Role of primary tumor volume and metastatic lymph node volume in response to curative effect of definitive radiotherapy for locally advanced head and neck cancer

BACKGROUND

Studies have shown mixed results concerning the role of primary tumor volume (TV) and metastatic lymph node (NV) volume in response to the curative effect of definitive radiotherapy for locally advanced head and neck squamous cell carcinoma (LAHNSCC).

OBJECTIVE

We aimed to evaluate the impact of TV and NV on the efficacy of radical radiotherapy in LAHNSCC patients, with the goal of guiding individualized therapy.

PATIENTS AND METHODS

Patients with LAHNSCC who received radical radiation therapy and were reexamined within 6 months post-therapy from January 2012 to December 2021 were selected. The volumes of the primary tumors and metastatic lymph nodes were calculated by software and then were divided into a large TV group vs small TV group and a large NV group vs small NV group according to the relationship with the median. Additionally, patients who received concurrent chemoradiotherapy (CCRT) or not were divided into the CCRT group and the radiotherapy (RT) group. Patients with lymph node metastasis were divided into node concurrent chemotherapy (N-CCRT) group and a node metastatic chemotherapy (N-RT) group according to whether they received concurrent chemotherapy or not. The volume shrinkage rate (VSR), objective response rate (ORR), local control rate (LCR) and overall survival (OS) were recorded and analyzed.

RESULTS

96 patients were included in the primary tumor volume group, and 73 patients were included in the metastatic lymph node group. Receiver operating characteristic (ROC) curves were constructed for objective remission (OR) endpoints, and a volume threshold was defined for TV and NV patients. The threshold primary tumor volume was 32.45 cm3, and the threshold metastatic lymph node volume was 6.05 cm3.The primary TV shrinkage rates of the small TV and the large TV groups were basically the same, P = 0.801. Similarly, the ORR and LCR were not significantly different between the small TV group and the large TV group (PORR = 0.118, PLCR = 0.315). Additionally, the TV shrinkage rate did not significantly differ between the CCRT group and the RT group, P = 0.133. Additionally, there was no significant difference in ORR or LCR in CCRT group (PORR = 0.057, PLCR = 0.088). However, the metastatic lymph node volume shrinkage rate in the small NV group was significantly greater than that in the large NV group (P = 0.001). The ORR and LCR of the small NV subgroup were significantly greater than those of the large NV subgroup (PORR = 0.002, PLCR = 0.037). Moreover, compared with that of the N-RT group, the NV shrinkage rate of the N-CCRT group was 84.10 ± s3.11%, and the shrinkage rate was 70.76 ± s5.77% (P = 0.047). For the ORR and LCR, the N-CCRT group and N-RT group were significantly different (PORR = 0.030, PLCR = 0.037). The median OS of the whole group was 26 months. However, neither TV/NV nor concurrent chemotherapy seemed to influence OS.

CONCLUSION

Primary tumor volume is not a prognostic factor for the response to curative effect radiotherapy in LAHNSCC patients. Nevertheless, metastatic lymph nodes are a prognostic factor for the response to curative effect radiotherapy in LAHNSCC patients. Patients with smaller lymph nodes have better local control.

Prognostic value of interim CT-based peritumoral and intratumoral radiomics in laryngeal and hypopharyngeal cancer patients undergoing definitive radiotherapy

BACKGROUND AND PURPOSE

We aimed to investigate the prognostic value of peritumoral and intratumoral computed tomography (CT)-based radiomics during the course of radiotherapy (RT) in patients with laryngeal and hypopharyngeal cancer (LHC).

MATERIALS AND METHODS

A total of 92 eligible patients were 1:1 randomly assigned into training and validation cohorts. Pre-RT and mid-RT radiomic features were extracted from pre-treatment and interim CT. LASSO-Cox regression was used for feature selection and model construction. Time-dependent area under the receiver operating curve (AUC) analysis was applied to evaluate the models' prognostic performances. Risk stratification ability on overall survival (OS) and progression-free survival (PFS) were assessed using the Kaplan-Meier method and Cox regression. The associations between radiomics and clinical parameters as well as circulating lymphocyte counts were also evaluated.

RESULTS

The mid-RT peritumoral (AUC: 0.77) and intratumoral (AUC: 0.79) radiomic models yielded better performance for predicting OS than the pre-RT intratumoral model (AUC: 0.62) in validation cohort. This was confirmed by Kaplan-Meier analysis, in which risk stratification depended on the mid-RT peritumoral (p = 0.009) and intratumoral (p = 0.003) radiomics could be improved for OS, in comparison to the pre-RT intratumoral radiomics (p = 0.199). Multivariate analysis identified mid-RT peritumoral and intratumoral radiomic models as independent prognostic factors for both OS and PFS. Mid-RT peritumoral and intratumoral radiomics were correlated with treatment-related lymphopenia.

CONCLUSION

Mid-RT peritumoral and intratumoral radiomic models are promising image biomarkers that could have clinical utility for predicting OS and PFS in patients with LHC treated with RT.

Pretreatment Tumor Volume and Tumor Sphericity as Prognostic Factors in Patients with Oral Cavity Squamous Cell Carcinoma: A Prospective Clinical Study in 95 Patients

The prognostic impact of tumor volume and tumor sphericity was analyzed in 95 patients affected by oral cancer. The pre-operative computed tomography (CT) scans were used to segment the tumor mass with threshold tools, obtaining the corresponding volume and sphericity. Events of recurrence and tumor-related death were detected for each patient. The mean follow-up time was 31 months. A p-value of 0.05 was adopted. Mean tumor volume resulted higher in patients with recurrence or tumor-related death at the Student's t-test (respectively, 19.8 cm3 vs. 11.1 cm3, p = 0.03; 23.3 cm3 vs. 11.7 cm3, p = 0.02). Mean tumor sphericity was higher in disease-free patients (0.65 vs. 0.59, p = 0.04). Recurrence-free survival and disease-specific survival were greater for patients with a tumor volume inferior to the cut-off values of 21.1 cm3 (72 vs. 21 months, p < 0.01) and 22.4 cm3 (85 vs. 32 months, p < 0.01). Recurrence-free survival and disease-specific survival were higher for patients with a tumor sphericity superior to the cut-off value of 0.57 (respectively, 49 vs. 33 months, p < 0.01; 56 vs. 51 months, p = 0.01). To conclude, tumor volume and sphericity, three-dimensional parameters, could add useful information for better stratification of prognosis in oral cancer.

Hypopharyngeal cancer trends in a high-incidence region: A retrospective tertiary single center study

BACKGROUND

Hypopharyngeal cancer has the bleakest prognosis among head and neck cancers due to its extensive submucosal involvement, advanced tumor stage, and limited surgical reconstruction options. Its primary causes include alcohol consumption, tobacco use, genetic predisposition, 1` diet, and socioeconomic conditions. While squamous cell carcinoma (SCC) accounts for 95% of hypopharyngeal tumors, it remains a rare form, comprising only 3%-5% of all SCC cases in the head and neck region. Globally, Central and Eastern Europe have the highest incidence rates for males (3.9 per 100000) and the third highest for females (2.26 per 100000), underscoring the significance of this seemingly uncommon condition. In Romania, hypopharyngeal cancer ranked 24th in incidence rate, with 634 new cases in 2020.

AIM

To study the incidence, treatment and survival rates of hypopharyngeal tumor cases in a major ear, nose, throat (ENT) surgical center.

METHODS

A retrospective epidemiological clinical study was conducted on patients diagnosed and treated for hypopharyngeal cancer at the ENT department of "Carol Davila Central University Emergency Military Hospital" in Bucharest between January 2018 and August 2022. The study included 53 patients and was authorized by the Ethics Committee of Titu Maiorescu Doctoral School (Bucharest, Romania) and the Ethics Committee of Carol Davila Central University Emergency Military Hospital (Bucharest, Romania). Inclusion criteria required a positive histopathological diagnosis of hypopharyngeal cancer, tumor localization in the hypopharyngeal region, and informed consent for data usage. Exclusion criteria involved major psychiatric pathologies and disagreement for data usage. Diagnosis was based on ENT assessment, imaging reports, and laboratory data. Treatment methods were determined based on various factors. Additional tools, such as Adult Comorbidity Evaluation-27 and Karnofski Performance Status Scale, were used for risk assessment and functional capacity evaluation. Quality of life aspects were measured using the European Organisation for Reasearch and Treatment of Cancer Quality of Life Questionnaire Head and Neck-35 questionnaire.

RESULTS

Our retrospective study examined 53 patients with hypopharyngeal cancer between January 2018 and August 2022. The majority of patients were male (94.3%), with an average age at diagnosis of 62.5 years. Among the patients, 20.75% were employed, 66.03% were retired, and 9.43% were unemployed. Smoking was prevalent among 69.81% of patients, while alcohol consumption was frequent in 32.07% of cases. The tumors were mostly diagnosed at an advanced stage (stage IV) and were predominantly SCC. Comorbidities were present in 83.01% of patients, with cardiovascular diseases being the most common. Dysphagia and neck mass were the most common symptoms reported. Treatment methods included surgery, radiation therapy, and chemotherapy. A favorable treatment response was observed in 22.64% of cases, while relapse occurred in 6 cases. Follow-up data was unavailable for some patients.

CONCLUSION

In summary, our findings align with existing literature; however, we observed a higher severity.

Prognosticating Gross Tumor Volume in Head-and-Neck Cancer - Redefining Gross Tumor Volume Beyond Contouring

Purpose

Precision radiotherapy (RT) requires accurate delineation of gross tumor volumes (GTVs) for targeted dose delivery. Volumetric measurement of this GTV can predict the treatment outcomes. This volume has been limited for mere contouring and its potential as the prognostic factor is less explored.

Materials and Methods

The data of 150 patients with oropharynx, hypopharynx, and larynx cancer undergoing curative intensity-modulated RT and weekly cisplatin between April 2015 and December 2019 were retrospectively evaluated. GTV-P (primary), GTV-N (nodal), and GTV-P+N were defined, and volumetric parameters were generated. Volume thresholds were defined as per the receiver operating characteristics, and the prognostic value of these tumor volumes (TVs) with respect to treatment outcomes was analyzed.

Results

All patients completed 70 Gy, median chemotherapy cycles were six. Mean GTV-P, GTV-N, and GTV-P+N were 44.5 cc, 13.4 cc, and 57.9 cc, respectively. Oropharynx constituted 45% of cases. Forty-nine percent had Stage III disease. Sixty-six percent had complete response (CR). As per the defined cutoff values, GTV-P <30cc, GTV-N <4 cc, and GTV-P+N <50 cc had better CR rates with P < 0.05 (82.6% vs. 51.9%; 74% vs. 58.4% and 81.5% vs. 47.8%, respectively). At median follow-up of 21.4 months, overall survival (OS) was 60% and median OS was 32.3 months. The median OS in patients with GTV-P <30 cc, GTV-N <4 cc, and GTV-P+N <50 cc was better with P < 0.05 (59.2 vs. 21.4; 59.2 vs. 22.2, and 59.2 vs. 19.8 months, respectively).

Conclusion

GTV should not just be limited for contouring but its role as an important prognostic factor has to be recognized.

Multicenter Study of Carbon-ion Radiotherapy for Oropharyngeal Non-squamous Cell Carcinoma

BACKGROUND/AIM

To evaluate treatment outcomes of carbon-ion radiotherapy for oropharyngeal non-squamous cell carcinoma at four carbon-ion facilities in Japan.

PATIENTS AND METHODS

We retrospectively analyzed the cases of 33 patients with oropharyngeal non-squamous cell carcinoma who were treated with carbon-ion radiotherapy between November 2003 and December 2014.

RESULTS

The histology included adenoid cystic carcinoma (n=25) and mucosal malignant melanoma (n=4). No patients had T1 tumors; 23 had T4 tumors. The most-commonly prescribed dose was 57.6 Gy (RBE) in 16 fractions. The median follow-up period was 34.8 months (range=4.2-122.8 months). The 3-year local control and overall survival rates were 94.7% and 90.7%, respectively. There were no grade ≥4 acute adverse events. Only one patient experienced a grade ≥4 late adverse event. No patients experienced late adverse events related to swallowing or salivary function.

CONCLUSION

Carbon-ion radiotherapy appears to be a promising treatment option for oropharyngeal non-squamous cell carcinoma.

Implications of limited exolaryngeal disease and cricoarytenoid joint involvement in organ conservation protocols for laryngopharyngeal cancers: Results from a prospective study

BACKGROUND

To identify clinicoradiological factors that determine functional outcomes in laryngopharyngeal cancers treated with chemoradiotherapy.

METHODS

One hundred patients of locally advanced laryngopharyngeal cancers who were treated with chemoradiotherapy were accrued in this prospective study. The coprimary endpoint of the study was local control (LC) and functional larynx preservation survival (FLPS).

RESULTS

The median follow-up was 39 months. Thirty-nine patients had a local failure of which 17 underwent a salvage laryngectomy. A dysfunctional larynx with clinic-radiologically disease was seen in only 1 patient. Factors significant for LC were thyroid cartilage erosion/lysis and cricoarytenoid joint involvement. Within the T4a subset, patients with exolaryngeal disease through the soft tissue framework had significantly better LC and FLPS than those with cartilage erosion/lysis.

CONCLUSIONS

Patients with limited exolaryngeal disease through the soft-tissue framework can be considered for functional organ preservation, while those with thyroid cartilage involvement and cricoarytenoid joint involvement are not suitable.

Magnetic resonance imaging-derived radiomic signature predicts locoregional failure after organ preservation therapy in patients with hypopharyngeal squamous cell carcinoma

•

The first study to develop and validate an MRI-derived radiomic signature (RS) for the prediction of 1-year locoregional failure in HPSCC patients receiving OPT.

•

The RS-based model (RS of 0.0326 as the cut-off value) provides a novel and convenient approach for the prediction of the 1-year clinical outcomes.

•

The proposed RS-based model can help physicians characterize and facilitate decision-making for the clinical management of patients with locally advanced HPSCC.

Background and purpose

To develop and validate a magnetic resonance imaging (MRI)-derived radiomic signature (RS) for the prediction of 1-year locoregional failure (LRF) in patients with hypopharyngeal squamous cell carcinoma (HPSCC) who received organ preservation therapy (OPT)

Material and methods

A total of 800 MRI-based features of pretreatment tumors were obtained from 116 patients with HPSCC who received OPT from two independent cohorts. The least absolute shrinkage and selection operator regression model were used to select the features used to develop the RS. Harrell’s C-index and corrected C-index were used to evaluate the discriminative ability of RS. The Youden index was used to select the optimal cut-point for risk category.

Results

The RS yielded 1000 times bootstrapping corrected C-index of 0.8036 and 0.78235 in the experimental (n = 82) and validation cohorts (n = 34), respectively. With respect to the subgroup of patients with stage III/IV and cT4 disease, the RS also showed good predictive performance with corrected C-indices of 0.760 and 0.754, respectively. The dichotomized risk category using an RS of 0.0326 as the cut-off value yielded a 1-year LRF predictive accuracy of 79.27%, 79.41%, 76.74%, and 71.15% in the experimental, validation, stage III/IV, and cT4a cohorts, respectively. The low-risk group was associated with a significantly better progression-free laryngectomy-free and overall survival outcome in two independent institutions, stage III/IV, and cT4a cohorts.

Conclusion

The RS-based model provides a novel and convenient approach for the prediction of the 1-year LRF and survival outcome in patients with HPSCC who received OPT.

Primary tumor volume as a predictor of distant metastases and survival in patients with sinonasal mucosal melanoma

BACKGROUND

Sinonasal mucosal melanoma (SNMM) is an aggressive cancer with high mortality. Identifying patients at risk of distant metastasis assists with management and prognostication. We aimed to define the relationship between volume, survival, and risk of distant metastases.

METHODS

A retrospective review of all patients with SNMM treated at a single institution over a 21-year period was conducted. Tumor volume was calculated using cross-sectional imaging and survival analysis was performed.

RESULTS

Sixty-one patients were included. Tumor volume was predictive of local progression-free survival (P = .03), distant metastases-free survival (DMFS) (P = .002), and overall survival (OS) (P = .02). It was a better predictor than AJCC stage and T-classification. Tumor volume equal to or greater than 5 cm³ was associated with a significantly worse DMFS and OS (P = .02 and .009, respectively).

CONCLUSION

Calculation of tumor volume assists in quantifying the risk of distant metastases and death in SNMM.

Specific growth rates calculated from CTs in patients with head and neck squamous cell carcinoma: a retrospective study performed in Austria

OBJECTIVE

To provide data on specific growth rates (SGRs) of primary tumours (PT-SGR) and largest pathological cervical lymph nodes (LN-SGR) for head and neck squamous cell carcinoma (HNSCC). To explore PT-SGR's and LN-SGR's correlation with selected biomarkers epidermal growth factor receptor (EGFR), Ki67 and CD44.

DESIGN AND SETTING

Retrospective study performed at a tertiary oncological referral centre in Innsbruck, Austria.

PARTICIPANTS

Adult patients with incident HNSCC treated with primary radiotherapy (RT) or radiochemotherapy (RCT).

OUTCOME MEASURES

Volumes of the primary tumour (PT-volume) and largest pathological cervical lymph node (LN-volume) were measured in CT scans obtained at time of diagnosis and subsequent planning CTs immediately prior to RT or RCT. SGRs were calculated assuming an exponential growth function. PT-SGR's and LN-SGR's correlation with EGFR, Ki67 and CD44 were explored.

RESULTS

In 123 patients, mean interval between diagnostic and planning CT was 29±21 days. PT-SGR was 1.8±1.8% (mean±SD) per day and was positively correlated with EGFR, Ki67 and CD44 expression (p=0.02; p=0.02; p=0.03). LN-SGR was 1.7±2.0% per day and increased with larger initial LN-volume, was lower in laryngeal cancer (p=0.003) and slowed down with time. LN-SGR was not correlated with EGFR, Ki67 or CD44 expression in primary tumours (p>0.12). New cartilage or bone infiltration occurred in 10 patients and new central lymph node necrosis in 8 patients.

CONCLUSIONS

HNSCCs are fast-growing tumours for which treatment must not be delayed. Clinical tumour growth rates are influences by EGFR, KI67 and CD44 expression.

Pretreatment tumor volume and tumor sphericity as prognostic factors in patients with oral cavity squamous cell carcinoma

PURPOSE

This study was designed as a retrospective observational study, focusing on the correlation between the preoperative CT-scan tumor volume, tumor sphericity, and the disease-related prognosis.

METHODS

A total of 30 consecutive patients, affected by primary oral cancer, were retrospectively identified from our oral cancer database. The preoperative images (DICOM data) for the study population were uploaded into a modular software package designed to convert patients' medical images into 3D digital models. Multislice interpolation and threshold segmentation tools were used to segment the tumor mass. This was then converted into a 3D mesh and exported in STL format, in order to calculate the corresponding volume. We applied the concept of sphericity - a measurement of how closely the shape of an object approaches that of a mathematically perfect sphere - to the segmented tumor mass.

RESULTS

Mean tumor volume was larger in patients with tumor recurrence and/or who had died than in patients who were disease free/alive. Tumor sphericity was influential on clinical outcomes. It appeared to be lower in patients who had tumor recurrence and/or who had died (0.54 ± 0.09 and 0.53 ± 0.05) than in patients who were disease free/alive (0.65 ± 0.07). This difference was statistically significant (p < 0.05). Cumulative recurrence-free survival was 86.2% for patients with a tumor volume lower than the cut-off value. Otherwise, it was 0% for those with a tumor volume higher than the cut-off value (p < 0.01; log rank test). Cumulative recurrence-free survival was 86.3% for patients with a higher sphericity index, compared with 13.6% for those with a lower sphericity index.

CONCLUSION

The prognostic model, based on a tridimensional, CT-based characterization of the tumor size, which includes both tumor volume and tumor sphericity, uses readily available information and could be considered when formulating prognoses for patients with oral cancer.

Volumetric analysis at abdominal CT: oncologic and non-oncologic applications

Volumetric analysis is an objective three-dimensional assessment of a lesion or organ that may more accurately depict the burden of complex objects compared to traditional linear size measurement. Small changes in linear size are amplified by corresponding changes in volume, which could have significant clinical implications. Though early methods of calculating volumes were time-consuming and laborious, multiple software platforms are now available with varying degrees of user-software interaction ranging from manual to fully automated. For the assessment of primary malignancy and metastatic disease, volumetric measurements have shown utility in the evaluation of disease burden prior to and following therapy in a variety of cancers. Additionally, volume can be useful in treatment planning prior to resection or locoregional therapies, particularly for hepatic tumours. The utility of CT volumetry in a wide spectrum of non-oncologic pathology has also been described. While clear advantages exist in certain applications, some data have shown that volume is not always the superior method of size assessment and the associated labor intensity may not be worthwhile. Further, lack of uniformity among software platforms is a challenge to widespread implementation. This review will discuss CT volumetry and its potential oncologic and non-oncologic applications in abdominal imaging, as well as advantages and limitations to this quantitative technique.

The functional verification of EGFR-CAR T-cells targeted to hypopharyngeal squamous cell carcinoma

BACKGROUND

The aim of this study was to validate the antitumor function of EGFR-chimeric antigen T-cells (CART) targeted to FaDu cells, a hypopharyngeal squamous cell carcinoma cell line, and to provide a preclinical basis for the application of CART cell technology in hypopharyngeal squamous cell carcinoma.

METHODS

Detection of cytokine secretions of EGFR-CAR T and CART-controls in the presence of target cells and nontarget cells as an indicator of CART cell activation. Detection of the cytotoxic effects of EGFR-CAR T on specific tumors in the presence of target cells was evaluated by LDH release and CART cell proliferation.

RESULTS

The results showed that cytokine secretion increased significantly after EGFR-CAR T-cells were incubated with target cells, and EGFR-CAR T-cells has higher cytotoxic effect on target cells than the CART-control group. The target cell lysis rate was 52.66%. The proliferation of EGFR-CAR T-cells in the presence of target cells was not distinctly observed.

CONCLUSION

In this study, we validated the antitumor function of EGFR-CAR T-cells targeted to the FaDu cell line and provided the foundation for application of the CART technique in the treatment of hypopharyngeal carcinoma.

Tumor volume as a prognostic marker in p16-positive and p16-negative oropharyngeal cancer patients treated with definitive intensity-modulated radiotherapy

PURPOSE

To investigate the impact of primary gross tumor volume (pGTV) and nodal gross tumor volume (nGTV) in oropharyngeal squamous cell carcinoma (OPSCC) and the difference in their role between human papillomavirus (HPV)-positive and HPV-negative patients.

METHODS

The patient cohort consists of 91 OPSCC patients treated with definitive radiochemotherapy or radiotherapy using intensity-modulated radiotherapy (IMRT). All patients had a minimum follow-up of 31 months. Volume measurements were made from computer tomography (CT) scans and HPV status was assessed by p16 immunohistochemistry. The end points were as follows: overall survival (OS), disease-free survival (DFS) and locoregional control (LRC).

RESULTS

pGTV was a significant independent prognostic factor for overall survival (OS; p = 0.020) in p16-negative patients. nGTV of p16-negative tumors had significant prognostic value in all end points in multivariate analyses. High-stage (III-IVc) p16-negative tumors were only associated with significantly poorer OS (p = 0.046) but not with poorer LRC or DFS when compared with the low-stage (I-II) tumors. nGTV of p16-positive tumors was an independent prognostic factor for DFS (p = 0.005) and LRC (p = 0.007) in multivariate analyses.

CONCLUSION

pGTV may serve as an independent prognostic factor in p16-negative patients and nGTV may serve as an independent prognostic factor both in p16-positive and p16-negative patients treated with radiochemotherapy or radiotherapy using IMRT. Tumor volume may have an impact on selecting patients for de-escalation protocols in the future, both in p16-positive and p16-negative patients.

Prognostic value of tumor volume in patients with head and neck squamous cell carcinoma treated with primary surgery

BACKGROUND

Tumor volume in head and neck squamous cell carcinoma (HNSCC) was mainly measured in nonsurgically treated patients. We analyzed the influence of tumor volume on complete response (CR), overall survival (OS), and clear surgical margins also in primarily surgically treated patients.

METHODS

In contrast-enhanced CTs, the tumor volumes of patients with incident HNSCC were measured.

RESULTS

The tumor volumes of 259 patients were measured, of which 125 patients (48%) underwent primary surgery and 102 patients (84%) had clear margins. The tumor volume was not an independent factor for CR at the primary tumor site. Risk of death increased by 1.4% per mL of tumor volume (95% confidence interval [CI] 0.8%-2.0%; P < .001). The OS was better in patients treated with primary surgery, if the tumor volume was ≤12 mL (P < .001). Risk of involved margins increased by 4.5% per mL of tumor volume (95% CI 0.9%-8.3%; P = .003). The predicted probability of clear margins was ≥80% in tumor volumes ≤ 16 mL.

CONCLUSION

The tumor volume had an impact on CR, OS, and clear margins. The tumor volume may also aid in selecting HNSCC treatment.

Metabolic tumor volume of primary tumor predicts survival better than T classification in the larynx preservation approach

We aimed to determine whether pretreatment metabolic tumor volume of the primary tumor (T-MTV) or T classification would be a better predictor of laryngectomy-free survival (LFS) and overall survival (OS) after chemoradiotherapy in patients with locally advanced laryngeal or hypopharyngeal cancer requiring total laryngectomy. We analyzed 85 patients using a Cox proportional hazards model and evaluated its usefulness by Akaike's information criterion. A T-MTV cut-off value was determined by time-dependent receiver operating characteristic curve analysis. Interobserver reliability for measuring T-MTV was estimated by the intraclass correlation coefficient (ICC). After adjustment for covariables, T-MTV, irrespective of whether a continuous or dichotomized variable, and T classification remained independent predictors of LFS and OS. Large T-MTV (>28.7 mL) was associated with inferior LFS (hazard ratio [HR], 4.16; 95% confidence interval [CI], 1.97-8.70; P = 0.0003) and inferior OS (HR, 3.18; 95% CI, 1.47-6.69; P = 0.004) compared with small T-MTV (≤28.7 mL). The T-MTV model outperformed the T classification model in predicting LFS and OS (P = 0.007 and 0.01, respectively). Three-year LFS and OS rates for patients with small versus large T-MTV were 68% vs 9% (P < 0.0001) and 77% vs 25% (P < 0.0001), respectively, whereas those for patients with T2-T3 versus T4a were 61% vs 31% (P = 0.003) and 71% vs 48% (P = 0.10), respectively. ICC was 0.99 (95% CI, 0.99-1.00). Given the excellent interobserver reliability, T-MTV is better than T classification to identify patients who would benefit from the larynx preservation approach.

Quantitative pretreatment CT volumetry: Association with oncologic outcomes in patients with T4a squamous carcinoma of the larynx

BACKGROUND

The purpose of this study was to determine the impact of CT-determined pretreatment primary tumor volume on survival and disease control in T4a laryngeal squamous cell carcinoma (SCC).

METHODS

We retrospectively reviewed 124 patients with T4a laryngeal cancer from 2000-2011. Tumor volume measurements were collected and correlated with outcomes.

RESULTS

Five-year overall survival (OS) for patients with tumor volume ≥21 cm³ treated with larynx preservation (n = 26 of 41) was significantly inferior compared to <21 cm³ (42% vs 64%, respectively; P = .003). Five-year OS for patients with tumor volumes ≥21 cm³ in the cohort treated with total laryngectomy followed by radiotherapy (RT; n = 42 of 83) was not statistically significant when compared to <21 cm³ (50% vs 63%, respectively; P = .058). On multivariate analysis, tumor volume ≥21 cm³ was a significant independent correlate of worse disease-specific survival (DSS; P = .004), event-free survival (P = .005), recurrence-free survival (RFS; P = .04), noncancer cause-specific survival (P = .02), and OS (P = .0002).

CONCLUSION

Pretreatment CT-based tumor volume is an independent prognostic factor of outcomes in T4a laryngeal cancer.

Volumetric Versus Unidimensional Measures of Metastatic Colorectal Cancer in Assessing Disease Response

INTRODUCTION

The purpose of this study was to compare unidimensional (1D/linear) and volumetric (3D) measures of metastatic colorectal cancer (mCRC) at computed tomography (CT) for predicting clinical outcome.

PATIENTS AND METHODS

Analysis of CT images in 105 patients (mean age, 59 years; range, 25-81 years; 45 women, 60 men) receiving treatment for mCRC was performed. Both unidimensional and volumetric measures were obtained on index lesions at 3 time points (baseline/midpoint/post-therapy; mean interval, 4.1 months; median, 3.7 months) by 3 readers using a semi-automated technique. Measurements were summed and compared using best overall response across the 3 time points. Patient response was categorized based on Response Evaluation Criteria In Solid Tumors (RECIST) 1.1 thresholds for unidimensional and volume measures (CR, complete response; PR, partial response; SD, stable disease; PD, progressive disease). Survival data was correlated (mean follow-up, 19.9 ± 17.1 months; median, 14.7 months). Intra/interobserver variability and reproducibility of 1D and 3D measures was assessed. Cox survival and Kaplan-Meier models were constructed and compared.

RESULTS

Cox models and Kaplan-Meier curves for unidimensional versus volumetric assessment were very similar in appearance. Both 1D and 3D measurements effectively separated PD from the SD/PR groups, but neither separated SD from PR well. Volumetric measures showed comparable intra/interobserver variability on Bland-Altman analysis to unidimensional measures across readers using a semi-automated measurement technique. Metastatic site (lung, liver, node, other) did not seem to impact measurement reproducibility.

CONCLUSIONS

Although CT volumetric assessment of metastatic colorectal cancer is fairly reproducible by reader and site using a semi-automated technique, the ability to stratify progressive disease from other disease response categories in terms of survival was similar to unidimensional measurement.

Tumour volumes: Predictors of early treatment response in locally advanced head and neck cancers treated with definitive chemoradiation

AIM

To analyse and predict early response 3 months post definitive chemoradiation (CCRT) utilising tumour volume (TV) measurement in locally advanced head and neck cancers (LAHNC).

BACKGROUND

LAHNC are 3-dimentional lesions. The largest diameter of these tumours measured for T-classification may not necessarily reflect the true tumour dimensions. TV accurately reflects the tumour burden because it is a measurement of tumour burden in all three dimensions.

MATERIALS AND METHODS

It is a single institutional prospective study including 101 patients with LAHNC treated with definitive CCRT. TV data noted were primary tumour volume (PTV), total nodal volume (TNV) and total tumour volume (TTV). Response evaluation was done at 3 months after the completion of definitive CCRT and patients were categorised either having achieved complete response (CR) or residual disease.

RESULTS

Patients who had not achieved CR were found to have larger TV compared with those who had achieved CR. There were significant inverse correlations between PTV and response (median 16.37 cm(3) vs. 45.2 cm(3); p = 0.001), and between TTV and response (median 36.14 cm(3) vs. 66.06 cm(3); p < 0.001). Receiver operating characteristic (ROC) analysis identified an "optimal cut-off" value of 41 cm(3) for PTV and 42 cm(3) for TTV above and below which the magnitude of difference in response was the greatest.

CONCLUSIONS

If response evaluation 3 months post CCRT is to be predicted it is simply not enough to measure the largest single dimension of the tumour. TV seems to be a better and more accurate reflection of the true total tumour burden or extent of the disease.

Approximation of head and neck cancer volumes in contrast enhanced CT

Background

Tumor volume may serve as a predictor of response to radiochemotherapy (RCT) in head and neck squamous cell carcinoma (HNSCC). Computer assisted tumor volumetry requires time-consuming slice-by-slice manual or semi-automated segmentation. We questioned how accurately primary tumor and suspect cervical lymph node (LN) volumes can be approximated by the maximum tumor diameters in three dimensions.

Methods

In contrast-enhanced diagnostic CT scans of 74 patients with incident advanced HNSCC, manual slice-by-slice segmentation volumetry of primary tumor, total- and largest suspect cervical LN served as the reference method. In the same scans, maximum orthogonal diameters were measured using the distance measurement tool in standard visualization software in axial and coronal sections. From these diameters, approximate volumes were calculated using the cubic and ellipsoid formula. A second segmentation volumetry was performed in contrast enhanced radiotherapy-planning CT scans obtained prior to primary concurrent RCT 24 days (+/− 13 days) following the initial diagnostic CT scans. Intraclass correlation coefficients and Bland-Altman analyses were used to compare results.

Results

Slice-by-slice manual segmentation volumetry of primary and LN volumes revealed a lognormal distribution and ranged from 0 to 86 ml and 0 to 129 ml, respectively. Volume approximations in diagnostic CT scans with the ellipsoid formula resulted in an −8 % underestimation of tumor volumes (95 % CI −14 % to −1 %; p = 0.022) and an −18 % underestimation of suspect cervical LN volumes (95 % CI −25 % to −12 %; p = 0.001). Inter rater intraclass correlation for primaries was 0.95 (95 % CI +0.92 to +0.97; p = 0.001), and intra rater intraclass correlation was 0.99 (95 % CI +0.98 to +0.99; p = 0.001). The cubic formula resulted in pronounced overestimation of primary and LN volumes. Primary tumor volumes obtained by the second segmentation volumetry in radiotherapy-planning CT scans obtained on average 24 days following the initial volumetry resulted in larger primary tumor volumes (mean bias +28 %, 95 % CI +14 % to +41 %; p = 0.001). Tumor volume increase correlated with time between the diagnostic and planning CTs (r = 0.24, p = 0.05) and was approximately 1 % per day.

Discussion

Ellipsoid approximations of tumor and lymph node volumes in HNSCC using maximum orthogonal diameters underestimates volumes based on segmentation in multiple slices. Due to time difference and safety margins, segmented volumes in radiotherapy-planning CT scans tend to be larger than in diagnostic CT scans.

Conclusion

Ellipsoid approximations of tumor and lymph node volumes in HNSCC are easily available from diagnostic CT scans. Volume estimates are applicable over a wide range of tumor and LN sizes and may be useful in clinical decision-making and oncologic research.

A prognostic volumetric threshold of gross tumor volume in head and neck cancer patients treated with radiotherapy

OBJECTIVES

To determine the prognostic utility of a volumetric threshold for gross tumor volume (GTV) of the primary and nodal disease when accounting for the TNM classification in head and neck cancer (HNC) patients treated with definitive radiotherapy (RT).

MATERIALS AND METHODS

From 2004 to 2011, 79 HNC patients were treated to a median dose of 70 Gy, using intensity-modulated RT in 78.5% and 3-dimensional conformal RT in 21.5% with 83.5% receiving concurrent chemotherapy. Primary (GTV-P) and nodal (GTV-N) GTVs were derived from computed tomography (CT)-based contours for RT planning, of which 89.7% were aided by positron emission tomography-computed tomography. Local (LC), nodal (NC), distant (DC) control, and overall survival (OS) were assessed using the Kaplan-Meier product-limit method.

RESULTS

With a median follow-up of 27.1 months GTV-P, threshold of <32.9 mL (mean value) compared with ≥32.9 mL, correlated with improved 2-year LC (96.2% vs. 63.9%, P<0.0001), NC (100% vs. 69.2%, P<0.0001), DC (87.9% vs. 64.2%, P=0.001), and OS (88.4% vs. 58.6%, P=0.001). GTV-P demonstrated its prognostic utility in multivariate analyses when adjusted for tumor category, cancer site, and chemotherapy regimen. Nodal GTV (mean, 34.0 mL) was not predictive of nodal control and survival.

CONCLUSIONS

A volumetric threshold of the primary tumor may be used as an independent prognostic factor in patients with HNC undergoing definitive RT.

Volumetric evaluation of hepatic tumors: multi-vendor, multi-reader liver phantom study

PURPOSE

To compare liver lesion volume measurement on multiple 3D software platforms using a liver phantom.

METHODS

An anthropomorphic phantom constructed with ten liver lesions of varying size, attenuation, and shape with known volume and long axis measurement was scanned (120 kVp, 80-440 smart mA, NI 12). DICOM data were uploaded to five commercially available 3D visualization systems and manual tumor volume was obtained by three-independent readers. Accuracy and reproducibility of linear and volume measurements were compared. The two most promising systems were then compared with an additional prototype system by two readers using both manual and semi-automated measurement with similar comparison between linear and volume measures. Measurements were performed on 5- and 1.25-mm data sets. Inter- and intra-observer variability was also assessed.

RESULTS

Overall mean % volume error on the five commercially available software systems (averaging all ten liver lesions among all three readers) was 8.0% ± 7.5%, 13.7% ± 11.2%, 14.2% ± 15.2%, 16.4% ± 14.8 %, and 16.9% ± 13.8%, varying almost twofold across vendor. Moderate inter-observer variability was present. Volume measurement was slightly more accurate than linear measurement, but linear measurement was more reproducible across readers and systems. On the two "best" systems, the manual measurement method was more accurate than the automated method (p = 0.001). The prototype system demonstrated superior semi-automated assessment, with a mean % volume error of 5.3% ± 4.1% (vs. 17.8% ± 11.1% and 31.5% ± 19.7%, p < 0.001), with improved inter- and intra-observer variability.

CONCLUSIONS

Accuracy and reproducibility of volume assessment of liver lesions varies significantly by vendor, which has important implications for clinical use.

Clinical utility of multimodality imaging with dynamic contrast-enhanced MRI, diffusion-weighted MRI, and 18F-FDG PET/CT for the prediction of neck control in oropharyngeal or hypopharyngeal squamous cell carcinoma treated with chemoradiation

The clinical usefulness of pretreatment imaging techniques for predicting neck control in patients with oropharyngeal or hypopharyngeal squamous cell carcinoma (OHSCC) treated with chemoradiation remains unclear. In this prospective study, we investigated the role of pretreatment dynamic contrast-enhanced perfusion MR imaging (DCE-PWI), diffusion-weighted MR imaging (DWI), and [¹⁸F]fluorodeoxyglucose-positron emission tomography (¹⁸F-FDG PET)/CT derived imaging markers for the prediction of neck control in OHSCC patients treated with chemoradiation. Patients with untreated OHSCC scheduled for chemoradiation between August, 2010 and July, 2012 were eligible for the study. Clinical variables and the following imaging parameters of metastatic neck lymph nodes were examined in relation to neck control: transfer constant, volume of blood plasma, and volume of extracellular extravascular space (V_e) on DCE-PWI; apparent diffusion coefficient (ADC) on DWI; maximum standardized uptake value, metabolic tumor volume, and total lesion glycolysis on ¹⁸F-FDG PET/CT. There were 69 patients (37 with oropharynx SCC and 32 with hypopharynx SCC) with successful pretreatment DCE-PWI and DWI available for analysis. After a median follow-up of 31 months, 25 (36.2%) participants had neck failure. Multivariate analysis identified hemoglobin level <14.3 g/dL (P = 0.019), V_e <0.23 (P = 0.040), and ADC >1.14×10⁻³ mm²/s (P = 0.003) as independent prognostic factors for 3-year neck control. A prognostic scoring system was formulated by summing up the three significant predictors of neck control. Patients with scores of 2–3 had significantly poorer neck control and overall survival rates than patients with scores of 0–1. We conclude that hemoglobin levels, V_e, and ADC are independent pretreatment prognostic factors for neck control in OHSCC treated with chemoradiation. Their combination may identify a subgroup of patients at high risk of developing neck failure.

Interim FDG PET/CT for predicting the outcome in patients with head and neck cancer

OBJECTIVES/HYPOTHESIS

The study aimed to investigate the prognostic effects of interim (18) fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (PET/CT) during definitive radiotherapy (RT) or chemoradiotherapy (CRT) in patients with head and neck cancer.

STUDY DESIGN

This is a prospectively treatment study.

METHODS

The pretreatment and interim PET/CT images of 51 patients with advanced pharyngeal cancers receiving definitive RT/CRT were evaluated prospectively. The interim PET/CT images were taken at a cumulative RT dose ranging from 41.4 to 46.8 Gy. The maximum standardized uptake value (SUVm) of the interim PET/CT and the reduction ratio of the SUVm (SRR) between the two images were measured. The differences between patients with or without local failures were examined using the Mann-Whitney test. Overall survival (OS), disease-free survival (DFS), and primary and nodal relapse-free survival rates were calculated using the Kaplan-Meier method. Independent prognosticators were identified using Cox regression analysis.

RESULTS

After a median follow-up duration of 23 months, a higher interim SUVm was associated with local failures. Conducting a multivariate analysis revealed that a SUVmax reduction ratio of primary tumor (SRR-P) < 0.64 was associated with the inferior OS (hazard ratio 2.64; P =0.035) and DFS (hazard ratio 2.33; P = 0.045). Patients who had tumors with an SRR-P < 0.64 had a considerably lower 2-year OS and DFS compared with those who had SRR-P ≥ 0.64 (47% vs. 66%; 41% vs. 64%).

CONCLUSION

A higher interim SUVm was associated with local recurrence. In addition, patients with a lower SRR-P should be considered to be at risk of primary failure.

LEVEL OF EVIDENCE

4.

The role of tumor volume in radiotherapy of patients with head and neck cancer

The assumption that the larger tumor contains a higher number of clonogenic cells what may deteriorate prognosis of patients treated with RT has been confirmed in many clinical studies. Significant prognostic influence of tumor volume (TV) on radiotherapy (RT) outcome has been found for tumors of different localizations including patients with head and neck cancer (HNC). Although TV usually is a stronger prognostic factor than T stage, commonly used TNM classification system dose not incorporate TV data. The aim of the paper is to refresh clinical data regarding the role of TV in RT of patients with HNC. At present somehow new meaning of TV could be employed in the aspect of modern RT techniques and combined treatment strategies. For larger TV more aggressive treatment options may be considered. In modern RT techniques escalated dose could be provided highly conformal or RT can be combined with systemic treatment increasing therapeutic ratio. In the study several reports estimating prognostic value of TV for patients with HNC treated with RT has been reviewed.Due to substantially various reported groups of patients as to tumor site, stage of disease or treatment strategies, precise cut-off value could not be establish in general, but the significant association between TV and treatment outcome had been found in almost all studies. There is a strong suggestion that TV should supplement clinical decision in the choice of optimal treatment strategy for patients with HNC.

Volumetric stratification of cT4 stage head and neck cancer

BACKGROUND

Locoregionally advanced stage head and neck cancer (HNC) is known for unfavorable outcome with only ~ 40-50% 3-year overall survival (OS). Clinical T4 stage includes a wide range of tumor burden. The lack of further nonsurgical subgrouping of cT4 stage makes intercenter outcome of irradiated cohorts difficult. Aim of this analysis was to further stratify cT4 stage HNC using volumetric staging.

MATERIAL AND METHODS

Between January 2002 and January 2013, a total of 201 cT4 stage squamous cell cancer (SCC) HNC patients referred to our center for curative definitive radiation were consecutively irradiated. Radiation was performed using modulated techniques. Total gross tumor volumes (tGTV: primary+nodal tumor volume) of all patients have retrospectively been stratified using a prospectively evaluated volumetric staging system which bases on 3 cut-offs (15/70/130 ml), translating into 4 prognostic subgroups [V1: 1-15 ml (n=15), V2: 16-70 ml (108), V3: 71-130 ml (62), V4: >130 ml (16)]. OS, disease-free survival (DFS), locoregional control (LRC), and distant metastasis-free survival (DMFS) rates were calculated.

RESULTS

The mean/median follow-up was 31/23 months (range 1-116 months). The 3-year OS, DFS, LRC, and DMFS rates of the entire cohort were 63, 44, 48, and 77%, respectively. Volumetric staging revealed its potential to prognostically statistically significantly divide the cT4 cohort into 4 volume subgroups (V1/2/3/4): OS: 90%/72%/58%/18%; DFS: 83%/50%/39%/10%; LRC: 81%/53%/47%/15%; DMFS: 93%/90%/70%/41%, all p<0.0001.

CONCLUSION

Volumetric staging allowed a highly statistically significant stratification of cT4 HNC stages into prognostic subgroups, which offers the chance of better intercenter comparability of irradiated advanced stage HNC cohorts.

Dynamic contrast-enhanced MR imaging predicts local control in oropharyngeal or hypopharyngeal squamous cell carcinoma treated with chemoradiotherapy

The role of pretreatment dynamic contrast-enhanced perfusion MR imaging (DCE-PWI) and diffusion-weighted MR imaging (DWI) in predicting the treatment response of oropharyngeal or hypopharyngeal squamous cell carcinoma (OHSCC) to chemoradiation remains unclear. We prospectively investigated the ability of pharmacokinetic parameters derived from pretreatment DCE-PWI and DWI to predict the local control of OHSCC patients treated with chemoradiation. Between August, 2010 and March, 2012, patients with untreated OHSCC scheduled for chemoradiation were eligible for this prospective study. DCE-PWI and DWI were performed in addition to conventional MRI. The relationship of local control with the following clinical and imaging variables was analyzed: the hemoglobin level, T-stage, tumor location, gross tumor volume, maximum standardized uptake value, metabolic tumor volume and total lesion glycolysis on FDG PET/CT, transfer constant (K^trans), volume of blood plasma and volume of extracellular extravascular space on DCE-PWI, and apparent diffusion coefficient on DWI of the primary tumor. The patients were also divided into a local control group and a local failure group, and their clinical and imaging parameters were compared. There were 58 patients (29 with oropharynx squamous cell carcinoma [SCC] and 29 with hypopharynx SCC) with successful pretreatment DCE-PWI and DWI available for analysis. After a median follow-up of 18.2 months, 17 (29.3%) participants had local failure, whereas the remaining 41 patients achieved local control. Univariate analysis revealed that only the K^trans value was significantly associated with local control (P = 0.03). When the local control and local failure groups were compared, significant differences were observed in K^trans and the tumor location (P = 0.01 and P = 0.04, respectively). In the multivariable analysis, only K^trans was statistically significant (P = 0.04). Our results suggest that pretreatment K^trans may help predict the local control in OHSCC patients treated with chemoradiation.

Treatment outcomes of definitive chemoradiotherapy for patients with hypopharyngeal cancer

We analyzed the efficacy of definitive chemoradiotherapy (CRT) for patients with hypopharyngeal cancer (HPC). Subjects comprised 97 patients who were treated with definitive CRT from 1990 to 2006. Sixty-one patients (62.9%) with resectable disease who aimed to preserve the larynx received induction chemotherapy (ICT), whereas 36 patients (37.1%) with resectable disease who refused an operation or who had unresectable disease received primary alternating CRT or concurrent CRT (non-ICT). The median dose to the primary lesion was 66 Gy. The median follow-up time was 77 months. The 5-year rates of overall survival (OS), progression-free survival (PFS), local control (LC), and laryngeal preservation were 68.7%, 57.5%, 79.1%, and 70.3%, respectively. The T-stage was a significant prognostic factor in terms of OS, PFS and LC in both univariate and multivariate analyses. The 5-year rates of PFS were 45.4% for the ICT group and 81.9% for the non-ICT group. The difference between these groups was significant with univariate analysis (P = 0.006). Acute toxicity of Grade 3 to 4 was observed in 34 patients (35.1%). Grade 3 dysphagia occurred in 20 patients (20.6%). Twenty-nine (29.8%) of 44 patients with second primary cancer had esophageal cancer. Seventeen of 29 patients had manageable superficial esophageal cancer. The clinical efficacy of definitive CRT for HPC is thought to be promising in terms of not only organ preservation but also disease control. Second primary cancer may have a clinical impact on the outcome for HPC patients, and special care should be taken when screening at follow-up.

Treatment of hypopharyngeal carcinoma with primary chemoradiotherapy: functional morbidity

PURPOSE OF REVIEW

This review aims at unravelling the medical literature which has reported on the treatment of 'larynx preserving' chemoradiotherapy strategies and separating the treatment sites, larynx and hypopharynx, from each other and reporting on the adverse effects and functional outcomes of patients with hypopharyngeal cancer.

RECENT FINDINGS

The literature reports on the treatment of advanced laryngeal and hypopharyngeal cancer with chemoradiotherapy together as a 'common cancer site'. Although the chemotherapeutic drugs affect the tumour and the normal tissues similarly in both the larynx and hypopharynx, their effects on the patient groups are different, mainly affecting swallow, airway protection mechanisms and voice/speech to a greater or lesser extent. Pretreatment symptoms and function should be documented subjectively and objectively prior to commencing nonsurgical treatment. Hypopharyngeal cancer should be reported separately, and preferably stratified into the three subsites, according to the T stage of disease rather than TNM stage. Equipment for such testing and the process for such documentation are available in most clinical areas, worldwide.

SUMMARY

Future analysis relies on the conscientious monitoring of adverse effects of all treatment modalities and an assessment of function as well as quality of life impact on the patient. Thus, the specialty can make informed decisions on the most appropriate and most suitable mode of treatment for individual patients based upon their tumour, their preoperative organ function, their likely future organ function and the likelihood of cure.

Prognostic value of gross tumor volume delineated by FDG-PET-CT based radiotherapy treatment planning in patients with locally advanced pancreatic cancer treated with chemoradiotherapy

Background

We aimed to assess whether gross tumor volume (GTV) determined by fusion of contrast-enhanced computerized tomography (CT) and 18F-fluoro-deoxy-D-glucose positron emission tomography-CT (FDG-PET-CT) based radiotherapy planning could predict outcomes, namely overall survival (OS), local-regional progression-free survival (LRPFS), and progression-free survival (PFS) in cases with locally advanced pancreas cancer (LAPC) treated with definitive concurrent chemoradiotherapy.

Methods

A total of 30 patients with histological proof of LAPC underwent 50.4 Gy (1.8 Gy/28 fractions) of radiotherapy concurrent with continuously infused 5-FU followed by 4 to 6 courses of maintenance gemcitabine. Target volume delineations were performed on FDG-PET-CT-based RTP. Patients were stratified into 2 groups: GTV lesser (GTV_L) versus greater (GTV_G) than cut off value determined by receiver operating characteristic (ROC) analysis, and compared in terms of OS, LRPFS and PFS.

Results

Median GTV delineated according to the FDG-PET-CT data was 100.0 cm³. Cut off GTV value determined from ROC curves was 91.1 cm³. At a median follow up of 11.2 months, median OS, LRPFS and PFS for the entire population were 10.3, 7.8 and 5.7 months, respectively. Median OS, LRPFS and PFS for GTV_L and GTV_G cohorts were 16.3 vs. 9.5 (p = 0.005), 11.0 vs. 6.0 (p = 0.013), and 9.0 vs. 4.8 months (p = 0.008), respectively.

Conclusions

The superior OS, LRPFS and PFS observed in GTV_L patients over GTV_G ones suggests a potential for FDG-PET-CT-defined GTV size in predicting outcomes of LAPC patients treated with definitive C-CRT, which needs to be validated by further studies with larger cohorts.

Prognostic significance of radiologically determined neck node volume in head and neck cancer: a systematic review

This systematic review addresses the prognostic significance of neck node volume in head and neck cancer. Primary tumor volume evolved as an independent significant factor for survival in head and neck cancer patients. Besides primary tumor volume, multiple prognostic features related to the regional lymph nodes were studied in literature. In literature, some authors showed the significance of total tumor volume/nodal volume for survival and loco-regional control. Articles reporting prognosis and survival in nodal tumor volumes were collected by systematically reviewing publications listed in the Pubmed and Embase databases. Publications were included when they at least reported on total tumor volume (TTV) or nodal volume and survival. In this systematic review we studied 21 articles. For measurement of nodal volume different formulas were used. Until now, there's no clear statistical evidence for the use of either TTV or nodal volume versus primary tumor volume to predict the individual loco-regional control or survival after treatment. There is wide variety of tumor measuring systems in the literature. The cut-off value for local tumor response also shows large variation. Firstly consensus should be accomplished on standardization of volume measurements, preferably automatic, and secondly large study groups are needed with identical treatment modalities to further unravel the role of neck node volume as separate staging tool.

Tumor volume as prognostic factor in chemoradiation for advanced head and neck cancer

BACKGROUND

Tumor volume is an important predictor of outcome in radiotherapy alone. Its significance in concomitant chemoradiation (CCRT) is much less clear. We analyzed the prognostic value of primary tumor volume for advanced head and neck squamous cell carcinoma (HNSCC) treated with CCRT.

METHODS

Three hundred sixty patients treated with definitive CCRT for advanced HNSCC were selected. The pretreatment MRI or CT scan was used to calculate the primary tumor volume. Median follow-up was 19.8 months.

RESULTS

The average primary tumor volume was 37.0 cm³ (range, 2.1-182.7 cm³; median, 28.7 cm³). Multivariate analysis showed a significant effect of tumor volume on local control. The hazard ratio for a local recurrence increased by 14% per 10 cm³ volume increase (95% CI, 8% to 21%). There was no significant independent effect of T and N status on local control.

CONCLUSION

For advanced HNSCC, tumor volume is more powerful for predicting outcome after CCRT than TNM status.

Primary tumor volume is an important predictor of clinical outcomes among patients with locally advanced squamous cell cancer of the head and neck treated with definitive chemoradiotherapy

PURPOSE

The tumor volume has been established as a significant predictor of outcomes among patients with head-and-neck cancer undergoing radiotherapy alone. The present study attempted to add to the existing data on tumor volume as a prognostic factor among patients undergoing chemoradiotherapy.

METHODS AND MATERIALS

A total of 78 patients who had undergone definitive chemoradiotherapy for Stage III-IV squamous cell cancer of the hypopharynx, oropharynx, and larynx were identified. The primary tumor volumes were calculated from the treatment planning computed tomography scans, and these were correlated to the survival and tumor control data obtained from the retrospective analysis.

RESULTS

The interval to progression correlated with the primary tumor volume (p = .007). The critical cutoff point for the tumor volume was identified as 35 cm(3), and patients with a tumor volume <35 cm(3) had a significantly better prognosis than those with a tumor volume >35 cm(3) at 5 years (43% vs. 71%, p = .010). Longer survival was also correlated with smaller primary tumor volumes (p = .022). Similarly, patients with a primary tumor volume <35 cm(3) had a better prognosis in terms of both progression-free survival (61% vs. 33%, p = .004) and overall survival (84% vs. 41%, p = < .001). On multivariate analysis, the primary tumor volume was the best predictor of recurrence (hazard ratio 4.7, 95% confidence interval 1.9-11.6; p = .001) and survival (hazard ratio 10.0, 95% confidence interval 2.9-35.1; p = < .001). In contrast, the T stage and N stage were not significant factors. Analysis of variance revealed that tumors with locoregional failure were on average 21.6 cm(3) larger than tumors without locoregional failure (p = .028) and 27.1-cm(3) larger than tumors that recurred as distant metastases (p = .020).

CONCLUSION

The results of our study have shown that the primary tumor volume is a significant prognostic factor in patients with advanced cancer of the head and neck undergoing definitive chemoradiotherapy and correlated with the treatment outcomes better than the T or N stage.

Does primary tumour volumetry performed early in the course of definitive concomitant chemoradiotherapy for head and neck squamous cell carcinoma improve prediction of primary site outcome?

Although previous studies have documented correlations between pre-treatment or post-treatment primary tumour volumes and local outcome following definitive concomitant chemoradiotherapy (CCRT) in head and neck squamous cell carcinoma (HNSCC), no study has included and compared tumour volumes during CCRT. We reviewed the MRIs of 69 HNSCC patients treated with a 6 weeks course of CCRT and who underwent successful MRI pre-treatment (n = 69), 2 weeks intra-treatment (n = 48) and 6 weeks post-treatment (n = 61). Primary tumour volumes on MRI at the three time points were calculated and compared for their predictive value for primary site outcome. Volume thresholds optimised to predict failure with the highest accuracy and positive predictive value (PPV) were calculated. The mean pre-treatment volume was 24.6 cm³ (range, 1.1-187.9 cm³) and the mean follow-up interval was 41 months (range, 12-100 months). 23 primary tumours failed treatment (33%). Volumes before, during and after CCRT were positively associated with local failure (p = 0.015, p = 0.009, p<0.0001). Volume reductions during and after CCRT were negatively associated with local failure (p = 0.021, p = 0.001). Pre-treatment and intra-treatment volume thresholds achieved the highest accuracy and produced intermediate PPVs (51-64%) for predicting local failure. Optimised intra-treatment thresholds did not identify any more treatment failures than the pre-treatment thresholds. By comparison, a 6 weeks post-treatment volume reduction (<35%) achieved 100% PPV for failure, albeit with 26% sensitivity. In conclusion, primary tumour volumetry performed early in CCRT provides minimal additional information compared with pre-treatment volumetry, with respect to predicting post-treatment local failures. Therefore, volumetry during CCRT is unlikely to be useful for guiding individual response-based therapeutic modifications.

Current trends in initial management of hypopharyngeal cancer: the declining use of open surgery

Squamous cell carcinoma of the hypopharynx represents a distinct clinical entity. Most patients present with significant comorbidities and advanced-stage disease. The overall survival is relatively poor because of high rates of regional and distant metastasis at presentation or early in the course of the disease. A multidisciplinary approach is crucial in the overall management of these patients to achieve the best results and maintain or improve functional results. Traditionally, operable hypopharyngeal cancer has been treated by total (occasionally partial) laryngectomy and partial or circumferential pharyngectomy, followed by reconstruction and postoperative radiotherapy in most cases. Efforts to preserve speech and swallowing function in the surgical treatment of hypopharyngeal (and laryngeal) cancer have resulted in a declining use of total laryngopharyngectomy and improved reconstructive efforts, including microvascular free tissue transfer. There are many surgical, as well as nonsurgical, options available for organ and function preservation, which report equally effective tumor control and survival. The selection of appropriate treatment is of crucial importance in the achievement of optimal results for these patients. In this article, several aspects of surgical and nonsurgical approaches in the treatment of hypopharyngeal cancer are discussed. Future studies must be carefully designed within clearly defined populations and use uniform terminology and standardized functional assessment and declare appropriate patient or disease endpoints. These studies should focus on improvement of results, without increasing patient morbidity. In this respect, technical improvements in radiotherapy such as intensity-modulated radiotherapy, advances in supportive care, and incorporation of newer systemic agents such as targeted therapy, are relevant developments.

18F-FDG PET/CT-based gross tumor volume definition for radiotherapy in head and neck cancer: a correlation study between suitable uptake value threshold and tumor parameters

Background

To define a suitable threshold setting for gross tumor volume (GTV) when using ¹⁸Fluoro-deoxyglucose positron emission tomography and computed tomogram (PET/CT) for radiotherapy planning in head and neck cancer (HNC).

Methods

Fifteen HNC patients prospectively received PET/CT simulation for their radiation treatment planning. Biological target volume (BTV) was derived from PET/CT-based GTV of the primary tumor. The BTVs were defined as the isodensity volumes when adjusting different percentage of the maximal standardized uptake value (SUVmax), excluding any artifact from surrounding normal tissues. CT-based primary GTV (C-pGTV) that had been previously defined by radiation oncologists was compared with the BTV. Suitable threshold level (sTL) could be determined when BTV value and its morphology using a certain threshold level was observed to be the best fitness of the C-pGTV. Suitable standardized uptake value (sSUV) was calculated as the sTL multiplied by the SUVmax.

Results

Our result demonstrated no single sTL or sSUV method could achieve an optimized volumetric match with the C-pGTV. The sTL was 13% to 27% (mean, 19%), whereas the sSUV was 1.64 to 3.98 (mean, 2.46). The sTL was inversely correlated with the SUVmax [sTL = -0.1004 Ln (SUVmax) + 0.4464; R² = 0.81]. The sSUV showed a linear correlation with the SUVmax (sSUV = 0.0842 SUVmax + 1.248; R² = 0.89). The sTL was not associated with the value of C-pGTVs.

Conclusion

In PET/CT-based BTV for HNC, a suitable threshold or SUV level can be established by correlating with SUVmax rather than using a fixed threshold.

Clinical implications of the tumor volume reduction rate in head-and-neck cancer during definitive intensity-modulated radiotherapy for organ preservation

PURPOSE

To investigate the prognostic value of the volume reduction rate (VRR) in patients with head-and-neck cancer treated with intensity-modulated radiotherapy (IMRT).

METHODS AND MATERIALS

Seventy-six patients with oropharyngeal cancer (OPC) and another 76 with hypopharyngeal cancer (HPC) were enrolled in volumetric analysis. All patients received allocated radiotherapy courses. Adaptive computed tomography was done 4 to 5 weeks after the start of IMRT. Primary tumor volume measurement was derived using separate images for the pretreatment gross tumor volume (pGTV) and the interval gross tumor volume.

RESULTS

In the OPC group, the pGTV ranged from 6.6 to 242.6 mL (mean, 49.9 mL), whereas the value of the VRR ranged from 0.014 to 0.74 (mean, 0.43). In HPC patients, the pGTV ranged from 4.1 to 152.4 mL (mean, 35.6 mL), whereas the VRR ranged from -1.15 to 0.79 (mean, 0.33). Multivariate analysis of the primary tumor relapse-free survival for OPC revealed three prognostic factors: T4 tumor (p = 0.0001, hazard ratio 7.38), pGTV ≥20 mL (p = 0.01, hazard ratio 10.61), and VRR <0.5 (p = 0.001, hazard ratio 6.49). Multivariate analysis of the primary tumor relapse-free survival for HPC showed two prognostic factors: pGTV ≥30 mL (p = 0.001, hazard ratio 2.87) and VRR <0.5 (p = 0.03, hazard ratio 2.25).

CONCLUSION

The VRR is an outcome predictor for local control in OPC and HPC patients treated with IMRT. Those with large tumor volumes or a VRR <0.5 should be considered for a salvage operation or a dose-escalation scheme.