, 95% CI: 0.85-4.11, P = .119). Stage change was associated with recurrence (P = .047) with downstaged patients less likely to recur (hazard ratio = 0.26, 95% CI: 0.08-0.82, P = .021). Stage change was not associated with positron emission tomography scan, subsite, time to surgery, or mortality.

CONCLUSIONS

A third of laryngeal cancer patients were downstaged or upstaged after laryngectomy with 18% and 24% of clinical T and N categories inaccurate, respectively. Stage change was less common for salvage patients and associated with risk of recurrence.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:559-565, 2021.

Outcomes after photoselective vaporization of the prostate and transurethral resection of the prostate in patients who develop prostatic obstruction after radiation therapy

OBJECTIVE

To compare the need for repeat treatment or urinary diversion in patients undergoing transurethral resection of the prostate (TURP) compared with photoselective vaporization of the prostate (PVP) after brachytherapy or external beam radiation therapy (EBRT).

METHODS

The prostate cancer database of Cleveland Clinic includes 3600 patients who have undergone prostate brachytherapy and 2500 patients who have undergone EBRT. We cross-referenced these patients with the electronic medical record to identify patients who required PVP or TURP after radiation. The primary outcome was the need for any further intervention after PVP or TURP, including bladder neck incision, repeat TURP, or permanent supravesicular diversion.

RESULTS

Sixty of the 3600 patients (1.7%) required prostate reduction surgery after brachytherapy. Of these 60 patients, 19 of 40 (47.5%) who underwent TURP required further intervention, and 10 of 20 patients (50%) who underwent PVP required subsequent intervention. Twenty-eight of the 2500 patients (1.1%) required prostate reduction surgery after EBRT. Of these 28 patients, 5 of 18 patients (27.8%) who underwent TURP required further intervention, and 5 of 10 patients (50%) who underwent PVP required subsequent intervention. Following either type of radiation there was not a significant difference in the need for further treatment based on the type of surgery (P >.999 for brachytherapy; P = .412 for EBRT). The median time between radiation and prostate reduction surgery is 20.2 months (range, 14.6-27.6) after brachytherapy and 53.3 months (range, 27.5-53.3) after EBRT (P = .0005).

CONCLUSION

This study suggests that PVP and TURP are comparable in treating prostatic obstruction after brachytherapy or EBRT. However, obstruction after brachytherapy occurs earlier compared with after EBRT.

Cloning of a Candida utilis gene which complements leu2 mutation in Saccharomyces cerevisiae

DNA fragments containing the LEU2 gene of Candida utilis have been isolated, utilizing the genome library (constructed in YRp12) of this organism. Two recombinant plasmids pZR84 and pZR32, containing the cloned LEU2 gene, were 4.24 kb and 10.4 kb, respectively, and were shown to complement leu2 mutation in Saccharomyces cerevisiae and leuB mutation in Escherichia coli. The cloned fragment in pZR84 contained one restriction site each for EcoRI and PvuII, and two for HindIII, but none for SalI, BamHI or PstI. This cloned fragment hybridized with the total DNA from C. utilis and from Leu+ transformants of S. cerevisiae, but not with that from untransformed S. cerevisiae. Subcloning analyses showed that a 2.34 kb BamHI-HindIII fragment of the cloned C. utilis sequence contains the region essential for the expression of the LEU2 gene.

Intensity modulated radiation therapy with pulsed reduced dose rate as a reirradiation strategy for recurrent central nervous system tumors: An institutional series and literature review

BACKGROUND

Pulsed reduced dose rate (PRDR) is a reirradiation technique that potentially overcomes volume and dose limitations in the setting of previous radiation therapy for recurrent central nervous system (CNS) tumors. Intensity modulated radiation therapy (IMRT) has not yet been reported as a PRDR delivery technique. We reviewed our IMRT PRDR outcomes and toxicity and reviewed the literature of available PRDR series for CNS reirradiation.

METHODS AND MATERIALS

A total of 24 patients with recurrent brain tumors received PRDR reirradiation between August 2012 and December 2014. Twenty-two patients were planned with IMRT. Linear accelerators delivered an effective dose rate of 0.0667 Gy/minute. Data collected included number of prior interventions, diagnosis, tumor grade, radiation therapy dose and fractionation, normal tissue dose, radiation therapy planning parameters, time to progression, overall survival, and adverse events.

RESULTS

The median time to PRDR from completion of initial radiation therapy was 47.8 months (range, 11-389.1 months). The median PRDR dose was 54 Gy (range, 38-60 Gy). The mean planning target volume was 369.1 ± 177.9 cm³. The median progression-free survival and 6-month progression-free survival after PRDR treatment was 3.1 months and 31%, respectively. The median overall survival and 6-month overall survival after PRDR treatment was 8.7 months and 71%, respectively. Fifty percent of patients had ≥4 chemotherapy regimens before PRDR. Toxicity was similar to initial treatment, including no cases of radiation necrosis.

CONCLUSION

IMRT PRDR reirradiation is a feasible and appropriate treatment strategy for large volume recurrent CNS tumors resulting in acceptable overall survival with reasonable toxicity in our patients who were heavily pretreated. Prospective studies are necessary to determine the optimal timing of PRDR reirradiation, the role of concurrent systemic agents, and the ideal patient population who would receive the maximal benefit from this treatment approach.

SUMMARY

Intensity modulated radiation therapy (IMRT) has not yet been reported as a pulsed reduced dose rate (PRDR) delivery technique for recurrent brain tumors and may allow for safe and comprehensive reirradiation for large volume tumors. We reviewed our IMRT PRDR outcomes and toxicity and reviewed the literature of available PRDR series for recurrent central nervous system tumors. We conclude that IMRT PRDR reirradiation is a feasible and appropriate treatment strategy for large volume recurrent brain tumors resulting in acceptable overall survival with reasonable toxicity in our patients who were heavily pretreated.

Association of Treatment Strategies and Tumor Characteristics With Overall Survival Among Patients With Anaplastic Thyroid Cancer: A Single-Institution 21-Year Experience

Importance

Survival outcomes for anaplastic thyroid cancer (ATC), the most aggressive subtype of thyroid cancers, have remained poor. However, targeted therapies and immunotherapies present new opportunities for treatment of this disease. Evaluations of survival outcomes over time with new multimodal therapies are needed for optimizing treatment plans.

Objective

To evaluate the association of treatment strategies and tumor characteristics with overall survival (OS) among patients with ATC.

Design, Setting, and Participants

This retrospective case series study evaluated the survival outcomes stratified by treatment strategies and tumor characteristics among patients with ATC treated at a tertiary level academic institution from January 1, 2000, to December 31, 2021. Demographic, tumor, treatment, and outcome characteristics were analyzed. Kaplan-Meier method and log rank test modeled OS by treatment type and tumor characteristics. Data were analyzed in May 2022.

Main Outcomes and Measures

Overall survival (OS).

Results

The study cohort comprised 97 patients with biopsy-proven ATC (median [range] age at diagnosis, 70 [38-93] years; 60 (62%) female and 85 [88%] White individuals; 59 [61%] never smokers). At ATC diagnosis, 18 (19%) patients had stage IVA, 19 (20%) had stage IVB, and 53 (55%) had stage IVC disease. BRAF status was assessed in 38 patients; 18 (47%) had BRAF-V600E variations and 20 (53%), BRAF wild type. Treatment during clinical course included surgery for 44 (45%) patients; chemotherapy, 41 (43%); definitive or adjuvant radiation therapy, 34 (RT; 35%); and targeted therapy, 28 (29%). Median OS for the total cohort was 6.5 (95% CI, 4.3-10.0) months. Inferior OS was found in patients who did not receive surgery (hazard ratio [HR], 2.12; 95% CI, 1.35-3.34; reference, received surgery), chemotherapy (HR, 3.28; 95% CI, 1.99-5.39; reference, received chemotherapy), and definitive or adjuvant RT (HR, 2.47; 95% CI, 1.52-4.02; reference, received definitive/adjuvant RT). On multivariable analysis, age at diagnosis (HR, 1.03; 95% CI, 1.01-1.06), tumor stage IVC (HR, 2.65; 95% CI, 1.35-5.18), and absence of definitive or adjuvant RT (HR, 1.90; 95% CI, 1.01-3.59) were associated with worse OS.

Conclusions and Relevance

This retrospective single-institution study found that lower tumor stage, younger age, and the ability to receive definitive or adjuvant RT were associated with improved OS in patients with ATC.

ERBB2 Amplification and HER2 Expression in Salivary Duct Carcinoma: Evaluation of Scoring Guidelines and Potential for Expanded Anti-HER2 Therapy

Salivary duct carcinoma (SDC) is aggressive with limited therapeutic options. A subset of SDC display human epidermal growth factor receptor 2 (HER2) protein overexpression by immunohistochemistry, and some show ERBB2 gene amplification. Guidelines for HER2 scoring are not firmly established. Recent advances in breast carcinoma have established a role for anti-HER2 therapies in lesions with low HER2 expression lacking ERBB2 amplification. Delineating HER2 staining patterns in SDC is critical for evaluating anti-HER2 treatments. In total, 53 cases of SDC resected at our institution between 2004 and 2020 were identified. Androgen receptor (AR) and HER2 immunohistochemistry and ERBB2 fluorescence in situ hybridization were performed in all cases. AR expression was scored for percentage positive cells and categorized as positive (>10% of cells), low positive (1%-10%), or negative (<1%). HER2 staining levels and patterns were recorded, scored using 2018 ASCO/CAP guidelines, and categorized into HER2-positive (3+ or 2+ with ERBB2 amplification), HER2-low (1+ or 2+ without ERBB2 amplification), HER2-very low (faint staining in <10% of cells), or HER2-absent types. Clinical parameters and vital status were recorded. Median age was 70 years, with a male predominance. ERBB2-amplified tumors (11/53; 20.8%) presented at lower pT stages (pTis/pT1/pT2; P = .005, Fisher exact test) and more frequently had perineural invasion (P = .007, Fisher exact test) compared with ERBB2 nonamplified tumors; no other pathologic features differed significantly by gene amplification status. In addition, 2+ HER2 staining by 2018 ASCO/CAP criteria was most common (26/53; 49%); only 4 cases (8%) were HER2-absent status; 3+ HER2 staining was found in 9 tumors, and all were ERBB2 amplified. Six patients with HER2-expressing tumors received trastuzumab therapy, including 2 with ERBB2-amplified tumors. Overall survival and recurrence-free survival did not differ significantly based on ERBB2 status. This work suggests that 2018 ASCO/CAP guidelines for HER2 evaluation in breast carcinoma could be applied to SDC. Our findings also show broad overexpression of HER2 in SDC raising the possibility that more patients may benefit from anti-HER2-directed therapies.

Adjuvant versus neoadjuvant androgen deprivation with radiotherapy for prostate cancer: does sequencing matter?

INTRODUCTION/BACKGROUND

Androgen deprivation therapy (ADT) is typically provided neoadjuvantly and concurrently with radiotherapy (RT) in the management of intermediate and high-risk prostate cancer. Our objective was to compare outcomes between patients who received adjuvant ADT (ADJ), ie, immediately after the completion of RT, to those who received a neoadjuvant and concurrent regimen (NEO).

MATERIALS AND METHODS

From 1995 to 2002, 515 patients with prostate cancer were definitively treated with RT and ADT. NEO was provided 2 to 3 months before the start of RT (n = 311). ADJ was initiated immediately after the completion of RT (n = 204). Kaplan-Meier analysis was used to calculate biochemical relapse-free survival (bRFS), distant metastasis-free survival (DMFS), and overall survival (OS). Cox proportional hazards regression was used to examine the impact of ADT timing on outcomes.

RESULTS

Ten-year bRFS, DMFS, and OS rates were 61%, 80%, and 66%, respectively. Ten-year bRFS rates for ADJ versus NEO were 63% versus 60% (P = .98). Ten-year DMFS rates for ADJ versus NEO were both 80% (P = .60). Ten-year OS rates for ADJ versus NEO were 65% versus 67% (P = .98).

CONCLUSION

There was no significant difference in bRFS, DMFS, or OS between neoadjuvant versus adjuvant ADT in the setting of dose-escalated RT for localized prostate cancer. This suggests that the synergy between RT and androgen deprivation is independent of the sequencing of both modalities and that the initiation of RT does not need to be delayed for a course of neoadjuvant ADT.

Risk Factors for Progression Among Low-Grade Gliomas After Gross Total Resection and Initial Observation in the Molecular Era

PURPOSE

To identify risk factors for progression-free survival (PFS) in the molecular era among patients with low-grade glioma (LGG) who undergo gross total resection (GTR) followed by initial observation.

METHODS AND MATERIALS

We reviewed patients with World Health Organization grade 2 LGG treated at a single institution. We included only those who underwent magnetic resonance imaging (MRI)-confirmed GTR followed by initial observation. Molecular classification was obtained at either the time of diagnosis or pathology review. Cox proportional hazards regression, the Kaplan-Meier method, and the log-rank test were used. P values <.05 were considered statistically significant.

RESULTS

We included 144 patients who underwent MRI-confirmed GTR between 1994 and 2014 followed by initial observation. Median age was 29 years (interquartile range [IQR], 18-41), median tumor size was 2.7 cm (IQR, 1.8-4.0), and median follow-up was 81 months (IQR, 36-132). Molecular classification was 13% IDH-mutant 1p19q-codeleted; 21% IDH-mutant 1p19q-intact; 39% IDH1-R132H-wildtype; and 28% undetermined. For the entire cohort, 5- and 10-year PFS and overall survival were 71% and 53%, and 98% and 90%, respectively. On multivariate analysis, factors associated with worse PFS included increasing age at diagnosis (hazard ratio [HR], 1.05; 95% CI, 1.00-1.09; P = .03), increasing preoperative tumor size (HR, 1.07; 95% CI, 1.04-1.10; P < .0001), and IDH-mutant 1p19q-intact classification (HR, 3.18; 95% CI, 1.15-8.74, P = .025). Median PFS for patients with IDH-mutant 1p19q-codeleted, IDH-mutant 1p19q-intact, and IDH1-R132H-wildtype tumors were 113 months, 56 months, and not reached, respectively. Molecular classification was significantly associated with PFS (P < .0001) but not overall survival (P = .20).

CONCLUSIONS

Among patients with LGG who undergo MRI-confirmed GTR and initial observation in the molecular era, increasing age, increasing tumor size, and IDH-mutant 1p19q-intact classification are associated with worse PFS. Because tumor progression is associated with adverse health-related quality of life, these factors may aid clinicians and patients in the shared decision-making process regarding goals of surgery and timing of postoperative therapy. Further study is required to elucidate why IDH-mutant 1p19q-intact LGGs are at higher risk for early progression.

Failure rate in the untreated contralateral node negative neck of small lateralized oral cavity cancers: A multi-institutional collaborative study

OBJECTIVES

The importance of treating the bilateral neck in lateralized small oral cavity squamous cell carcinoma (OCC) is unclear. We sought to define the incidence and predictors of contralateral neck failure (CLF) in patients who underwent unilateral treatment.

MATERIALS AND METHODS

We performed a multi-institutional retrospective study of patients with pathologic T1-T2 (AJCC 7th edition) OCC with clinically node negative contralateral neck who underwent unilateral treatment with primary surgical resection ± adjuvant radiotherapy between 2005 and 2015. Incidence of CLF was estimated using the cumulative incidence method. Clinicopathological factors were analyzed by univariate (UVA) and multivariate analysis (MVA) for possible association with CLF. Kaplan-Meier analysis was used to estimate overall survival (OS).

RESULTS

176 patients were evaluated with a median of 65.9 months of follow-up. Predominant pathologic T-stage was T1 (68%), 8.5% of patients were N1, 2.8% were N2b. Adjuvant radiotherapy was delivered to 17% of patients. 5-year incidence of CLF was 4.3% (95% CI 1.2-7.4%). Depth of invasion (DOI) > 10 mm and positive ipsilateral neck node were significant predictors for CLF on UVA. DOI > 10 mm remained significant on MVA (HR = 6.7, 95% CI 1.4-32.3, p = 0.02). The 2- and 5-year OS was 90.6% (95% CI 86.2-95.0%) and 80.6% (95% CI 74.5-86.8%), respectively.

CONCLUSION

Observation of the clinically node negative contralateral neck in small lateralized OCC can be a suitable management approach in well selected patients, however caution should be applied when DOI upstages small but deeply invasive tumors to T3 on 8th edition AJCC staging.

Hemin-dependent growth stimulation and cytochrome synthesis in Corynebacterium pyogenes

Growth of Corynebacterium pyogenes, an important pathogen in animals, was greatly increased on addition of hemin to a medium of tryptose plus mineral. The synthesis of a type b cytochrome in this organism appeared to depend on the presence of hemin in the growth medium.

Trends in Radiation Oncology Residency Applicant Interview Experiences and Post-Interview Communication

PURPOSE

To report trends in applicant interview experiences and post-interview communication (PIC) between the 2016 and 2018 radiation oncology interview cycles.

METHODS AND MATERIALS

An anonymous survey was sent to all 203 residency applicants to a single institution during the 2018 Match, and the results were compared to a similar 2016 survey.

RESULTS

Response rates in 2018 and 2016 were 53% and 56%, respectively. Applicants from 2018 were asked less frequently than 2016 applicants about where else they were interviewing (71% vs 84%, P = .024) and how highly they planned to rank a program (11% vs 23%, P = .018). A higher proportion of 2018 programs explicitly discouraged PIC (median, 53% vs 33%, P < .0001), and more 2018 respondents chose not to send any thank-you notes/emails (42% vs 17%, P < .0001). When comparing 2018 results to 2016, no significant differences were observed in the proportion of applicants who notified their top program that they would rank that program highly (54% vs 60%, P = .354). No difference was observed in the rate of reported distress associated with a sense of obligation to send PIC (49% vs 46%, P = .664), and similar rates of respondents said they would feel relieved if PIC was discouraged (94% vs 89%, P = .223). Most respondents again reported that they would prefer a policy to actively discourage applicants from notifying their top programs of their high rank (60% vs 66%, P = .974).

CONCLUSIONS

Compared to 2016, respondents in 2018 reported that fewer programs are engaging in potential Match violations, and more are actively discouraging PIC, possibly as a result of increased awareness from recent publications. A similar number of applicants continued to engage in "gamesmanship," but more are choosing not to send thank-you notes/emails. Most respondents continue to prefer a policy discouraging PIC.

Impact of routine surveillance imaging on detecting recurrence in human papillomavirus associated oropharyngeal cancer

OBJECTIVES

This study examines the utility of surveillance imaging in detecting locoregional failures (LRF), distant failures (DF) and second primary tumors (SPT) in patients with human papillomavirus (HPV) associated oropharyngeal cancer (OPC) after definitive chemoradiotherapy (CRT).

METHODS AND MATERIALS

An institutional database identified 225 patients with biopsy proven, non- metastatic HPV+ OPC treated with definitive CRT between 2004 and 2015, whose initial post-treatment imaging was negative for disease recurrence (DR). Two groups were defined: patients with <2 scans/year Group 1 and patients with ≥2 scans/year Group 2. The Mann-Whitney test or Chi-square was used to determine differences in baseline characteristics between groups. Fine & Gray regression was used to detect an association between imaging frequency, DR and diagnosis of SPT.

RESULTS

Median follow up was 40.8 months. 30% of patients had ≥T3 disease and 90% had ≥ N2 disease (AJCC 7th edition). Twenty one failures (9.3%) were observed, 7 LRF and 15 DF. Six LRF occurred within 24 months and 14 DF occurred within 36 months of treatment completion. Regression analysis showed Group 2 had increased risk of DR compared to Group1 (HR 10.3; p = 0.002) albeit with more advanced disease at baseline. Five SPT were found (2 lung, 2 esophagus, and 1 oropharynx) between 4.5 and 159 months post-CRT.

CONCLUSION

Surveillance imaging seems most useful in the first 2-3 years post treatment, and is particularly important in detecting DF. Surveillance scans for SPT has a low yield, but should be considered for those meeting lung cancer screening guidelines.