1
|
Cao LM, Zhong NN, Chen Y, Li ZZ, Wang GR, Xiao Y, Liu XH, Jia J, Liu B, Bu LL. Less is more: Exploring neoadjuvant immunotherapy as a de-escalation strategy in head and neck squamous cell carcinoma treatment. Cancer Lett 2024; 598:217095. [PMID: 38964728 DOI: 10.1016/j.canlet.2024.217095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 06/15/2024] [Accepted: 06/28/2024] [Indexed: 07/06/2024]
Abstract
Head and neck squamous cell carcinoma (HNSCC) constitutes a significant global cancer burden, given its high prevalence and associated mortality. Despite substantial progress in survival rates due to the enhanced multidisciplinary approach to treatment, these methods often lead to severe tissue damage, compromised function, and potential toxicity. Thus, there is an imperative need for novel, effective, and minimally damaging treatment modalities. Neoadjuvant treatment, an emerging therapeutic strategy, is designed to reduce tumor size and curtail distant metastasis prior to definitive intervention. Currently, neoadjuvant chemotherapy (NACT) has optimized the treatment approach for a subset of HNSCC patients, yet it has not produced a noticeable enhancement in overall survival (OS). In the contemporary cancer therapeutics landscape, immunotherapy is gaining traction at an accelerated pace. Notably, neoadjuvant immunotherapy (NAIT) has shown promising radiological and pathological responses, coupled with encouraging efficacy in several clinical trials. This potentially paves the way for a myriad of possibilities in treatment de-escalation of HNSCC, which warrants further exploration. This paper reviews the existing strategies and efficacies of neoadjuvant immune checkpoint inhibitors (ICIs), along with potential de-escalation strategies. Furthermore, the challenges encountered in the context of the de-escalation strategies of NAIT are explored. The aim is to inform future research directions that strive to improve the quality of life (QoL) for patients battling HNSCC.
Collapse
Affiliation(s)
- Lei-Ming Cao
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Somatology, School & Hospital of Stomatology, Wuhan University, Wuhan, 430079, China
| | - Nian-Nian Zhong
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Somatology, School & Hospital of Stomatology, Wuhan University, Wuhan, 430079, China
| | - Yang Chen
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Somatology, School & Hospital of Stomatology, Wuhan University, Wuhan, 430079, China
| | - Zi-Zhan Li
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Somatology, School & Hospital of Stomatology, Wuhan University, Wuhan, 430079, China
| | - Guang-Rui Wang
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Somatology, School & Hospital of Stomatology, Wuhan University, Wuhan, 430079, China
| | - Yao Xiao
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Somatology, School & Hospital of Stomatology, Wuhan University, Wuhan, 430079, China
| | - Xuan-Hao Liu
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Somatology, School & Hospital of Stomatology, Wuhan University, Wuhan, 430079, China
| | - Jun Jia
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Somatology, School & Hospital of Stomatology, Wuhan University, Wuhan, 430079, China; Department of Oral & Maxillofacial Head Neck Oncology, School & Hospital of Stomatology, Wuhan University, Wuhan, 430079, China.
| | - Bing Liu
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Somatology, School & Hospital of Stomatology, Wuhan University, Wuhan, 430079, China; Department of Oral & Maxillofacial Head Neck Oncology, School & Hospital of Stomatology, Wuhan University, Wuhan, 430079, China.
| | - Lin-Lin Bu
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Somatology, School & Hospital of Stomatology, Wuhan University, Wuhan, 430079, China; Department of Oral & Maxillofacial Head Neck Oncology, School & Hospital of Stomatology, Wuhan University, Wuhan, 430079, China.
| |
Collapse
|
2
|
de Leeuw ALMP, Giralt J, Tao Y, Benavente S, France Nguyen TV, Hoebers FJP, Hoeben A, Terhaard CHJ, Wai Lee L, Friesland S, Steenbakkers RJHM, Tans L, Heukelom J, Kayembe MT, van Kranen SR, Bartelink H, Rasch CRN, Sonke JJ, Hamming-Vrieze O. A multicentric randomized controlled phase III trial of adaptive and 18F-FDG-PET-guided dose-redistribution in locally advanced head and neck squamous cell carcinoma (ARTFORCE). Radiother Oncol 2024; 196:110281. [PMID: 38636708 DOI: 10.1016/j.radonc.2024.110281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 03/16/2024] [Accepted: 04/11/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND AND PURPOSE This multicenter randomized phase III trial evaluated whether locoregional control of patients with LAHNSCC could be improved by fluorodeoxyglucose-positron emission tomography (FDG-PET)-guided dose-escalation while minimizing the risk of increasing toxicity using a dose-redistribution and scheduled adaptation strategy. MATERIALS AND METHODS Patients with T3-4-N0-3-M0 LAHNSCC were randomly assigned (1:1) to either receive a dose distribution ranging from 64-84 Gy/35 fractions with adaptation at the 10thfraction (rRT) or conventional 70 Gy/35 fractions (cRT). Both arms received concurrent three-cycle 100 mg/m2cisplatin. Primary endpoints were 2-year locoregional control (LRC) and toxicity. Primary analysis was based on the intention-to-treat principle. RESULTS Due to slow accrual, the study was prematurely closed (at 84 %) after randomizing 221 eligible patients between 2012 and 2019 to receive rRT (N = 109) or cRT (N = 112). The 2-year LRC estimate difference of 81 % (95 %CI 74-89 %) vs. 74 % (66-83 %) in the rRT and cRT arm, respectively, was not found statistically significant (HR 0.75, 95 %CI 0.43-1.31,P=.31). Toxicity prevalence and incidence rates were similar between trial arms, with exception for a significant increased grade ≥ 3 pharyngolaryngeal stenoses incidence rate in the rRT arm (0 versus 4 %,P=.05). In post-hoc subgroup analyses, rRT improved LRC for patients with N0-1 disease (HR 0.21, 95 %CI 0.05-0.93) and oropharyngeal cancer (0.31, 0.10-0.95), regardless of HPV. CONCLUSION Adaptive and dose redistributed radiotherapy enabled dose-escalation with similar toxicity rates compared to conventional radiotherapy. While FDG-PET-guided dose-escalation did overall not lead to significant tumor control or survival improvements, post-hoc results showed improved locoregional control for patients with N0-1 disease or oropharyngeal cancer treated with rRT.
Collapse
Affiliation(s)
- Anna Liza M P de Leeuw
- Department of Radiation Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
| | - Jordi Giralt
- Department of Radiation Oncology, Hospital General Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Yungan Tao
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Sergi Benavente
- Department of Radiation Oncology, Hospital General Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | | | - Frank J P Hoebers
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ann Hoeben
- Division of Medical Oncology, Department of Internal Medicine, GROW-School of Oncology and Developmental Biology Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Chris H J Terhaard
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lip Wai Lee
- Department of Radiation Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Signe Friesland
- Department of Radiation Oncology, Karolinska Institute, Stockholm, Sweden
| | - Roel J H M Steenbakkers
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Lisa Tans
- Department of Radiation Oncology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jolien Heukelom
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Mutamba T Kayembe
- Department of Bioinformatics and Statistics, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Simon R van Kranen
- Department of Radiation Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Harry Bartelink
- Department of Radiation Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Coen R N Rasch
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Olga Hamming-Vrieze
- Department of Radiation Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
| |
Collapse
|
3
|
Li X, González-Maroto C, Tavassoli M. Crosstalk between CAFs and tumour cells in head and neck cancer. Cell Death Discov 2024; 10:303. [PMID: 38926351 PMCID: PMC11208506 DOI: 10.1038/s41420-024-02053-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 06/28/2024] Open
Abstract
Head and neck squamous cell carcinomas (HNSCCs) are amongst the most aggressive, complex, and heterogeneous malignancies. The standard of care treatments for HNC patients include surgery, radiotherapy, chemotherapy, or their combination. However, around 50% do not benefit while suffering severe toxic side effects, costing the individuals and society. Decades have been spent to improve HNSCC treatment outcomes with only limited success. Much of the research in HNSCC treatment has focused on understanding the genetics of the HNSCC malignant cells, but it has become clear that tumour microenvironment (TME) plays an important role in the progression as well as treatment response in HNSCC. Understanding the crosstalk between cancer cells and TME is crucial for inhibiting progression and treatment resistance. Cancer-associated fibroblasts (CAFs), the predominant component of stroma in HNSCC, serve as the primary source of extra-cellular matrix (ECM) and various pro-tumoral composites in TME. The activation of CAFs in HNSCC is primarily driven by cancer cell-secreted molecules, which in turn induce phenotypic changes, elevated secretive status, and altered ECM production profile. Concurrently, CAFs play a pivotal role in modulating the cell cycle, stemness, epithelial-mesenchymal transition (EMT), and resistance to targeted and chemoradiotherapy in HNSCC cells. This modulation occurs through interactions with secreted molecules or direct contact with the ECM or CAF. Co-culture and 3D models of tumour cells and other TME cell types allows to mimic the HNSCC tumour milieu and enable modulating tumour hypoxia and reprograming cancer stem cells (CSC). This review aims to provide an update on the development of HNSCC tumour models comprising CAFs to obtain better understanding of the interaction between CAFs and tumour cells, and for providing preclinical testing platforms of current and combination with emerging therapeutics.
Collapse
Affiliation(s)
- Xinyang Li
- Head and Neck Oncology Group, Centre for Host Microbiome Interaction, King's College London, Hodgkin Building, London, SE1 1UL, UK
| | - Celia González-Maroto
- Head and Neck Oncology Group, Centre for Host Microbiome Interaction, King's College London, Hodgkin Building, London, SE1 1UL, UK
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mahvash Tavassoli
- Head and Neck Oncology Group, Centre for Host Microbiome Interaction, King's College London, Hodgkin Building, London, SE1 1UL, UK.
| |
Collapse
|
4
|
Liu Z, Wang H, Xu Y, Wei H, Zhang Y, Dong H. Oropharyngeal cancer and human papillomavirus: a visualization based on bibliometric analysis and topic modeling. Front Microbiol 2024; 15:1387679. [PMID: 38919494 PMCID: PMC11197978 DOI: 10.3389/fmicb.2024.1387679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 04/30/2024] [Indexed: 06/27/2024] Open
Abstract
Objectives The incidence of oropharyngeal cancer (OPC) is increasing. This study used bibliometric analysis and topic modeling to explore the research trends and advancements in this disease over the past 10 years, providing valuable insights to guide future investigations. Methods 7,355 English articles from 2013 to 2022 were retrieved from the Web of Science Core Collection for bibliometric analysis. Topic modeling was applied to 1,681 articles from high-impact journals, followed by an assessment of topic significance ranking (TSR). Medical Subject Headings (MeSH) terms were extracted using R and Python, followed by an analysis of the terms associated with each topic and on an annual basis. Additionally, genes were extracted and the number of genes appearing each year and the newly emerged genes were counted. Results The bibliometric analysis suggested that the United States and several European countries hold pivotal positions in research. Current research is focused on refining treatments, staging and stratification. Topic modeling revealed 12 topics, emphasizing human papillomavirus (HPV) and side effect reduction. MeSH analysis revealed a growing emphasis on prognosis and quality of life. No new MeSH terms emerged after 2018, suggesting that the existing terms have covered most of the core concepts within the field of oropharyngeal cancers. Gene analysis identified TP53 and EGFR as the most extensively studied genes, with no novel genes discovered after 2019. However, CD69 and CXCL9 emerged as new genes of interest in 2019, reflecting recent research trends and directions. Conclusion HPV-positive oropharyngeal cancer research, particularly treatment de-escalation, has gained significant attention. However, there are still challenges in diagnosis and treatment that need to be addressed. In the future, more research will focus on this issue, indicating that this field still holds potential as a research hotspot.
Collapse
Affiliation(s)
- Zhu Liu
- Department of Head and Neck Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Haixu Wang
- Department of Abdominal Osteomalacia Radiotherapy, Cancer hospital of China Medical University/Liaoning Cancer hospital and Institute, Shenyang, China
- Department of Medical Oncology, the First Hospital of China Medical University, Shenyang, China
| | - Yang Xu
- Department of Head and Neck Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Hongming Wei
- Department of Head and Neck Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Yuchong Zhang
- Department of Medical Oncology, the First Hospital of China Medical University, Shenyang, China
| | - Huilei Dong
- Department of Head and Neck Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital & Institute, Shenyang, China
| |
Collapse
|
5
|
Panwar A, Shah S, Reid AE, Lydiatt W, Holcomb AJ, Osmolak A, Coughlin A, Militsakh O, Su YB, Mirmiran A, Huang TS, Nolan N, Duckert R, Barney C, Chiu M, Nguyen C, Sayles H, Ganti AK, Lindau R. Quality of Life and Depression Symptoms After Therapy De-Escalation in HPV+ Oropharyngeal Squamous Cell Carcinoma: A Nonrandomized Controlled Trial. JAMA Otolaryngol Head Neck Surg 2024; 150:429-435. [PMID: 38573597 PMCID: PMC11082684 DOI: 10.1001/jamaoto.2024.0262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 02/03/2024] [Indexed: 04/05/2024]
Abstract
Importance Despite interest in therapy de-escalation for survivors of human papillomavirus-mediated oropharyngeal squamous cell carcinoma (HPV-positive OPSCC), the association of de-escalated therapy with patient-reported quality of life (QoL) outcomes and burden of depressive symptoms remains unclear. Objective To identify associations between clinicopathologic and therapeutic variables with patient-reported QoL outcomes and depression symptom burden in patients with HPV-positive OPSCC, who were enrolled in a therapy de-escalation trial. Design, Setting, and Participants In this nonrandomized controlled, open-label, curative-intent therapy de-escalation clinical trial in adults with stage I, II, and III HPV-positive OPSCC, patients were recruited from a high-volume head and neck oncology practice. Main Outcomes and Measures The main outcomes of this study included quantitative, patient-reported QoL and depression symptoms per well-validated inventories. Patient-reported QoL was based on Functional Assessment of Cancer Therapy-Head & Neck (FACT-HN) scores (range, 0-148; lower score indicates inferior QoL). Patient-reported depression-related symptom burden was based on Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR) scores (range, 0-27; a higher score indicates a higher burden of depression symptoms). Baseline clinicopathologic and treatment variables were paired with FACT-HN and QIDS-SR scores at baseline, 3, 6, 12, 24, and 36 months. Linear mixed-effect models with a random intercept were used for each participant and fixed effects for other measures. Regression coefficients are reported with 95% CIs. Results A total of 95 patients were followed up for a median (IQR) of 2.2 (1.6-3.2) years. Of these, 93 patients (98%) were male with a mean (SD) age of 60.5 (8.2) years. Overall, 54 participants (57%) had a history of current or former smoking, 47 (50%) underwent curative-intent surgery (with or without adjuvant therapy), and 48 (50%) underwent primary radiotherapy (with or without chemotherapy). The median (IQR) radiotherapy dose was 60 (60-70) Gy. Five deaths and 2 recurrence events were observed (mean [SD] recurrence interval, 1.4 [1.5] years). A higher radiotherapy dose was the only modifiable factor associated with inferior patient-reported QoL (lower FACT-HN) (coefficient, -0.66 [95% CI, -1.09 to -0.23]) and greater burden of depression-related symptoms (higher QIDS-SR) (coefficient, 0.11 [95% CI, 0.04-0.19]). With the 70-Gy dose as reference, improvements in FACT-HN and QIDS-SR scores were identified when patients received 51 to 60 Gy (coefficient, 12.75 [95% CI, 4.58-20.92] and -2.17 [-3.49 to -0.85], respectively) and 50 Gy or lower (coefficient, 15.03 [4.36-25.69] and -2.80 [-4.55 to -1.04]). Conclusions and Relevance In this nonrandomized controlled, open-label, curative-intent therapy de-escalation trial, a higher radiotherapy dose was associated with inferior patient-reported QoL and a greater burden of depression-related symptoms. This suggests opportunities for improved QoL outcomes and reduced depression symptom burden with a reduction in radiotherapy dose. Trial Registration ClinicalTrials.gov Identifier: NCT04638465.
Collapse
Affiliation(s)
- Aru Panwar
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska
- Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Swapnil Shah
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska
| | - Abigail E. Reid
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska
| | - William Lydiatt
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska
- Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Andrew J. Holcomb
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska
- Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Angela Osmolak
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska
- Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Andrew Coughlin
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska
- Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Oleg Militsakh
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska
- Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Yungpo B. Su
- Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Alireza Mirmiran
- Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Tien-Shew Huang
- Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Nicole Nolan
- Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Randall Duckert
- Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Christian Barney
- Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Max Chiu
- Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Cam Nguyen
- Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| | - Harlan Sayles
- College of Public Health, University of Nebraska Medical Center, Omaha
| | - Apar Kishor Ganti
- Department of Internal Medicine, VA Nebraska Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | - Robert Lindau
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska
- Methodist Estabrook Cancer Center, Nebraska Methodist Hospital, Omaha
| |
Collapse
|
6
|
Plonowska-Hirschfeld KA, Gulati A, Stephens EM, Ochoa E, Xu MJ, Ha PK, Heaton CM, Yom SS, Chan JW, Algazi A, Kang H, Ryan WR. Treatment Modality Impact on Patient-Reported Quality of Life in Human Papilloma Virus-Associated Oropharyngeal Carcinoma. Laryngoscope 2024; 134:1687-1695. [PMID: 37767815 DOI: 10.1002/lary.31065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/11/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE To prospectively compare the impact of treatment modality on patient-reported quality of life (QOL) in human papillomavirus-associated oropharynx squamous cell carcinoma (HPV + OPSCC). STUDY DESIGN Prospective cohort study. SETTING Academic medical center. METHODS One hundred one patients with American Joint Committee on Cancer (AJCC) 8th edition T1-3 N0-2 HPV + OPSCC completed the European Organization for Research and Treatment of Cancer Quality of Life Core questionnaire and Head and Neck Module pretreatment and 3-month and 1-year posttreatment. Mean score changes were compared to published minimal clinically important differences. RESULTS Patients underwent surgery alone (SA: N = 42, 42%), surgery with adjuvant radiation (S-RT: N = 10, 10%), surgery with adjuvant chemoradiation (S-CRT: N = 8, 8%), definitive radiation (RT: N = 11, 11%), or definitive chemoradiation (CRT: N = 30, 30%). SA, S-[C]RT, and [C]RT patients all reported clinically significant difficulty with sense of taste/smell persisting at 1 year. S-[C]RT and [C]RT patients reported statistically and clinically significant worse salivary dysfunction and problems with social eating at 1 year than SA. S-[C]RT patients reported statistically and clinically significant worse fatigue and head and neck pain compared to [C]RT and SA patients at 3 months, but normalized at 1 year. S-CRT compared to S-RT had statistically and clinically worse physical and role functioning and swallowing difficulties at 3 months but this difference was resolved by 1-year posttreatment. CONCLUSION HPV + OPSCC patients after SA report the lowest posttreatment QOL impact, whereas after S-CRT report the highest symptom burden. Careful selection for definitive surgery is important given the possibility of adjuvant CRT. Patients can experience persistent sense taste and smell difficulties at 1 year with all treatment modalities. LEVEL OF EVIDENCE 3 Laryngoscope, 134:1687-1695, 2024.
Collapse
Affiliation(s)
- Karolina A Plonowska-Hirschfeld
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Arushi Gulati
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Erika M Stephens
- University of California- San Francisco School of Medicine, San Francisco, California, U.S.A
| | - Edgar Ochoa
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Mary Jue Xu
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Patrick K Ha
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Chase M Heaton
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Sue S Yom
- Department of Radiation Oncology, University of California-San Francisco, San Francisco, California, U.S.A
| | - Jason W Chan
- Department of Radiation Oncology, University of California-San Francisco, San Francisco, California, U.S.A
| | - Alain Algazi
- Department of Hematology and Oncology, University of California-San Francisco, San Francisco, California, U.S.A
| | - Hyunseok Kang
- Department of Hematology and Oncology, University of California-San Francisco, San Francisco, California, U.S.A
| | - William R Ryan
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| |
Collapse
|
7
|
Bouassaly J, Karimi N, Kowalski LP, Sultanem K, Alaoui-Jamali M, Mlynarek A, Mascarella M, Hier M, Sadeghi N, da Silva SD. Rethinking treatment paradigms: Neoadjuvant therapy and de-escalation strategies in HPV-positive head and neck cancer. Crit Rev Oncol Hematol 2024; 196:104326. [PMID: 38479584 DOI: 10.1016/j.critrevonc.2024.104326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 02/27/2024] [Accepted: 03/07/2024] [Indexed: 03/24/2024] Open
Abstract
Head and neck cancer (HNC) is the 6th most common cancer across the world, with a particular increase in HNC associated with human papilloma virus (HPV) among younger populations. Historically, the standard treatment for this disease consisted of combined surgery and radiotherapy or curative platinum-based concurrent chemoradiotherapy, with associated long term and late toxicities. However, HPV-positive HNC is recognized as a unique cancer subtype, typically with improved clinical outcomes. As such, treatment de-escalation strategies have been widely researched to mitigate the adverse effects associated with the current standard of care without compromising efficacy. These strategies include treatment de-escalation, such as novel surgical techniques, alternative radiation technologies, radiation dose and volume reduction, as well as neoadjuvant chemotherapies, immunotherapies, and combined therapies. Although these therapies show great promise, many of them are still under investigation due to hesitation surrounding their widespread implementation. The objective of this review is to summarize the most recent progress in de-escalation strategies and neoadjuvant therapies designed for HPV-positive HNC. While specific treatments may require additional research before being widely adopted, encouraging results from recent studies have highlighted the advantages of neoadjuvant chemotherapy and immunotherapy, as well as radiation and surgical de-escalation approaches in managing HPV-positive HNC.
Collapse
Affiliation(s)
- Jenna Bouassaly
- Division of Experimental Medicine, McGill University, Montreal QC H4A 3J1, Canada; Segal Cancer Centre and Lady Davis Institute for Medical Research, Sir Mortimer B. Davis-Jewish General Hospital, Montreal QC H3T 1E2, Canada
| | - Naser Karimi
- Department of Otolaryngology Head and Neck Surgery, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal QC H3T 1E2, Canada
| | - Luiz Paulo Kowalski
- AC Camargo Cancer Center, Faculty of Medicine - University of Sao Paulo, Sao Paulo, Brazil
| | - Khalil Sultanem
- Department of Otolaryngology Head and Neck Surgery, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal QC H3T 1E2, Canada
| | - Moulay Alaoui-Jamali
- Division of Experimental Medicine, McGill University, Montreal QC H4A 3J1, Canada; Segal Cancer Centre and Lady Davis Institute for Medical Research, Sir Mortimer B. Davis-Jewish General Hospital, Montreal QC H3T 1E2, Canada
| | - Alex Mlynarek
- Department of Otolaryngology Head and Neck Surgery, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal QC H3T 1E2, Canada
| | - Marco Mascarella
- Department of Otolaryngology Head and Neck Surgery, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal QC H3T 1E2, Canada
| | - Michael Hier
- Department of Otolaryngology Head and Neck Surgery, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal QC H3T 1E2, Canada
| | - Nader Sadeghi
- Department of Otolaryngology Head and Neck Surgery, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal QC H3T 1E2, Canada
| | - Sabrina Daniela da Silva
- Division of Experimental Medicine, McGill University, Montreal QC H4A 3J1, Canada; Department of Otolaryngology Head and Neck Surgery, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal QC H3T 1E2, Canada; Segal Cancer Centre and Lady Davis Institute for Medical Research, Sir Mortimer B. Davis-Jewish General Hospital, Montreal QC H3T 1E2, Canada; AC Camargo Cancer Center, Faculty of Medicine - University of Sao Paulo, Sao Paulo, Brazil.
| |
Collapse
|
8
|
Yarbrough WG, Schrank TP, Burtness BA, Issaeva N. De-Escalated Therapy and Early Treatment of Recurrences in HPV-Associated Head and Neck Cancer: The Potential for Biomarkers to Revolutionize Personalized Therapy. Viruses 2024; 16:536. [PMID: 38675879 PMCID: PMC11053602 DOI: 10.3390/v16040536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Human papillomavirus-associated (HPV+) head and neck squamous cell carcinoma (HNSCC) is the most common HPV-associated cancer in the United States, with a rapid increase in incidence over the last two decades. The burden of HPV+ HNSCC is likely to continue to rise, and given the long latency between infection and the development of HPV+ HNSCC, it is estimated that the effect of the HPV vaccine will not be reflected in HNSCC prevalence until 2060. Efforts have begun to decrease morbidity of standard therapies for this disease, and its improved characterization is being leveraged to identify and target molecular vulnerabilities. Companion biomarkers for new therapies will identify responsive tumors. A more basic understanding of two mechanisms of HPV carcinogenesis in the head and neck has identified subtypes of HPV+ HNSCC that correlate with different carcinogenic programs and that identify tumors with good or poor prognosis. Current development of biomarkers that reliably identify these two subtypes, as well as biomarkers that can detect recurrent disease at an earlier time, will have immediate clinical application.
Collapse
Affiliation(s)
- Wendell G. Yarbrough
- Department of Otolaryngology/Head and Neck Surgery, UNC School of Medicine, Chapel Hill, NC 27599, USA; (T.P.S.); (N.I.)
- Department of Pathology and Lab Medicine, UNC School of Medicine, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - Travis P. Schrank
- Department of Otolaryngology/Head and Neck Surgery, UNC School of Medicine, Chapel Hill, NC 27599, USA; (T.P.S.); (N.I.)
- Lineberger Comprehensive Cancer Center, UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - Barbara A. Burtness
- Department of Medicine, Medical Oncology, Yale School of Medicine, New Haven, CT 06510, USA;
- Yale Cancer Center, Yale School of Medicine, New Haven, CT 06510, USA
| | - Natalia Issaeva
- Department of Otolaryngology/Head and Neck Surgery, UNC School of Medicine, Chapel Hill, NC 27599, USA; (T.P.S.); (N.I.)
- Department of Pathology and Lab Medicine, UNC School of Medicine, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, UNC School of Medicine, Chapel Hill, NC 27599, USA
| |
Collapse
|
9
|
Sollecito TP, Helgeson ES, Lalla RV, Treister NS, Schmidt BL, Patton LL, Lin A, Brennan MT. Reduced mouth opening in patients with head and neck cancer treated with radiation therapy: an analysis of the Clinical Registry of Dental Outcomes in Head and Neck Cancer Patients (OraRad). Oral Surg Oral Med Oral Pathol Oral Radiol 2024; 137:264-273. [PMID: 38262773 PMCID: PMC10922984 DOI: 10.1016/j.oooo.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/02/2023] [Accepted: 11/20/2023] [Indexed: 01/25/2024]
Abstract
OBJECTIVE Trismus/reduced mouth opening (RMO) is a common side effect of radiotherapy (RT) for head and neck cancer (HNC). The objective was to measure RMO, identify risk factors for RMO, and determine its impact on quality of life (QOL). STUDY DESIGN OraRad is an observational, prospective, multicenter cohort study of patients receiving curative intent RT for HNC. Interincisal mouth opening measurements (n = 565) and patient-reported outcomes were recorded before RT and every 6 months for 2 years. Linear mixed-effects models were used to evaluate change in mouth opening and assess the relationship between trismus history and change in QOL measures. RESULTS Interincisal distance decreased from a mean (SE) of 45.1 (0.42) mm at baseline to 42.2 (0.44) at 6 months, with slight recovery at 18 months (43.3, 0.46 mm) but no additional improvement by 24 months. The odds of trismus (opening <35 mm) were significantly higher at 6 months (odds ratio [OR] = 2.21, 95% CI: 1.30 to 3.76) and 12 months (OR = 1.87, 95% CI: 1.08 to 3.25) compared with baseline. Females were more likely to experience trismus at baseline and during follow-up (P < .01). Patients with oral cavity cancer had the highest risk for trismus at baseline and post-RT (P < .01). RMO was associated with higher RT dose to the primary site and receiving concomitant chemotherapy (P < .01). Trismus was associated with self-reported difficulty opening the mouth and dry mouth (P < .01). CONCLUSIONS A decrease in mouth opening is a common treatment-related toxicity after RT, with some recovery by 18 months. Trismus has a significant impact on survivor QOL.
Collapse
Affiliation(s)
| | | | - Rajesh V. Lalla
- University of Connecticut School of Dental Medicine, Farmington, CT 06030, USA
| | | | - Brian L. Schmidt
- New York University School of Dentistry, New York, NY 10010, USA
| | - Lauren L. Patton
- University of North Carolina, Adams School of Dentistry, Chapel Hill, NC 27599-7450, USA
| | - Alexander Lin
- University of Pennsylvania, Philadelphia, PA 19104, USA
| | | |
Collapse
|
10
|
Fairweather D, Taylor RM, Simões R. Choosing the right questions - A systematic review of patient reported outcome measures used in radiotherapy and proton beam therapy. Radiother Oncol 2024; 191:110071. [PMID: 38142933 DOI: 10.1016/j.radonc.2023.110071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/01/2023] [Accepted: 12/16/2023] [Indexed: 12/26/2023]
Abstract
The implementation of PROMs into clinical practice has been shown to improve quality of care. This systematic review aims to identify which PROMs are suitable for implementation within routine clinical practice in a radiotherapy or PBT service.The bibliographic databases MEDLINE, EMBASE and EMCARE were searched. Articles published between 1st January 2008 to 1st June 2023, that reported PROMs being utilised as an outcome measure were included. Inclusion criteria also included being written in English, involving human patients, aged 16 and above, receiving external beam radiotherapy or PBT for six defined tumour sites. PROMs identified within the included articles were subjected to quality assessment using the COSMIN reporting guidelines. Results are reported as per PRISMA guidelines. A total of 268 studies were identified in the search, of which 52 fulfilled the inclusion criteria. The use of 39 different PROMs was reported. The PROMs identified were mostly tumour or site-specific quality of life (n = 23) measures but also included generic cancer (n = 3), health-related quality-of-life (n = 6), and symptom specific (n = 7) measures.None of the PROMs identified received a high GRADE score for good content. There were 13 PROMs that received a moderate GRADE score. The remaining PROMs either had limited evidence of development and validation within the patient cohorts investigated, or lacked relevance or comprehensiveness needed for routine PROMs collection in a radiotherapy or PBT service.This review highlights that there are a wide variety of PROMs being utilised within radiotherapy research, but most lack specificity to radiotherapy side-effects. There is a risk that by using non-specific PROMs in clinical practice, patients might not receive the supportive care that they need.
Collapse
Affiliation(s)
- Danielle Fairweather
- Cancer Division, University College London Hospitals NHS Foundation Trust, London, UK.
| | - Rachel M Taylor
- Centre for Nurse, Midwife and Allied Health Profession Led Research (CNMAR), University College London Hospitals NHS Foundation Trust, London, UK; Department of Targeted Intervention, University College London, London, UK
| | - Rita Simões
- Cancer Division, University College London Hospitals NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK; The Royal Marsden Hospital, London, UK; Radiotherapy Trials Quality Assurance (RTTQA) group, Mount Vernon Hospital, Northwood, UK
| |
Collapse
|
11
|
Bang J, Shin HI, Kim GJ, Kim SY, Sun DI. Oncologic and functional outcomes of neoadjuvant chemotherapy followed by surgery in human papillomavirus-positive tonsillar cancer. Head Neck 2023; 45:2580-2588. [PMID: 37587905 DOI: 10.1002/hed.27482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 03/09/2023] [Accepted: 07/18/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Functional outcomes of neoadjuvant chemotherapy in human papillomavirus (HPV)-positive tonsillar cancer remained unclear. METHODS We retrospectively reviewed the medical records of HPV-positive patients with tonsillar cancer. Of 112 patients, 38 were assigned to a neoadjuvant chemotherapy group and 74 were assigned to an upfront surgery group. RESULTS Pathological analyses showed that the risks of close or positive resection margins and lymphovascular invasion were lower in patients who received neoadjuvant chemotherapy. The 5-year disease-free survival was significantly higher in the neoadjuvant chemotherapy group than in the upfront surgery group, but the 5-year overall survival was not. The time to commencement of oral feeding and the mean hospital stay were significantly shorter in the neoadjuvant chemotherapy group. The neoadjuvant chemotherapy group was more likely than the upfront surgery group to resume a regular diet. CONCLUSIONS Compared with upfront surgery, neoadjuvant chemotherapy improved the functional outcomes and 5-year disease-free survival.
Collapse
Affiliation(s)
- Jooin Bang
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyun-Il Shin
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Geun-Jeon Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang-Yeon Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong-Il Sun
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| |
Collapse
|
12
|
Mendenhall WM, Beitler JJ, Saba NF, Shaha AR, Nuyts S, Strojan P, Bollen H, Cohen O, Smee R, Ng SP, Eisbruch A, Ng WT, Kirwan JM, Ferlito A. Proton Beam Radiation Therapy for Oropharyngeal Squamous Cell Carcinoma. Int J Part Ther 2023; 9:243-252. [PMID: 37169005 PMCID: PMC10166016 DOI: 10.14338/ijpt-22-00030.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 03/10/2023] [Indexed: 05/13/2023] Open
Abstract
Purpose To discuss the role of proton beam therapy (PBT) in the treatment of patients with oropharyngeal squamous cell carcinoma (OPSCC). Materials and Methods A review of the pertinent literature. Results Proton beam therapy likely results in reduced acute and late toxicity as compared with intensity-modulated radiation therapy (IMRT). The extent of the reduced toxicity, which may be modest, depends on the endpoint and technical factors such as pencil beam versus passive scattered PBT and adaptive replanning. The disease control rates after PBT are likely similar to those after IMRT. Conclusion Proton beam therapy is an attractive option to treat patients with OPSCC. Whether it becomes widely available depends on access.
Collapse
Affiliation(s)
- William M. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jonathan J. Beitler
- Harold Alfonds Center for Cancer Care, Maine General Hospital, Augusta, ME, USA
| | - Nabil F. Saba
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Ashok R. Shaha
- Department of Head and Neck Surgery and Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sandra Nuyts
- Department of Radiation Oncology, Leuven Cancer Institute, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium
- Laboratory of Experimental Radiotherapy, Department of Oncology, University of Leuven, Leuven, Belgium
| | - Primož Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Heleen Bollen
- Department of Radiation Oncology, Leuven Cancer Institute, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium
| | - Oded Cohen
- Department of Otolaryngology - Head and Neck Surgery and Oncology, Soroka Medical Center, Tel Aviv, Affiliated with Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Robert Smee
- Department of Radiation Oncology, The Prince of Wales Cancer Centre, Sydney, NSW, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre, Austin Health, Melbourne, Australia
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan Medicine, Ann Arbor, Michigan, USA
| | - Wai Tong Ng
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Jessica M. Kirwan
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, Padua, Italy
| |
Collapse
|
13
|
Cochicho D, Nunes A, Sobral D, Gomes JP, Esteves S, Mendonça J, Vieira L, Martins L, Cunha M, Montalvão P, Magalhães M, Gil da Costa RM, Félix A. Distribution and Clinical Significance of HPV16 Variants in Head and Neck Squamous Cell Carcinomas: Data from a Portuguese Cohort and Systematic Review. Pathobiology 2023; 90:333-343. [PMID: 37040716 DOI: 10.1159/000529723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 02/10/2023] [Indexed: 04/13/2023] Open
Abstract
INTRODUCTION Genomic variants of the human papillomavirus type 16 (HPV16) are thought to play differential roles in the susceptibility to head and neck squamous cell carcinomas (HNSCC) and its biological behaviour. This study aimed to establish the prevalence of HPV16 variants in an HNSCC cohort and associate them with clinical pathological characteristics and patient survival. METHODS We retrieved samples and clinical data from 68 HNSCC patients. DNA samples were available from tumour biopsy at the time of the primary diagnosis. Targeted next-generation sequencing was used to obtain whole-genome sequences, and variants were established based on phylogenetic classification. RESULTS 74% of samples clustered in lineage A, 5.7% in lineage B, 2.9% in lineage C, and 17.1% in lineage D. Comparative genome analysis revealed 243 single nucleotide variations. Of these, one hundred were previously reported, according to our systematic review. No significant associations with clinical pathological variables or patient survival were observed. The E6 amino acid variations E31G, L83V, and D25E and E7 N29S, associated with cervical cancer, were not observed, except for N29S in a single patient. CONCLUSION These results provide a comprehensive genomic map of HPV16 in HSNCC, highlighting tissue-specific characteristics which will help design tailored therapies for cancer patients.
Collapse
Affiliation(s)
- Daniela Cochicho
- Research Department, NOVA Medical School University, Lisbon, Portugal,
- Virology Laboratory from Clinical Pathology Department, IPOLFG Portuguese Oncology Institute Francisco Gentil, Lisbon, Portugal,
| | - Alexandra Nunes
- Bioinformatics Unit, Department of Infectious Diseases, National Institute of Health, Lisbon, Portugal
| | - Daniel Sobral
- Bioinformatics Unit, Department of Infectious Diseases, National Institute of Health, Lisbon, Portugal
| | - João P Gomes
- Bioinformatics Unit, Department of Infectious Diseases, National Institute of Health, Lisbon, Portugal
| | - Susana Esteves
- Clinical Research Unit, IPOLFG Portuguese Oncology Institute Francisco Gentil, Lisbon, Portugal
| | - Joana Mendonça
- Technology and Innovation Unit, Department of Human Genetics, National Institute of Health, Lisbon, Portugal
| | - Luis Vieira
- Technology and Innovation Unit, Department of Human Genetics, National Institute of Health, Lisbon, Portugal
| | - Luís Martins
- Virology Laboratory from Clinical Pathology Department, IPOLFG Portuguese Oncology Institute Francisco Gentil, Lisbon, Portugal
| | - Mario Cunha
- Virology Laboratory from Clinical Pathology Department, IPOLFG Portuguese Oncology Institute Francisco Gentil, Lisbon, Portugal
| | - Pedro Montalvão
- Otorhinolaryngology Department, IPOLFG Portuguese Oncology Institute Francisco Gentil, Lisbon, Portugal
| | - Miguel Magalhães
- Otorhinolaryngology Department, IPOLFG Portuguese Oncology Institute Francisco Gentil, Lisbon, Portugal
| | - Rui M Gil da Costa
- LEPABE, Laboratory for Process Engineering, Environment, Biotechnology and Energy, Faculty of Engineering, University of Porto, Rua Dr Roberto Frias, Porto, Portugal
- ALiCE - Associate Laboratory in Chemical Engineering, Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias, Porto, Portugal
- Post-graduate Programme in Adult Health (PPGSAD), University Hospital (HUUFMA) and Morphology Department, Federal University of Maranhão, São Luís, Brazil
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto), Porto Comprehensive Cancer Center (Porto.CCC), Porto, Portugal
| | - Ana Félix
- Research Department, NOVA Medical School University, Lisbon, Portugal
- Pathology Department, IPOLFG Portuguese Oncology Institute Francisco Gentil, Lisbon, Portugal
| |
Collapse
|
14
|
Kang JJ, Yu Y, Chen L, Zakeri K, Gelblum DY, McBride SM, Riaz N, Tsai CJ, Kriplani A, Hung T, Fetten JV, Dunn LA, Ho A, Boyle JO, Ganly IS, Singh B, Sherman EJ, Pfister DG, Wong RJ, Lee NY. Consensuses, controversies, and future directions in treatment deintensification for human papillomavirus-associated oropharyngeal cancer. CA Cancer J Clin 2023; 73:164-197. [PMID: 36305841 PMCID: PMC9992119 DOI: 10.3322/caac.21758] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/03/2022] [Accepted: 08/09/2022] [Indexed: 01/19/2023] Open
Abstract
The most common cancer caused by human papillomavirus (HPV) infection in the United States is oropharyngeal cancer (OPC), and its incidence has been rising since the turn of the century. Because of substantial long-term morbidities with chemoradiation and the favorable prognosis of HPV-positive OPC, identifying the optimal deintensification strategy for this group has been a keystone of academic head-and-neck surgery, radiation oncology, and medical oncology for over the past decade. However, the first generation of randomized chemotherapy deintensification trials failed to change the standard of care, triggering concern over the feasibility of de-escalation. National database studies estimate that up to one third of patients receive nonstandard de-escalated treatments, which have subspecialty-specific nuances. A synthesis of the multidisciplinary deintensification data and current treatment standards is important for the oncology community to reinforce best practices and ensure optimal patient outcomes. In this review, the authors present a summary and comparison of prospective HPV-positive OPC de-escalation trials. Chemotherapy attenuation compromises outcomes without reducing toxicity. Limited data comparing transoral robotic surgery (TORS) with radiation raise concern over toxicity and outcomes with TORS. There are promising data to support de-escalating adjuvant therapy after TORS, but consensus on treatment indications is needed. Encouraging radiation deintensification strategies have been reported (upfront dose reduction and induction chemotherapy-based patient selection), but level I evidence is years away. Ultimately, stage and HPV status may be insufficient to guide de-escalation. The future of deintensification may lie in incorporating intratreatment response assessments to harness the powers of personalized medicine and integrate real-time surveillance.
Collapse
Affiliation(s)
- Jung Julie Kang
- Yale University School of Medicine, Department of Therapeutic Radiology
| | - Yao Yu
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology
| | - Linda Chen
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology
| | - Kaveh Zakeri
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology
| | | | | | - Nadeem Riaz
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology
| | - C. Jillian Tsai
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology
| | - Anuja Kriplani
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | - Tony Hung
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | - James V. Fetten
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | - Lara A. Dunn
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | - Alan Ho
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | - Jay O. Boyle
- Memorial Sloan Kettering Cancer Center, Department of Surgery
| | - Ian S. Ganly
- Memorial Sloan Kettering Cancer Center, Department of Surgery
| | - Bhuvanesh Singh
- Memorial Sloan Kettering Cancer Center, Department of Surgery
| | - Eric J. Sherman
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | | | - Richard J. Wong
- Memorial Sloan Kettering Cancer Center, Department of Surgery
| | - Nancy Y. Lee
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| |
Collapse
|
15
|
Sim NS, Shin SJ, Park I, Yoon SO, Koh YW, Kim SH, Park YM. Investigation of somatic mutation profiles and tumor evolution of primary oropharyngeal cancer and sequential lymph node metastases using multiregional whole-exome sequencing. Mol Oncol 2023. [PMID: 36852664 DOI: 10.1002/1878-0261.13407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/01/2023] [Accepted: 02/27/2023] [Indexed: 03/01/2023] Open
Abstract
Lymph node (LN) metastasis is an important factor in determining the treatment and prognosis of oropharyngeal squamous cell carcinoma (OPSCC). Here, we compared the somatic mutational profiles and clonal evolution of primary and metastatic LNs using multiregion sequencing of human papilloma virus (HPV)-positive OPSCC and HPV-negative OPSCC. We performed high-depth whole-exome sequencing (200×) of 76 samples from 18 patients with OPSCC (10 HPV-positive and 8 HPV-negative), including 18 primary tumor samples, 40 metastatic LN samples, and 18 normal tissue samples. Among 40 metastatic LNs, 22 showed extranodal extension (ENE). Mutation profiles of HPV-positive OPSCC and HPV-negative OPSCC were similar to those reported previously. Somatic mutations in CDKN2A and TP53 were frequently detected in HPV-negative OPSCC. Somatic mutations in HPV-positive OPSCC samples showed APOBEC-related signatures. Somatic mutations from metastatic LNs showed a different pattern than the primary tumor. Somatic mutations acquired in the WNT pathway during metastasis showed a significant relationship with ENE. Clonal evolution analysis of primary and metastatic LNs showed that, in some cases, each metastatic LN originated from a different primary tumor sub-clone.
Collapse
Affiliation(s)
- Nam Suk Sim
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Su-Jin Shin
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Inho Park
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.,Center for Precision Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sun Och Yoon
- Department of Pathology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yoon Woo Koh
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Se-Heon Kim
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Min Park
- Department of Otorhinolaryngology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| |
Collapse
|
16
|
Pollock AE, Arons D, Alexander GS, Alicia D, Birkman KM, Molitoris JK, Mehra R, Cullen KJ, Hatten KM, Taylor RJ, Wolf JS, Regine WF, Witek ME. Gross tumor volume margin and local control in p16-positive oropharynx cancer patients treated with intensity modulated proton therapy. Head Neck 2023; 45:1088-1096. [PMID: 36840723 DOI: 10.1002/hed.27308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 01/24/2023] [Accepted: 02/06/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND To determine if the extent of high-dose gross tumor volume (GTV) to clinical target volume (CTV) expansion is associated with local control in patients with p16-positive oropharynx cancer (p16+ OPC) treated with definitive intensity modulated proton therapy (IMPT). METHODS We performed a retrospective analysis of patients with p16+ OPC treated with IMPT at a single institution between 2016 and 2021. Patients with a pre-treatment PET-CT and restaging PET-CT within 4 months following completion of IMPT were analyzed. RESULTS Sixty patients were included for analysis with a median follow-up of 17 months. The median GTV to CTV expansion was 5 mm (IQR: 2 mm). Thirty-three percent of patients (20 of 60) did not have a GTV to CTV expansion. There was one local failure within the expansion group (3%). CONCLUSION Excellent local control was achieved using IMPT for p16+ OPC independent of GTV expansion. IMPT with minimal target expansions represent a potential harm-minimization technique for p16-positive oropharynx cancer.
Collapse
Affiliation(s)
- Ariel E Pollock
- Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Danielle Arons
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Gregory S Alexander
- Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - David Alicia
- Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Kayla M Birkman
- Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Jason K Molitoris
- Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Ranee Mehra
- Department of Medicine, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Kevin J Cullen
- Department of Medicine, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Kyle M Hatten
- Department of Otolaryngology, Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rodney J Taylor
- Department of Otolaryngology, Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jeffrey S Wolf
- Department of Otolaryngology, Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Matthew E Witek
- Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
17
|
Treating Head and Neck Cancer in the Age of Immunotherapy: A 2023 Update. Drugs 2023; 83:217-248. [PMID: 36645621 DOI: 10.1007/s40265-023-01835-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/17/2023]
Abstract
Most patients diagnosed with head and neck squamous cell carcinoma (HNSCC) will present with locally advanced disease, requiring multimodality therapy. While this approach has a curative intent, a significant subset of these patients will develop locoregional failure and/or distant metastases. The prognosis of these patients is poor, and therapeutic options other than palliative chemotherapy are urgently needed. Epidermal growth factor receptor (EGFR) overexpression is an important factor in the pathogenesis of HNSCC, and a decade ago, the EGFR targeting monoclonal antibody cetuximab was approved for the treatment of late-stage HNSCC in different settings. In 2016, the anti-programmed death-1 (PD-1) immune checkpoint inhibitors nivolumab and pembrolizumab were both approved for the treatment of patients with recurrent or metastatic HNSCC with disease progression on or after platinum-containing chemotherapy, and in 2019, pembrolizumab was approved for first-line treatment (either as monotherapy in PD-L1 expressing tumors, or in combination with chemotherapy). Currently, trials are ongoing to include immune checkpoint inhibition in the (neo)adjuvant treatment of HNSCC as well as in novel combinations with other drugs in the recurrent/metastatic setting to improve response rates and survival and help overcome resistance mechanisms to immune checkpoint blockade. This article provides a comprehensive review of the management of head and neck cancers in the current era of immunotherapy.
Collapse
|
18
|
Svajdova M, Dubinsky P, Kazda T, Jeremic B. Human Papillomavirus-Related Non-Metastatic Oropharyngeal Carcinoma: Current Local Treatment Options and Future Perspectives. Cancers (Basel) 2022; 14:5385. [PMID: 36358801 PMCID: PMC9658535 DOI: 10.3390/cancers14215385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 08/26/2023] Open
Abstract
Over the last two decades, human papillomavirus (HPV) has caused a new pandemic of cancer in many urban areas across the world. The new entity, HPV-associated oropharyngeal squamous cell carcinoma (OPSCC), has been at the center of scientific attention ever since, not only due to its distinct biological behavior, but also because of its significantly better prognosis than observed in its HPV-negative counterpart. The very good treatment outcomes of the disease after primary therapy (minimally-invasive surgery, radiation therapy with or without chemotherapy) resulted in the creation of a separate staging system, reflecting this excellent prognosis. A substantial proportion of newly diagnosed HPV-driven OPSCC is diagnosed in stage I or II, where long-term survival is observed worldwide. Deintensification of the primary therapeutic methods, aiming at a reduction of long-term toxicity in survivors, has emerged, and the quality of life of the patient after treatment has become a key-point in many clinical trials. Current treatment recommendations for the treatment of HPV-driven OPSCC do not differ significantly from HPV-negative OPSCC; however, the results of randomized trials are eagerly awaited and deemed necessary, in order to include deintensification into standard clinical practice.
Collapse
Affiliation(s)
- Michaela Svajdova
- Department of Radiation and Clinical Oncology, General Hospital Rimavska Sobota, 979 01 Rimavska Sobota, Slovakia
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, 602 00 Brno, Czech Republic
| | - Pavol Dubinsky
- Department of Radiation Oncology, East Slovakia Oncology Institute, 040 01 Kosice, Slovakia
- Faculty of Health, Catholic University Ruzomberok, 034 01 Ruzomberok, Slovakia
| | - Tomas Kazda
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, 602 00 Brno, Czech Republic
| | - Branislav Jeremic
- School of Medicine, University of Kragujevac, 340 00 Kragujevac, Serbia
| |
Collapse
|
19
|
Schrank TP, Landess L, Stepp WH, Rehmani H, Weir WH, Lenze N, Lal A, Wu D, Kothari A, Hackman TG, Sheth S, Patel S, Jefferys SR, Issaeva N, Yarbrough WG. Comprehensive Viral Genotyping Reveals Prognostic Viral Phylogenetic Groups in HPV16-Associated Squamous Cell Carcinoma of the Oropharynx. Mol Cancer Res 2022; 20:1489-1501. [PMID: 35731223 PMCID: PMC11249119 DOI: 10.1158/1541-7786.mcr-21-0443] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 01/05/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022]
Abstract
Human papillomavirus-positive (HPV+) squamous cell carcinoma of the oropharynx (OPSCC) is the most prevalent HPV-associated malignancy in the United States and is primarily caused by HPV subtype 16 (HPV16). Favorable treatment outcomes have led to increasing interest in treatment deescalation to reduce treatment-related morbidity. Prognostic biomarkers are needed to identify appropriately low-risk patients for reduced treatment intensity. Targeted DNA sequencing including all HPV16 open reading frames was performed on tumors from 104 patients with HPV16+ OPSCC treated at a single center. Genotypes closely related to the HPV16-A1 reference were associated with increased numbers of somatic copy-number variants in the human genome and poor recurrence-free survival (RFS). Genotypes divergent from HPV16-A1 were associated with favorable RFS. These findings were independent of tobacco smoke exposure. Total RNA sequencing was performed on a second independent cohort of 89 HPV16+ OPSCC cases. HPV16 genotypes divergent from HPV16-A1 were again validated in this independent cohort, to be prognostic of improved RFS in patients with moderate (less than 30 pack-years) or low (no more than 10 pack-years) of tobacco smoke exposure. In summary, we show in two independent cohorts that viral sequence divergence from the HPV16-A1 reference is correlated with improved RFS in patients with moderate or low tobacco smoke exposure. IMPLICATIONS HPV16 genotype is a potential biomarker that could be easily adopted to guide therapeutic decision-making related to deescalation therapy.
Collapse
Affiliation(s)
- Travis P Schrank
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
- Linberger Comprehensive Cancer Center, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
| | - Lee Landess
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
| | - Wesley H Stepp
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
| | - Hina Rehmani
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
| | - William H Weir
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
| | - Nicholas Lenze
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
| | - Asim Lal
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
| | - Di Wu
- Linberger Comprehensive Cancer Center, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
- Department of Biostatistics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Division of Oral and Craniofacial Health Sciences, Adams School of Dentistry, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
| | - Aditi Kothari
- Linberger Comprehensive Cancer Center, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
| | - Trevor G Hackman
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
| | - Siddharth Sheth
- Department of Medicne, Division of Oncology, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
| | - Shetal Patel
- Department of Medicne, Division of Oncology, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
| | - Stuart R Jefferys
- Linberger Comprehensive Cancer Center, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
| | - Natalia Issaeva
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
- Linberger Comprehensive Cancer Center, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
- Department of Pathology and Lab Medicine, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
| | - Wendell G Yarbrough
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
- Linberger Comprehensive Cancer Center, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
- Department of Pathology and Lab Medicine, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|
20
|
Sung SY, Kim YS, Kim SH, Lee SJ, Lee SW, Kwak YK. Current Evidence of a Deintensification Strategy for Patients with HPV-Related Oropharyngeal Cancer. Cancers (Basel) 2022; 14:cancers14163969. [PMID: 36010959 PMCID: PMC9406155 DOI: 10.3390/cancers14163969] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/13/2022] [Accepted: 08/15/2022] [Indexed: 11/20/2022] Open
Abstract
Simple Summary Human papillomavirus (HPV)-related oropharyngeal cancer represents a distinct disease entity, showing favorable treatment responses and survival outcomes. While the deintensification of treatment for HPV-related oropharyngeal cancer is widely considered necessary, details concerning patient selection and optimal strategies are undetermined. The heterogeneity of study populations and interventions in trials complicate the ability of physicians to apply the results in daily practice. The evolving landscape also requires physicians to consistently update the results of these trials. This article reviews the most recent evidence on the deintensification of HPV-related oropharyngeal cancer. We aim to provide physicians with some guidance regarding management options and assist researchers in appropriately designing trials in the future. Abstract Human papillomavirus (HPV)-related oropharyngeal cancer differs from HPV-negative oropharyngeal cancer in terms of etiology, epidemiology, and prognosis. Younger and lower comorbidity patient demographics and favorable prognosis allow HPV-related oropharyngeal cancer patients to anticipate longer life expectancy. Reducing long-term toxicities has become an increasingly important issue. Treatment deintensification to reduce toxicities has been investigated in terms of many aspects, and the reduction of radiotherapy (RT) dose in definitive treatment, replacement of platinum-based chemotherapy with cetuximab, response-tailored dose prescription after induction chemotherapy, and reduction of adjuvant RT dose after transoral surgery have been evaluated. We performed a literature review of prospective trials of deintensification for HPV-related oropharyngeal cancer. In phase II trials, reduction of RT dose in definitive treatment showed comparable survival outcomes to historical results. Two phase III randomized trials reported inferior survival outcomes for cetuximab-based chemoradiation compared with cisplatin-based chemoradiation. In a randomized phase III trial investigating adjuvant RT, deintensified RT showed noninferior survival outcomes in patients without extranodal extension but worse survival in patients with extranodal extension. Optimal RT dosage and patient selection require confirmation in future studies. Although many phase II trials have reported promising outcomes, the results of phase III trials are needed to change the standard treatment. Since high-level evidence has not been established, current deintensification should only be performed as part of a clinical study with caution. Implementation in clinical practice should not be undertaken until evidence from phase III randomized trials is available.
Collapse
Affiliation(s)
- Soo-Yoon Sung
- Department of Radiation Oncology, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, Korea
- Correspondence: ; Tel.: +82-2-2030-3077; Fax: +82-2-2030-3073
| | - Yeon-Sil Kim
- Department of Radiation Oncology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
| | - Sung Hwan Kim
- Department of Radiation Oncology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 16247, Korea
| | - Seung Jae Lee
- Medical Library, The Catholic University of Korea, Seoul 06591, Korea
| | - Sea-Won Lee
- Department of Radiation Oncology, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, Korea
| | - Yoo-Kang Kwak
- Department of Radiation Oncology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 21431, Korea
| |
Collapse
|
21
|
Shiao JC, Holt D, Ladbury C, Gao D, Jones B, Karam SD, Amini A. The role of concomitant chemoradiotherapy versus radiation alone in T1-3N0 HPV-positive and HPV-negative oropharyngeal squamous cell carcinoma. Oral Oncol 2022; 130:105907. [PMID: 35605559 PMCID: PMC9947859 DOI: 10.1016/j.oraloncology.2022.105907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 05/06/2022] [Accepted: 05/07/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the role of curative intent concurrent chemoradiation (CCRT) vs radiation (RT) alone for T1-T3N0 HPV-positive and HPV-negative oropharyngeal squamous cell cancer (OPSCC). METHODS The NCDB was queried for patients diagnosed between 2010 and 2017 with cT1-3N0M0 OPSCC treated with definitive RT or CCRT. Univariable analysis (UVA) and multivariable analysis (MVA) Cox regression analysis was performed with OS as the endpoint. Propensity score matching (PSM) 1:1 was performed. Interaction test to assess heterogeneity of treatment effect. RESULTS A total of 2830 patients were queried. On MVA, CCRT was associated with improved OS for T3N0 tumors (HR 0.49; 95% CI 0.39-0.63) but not for T1N0 (HR 1.43; 95% CI 0.99-2.07) and T2N0 (HR 0.92; 95% CI 0.75-1.13). For T3 patients, CCRT improved OS for HPV-negative (HR 0.43; 95% CI 0.31-0.59) and HPV-positive tumors (HR 0.39; 95% CI 0.25-0.61). After PSM, CCRT was not statistically different to RT for patients with T1-2N0 HPV-negative tumors (HR 1.10; 95% CI 0.85-1.43; p = 0.48) and T1-2N0 HPV-positive tumors (HR 1.15; 95% CI 0.79-1.68; p = 0.45). After PSM, CCRT improved OS compared to RT alone for patients with T3N0 HPV-negative (HR 0.43; 95% CI 0.31-0.59; p < 0.01) and HPV-positive tumors (HR 0.39; 95 %CI 0.25-0.61; p < 0.01). CONCLUSIONS CCRT is associated with improved OS in HPV-positive and HPV-negative T3N0 OPSCC. RT alone vs. CCRT demonstrated similar OS for T1-T2N0 OPSCC for both HPV negative and HPV positive tumors.
Collapse
Affiliation(s)
- Jay C. Shiao
- Department of Radiation Oncology, University of Colorado Cancer Center, Aurora, CO, United States
| | - Douglas Holt
- Department of Radiation Oncology, University of Colorado Cancer Center, Aurora, CO, United States
| | - Colton Ladbury
- Department of Radiation Oncology, City of Hope, Duarte, CA, United States
| | - Dexiang Gao
- Department of Biostatistics, University of Colorado Cancer Center, Aurora, CO, United States
| | - Bernard Jones
- Department of Radiation Oncology, University of Colorado Cancer Center, Aurora, CO, United States
| | - Sana D. Karam
- Department of Radiation Oncology, University of Colorado Cancer Center, Aurora, CO, United States
| | - Arya Amini
- Department of Radiation Oncology, City of Hope, Duarte, CA, United States.
| |
Collapse
|
22
|
Paramasivam A. Plasma circulating tumor DNA as a molecular marker for oral cancer. Oral Oncol 2022; 130:105926. [PMID: 35596978 DOI: 10.1016/j.oraloncology.2022.105926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 05/10/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Arumugam Paramasivam
- Centre for Cellular and Molecular Research, Saveetha Dental College & Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai, India.
| |
Collapse
|
23
|
Silver JA, Turkdogan S, Roy CF, Subramaniam T, Henry M, Sadeghi N. De-Escalation Strategies for Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma—Where Are We Now? Curr Oncol 2022; 29:3668-3697. [PMID: 35621685 PMCID: PMC9139371 DOI: 10.3390/curroncol29050295] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/04/2022] [Accepted: 05/13/2022] [Indexed: 12/22/2022] Open
Abstract
The prevalence of oropharyngeal squamous cell carcinoma has been increasing in North America due to human papillomavirus-associated disease. It is molecularly distinct and differs from other head and neck cancers due to the young population and high survival rate. The treatment regimens currently in place cause significant long-term toxicities. Studies have transitioned from mortality-based outcomes to patient-reported outcomes assessing quality of life. There are many completed and ongoing trials investigating alternative therapy regimens or de-escalation strategies to minimize the negative secondary effects while maintaining overall survival and disease-free survival. The goal of this review is to discuss the most recent advancements within the field while summarizing and reviewing the available evidence.
Collapse
Affiliation(s)
- Jennifer A. Silver
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, QC H4A 3JI, Canada; (J.A.S.); (S.T.); (C.F.R.); (T.S.)
- Department of Otolaryngology—Head and Neck Surgery, McGill University, Montreal, QC H4A 3JI, Canada;
| | - Sena Turkdogan
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, QC H4A 3JI, Canada; (J.A.S.); (S.T.); (C.F.R.); (T.S.)
- Department of Otolaryngology—Head and Neck Surgery, McGill University, Montreal, QC H4A 3JI, Canada;
| | - Catherine F. Roy
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, QC H4A 3JI, Canada; (J.A.S.); (S.T.); (C.F.R.); (T.S.)
- Department of Otolaryngology—Head and Neck Surgery, McGill University, Montreal, QC H4A 3JI, Canada;
| | - Thavakumar Subramaniam
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, QC H4A 3JI, Canada; (J.A.S.); (S.T.); (C.F.R.); (T.S.)
- Department of Otolaryngology—Head and Neck Surgery, McGill University, Montreal, QC H4A 3JI, Canada;
| | - Melissa Henry
- Department of Otolaryngology—Head and Neck Surgery, McGill University, Montreal, QC H4A 3JI, Canada;
- Gerald Bronfman Department of Oncology, McGill University, Montreal, QC H4A 3JI, Canada
- Lady-Davis Institute for Medical Research, Montreal, QC H3T 1E2, Canada
- Segal Cancer Centre, Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - Nader Sadeghi
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, QC H4A 3JI, Canada; (J.A.S.); (S.T.); (C.F.R.); (T.S.)
- Department of Otolaryngology—Head and Neck Surgery, McGill University, Montreal, QC H4A 3JI, Canada;
- Research Institute of McGill University Health Center, McGill University, Montreal, QC H4A 3JI, Canada
- Correspondence: ; Tel.: +1-514-934-1934 (ext. 34974); Fax: +1-514-843-1403
| |
Collapse
|
24
|
Witek ME, Kimple RJ, Avey GD, Burr AR, Chandereng T, Yu M, Hu R, Wieland AM, Labby ZE, Bruce JY, Brower JV, Hartig GK, Harari PM. Prospective Study of PET/MRI Tumor Response During Chemoradiotherapy for Patients With Low-risk and Intermediate-risk p16-positive Oropharynx Cancer. Am J Clin Oncol 2022; 45:202-207. [PMID: 35446279 PMCID: PMC9623610 DOI: 10.1097/coc.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to examine tumor response with positron emission tomography (PET)/magnetic resonance imaging (MRI) during chemoradiotherapy as a predictor of outcome in patients with p16-positive oropharynx cancer. MATERIALS AND METHODS Patients with p16-positive oropharynx cancer were treated with chemoradiotherapy. Low-risk (LR) disease was defined as T1-T3 and N0-2b and ≤10 pack-years and intermediate-risk (IR) disease as T4 or N2c-3 or >10 pack-years. Patients underwent a PET/MRI scan pretreatment and at fraction 10. Change in value of imaging means were analyzed by analysis of variance. K-means clustering with Euclidean distance functions were used for patient clustering. Silhouette width was used to determine the optimal number of clusters. Linear regression was performed on all radiographic metrics using patient and disease characteristics. RESULTS Twenty-four patients were enrolled with 7 LR and 11 IR patients available for analysis. Pretreatment imaging characteristics between LR and IR patients were similar. Patients with LR disease exhibited a larger reduction in maximum standardized uptake value (SUV) compared with IR patients (P<0.05). Cluster analysis defined 2 cohorts that exhibited a similar intratreatment response. Cluster 1 contained 7 of 7 LR patients and 8 of 11 IR patients. Cluster 2 contained 3 of 11 IR patients. Cluster 2 exhibited significant differences compared with cluster 1 in the change in primary tumor peak SUV and largest lymph node median SUV. CONCLUSIONS We identified that IR p16-positive oropharynx cancers exhibit heterogeneity in their PET/MRI response to chemoradiotherapy. These data support further study of intratreatment imaging response as a potential mechanism to identify patients with IR oropharynx cancer suitable for treatment deintensification.
Collapse
Affiliation(s)
- Matthew E. Witek
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI, USA
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Randall J. Kimple
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI, USA
- UW Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Gregory D. Avey
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Adam R. Burr
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI, USA
| | | | - Menggang Yu
- UW Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Rong Hu
- UW Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Aaron M. Wieland
- Deparmtent of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Zacariah E. Labby
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI, USA
| | - Justine Y. Bruce
- UW Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jeffrey V. Brower
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI, USA
| | - Gregory K. Hartig
- Deparmtent of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Paul M. Harari
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI, USA
- UW Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| |
Collapse
|
25
|
Takahashi M, Hwang M, Misiukiewicz K, Gupta V, Miles BA, Bakst R, Genden E, Selkridge I, Botzler J, Virani V, Moshier E, Bonomi MR, Posner MR. Quality of Life Analysis of HPV-Positive Oropharyngeal Cancer Patients in a Randomized Trial of Reduced-Dose Versus Standard Chemoradiotherapy: 5-Year Follow-Up. Front Oncol 2022; 12:859992. [PMID: 35463348 PMCID: PMC9024140 DOI: 10.3389/fonc.2022.859992] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background Human papillomavirus-positive oropharyngeal carcinoma (HPVOPC) portends a more favorable prognosis compared to environmentally related oropharynx cancer (EROPC). Patients with HPVOPC may be overtreated and endure unnecessary long-term toxicities. Methods Patients with untreated locally advanced HPVOPC received induction chemotherapy with docetaxel, cisplatin, and 5-fluorouracil (TPF) and were randomized to standard chemoradiotherapy (sdCRT) (70 Gy) or reduced-dose chemoradiotherapy (rdCRT) (56 Gy) with weekly carboplatin. Patients were followed for changes in five validated quality of life (QoL) surveys: MD Anderson Dysphagia Inventory and Symptom Inventory for head and neck cancer (MDADI, MDASI-HN), Xerostomia Questionnaire (XQ), and European Organization for Research and Treatment of Cancer Questionnaire (EORTC) with head and neck module (EORTC HN). The secondary endpoints of this study were 5-year progression-free survival (PFS) and overall survival (OS). Results Twenty patients were enrolled and randomized to rdCRT (n = 12) or sdCRT (n = 8). Median follow-up was 88 months. At 5 years, difference in QoL changes all favored the rdCRT arm and two QoL scales reached statistical significance (EORTC global health score: 11.49 vs. -23.94, P = 0.014; EORTC symptom scale: -7.76 vs. 15.19, P = 0.015). The 5-year PFS and OS were 87.5% and 83.3% for sdCRT and rdCRT, respectively. Conclusions Therefore, rdCRT after TPF in HPVOPC is feasible in accordance with the earlier results of the Quarterback Trial and long-term follow-up. These limited results are more favorable in specific QoL domains compared to those of sdCRT and demonstrate equivalent long-term survival. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT01706939, The Quarterback Trial [NCT 01706939].
Collapse
Affiliation(s)
- Mai Takahashi
- The Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, United States
| | - Michael Hwang
- The Departments of Hematology/Oncology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Krysztof Misiukiewicz
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,The Departments of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Vishal Gupta
- Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Brett A Miles
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Richard Bakst
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Eric Genden
- Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Isaiah Selkridge
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - John Botzler
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Vruti Virani
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Erin Moshier
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Biostatistics in the Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Marcelo R Bonomi
- The Departments of Hematology/Oncology, The Ohio State University, Columbus, OH, United States
| | - Marshall R Posner
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,The Departments of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| |
Collapse
|
26
|
Lin A, Helgeson ES, Treister NS, Schmidt BL, Patton LL, Elting LS, Lalla RV, Brennan MT, Sollecito TP. The impact of head and neck radiotherapy on salivary flow and quality of life: Results of the ORARAD study. Oral Oncol 2022; 127:105783. [PMID: 35231809 PMCID: PMC8977268 DOI: 10.1016/j.oraloncology.2022.105783] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/09/2022] [Accepted: 02/15/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Salivary hypofunction and xerostomia, are common side effects of radiotherapy, negatively impacting quality of life. The OraRad study presents results on the longitudinal impact of radiotherapy on salivary flow and patient-reported outcomes. PATIENTS AND METHODS Prospective, multicenter cohort study of 572 patients receiving curative-intent head and neck radiotherapy (RT). Stimulated salivary flow (SSF) rate and patient-reported outcomes were measured prior to RT and at 6- and 18-months post-RT. Linear mixed effects models examined the relationship between RT dose and change in salivary flow, and change in patient-reported outcomes. RESULTS 544 patients had baseline salivary flow measurement, with median (IQR) stimulated flow rate of 0.975 (0.648, 1.417) g/min. Average RT dose to parotid glands was associated with change in salivary flow post-RT (p < 0.001). Diminished flow to 37% of pre-RT level was observed at 6 months (median: 0.358, IQR: 0.188 to 0.640 g/min, n = 481) with partial recovery to 59% of pre-RT at 18 months (median: 0.575, IQR: 0.338 to 0.884 g/min, n = 422). Significant improvement in patient-reported swallowing, senses (taste and smell), mouth opening, dry mouth, and sticky saliva (p-values < 0.03) were observed between 6 and 18 months post-RT. Changes in swallowing, mouth opening, dry mouth, and sticky saliva were significantly associated with changes in salivary flow from baseline (p-values < 0.04). CONCLUSION Salivary flow and patient-reported outcomes decreased as a result of RT, but demonstrated partial recovery during follow-up. Continued efforts are needed to improve post-RT salivary function to support quality of life.
Collapse
|
27
|
Caudell JJ, Gillison ML, Maghami E, Spencer S, Pfister DG, Adkins D, Birkeland AC, Brizel DM, Busse PM, Cmelak AJ, Colevas AD, Eisele DW, Galloway T, Geiger JL, Haddad RI, Hicks WL, Hitchcock YJ, Jimeno A, Leizman D, Mell LK, Mittal BB, Pinto HA, Rocco JW, Rodriguez CP, Savvides PS, Schwartz D, Shah JP, Sher D, St John M, Weber RS, Weinstein G, Worden F, Yang Bruce J, Yom SS, Zhen W, Burns JL, Darlow SD. NCCN Guidelines® Insights: Head and Neck Cancers, Version 1.2022. J Natl Compr Canc Netw 2022; 20:224-234. [PMID: 35276673 DOI: 10.6004/jnccn.2022.0016] [Citation(s) in RCA: 172] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The NCCN Guidelines for Head and Neck Cancers address tumors arising in the oral cavity (including mucosal lip), pharynx, larynx, and paranasal sinuses. Occult primary cancer, salivary gland cancer, and mucosal melanoma (MM) are also addressed. The specific site of disease, stage, and pathologic findings guide treatment (eg, the appropriate surgical procedure, radiation targets, dose and fractionation of radiation, indications for systemic therapy). The NCCN Head and Neck Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel's most recent recommendations regarding management of HPV-positive oropharynx cancer and ongoing research in this area.
Collapse
Affiliation(s)
| | | | | | | | | | - Douglas Adkins
- 6Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | | | | | - David W Eisele
- 12The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | - Jessica L Geiger
- 14Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | - Debra Leizman
- 14Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | - Bharat B Mittal
- 20Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - James W Rocco
- 21The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | - David Schwartz
- 24St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | - David Sher
- 25UT Southwestern Simmons Comprehensive Cancer Center
| | | | | | | | | | | | - Sue S Yom
- 30UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | |
Collapse
|
28
|
Lee CT, Galloway TJ. Pathogenesis and Amelioration of Radiation-Induced Oral Mucositis. Curr Treat Options Oncol 2022; 23:311-324. [PMID: 35244887 PMCID: PMC8931694 DOI: 10.1007/s11864-022-00959-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/29/2022]
Abstract
OPINION STATEMENT Oral mucositis (OM) causes significant detriment to patient quality of life. Despite advances in RT, chemotherapy, and surgery for HNC which have led to improved local control and survival, management of certain toxicities such as OM have not kept pace. Numerous strategies have emerged with demonstrable benefit in preventing severe OM. However, ones which are not only effective, but practical and affordable to implement are rare. For example, infusion of growth factors or free radical scavengers, and daily treatment of intra-oral sites with lasers are supported by high-quality evidence but have not become widely adopted. It falls to familiarity of the physician with the available preventative measures and ultimately, patient preference in accepting which strategies for OM amelioration are used. In this review, we present a pathophysiological-based review of prevention techniques available for reducing the incidence and duration of severe OM.
Collapse
Affiliation(s)
- Charles T. Lee
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Thomas J. Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| |
Collapse
|
29
|
Induction Chemotherapy in Low-Risk HPV+ Oropharyngeal Cancer. Curr Treat Options Oncol 2022; 23:54-67. [PMID: 35171457 DOI: 10.1007/s11864-022-00941-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 12/08/2022]
Abstract
OPINION STATEMENT Human papillomavirus (HPV) associated oropharyngeal squamous cell carcinoma (OPSCC) is rapidly increasing in incidence, and has now become the most common head and neck cancer (HNC). Studies have demonstrated that HPV associated OPSCC is associated with a favorable prognosis compared with its HPV-negative counterparts, yet standard multimodality therapy is often associated with substantial acute and late treatment-related toxicity. While locoregional control is improved in HPV+ OPSCC, distant metastasis rate has gained recognition as a major cause of death in this population, with some studies suggesting similar rates as non-HPV-related cancers. Induction chemotherapy has been of long-standing interest in locoregionally advanced HNC, yet its use in combination with concomitant chemoradiation remains an area of controversy as a survival benefit remains unproven following randomized trials. Nevertheless, response to induction chemotherapy remains an important dynamic and prognostic biomarker, with response-adaptive de-intensified therapy in HPV+ OPSCC gaining traction in single-arm phase II studies demonstrating promising results. The emergence of immunotherapy in the recurrent/metastatic setting for HNC has led to enthusiasm to incorporate in the curative setting, yet its role remains undefined. Our institutional paradigm for HPV+ OPSCC incorporates induction therapy followed by risk and response adaptive locoregional treatment. Ultimately, the role of induction therapy in HPV+ OPSCC will need to be investigated in a randomized setting to be incorporated routinely into clinical practice.
Collapse
|
30
|
Routman DM, Kumar S, Chera BS, Jethwa KR, Van Abel KM, Frechette K, DeWees T, Golafshar M, Garcia JJ, Price DL, Kasperbauer JL, Patel SH, Neben-Wittich MA, Laack NL, Chintakuntlawar AV, Price KA, Liu MC, Foote RL, Moore EJ, Gupta GP, Ma DJ. Detectable Post-operative Circulating Tumor Human Papillomavirus (HPV) DNA And Association with Recurrence in Patients with HPV-Associated Oropharyngeal Squamous Cell Carcinoma. Int J Radiat Oncol Biol Phys 2022; 113:530-538. [PMID: 35157995 DOI: 10.1016/j.ijrobp.2022.02.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 01/22/2022] [Accepted: 02/06/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE To determine the rate of detectability of ctHPVDNA after surgery but before adjuvant therapy in patients with HPV-associated oropharyngeal squamous cell carcinoma (HPV(+)OPSCC) and to investigate whether detectable ctHPVDNA at this time point may be associated with risk of recurrence. METHODS AND MATERIALS Prospectively collected samples from patients with OPSCC were examined in a blinded fashion using a multi-analyte PCR assay. 45 samples were collected from HPV(+)OPSCC patients pre-op (prior to any treatment), and 159 samples post-op (before or at the start of adjuvant RT). Samples were identified via the radiation oncology biobank or via participation in a clinical trial. RT consisted of 60 Gy +/- cisplatin or de-escalation (30 Gy to 36 Gy in 20 b.i.d. fractions + docetaxel). 32 patients had paired samples available pre and post-op for the primary analysis. Additional exploratory analyses including associations of patient and tumor characteristics with recurrence were assessed using Cox proportional hazards models for all 159 post-op samples.. Detectability of ctHPVDNA was compared across groups utilizing logistic regression. Estimates of recurrence free survival (RFS) were made using Kaplan-Meier (KM). RESULTS In a paired analysis of 32 pre and post-op timepoints, 94% of patients had detectable ctHPVDNA pre-op and 41% post-op. RFS at 18 months was 83% (95% CI: 47-95%) for patients with detectable post-op ctHPVDNA compared to 100% for patients with undetectable post-op ctHPVDNA (p=.094).In an exploratory analysis of non-paired post-op samples, ctHPVDNA was detectable in 26% (41 of 159) of patients (median of 22 days post-op). Age (1.06, p=0.025), LVSI (OR 3.17, p=0.011) and ENE (OR=5.67, p=0.001) were associated with detectable ctHPVDNA after surgery. Detectable post-op ctHPVDNA was significantly associated with RFS (p<0.001). CONCLUSION Amongst patients with detectable pre-op ctHPVDNA, a significant proportion have detectable post-op ctHPVDNA in paired post-op samples, collected prior to the initiation of adjuvant radiation therapy. Future prospective study is warranted to investigate the association of detectable post-op ctHPVDNA with recurrence, including in comparison to established clinical and pathologic risk factors.
Collapse
Affiliation(s)
- D M Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA.
| | - S Kumar
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - B S Chera
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - K R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA; Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - K M Van Abel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester MN, USA
| | - K Frechette
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - T DeWees
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Phoenix AZ, USA
| | - M Golafshar
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Phoenix AZ, USA
| | - J J Garcia
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester MN, USA
| | - D L Price
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester MN, USA
| | - J L Kasperbauer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester MN, USA
| | - S H Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix AZ, USA
| | | | - N L Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - K A Price
- Division of Medical Oncology, Mayo Clinic, Rochester MN, USA
| | - M C Liu
- Division of Medical Oncology, Mayo Clinic, Rochester MN, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester MN, USA
| | - R L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - E J Moore
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester MN, USA
| | - G P Gupta
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - D J Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
31
|
HPV-associated oropharyngeal cancer: epidemiology, molecular biology and clinical management. Nat Rev Clin Oncol 2022; 19:306-327. [PMID: 35105976 PMCID: PMC8805140 DOI: 10.1038/s41571-022-00603-7] [Citation(s) in RCA: 259] [Impact Index Per Article: 129.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 12/13/2022]
Abstract
Human papillomavirus (HPV)-positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC) has one of the most rapidly increasing incidences of any cancer in high-income countries. The most recent (8th) edition of the UICC/AJCC staging system separates HPV+ OPSCC from its HPV-negative (HPV−) counterpart to account for the improved prognosis seen in the former. Indeed, owing to its improved prognosis and greater prevalence in younger individuals, numerous ongoing trials are examining the potential for treatment de-intensification as a means to improve quality of life while maintaining acceptable survival outcomes. In addition, owing to the distinct biology of HPV+ OPSCCs, targeted therapies and immunotherapies have become an area of particular interest. Importantly, OPSCC is often detected at an advanced stage owing to a lack of symptoms in the early stages; therefore, a need exists to identify and validate possible diagnostic biomarkers to aid in earlier detection. In this Review, we provide a summary of the epidemiology, molecular biology and clinical management of HPV+ OPSCC in an effort to highlight important advances in the field. Ultimately, a need exists for improved understanding of the molecular basis and clinical course of this disease to guide efforts towards early detection and precision care, and to improve patient outcomes. The incidence of human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) is increasing rapidly in most developed countries. In this Review, the authors provide an overview of the epidemiology, molecular biology and treatment of HPV-positive OPSCC, including discussions of the role of treatment de-escalation and emerging novel therapies. The incidence of human papillomavirus-associated oropharyngeal cancer (HPV+ OPSCC) is expected to continue to rise over the coming decades until the benefits of gender-neutral prophylactic HPV vaccination begin to become manifest. The incidence of HPV+ OPSCC appears to be highest in high-income countries, although more epidemiological data are needed from low- and middle-income countries, in which HPV vaccination coverage remains low. The substantially better prognosis of patients with HPV+ OPSCC compared to those with HPV– OPSCC has been recognized in the American Joint Committee on Cancer TNM8 staging guidelines, which recommend stratification by HPV status to improve staging. The molecular biology and genomic features of HPV+ OPSCC are similar to those of other HPV-associated malignancies, with HPV oncogenes (E6 and E7) acting as key drivers of pathogenesis. Treatment de-intensification is being pursued in clinical trials, although identifying the ~15% of patients with HPV+ OPSCC who have recurrent disease, and who therefore require more intensive treatment, remains a key challenge.
Collapse
|
32
|
Witek ME, Woody NM, Musunuru HB, Hill PM, Yadav P, Burr AR, Ko HC, Ross RB, Kimple RJ, Harari PM. Defining high-risk elective contralateral neck radiation volumes for oropharynx cancer. Head Neck 2022; 44:317-324. [PMID: 34761832 PMCID: PMC9723806 DOI: 10.1002/hed.26924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/22/2021] [Accepted: 10/26/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND To define the location of the initial contralateral lymph node (LN) metastasis in patients with oropharynx cancer. METHODS The location of the LN centroids from patients with oropharynx cancer and a single radiographically positive contralateral LN was defined. A clinical target volume (CTV) inclusive of all LN centroids was created, and its impact on dose to organs at risk was assessed. RESULTS We identified 55 patients of which 49/55 had a single contralateral LN in level IIA, 4/55 in level III, 1/55 in level IIB, and 1/55 in the retropharynx. Mean radiation dose to the contralateral parotid gland was 15.1 and 21.0 Gy, (p <0.001) using the modeled high-risk elective CTV and a consensus CTV, respectively. CONCLUSIONS We present a systematic approach for identifying the contralateral nodal regions at highest risk of harboring subclinical disease in patients with oropharynx cancer that warrants prospective clinical study.
Collapse
Affiliation(s)
- Matthew E. Witek
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI,Department of Radiation Oncology, University of Maryland, School of Medicine, MD
| | - Neil M. Woody
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland OH, USA
| | - Hima B. Musunuru
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Patrick M. Hill
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI
| | - Poonam Yadav
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI
| | - Adam R. Burr
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI
| | - Huaising C. Ko
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI
| | - Richard B. Ross
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Randall J. Kimple
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI
| | - Paul M. Harari
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI
| |
Collapse
|
33
|
Schrank T, Weir W, Lal A, Landess L, Lenze N, Hackman T. Quantifying smoking exposure, genomic correlates, and related risk of treatment failure in p16+ squamous cell carcinoma of the oropharynx. Laryngoscope Investig Otolaryngol 2021; 6:1376-1382. [PMID: 34938877 PMCID: PMC8665424 DOI: 10.1002/lio2.695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/14/2021] [Accepted: 06/27/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES HPV-associated (p16+) squamous cell carcinoma of the oropharynx (OPSCC) has improved survival as compared to HPV-negative, smoking-associated disease. Intermediate outcomes have been noted in patients with p16+ tumors and smoking exposure. However, the extent of smoking exposure required for outcomes to decrease has not been delineated due to low failure rates and poor availability of quantitative tobacco smoke exposure data. Our primary objective is to characterize the dose-dependent relationship between recurrence-free survival (RFS) and tobacco smoke exposure in p16+ OPSCC and secondarily correlate tobacco smoke exposure with genomic alterations. METHODS Single institution chart review was performed of patients diagnosed with p16+ OPSCC from 2003 to 2015. Patients were excluded if staging, treatment details, recurrence status, or smoking exposure in pack-years were not available. Two hundred and forty-four patients were included. RESULTS Patients with 25 pack-years or greater smoking history exhibited a dose-dependent decrease in RFS compared to never smokers. This was robust to multivariate analysis for including staging and demographic factors. Forty-three patients with available targeted tumor sequencing data were identified. A strong trend was observed for increased C to A transversion mutations above 25 pack-years, which are known to be associated with exposure to tobacco smoke. Similarly, the proportion of COSMIC Signature 4 mutations were also found to be more common in patients with more than 25 pack-years of smoking exposure. CONCLUSION Evidence-based smoking exposure thresholds are needed to define inclusion criteria for trials of de-escalation therapy for p16+ OPSCC. Patients with smoking exposure greater than 20 pack-years have increased risk of recurrence and a distinct pattern of genomic alterations. Further studies are needed to delineate the potential consequences of mild smoking exposure. Smoking-related mutational signatures may hold potential for biomarker development in p16+ OPSCC. LEVEL OF EVIDENCE 2B.
Collapse
Affiliation(s)
- Travis Schrank
- Department of Otolaryngology—Head and Neck SurgeryUniversity of North CarolinaChapel HillNorth CarolinaUSA
- Lineberger Comprehensive Cancer Center—Head and Neck SurgeryUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - William Weir
- Department of Otolaryngology—Head and Neck SurgeryUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Asim Lal
- Department of Otolaryngology—Head and Neck SurgeryUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Lee Landess
- Department of Otolaryngology—Head and Neck SurgeryUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Nicholas Lenze
- Department of Otolaryngology—Head and Neck SurgeryUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Trevor Hackman
- Department of Otolaryngology—Head and Neck SurgeryUniversity of North CarolinaChapel HillNorth CarolinaUSA
| |
Collapse
|
34
|
Ho AS, Robinson A, Shon W, Laury A, Raedschelders K, Venkatraman V, Holewinski R, Zhang Y, Shiao SL, Chen MM, Mallen-St Clair J, Lin DC, Zumsteg ZS, Van Eyk JE. Comparative Proteomic Analysis of HPV(+) Oropharyngeal Squamous Cell Carcinoma Recurrence. J Proteome Res 2021; 21:200-208. [PMID: 34846153 DOI: 10.1021/acs.jproteome.1c00757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Deintensification therapy for human papillomavirus-related oropharyngeal squamous cell carcinoma (HPV(+) OPSCC) is under active investigation. An adaptive treatment approach based on molecular stratification could identify high-risk patients predisposed to recurrence and better select for appropriate treatment regimens. Collectively, 40 HPV(+) OPSCC FFPE samples (20 disease-free, 20 recurrent) were surveyed using mass spectrometry-based proteomic analysis via data-independent acquisition to obtain fold change and false discovery differences. Ten-year overall survival was 100.0 and 27.7% for HPV(+) disease-free and recurrent cohorts, respectively. Of 1414 quantified proteins, 77 demonstrated significant differential expression. Top enriched functional pathways included those involved in programmed cell death (73 proteins, p = 7.43 × 10-30), apoptosis (73 proteins, p = 5.56 × 10-9), β-catenin independent WNT signaling (47 proteins, p = 1.45 × 10-15), and Rho GTPase signaling (69 proteins, p = 1.09 × 10-5). PFN1 (p = 1.0 × 10-3), RAD23B (p = 2.9 × 10-4), LDHB (p = 1.0 × 10-3), and HINT1 (p = 3.8 × 10-3) pathways were significantly downregulated in the recurrent cohort. On functional validation via immunohistochemistry (IHC) staining, 46.9% (PFN1), 71.9% (RAD23B), 59.4% (LDHB), and 84.4% (HINT1) of cases were corroborated with mass spectrometry findings. Development of a multilateral molecular signature incorporating these targets may characterize high-risk disease, predict treatment response, and augment current management paradigms in head and neck cancer.
Collapse
|
35
|
Wright CM, Baron J, Lee DY, Kim M, Barsky AR, Teo BKK, Lukens JN, Swisher-McClure S, Lin A. Dosimetric Results for Adjuvant Proton Radiation Therapy of HPV-Associated Oropharynx Cancer. Int J Part Ther 2021; 8:47-54. [PMID: 35530184 PMCID: PMC9009460 DOI: 10.14338/ijpt-d-21-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/11/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose One significant advantage of proton therapy is its ability to improve normal tissue sparing and toxicity mitigation, which is relevant in the treatment of oropharyngeal squamous cell carcinoma (OPSCC). Here, we report our institutional experience and dosimetric results with adjuvant proton radiation therapy (PRT) versus intensity-modulated radiotherapy (IMRT) for Human Papilloma Virus (HPV)-associated OPSCC. Materials and Methods This was a retrospective, single institutional study of all patients treated with adjuvant PRT for HPV-associated OPSCC from 2015 to 2019. Each patient had a treatment-approved equivalent IMRT plan to serve as a reference. Endpoints included dosimetric outcomes to the organs at risk (OARs), local regional control (LRC), progression-free survival (PFS), and overall survival (OS). Descriptive statistics, a 2-tailed paired t test for dosimetric comparisons, and the Kaplan-Meier method for disease outcomes were used. Results Fifty-three patients were identified. Doses delivered to OARs compared favorably for PRT versus IMRT, particularly for the pharyngeal constrictors, esophagus, larynx, oral cavity, and submandibular and parotid glands. The achieved normal tissue sparing did not negatively impact disease outcomes, with 2-year LRC, PFS, and OS of 97.0%, 90.3%, and 97.5%, respectively. Conclusion Our study suggests that meaningful normal tissue sparing in the postoperative setting is achievable with PRT, without impacting disease outcomes.
Collapse
Affiliation(s)
| | - Jonathan Baron
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Y. Lee
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Michele Kim
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew R. Barsky
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Boon-Keng Kevin Teo
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - John N. Lukens
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
36
|
Rosenberg AJ, Agrawal N, Pearson A, Gooi Z, Blair E, Cursio J, Juloori A, Ginat D, Howard A, Chin J, Kochanny S, Foster C, Cipriani N, Lingen M, Izumchenko E, Seiwert TY, Haraf D, Vokes EE. Risk and response adapted de-intensified treatment for HPV-associated oropharyngeal cancer: Optima paradigm expanded experience. Oral Oncol 2021; 122:105566. [PMID: 34662771 DOI: 10.1016/j.oraloncology.2021.105566] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 09/28/2021] [Accepted: 10/04/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Favorable prognosis for Human papillomavirus-associated (HPV+) oropharyngeal cancer (OPC) led to investigation of response-adaptive de-escalation, yet long-term outcomes are unknown. We present expanded experience and follow-up of risk/response adaptive treatment de-intensification in HPV+ OPC. METHODS A phase 2 trial (OPTIMA) and subsequent cohort of sequential off-protocol patients treated from September 2014 to November 2018 at the University of Chicago were reviewed. Eligible patients had T3-T4 or N2-3 (AJCC 7th edition) HPV+ OPC. Patients were stratified by risk: High-risk (HR) (T4, ≥N2c, or >10PYH), all others low-risk (LR). Induction chemotherapy (IC) included 3 cycles of carboplatin and nab-paclitaxel (OPTIMA) or paclitaxel (off-protocol). LR with ≥50% response received low-dose radiotherapy (RT) alone to 50 Gy (RT50). LR with 30-50% response and HR with ≥50% response received intermediate-dose chemoradiotherapy (CRT) to 45 Gy (CRT45). All others received full-dose CRT to 75 Gy (CRT75). RESULTS 91 patients consented and 90 patients were treated, of which 31% had >10PYH, 34% had T3/4 disease, and 94% had N2b/N2c/N3 disease. 49% were LR and 51% were HR. Overall response rate to induction was 88%. De-escalated treatment was administered to 83%. Median follow-up was 4.2 years. Five-year OS, PFS, LRC, and DC were 90% (95% CI 81,95), 90% (95% CI 80,95), 96% (95% CI 90,99), and 96% (88,99) respectively. G-tube placement rates in RT50, CRT45, and CRT75 were 3%, 33%, and 80% respectively (p < 0.05). CONCLUSION Risk/response adaptive de-escalated treatment for an inclusive cohort of HPV+ OPC demonstrates excellent survival with reduced toxicity with long-term follow-up.
Collapse
Affiliation(s)
- Ari J Rosenberg
- Department of Medicine, Section of Hematology and Oncology, University of Chicago, Chicago, IL, USA.
| | - Nishant Agrawal
- Section of Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, IL, USA
| | - Alexander Pearson
- Department of Medicine, Section of Hematology and Oncology, University of Chicago, Chicago, IL, USA
| | - Zhen Gooi
- Section of Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, IL, USA
| | - Elizabeth Blair
- Section of Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, IL, USA
| | - John Cursio
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| | - Aditya Juloori
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
| | - Daniel Ginat
- Department of Radiology, University of Chicago, Chicago, IL, USA
| | - Adam Howard
- Section of Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, IL, USA
| | - Jeffrey Chin
- Department of Medicine, Section of Hematology and Oncology, University of Chicago, Chicago, IL, USA
| | - Sara Kochanny
- Department of Medicine, Section of Hematology and Oncology, University of Chicago, Chicago, IL, USA
| | - Corey Foster
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nicole Cipriani
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | - Mark Lingen
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | - Evgeny Izumchenko
- Department of Medicine, Section of Hematology and Oncology, University of Chicago, Chicago, IL, USA
| | - Tanguy Y Seiwert
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel Haraf
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
| | - Everett E Vokes
- Department of Medicine, Section of Hematology and Oncology, University of Chicago, Chicago, IL, USA
| |
Collapse
|
37
|
Reduction of Elective Radiotherapy Treatment Volume in Definitive Treatment of Locally Advanced Head and Neck Cancer-Comparison of a Prospective Trial with a Revised Simulated Contouring Approach. J Clin Med 2021; 10:jcm10204653. [PMID: 34682782 PMCID: PMC8537676 DOI: 10.3390/jcm10204653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/05/2021] [Accepted: 10/08/2021] [Indexed: 11/16/2022] Open
Abstract
Definitive radiochemotherapy of locally advanced head and neck squamous cell cancer (HNSCC) achieves high locoregional tumor control rates; but is frequently associated with long-term toxicity. A future direction could be a de-escalation strategy focusing on treated volume rather than radiotherapy dose. This analysis evaluates radiotherapy dose and volume parameters of patients treated with a standard contouring approach in a clinical trial context compared with a revised volume-reduced contouring approach. In this case, 30 consecutive patients from the CheckRad-CD8 trial treated at a single study center were included in this analysis. Treatment toxicity and quality of life were assessed at the end of radiotherapy. Standard treatment plans (ST) following state of the art contouring guidelines that were used for patient treatment and volume reduced treatment plans (VRT) according to a revised simulated approach were calculated for each patient. Planning target volumes (PTV) and mean doses to 38 organs-at-risk structures were compared. At the end of radiotherapy patients reported high rates of mucositis; dysphagia and xerostomia. In addition; patient reported quality of life as assessed by the EORTC QLQ-HN35 questionnaire deteriorated. Comparing the two contouring approaches; the elective PTV_56 Gy and the high risk PTV_63 Gy (shrinking field) were significantly smaller in the VRT group. Significant reduction of mean dose to structures of the oral cavity; the larynx as well as part of the swallowing muscles and the submandibular glands was achieved in the simulated VRT-plan. Treatment de-intensification by reduction of the irradiated volume could potentially reduce treatment volume and mean doses to organs at risk. The proposed contouring approach should be studied further in the context of a clinical trial.
Collapse
|
38
|
Kaffenberger TM, Patel AK, Lyu L, Li J, Wasserman‐Wincko T, Zandberg DP, Clump DA, Johnson JT, Nilsen ML. Quality of life after radiation and transoral robotic surgery in advanced oropharyngeal cancer. Laryngoscope Investig Otolaryngol 2021; 6:983-990. [PMID: 34667840 PMCID: PMC8513430 DOI: 10.1002/lio2.628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/08/2021] [Accepted: 07/09/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Oropharyngeal squamous cell carcinoma (OPSCC) treatment results in impaired swallowing and quality of life (QOL). We analyzed a cross-section of advanced stage OPSCC patients treated with multimodal therapies at our Survivorship Clinic to investigate treatment factors associated with QOL. METHODS Retrospective analysis of patient-reported outcomes (PROMs) after primary OPSCC treatment using AJCC seventh edition staging. RESULTS A total of 73 patients were included (90.1% human papillomavirus positive [HPV+]). There were no QOL differences between robotic surgery with radiation ± chemotherapy patients (n = 29) and those treated by radiation ± chemotherapy (n = 44). Radiation field analysis demonstrated significant correlations between increasing doses to larynx and contralateral parotid and submandibular gland and worse swallowing as measured by the Eating Assessment Tool-10 (P = .02; P = .01; P = .01). CONCLUSIONS In advanced, mostly HPV+, OPSCC, we did not find clinically significant differences between QOL PROMs between surgical and radiation ± chemotherapy treatment groups. This highlights the need for continued therapy de-escalation along with improved interventions for treatment related toxicities. LEVEL OF EVIDENCE 4.
Collapse
Affiliation(s)
- Thomas M. Kaffenberger
- Department of Otolaryngology—Head and Neck SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Ankur K. Patel
- Department of Radiation OncologyUPMC Hillman Cancer Center, University of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Lingyun Lyu
- Department of BiostatisticsUniversity of Pittsburgh School of Public HealthPittsburghPennsylvaniaUSA
| | - Jinhong Li
- Department of BiostatisticsUniversity of Pittsburgh School of Public HealthPittsburghPennsylvaniaUSA
| | - Tamara Wasserman‐Wincko
- Department of Otolaryngology—Head and Neck SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Dan P. Zandberg
- Department of Hematology/OncologyUPMC Hillman Cancer Center, University of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - David A. Clump
- Department of Radiation OncologyUPMC Hillman Cancer Center, University of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Jonas T. Johnson
- Department of Otolaryngology—Head and Neck SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Marci L. Nilsen
- Department of Otolaryngology—Head and Neck SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- Department of Acute and Tertiary CareUniversity of Pittsburgh School of NursingPittsburghPennsylvaniaUSA
| |
Collapse
|
39
|
De-Escalating Strategies in HPV-Associated Head and Neck Squamous Cell Carcinoma. Viruses 2021; 13:v13091787. [PMID: 34578368 PMCID: PMC8473011 DOI: 10.3390/v13091787] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/02/2021] [Accepted: 09/06/2021] [Indexed: 12/22/2022] Open
Abstract
HPV-related head and neck squamous cell carcinoma (HNSCC) has emerged as a diverse clinical and biological disease entity, mainly in young patients with oropharyngeal tumors who are nonsmokers and nondrinkers. Indeed, during the past few years, the pendulum has shifted towards a new epidemiological reality, the “HPV pandemic”, where the majority of oropharyngeal squamous cell carcinomas (OPSCCs) are attributed to HPV. The oncogenic potential of the virus is associated to its capacity of integrating oncogenes E6 and E7 into the host cell, leading to the inactivation of several tumor suppressor genes, such as Rb. HPV status can affect prognosis in OPSCC, but its role as a predictive biomarker remains to be elucidated. Given the favorable prognosis associated with HPV-positive disease, the concept of de-escalation treatment strategies has been developed with the primary intent being the reduction of treatment-related long-term toxicities. In this review, we aim to depict current data regarding treatment de-escalation in HPV-associated OPSCC and discuss ongoing clinical trials.
Collapse
|
40
|
Dagan R, Galloway TJ. Radiation Treatment Deintensification for HPV-Associated Oropharyngeal Cancer. Semin Radiat Oncol 2021; 31:324-331. [PMID: 34455987 DOI: 10.1016/j.semradonc.2021.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Human papillomavirus-associated oropharyngeal cancer (HPV-OPC) is a distinct clinical entity with a favorable prognosis compared with non-HPV-OPC. Surgery and radiotherapy (RT) result in adverse effects, and negative quality of life or functional outcomes, which impact a significant proportion of HPV-OPC survivors. Ongoing studies aim to reduce these negative treatment effects while maintaining high cure rates through deintensified therapy typically use either a primary surgical or RT approach. A single-day curative surgery will remain relevant for many patients with early-stage disease. However, the average patient with HPV-OPC will have indications for adjuvant therapy. A primary RT approach to deintensified therapy has more available data from patients on prospective multi-institutional trials, provides broader patient selection, and may be more cost-effective. Anticipated results from an active phase II/III NCTN trial will help guide the standard of care using primary RT. Next generation trials will help further refine patient selection and/or radical deintensification (30-50 Gy).
Collapse
Affiliation(s)
- Roi Dagan
- Department of Radiation Oncology, University of Florida Proton Therapy Institute, Jacksonville, FL.
| | - Thomas J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| |
Collapse
|
41
|
Cmelak AJ, Ferris RL, Chen AM, Seiwert T, Burtness B. Treatment De-intensification for HPV-Positive Oropharynx Cancer: What Is Currently Acceptable? J Clin Oncol 2021; 39:2732-2733. [PMID: 34043410 DOI: 10.1200/jco.21.00594] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Anthony J Cmelak
- Anthony J. Cmelak, MD, Vanderbilt University Medical Center, Nashville, TN; Robert L. Ferris, MD, PhD, UPMC Hillman Cancer Center, Pittsburgh, PA; Allen M. Chen, MD, University of California Irvine, Irvine, CA; Tanguy Seiwert, MD, Johns Hopkins Medical Institutions, Johns Hopkins Medical Center, Baltimore, MD; and Barbara Burtness, MD, Yale School of Medicine, Yale University, New Haven, CT
| | - Robert L Ferris
- Anthony J. Cmelak, MD, Vanderbilt University Medical Center, Nashville, TN; Robert L. Ferris, MD, PhD, UPMC Hillman Cancer Center, Pittsburgh, PA; Allen M. Chen, MD, University of California Irvine, Irvine, CA; Tanguy Seiwert, MD, Johns Hopkins Medical Institutions, Johns Hopkins Medical Center, Baltimore, MD; and Barbara Burtness, MD, Yale School of Medicine, Yale University, New Haven, CT
| | - Allen M Chen
- Anthony J. Cmelak, MD, Vanderbilt University Medical Center, Nashville, TN; Robert L. Ferris, MD, PhD, UPMC Hillman Cancer Center, Pittsburgh, PA; Allen M. Chen, MD, University of California Irvine, Irvine, CA; Tanguy Seiwert, MD, Johns Hopkins Medical Institutions, Johns Hopkins Medical Center, Baltimore, MD; and Barbara Burtness, MD, Yale School of Medicine, Yale University, New Haven, CT
| | - Tanguy Seiwert
- Anthony J. Cmelak, MD, Vanderbilt University Medical Center, Nashville, TN; Robert L. Ferris, MD, PhD, UPMC Hillman Cancer Center, Pittsburgh, PA; Allen M. Chen, MD, University of California Irvine, Irvine, CA; Tanguy Seiwert, MD, Johns Hopkins Medical Institutions, Johns Hopkins Medical Center, Baltimore, MD; and Barbara Burtness, MD, Yale School of Medicine, Yale University, New Haven, CT
| | - Barbara Burtness
- Anthony J. Cmelak, MD, Vanderbilt University Medical Center, Nashville, TN; Robert L. Ferris, MD, PhD, UPMC Hillman Cancer Center, Pittsburgh, PA; Allen M. Chen, MD, University of California Irvine, Irvine, CA; Tanguy Seiwert, MD, Johns Hopkins Medical Institutions, Johns Hopkins Medical Center, Baltimore, MD; and Barbara Burtness, MD, Yale School of Medicine, Yale University, New Haven, CT
| |
Collapse
|
42
|
Beesley LJ, Shuman AG, Mierzwa ML, Bellile EL, Rosen BS, Casper KA, Ibrahim M, Dermody SM, Wolf GT, Chinn SB, Spector ME, Baatenburg de Jong RJ, Dronkers EAC, Taylor JMG. Development and Assessment of a Model for Predicting Individualized Outcomes in Patients With Oropharyngeal Cancer. JAMA Netw Open 2021; 4:e2120055. [PMID: 34369988 PMCID: PMC8353539 DOI: 10.1001/jamanetworkopen.2021.20055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Recent insights into the biologic characteristics and treatment of oropharyngeal cancer may help inform improvements in prognostic modeling. A bayesian multistate model incorporates sophisticated statistical techniques to provide individualized predictions of survival and recurrence outcomes for patients with newly diagnosed oropharyngeal cancer. OBJECTIVE To develop a model for individualized survival, locoregional recurrence, and distant metastasis prognostication for patients with newly diagnosed oropharyngeal cancer, incorporating clinical, oncologic, and imaging data. DESIGN, SETTING, AND PARTICIPANTS In this prognostic study, a data set was used comprising 840 patients with newly diagnosed oropharyngeal cancer treated at a National Cancer Institute-designated center between January 2003 and August 2016; analysis was performed between January 2019 and June 2020. Using these data, a bayesian multistate model was developed that can be used to obtain individualized predictions. The prognostic performance of the model was validated using data from 447 patients treated for oropharyngeal cancer at Erasmus Medical Center in the Netherlands. EXPOSURES Clinical/oncologic factors and imaging biomarkers collected at or before initiation of first-line therapy. MAIN OUTCOMES AND MEASURES Overall survival, locoregional recurrence, and distant metastasis after first-line cancer treatment. RESULTS Of the 840 patients included in the National Cancer Institute-designated center, 715 (85.1%) were men and 268 (31.9%) were current smokers. The Erasmus Medical Center cohort comprised 300 (67.1%) men, with 350 (78.3%) current smokers. Model predictions for 5-year overall survival demonstrated good discrimination, with area under the curve values of 0.81 for the model with and 0.78 for the model without imaging variables. Application of the model without imaging data in the independent Dutch validation cohort resulted in an area under the curve of 0.75. This model possesses good calibration and stratifies patients well in terms of likely outcomes among many competing events. CONCLUSIONS AND RELEVANCE In this prognostic study, a multistate model of oropharyngeal cancer incorporating imaging biomarkers appeared to estimate and discriminate locoregional recurrence from distant metastases. Providing personalized predictions of multiple outcomes increases the information available for patients and clinicians. The web-based application designed in this study may serve as a useful tool for generating predictions and visualizing likely outcomes for a specific patient.
Collapse
Affiliation(s)
| | - Andrew G. Shuman
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan, Ann Arbor
| | | | | | | | - Keith A. Casper
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan, Ann Arbor
| | | | - Sarah M. Dermody
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan, Ann Arbor
| | - Gregory T. Wolf
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan, Ann Arbor
| | - Steven B. Chinn
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan, Ann Arbor
| | - Matthew E. Spector
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan, Ann Arbor
| | - Robert J. Baatenburg de Jong
- Department of Otorhinolaryngology–Head and Neck Surgery, Erasmus Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Emilie A. C. Dronkers
- Department of Otorhinolaryngology–Head and Neck Surgery, Erasmus Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | |
Collapse
|
43
|
[Moderate dose de-escalation of cisplatin-based chemoradiation for HPV-associated oropharyngeal carcinoma : Results of the NRG-HN002 trial]. Strahlenther Onkol 2021; 197:950-952. [PMID: 34312699 PMCID: PMC8458172 DOI: 10.1007/s00066-021-01823-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 11/22/2022]
|
44
|
Hintelmann K, Berenz T, Kriegs M, Christiansen S, Gatzemeier F, Struve N, Petersen C, Betz C, Rothkamm K, Oetting A, Rieckmann T. Dual Inhibition of PARP and the Intra-S/G2 Cell Cycle Checkpoints Results in Highly Effective Radiosensitization of HPV-Positive HNSCC Cells. Front Oncol 2021; 11:683688. [PMID: 34354944 PMCID: PMC8329549 DOI: 10.3389/fonc.2021.683688] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 06/29/2021] [Indexed: 12/20/2022] Open
Abstract
In head and neck squamous cell carcinoma (HNSCC), tumors positive for human papillomavirus (HPV) represent a distinct biological entity with favorable prognosis. An enhanced radiation sensitivity of these tumors is evident in the clinic and on the cellular level when comparing HPV-positive and HPV-negative HNSCC cell lines. We could show that the underlying mechanism is a defect in DNA double-strand break repair associated with a profound and sustained G2 arrest. This defect can be exploited by molecular targeting approaches additionally compromising the DNA damage response to further enhance their radiation sensitivity, which may offer new opportunities in the setting of future de-intensified regimes. Against this background, we tested combined targeting of PARP and the DNA damage-induced intra-S/G2 cell cycle checkpoints to achieve effective radiosensitization. Enhancing CDK1/2 activity through the Wee1 inhibitor adavosertib or a combination of Wee1 and Chk1 inhibition resulted in an abrogation of the radiation-induced G2 cell cycle arrest and induction of replication stress as assessed by γH2AX and chromatin-bound RPA levels in S phase cells. Addition of the PARP inhibitor olaparib had little influence on these endpoints, irrespective of checkpoint inhibition. Combined PARP/Wee1 targeting did not result in an enhancement in the absolute number of residual, radiation induced 53BP1 foci as markers of DNA double-strand breaks but it induced a shift in foci numbers from S/G2 to G1 phase cells. Most importantly, while sole checkpoint or PARP inhibition induced moderate radiosensitization, their combination was clearly more effective, while exerting little effect in p53/G1 arrest proficient normal human fibroblasts, thus indicating tumor specificity. We conclude that the combined inhibition of PARP and the intra-S/G2 checkpoint is a highly effective approach for the radiosensitization of HPV-positive HNSCC cells and may represent a viable alternative for the current standard of concomitant cisplatin-based chemotherapy. In vivo studies to further evaluate the translational potential are highly warranted.
Collapse
Affiliation(s)
- Katharina Hintelmann
- Department of Otorhinolaryngology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Berenz
- Department of Otorhinolaryngology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte Kriegs
- Department of Radiotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sabrina Christiansen
- Department of Otorhinolaryngology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fruzsina Gatzemeier
- Department of Otorhinolaryngology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nina Struve
- Department of Radiotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Mildred-Scheel Cancer Career Center HATRICs4, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cordula Petersen
- Department of Radiotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Betz
- Department of Otorhinolaryngology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kai Rothkamm
- Department of Radiotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Agnes Oetting
- Department of Otorhinolaryngology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thorsten Rieckmann
- Department of Otorhinolaryngology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
45
|
De Leo AN, Mendenhall WM, Dagan R, Hitchcock KE, Dziegielewski PT, Morris CG, Amdur RJ. Sparing the Larynx and Hypopharynx With Radiation Therapy for Squamous Cell Carcinoma of Unknown Primary Site and Predominant Adenopathy in Level IIA. Pract Radiat Oncol 2021; 11:366-373. [PMID: 34175470 DOI: 10.1016/j.prro.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/04/2021] [Accepted: 06/16/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE There is controversy about the need to target the mucosa of the larynx and hypopharynx during radiation therapy (RT) for squamous cell carcinoma of an unknown primary site (SCCA-UP). By 1997, the policy in our department was to target only the oropharynx and nasopharynx in patients with SCCA-UP metastatic to the level II cervical nodes. The purpose of this study was to report the rate of cancer recurrence in the larynx or hypopharynx using an approach that excluded these areas from the RT target volumes. METHODS AND MATERIALS The inclusion criteria for this study were RT in our department for SCCA-UP between January 1, 1997, and December 31, 2019; no history of surgery that could disrupt the cervical lymphatics; predominant adenopathy in level IIA; and neck stage N1-2c. We excluded N3 because the incidental dose to the larynx and hypopharynx is usually high in patients with a >6-cm nodal conglomerate. RESULTS The study population was comprised of 50 patients with a median follow-up after RT of 7.1 years. No patient developed recurrent cancer in a mucosal site (0/50), 2% (1/50) developed a neck recurrence in a high-dose area with synchronous distant metastases, and 2% (1/50) developed distant metastases with no evidence of local or regional recurrence. CONCLUSIONS When delivering RT for SCCA-UP metastatic predominantly to level IIA, it is not necessary to target the mucosa of the larynx or hypopharynx. The extent to which the incidental RT dose to these areas contributes to cancer control is not evaluated in this study.
Collapse
|
46
|
Rühle A, Grosu AL, Nicolay NH. De-Escalation Strategies of (Chemo)Radiation for Head-and-Neck Squamous Cell Cancers-HPV and Beyond. Cancers (Basel) 2021; 13:2204. [PMID: 34064321 PMCID: PMC8124930 DOI: 10.3390/cancers13092204] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/29/2021] [Accepted: 05/01/2021] [Indexed: 12/17/2022] Open
Abstract
Oncological outcomes for head-and-neck squamous cell carcinoma (HNSCC) patients are still unsatisfactory, especially for advanced tumor stages. Besides the moderate survival rates, the prevalence of severe treatment-induced normal tissue toxicities is high after multimodal cancer treatments, both causing significant morbidity and decreasing quality of life of surviving patients. Therefore, risk-adapted and individualized treatment approaches are urgently needed for HNSCC patients to optimize the therapeutic gain. It has been a well-known fact that especially HPV-positive oropharyngeal squamous cell carcinoma (OSCC) patients exhibit an excellent prognosis and may therefore be subject to overtreatment, resulting in long-term treatment-related toxicities. Regarding the superior prognosis of HPV-positive OSCC patients, treatment de-escalation strategies are currently investigated in several clinical trials, and HPV-positive OSCC may potentially serve as a model for treatment de-escalation also for other types of HNSCC. We performed a literature search for both published and ongoing clinical trials and critically discussed the presented concepts and results. Radiotherapy dose or volume reduction, omission or modification of concomitant chemotherapy, and usage of induction chemotherapy are common treatment de-escalation strategies that are pursued in clinical trials for biologically selected subgroups of HNSCC patients. While promising data have been reported from various Phase II trials, evidence from Phase III de-escalation trials is either lacking or has failed to demonstrate comparable outcomes for de-escalated treatments. Therefore, further data and a refinement of biological HNSCC stratification are required before deescalated radiation treatments can be recommended outside of clinical trials.
Collapse
Affiliation(s)
- Alexander Rühle
- Department of Radiation Oncology, University of Freiburg—Medical Center, Robert-Koch-Str. 3, 79106 Freiburg, Germany; (A.R.); (A.-L.G.)
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University of Freiburg—Medical Center, Robert-Koch-Str. 3, 79106 Freiburg, Germany; (A.R.); (A.-L.G.)
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Nils H. Nicolay
- Department of Radiation Oncology, University of Freiburg—Medical Center, Robert-Koch-Str. 3, 79106 Freiburg, Germany; (A.R.); (A.-L.G.)
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120 Heidelberg, Germany
| |
Collapse
|
47
|
Beaty BT, Moon DH, Shen CJ, Amdur RJ, Weiss J, Grilley-Olson J, Patel S, Zanation A, Hackman TG, Thorp B, Blumberg JM, Patel SN, Weissler MC, Yarbrough WG, Sheets NC, Parker JS, Neil Hayes D, Weck KE, Ramkissoon LA, Mendenhall WM, Dagan R, Tan X, Gupta GP, Chera BS. PIK3CA Mutation in HPV-Associated OPSCC Patients Receiving Deintensified Chemoradiation. J Natl Cancer Inst 2021; 112:855-858. [PMID: 31747025 DOI: 10.1093/jnci/djz224] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/14/2019] [Accepted: 11/19/2019] [Indexed: 12/13/2022] Open
Abstract
PIK3CA is the most frequently mutated gene in human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC). Prognostic implications of such mutations remain unknown. We sought to elucidate the clinical significance of PIK3CA mutations in HPV-associated OPSCC patients treated with definitive chemoradiation (CRT). Seventy-seven patients with HPV-associated OPSCC were enrolled on two phase II clinical trials of deintensified CRT (60 Gy intensity-modulated radiotherapy with concurrent weekly cisplatin). Targeted next-generation sequencing was performed. Of the 77 patients, nine had disease recurrence (two regional, four distant, three regional and distant). Thirty-four patients had mutation(s) identified; 16 had PIK3CA mutations. Patients with wild-type-PIK3CA had statistically significantly higher 3-year disease-free survival than PIK3CA-mutant patients (93.4%, 95% confidence interval [CI] = 85.0% to 99.9% vs 68.8%, 95% CI = 26.7% to 89.8%; P = .004). On multivariate analysis, PIK3CA mutation was the only variable statistically significantly associated with disease recurrence (hazard ratio = 5.71, 95% CI = 1.53 to 21.3; P = .01). PIK3CA mutation is associated with worse disease-free survival in a prospective cohort of newly diagnosed HPV-associated OPSCC patients treated with deintensified CRT.
Collapse
Affiliation(s)
- Brian T Beaty
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC
| | - Dominic H Moon
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC.,University of North Carolina, Chapel Hill, NC.,Department of Medical Oncology, University of Tennessee, Memphis, TN
| | - Colette J Shen
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC
| | - Robert J Amdur
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | | | | | | | | | | | - Brian Thorp
- Department of Otolaryngology/Head and Neck Surgery
| | | | | | | | | | - Nathan C Sheets
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC
| | | | | | | | | | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - Roi Dagan
- University of Florida Health Proton Therapy Institute, Jacksonville, FL
| | | | - Gaorav P Gupta
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC
| | - Bhishamjit S Chera
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC
| |
Collapse
|
48
|
Schrank TP, Lenze N, Landess LP, Hoyle A, Parker J, Lal A, Sheth S, Chera BS, Patel SN, Hackman TG, Major MB, Issaeva N, Yarbrough WG. Genomic heterogeneity and copy number variant burden are associated with poor recurrence-free survival and 11q loss in human papillomavirus-positive squamous cell carcinoma of the oropharynx. Cancer 2021; 127:2788-2800. [PMID: 33819343 DOI: 10.1002/cncr.33504] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 01/15/2021] [Accepted: 01/23/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Human papillomavirus-positive (HPV+) squamous cell carcinoma of the oropharynx (OPSCC) is the most prevalent HPV-associated malignancy in the United States. Favorable treatment outcomes have led to increased interest in treatment de-escalation to reduce treatment morbidity as well as the development of prognostic markers to identify appropriately low-risk patients. Intratumoral genomic heterogeneity and copy number alteration burden have been demonstrated to be predictive of poor outcomes in many other cancers; therefore, we sought to determine whether intratumor heterogeneity and genomic instability are associated with poor outcomes in HPV+ OPSCC. METHODS Tumor heterogeneity estimates were made based on targeted exome sequencing of 45 patients with HPV+ OPSCC tumors. Analysis of an additional cohort of HPV+ OPSCC tumors lacking matched normal sequencing allowed copy number analysis of 99 patient tumors. RESULTS High intratumorally genomic heterogeneity and high numbers of copy number alterations were strongly associated with worse recurrence-free survival. Tumors with higher heterogeneity and frequent copy number alterations were associated with loss of distal 11q, which encodes key genes related to double-strand break repair, including ATM and MRE11A. CONCLUSIONS Both intratumor genomic heterogeneity and high-burden copy number alterations are strongly associated with poor recurrence-free survival in patients with HPV+ OPSCC. The drivers of genomic instability and heterogeneity in these tumors remains to be elucidated. However, 11q loss and defective DNA double-strand break repair have been associated with genomic instability in other solid tumors. Copy number alteration burden and intratumoral heterogeneity represent promising avenues for risk stratification of patients with HPV+OPSCC.
Collapse
Affiliation(s)
- Travis P Schrank
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Linberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Nicholas Lenze
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lee P Landess
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Alan Hoyle
- Linberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joel Parker
- Linberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Asim Lal
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Siddharth Sheth
- Division of Hematology and Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Bhishamjit S Chera
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Samip N Patel
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Trevor G Hackman
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - M Ben Major
- Linberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Cell Biology and Physiology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Cell Biology and Physiology, Washington University in St. Louis, St. Louis, Missouri.,Institute for Informatics, School of Medicine, Washington University in St. Louis, St. Louis, Missouri.,Department of Otolaryngology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Natalia Issaeva
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Linberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Pathology and Lab Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Wendell G Yarbrough
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Linberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Pathology and Lab Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|
49
|
Thomson DJ. Reduced Dose and Volume Elective Nodal Radiation Therapy for Head and Neck Cancer: Challenging the Paradigm. Int J Radiat Oncol Biol Phys 2021; 109:941-943. [PMID: 33610303 DOI: 10.1016/j.ijrobp.2020.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/03/2020] [Accepted: 11/05/2020] [Indexed: 12/16/2022]
Affiliation(s)
- David J Thomson
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.
| |
Collapse
|
50
|
Petar S, Marko S, Ivica L. De-escalation in HPV-associated oropharyngeal cancer: lessons learned from the past? A critical viewpoint and proposal for future research. Eur Arch Otorhinolaryngol 2021; 278:4599-4603. [PMID: 33599841 DOI: 10.1007/s00405-021-06686-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/17/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Among head and neck squamous cell carcinomas (HNSCCs), oropharyngeal cancer (OPC) was historically thought to be a homogenous entity, mainly caused by excessive alcohol and tobacco consumption. However, the discovery of human papillomavirus (HPV) infection as an independent risk factor for the development of OPC has led to changes in diagnostics and treatment of this cancer. HPV-positive OPC is associated with improved survival and reduced recurrence rates compared to similar stage HPV-negative OPC and HNSCC in general. These favorable outcomes have led the medical and scientific communities to consider de-escalation treatment options in this specific population to spare patients from unnecessary toxicity, without compromising survival. This comment aimed to critically evaluate de-intensification treatment strategies in HPV-related OPC and to propose future treatment approaches as well as trial design. METHODS A review of the literature was performed. RESULTS Among nine published non-surgical de-intensification trials, only three studies had a comparison head-to-head with the standard of care, with two trials demonstrating clear inferiority of de-escalating treatment option (cetuximab-based radiotherapy). Additionally, there has been significant heterogeneity among induction chemotherapy (IC) protocols in de-escalating studies. Also, the toxicity among these studies varies in terms of the manner of reporting (physician vs patient-reported adverse events). CONCLUSIONS Data obtained with de-intensified strategies should only serve to help select an appropriate experimental arm for a randomized controlled trial phase III comparison against cisplatin and 70 Gy of radiotherapy. Without a proper randomized trial, there remains the possibility of compromising survival, which raises ethical questions about conducting any de-escalation trial.
Collapse
Affiliation(s)
- Suton Petar
- Department of Radiotherapy and Medical Oncology, University Hospital for Tumors, University Hospital Centre "Sisters of Mercy", Ilica 197, 10000, Zagreb, Croatia.
| | - Skelin Marko
- Pharmacy Department, General Hospital Sibenik, Stjepana Radica 83, 22000, Šibenik, Croatia
| | - Luksic Ivica
- Department of Maxillofacial Surgery, University of Zagreb School of Medicine, University Hospital Dubrava, Avenue Gojko Susak 6, 10000, Zagreb, Croatia
| |
Collapse
|