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Sahin O, Kamel S, Wahid KA, Dede C, Taku N, He R, Naser MA, Sharafi S, Mäkitie A, Kann BH, Kaski K, Sahlsten J, Jaskari J, Amit M, Chronowski GM, Diaz EM, Garden AS, Goepfert RP, Guenette JP, Gunn GB, Hirvonen J, Hoebers F, Hutcheson KA, Guha-Thakurta N, Johnson J, Kaya D, Khanpara SD, Nyman K, Lai SY, Lango M, Learned KO, Lee A, Lewis CM, Maniakas A, Moreno AC, Myers JN, Phan J, Pytynia KB, Rosenthal DI, Sandulache VC, Schellingerhout D, Shah SJ, Sikora AG, Mohamed ASR, Chen MM, Fuller CD. International Multi-Specialty Expert Physician Preoperative Identification of Extranodal Extension n Oropharyngeal Cancer Patients using Computed Tomography: Prospective Blinded Human Inter-Observer Performance Evaluation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.02.25.23286432. [PMID: 36865096 PMCID: PMC9980252 DOI: 10.1101/2023.02.25.23286432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Importance Extranodal extension (pENE) is a critical prognostic factor in oropharyngeal cancer (OPC) that drives therapeutic disposition. Determination of pENE from radiological imaging has been associated with high inter-observer variability. However, the impact of clinician specialty on human observer performance of imaging-detected extranodal extension (iENE) remains poorly understood. Objective To characterize the impact of clinician specialty on the accuracy of pre-operative iENE in human papillomavirus-positive (HPV+) OPC using computed tomography (CT) images. Design Setting and Participants This prospective observational human performance study analyzed pre-therapy CT images from 24 HPV+ OPC patients, with duplication of 6 scans (n=30) of which 21 were pathologically confirmed pENE. Thirty-four expert observers, including 11 radiologists, 12 surgeons, and 11 radiation oncologists, independently assessed these scans for iENE and reported human-detected radiologic criteria and observer confidence. Main Outcomes and Measures The primary outcomes included accuracy, sensitivity, specificity, area under the receiver operating characteristic curve (AUC), and Brier score for each physician, compared to ground-truth pENE. The significance of radiographic signs for prediction of pENE were determined through logistic regression analysis. Fleiss' kappa measured interobserver agreement, and Hanley-MacNeil AUC discrimination testing. Results Median accuracy across all specialties was 0.57 (95%CI 0.39 to 0.73), with no specialty showing discriminate performance greater than random estimation (median AUC 0.64, 95%CI 0.44 to 0.83). Significant differences between radiologists and surgeons in Brier scores (0.33 vs. 0.26, p < 0.01), radiation oncologists and surgeons in sensitivity (0.48 vs. 0.69, p > 0.1), and radiation oncologists and radiologists/surgeons in specificity (0.89 vs. 0.56, p > 0.1). Indistinct capsular contour and nodal necrosis were significant predictors of correct pENE status among all specialties. Interobserver agreement was weak for all the radiographic criteria, regardless of specialty (κ<0.6). Conclusions and Relevance Multiobserver testing shows physician discrimination of HPV+OPC pENE on pre-operative CT remains non-different than blind guessing, with high interrater variability and low diagnostic accuracy, regardless of clinician specialty. While minor differences in diagnostic performance among specialties are noted, they do not significantly affect the overall poor agreement and discrimination rates observed. The findings underscore the need for further research into automated detection systems or enhanced imaging techniques to improve the accuracy and reliability of iENE assessments in clinical practice.
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Affiliation(s)
| | - Onur Sahin
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Kareem A. Wahid
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Cem Dede
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Nicolette Taku
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Renjie He
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Setareh Sharafi
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Antti Mäkitie
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Benjamin H. Kann
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | | | | | | | - Moran Amit
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Eduardo M. Diaz
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Adam S. Garden
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Jeffrey P. Guenette
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - G. Brandon Gunn
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Jussi Hirvonen
- Tampere University, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere, Finland
| | - Frank Hoebers
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | | | | | - Jason Johnson
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Diana Kaya
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Kristofer Nyman
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Stephen Y. Lai
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Miriam Lango
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Kim O. Learned
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Anna Lee
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Carol M. Lewis
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Amy C. Moreno
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Jack Phan
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | | | - Vlad C. Sandulache
- Department of Otolaryngology Head and Neck Surgery, Baylor College of Medicine, Houston, USA
| | | | - Shalin J. Shah
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Abdallah S. R. Mohamed
- The University of Texas MD Anderson Cancer Center, Houston, USA
- Department of Otolaryngology Head and Neck Surgery, Baylor College of Medicine, Houston, USA
| | - Melissa M. Chen
- The University of Texas MD Anderson Cancer Center, Houston, USA
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2
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Swiecicki PL, Bellile E, Dragovic AF, McHugh J, Udager A, Mierzwa ML, Shah J, Heft-Neal M, Rosko A, Malloy KM, Casper K, Chinn SB, Shuman AG, Stucken C, Chepeha DB, Wolf GT, Bradford CR, Eisbruch A, Prince ME, Worden FP, Spector ME. Upfront Neck Dissection for Treatment Selection and Improvement in Quality of Life as a Novel Treatment Paradigm for Deintensification in HPV+ OPSCC. Clin Cancer Res 2024; 30:2393-2401. [PMID: 38517480 PMCID: PMC11147695 DOI: 10.1158/1078-0432.ccr-23-3247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/18/2023] [Accepted: 03/20/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE Locoregionally advanced HPV+ oropharyngeal squamous cell carcinoma (OPSCC) has excellent cure rates, although current treatment regimens are accompanied by acute and long-term toxicities. We designed a phase II deescalation trial for patients with HPV+ OPSCC to evaluate the feasibility of an upfront neck dissection to individualize definitive treatment selection to improve the quality of life without compromising survival. PATIENTS AND METHODS Patients with T1-3, N0-2 HPV+ OPSCC underwent an upfront neck dissection with primary tumor biopsy. Arm A included patients with a single lymph node less than six centimeters, with no extracapsular spread (ECS) and no primary site adverse features underwent transoral surgery. Arm B included patients who had two or more positive lymph nodes with no ECS, or those with primary site adverse features were treated with radiation alone. Arm C included patients who had ECS in any lymph node and were treated with chemoradiation. The primary endpoint was quality of life at 1 year compared with a matched historical control. RESULTS Thirty-four patients were enrolled and underwent selective neck dissection. On the basis of pathologic characteristics, 14 patients were assigned to arm A, 10 patients to arm B, and 9 to arm C. A significant improvement was observed in Head and Neck Quality of Life (HNQOL) compared with historical controls (-2.6 vs. -11.9, P = 0.034). With a median follow-up of 37 months, the 3-year overall survival was 100% and estimated 3-year estimated progression-free survival was 96% [95% confidence interval (CI), 76%-99%]. CONCLUSIONS A neck dissection-driven treatment paradigm warrants further research as a deintensification strategy.
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Affiliation(s)
- Paul L Swiecicki
- Division of Hematology and Oncology, Department of Internal Medicine, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Emily Bellile
- Cancer Data Science Shared Resource, Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Aleksandar F Dragovic
- Department of Radiation Oncology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Jonathan McHugh
- Department of Pathology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Aaron Udager
- Department of Pathology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Michelle Lynn Mierzwa
- Department of Radiation Oncology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Jennifer Shah
- Department of Radiation Oncology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Molly Heft-Neal
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew Rosko
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kelly M Malloy
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Keith Casper
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Steven Bennett Chinn
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew G Shuman
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Chaz Stucken
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Douglas B Chepeha
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gregory T Wolf
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Avraham Eisbruch
- Department of Radiation Oncology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Mark E Prince
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Francis P Worden
- Division of Hematology and Oncology, Department of Internal Medicine, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Matthew E Spector
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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3
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Meulemans J, Werpin L, Hermans R, Laenen A, Nuyts S, Clement PM, Delaere P, Van Lierde C, Vander Poorten V. The prognostic effect of radiological extranodal extension in HPV-positive oropharyngeal squamous cell carcinomas: a retrospective cohort analysis. Eur Arch Otorhinolaryngol 2024; 281:1541-1558. [PMID: 38170212 DOI: 10.1007/s00405-023-08409-8] [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: 08/31/2023] [Accepted: 12/10/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE Radiological extranodal extension (rENE) is a well-known negative prognosticator in head and neck squamous cell carcinoma (HNSCC). However, controversy remains regarding the prognostic effect of rENE in HPV-positive oropharyngeal SCCs (OPSCC). This single-center retrospective cohort analysis assessed the prognostic role of rENE in an HPV + OPSCC population and tried to validate a recently proposed modification of the TNM8 N-classification. METHODS 129 patients with HPV + OPSCC, of whom 106 cN + patients, were included. Radiological imaging (CT, MRI or both) was reanalyzed by a senior head and neck radiologist. Overall survival (OS), disease-free survival (DFS), locoregional recurrence-free survival (LRFS), and disease-specific survival (DSS) were evaluated. Cox proportional hazard models were used for estimating hazard ratios (HR). RESULTS A non-significant trend towards better outcomes in the rENE- group, as compared to the rENE + population, was observed for 5 year OS [80.99% vs 68.70%, HR: 2.05, p = 0.160], 5 year RFS [78.81% vs 67.87%, HR: 1.91, p = 0.165], 5 year DFS [77.06% vs 60.16%, HR: 2.12, p = 0.0824] and 5 year DSS [88.83% vs 81.93%, HR: 2.09, p = 0.195]. OS declined with ascending levels of rENE (p = 0.020). Multivariate analysis identified cT-classification and smoking as independent negative predictors for OS/DFS. The proposed modification of the TNM8 N-classification could not be validated. CONCLUSIONS Although rENE could not be identified as an independent negative prognosticator for outcome in our HPV + OPSCC population, outcomes tend to deteriorate with increasing rENE.
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Affiliation(s)
- Jeroen Meulemans
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium.
| | - Louis Werpin
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | | | - Annouschka Laenen
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Leuven, Belgium
| | - Sandra Nuyts
- Laboratory of Experimental Radiotherapy, Department of Oncology, KU Leuven, Leuven, Belgium
- Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Paul M Clement
- Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Pierre Delaere
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Charlotte Van Lierde
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
| | - Vincent Vander Poorten
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
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Kang YJ, Park G, Park SY, Kim T, Kim E, Heo Y, Lee C, Jeong HS. Extra-Capsular Spread of Lymph Node Metastasis in Oral, Oropharyngeal and Hypopharyngeal Cancer: A Comparative Subsite Analysis. Cancers (Basel) 2024; 16:659. [PMID: 38339410 PMCID: PMC10854589 DOI: 10.3390/cancers16030659] [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: 01/03/2024] [Revised: 01/23/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND The extra-capsular spread (ECS) of lymph node metastasis (LNM) is a hallmark of aggressive primary tumor phenotype in head and neck cancer (HNC); however, the factors influencing ECS are poorly understood. PATIENTS AND METHODS This was a retrospective study, including 190 cases of oral tongue cancer (OTC), 148 cases of oropharyngeal cancer (OPC) (118 HPV-positive and 30 HPV-negative), and 100 cases of hypopharyngeal cancer (HPC). Tumor dimension, tumor biological variables (lymphovascular/perineural invasion and histologic grade), and LNM variables (LNM number and size) were analyzed according to the presence of ECS using multivariable logistic regression and receiver operating characteristic (ROC) curve analyses. RESULTS LNM variables were significant factors for ECS in all subsites of HNC (p < 0.05), except HPV-positive OPC. In OTC, tumor dimensional variables were significantly related to ECS (p < 0.01). Meanwhile, in OPC and HPC, neither the primary tumor dimension nor the T status were significant factors for ECS occurrence. The predictability of ECS by ROC curve using multiple variables was 0.819 [95% confidence interval: 0.759-0.878] in OTC, 0.687 [0.559-0.815] in HPV-positive OPC, 0.823 [0.642-1.000] in HPV-negative OPC, and 0.907 [0.841-0.973] in HPC. CONCLUSION LNM variables were correlated with ECS occurrence for most HNC subsites, and site-dependent primary tumor characteristics might contribute differentially to the ECS development of LNM in HNC.
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Affiliation(s)
- Yung Jee Kang
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (Y.J.K.); (S.Y.P.); (T.K.); (E.K.); (Y.H.); (C.L.)
| | - Goeun Park
- Center for Biomedical Statistics, Samsung Medical Center, Seoul 06351, Republic of Korea;
| | - Sung Yool Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (Y.J.K.); (S.Y.P.); (T.K.); (E.K.); (Y.H.); (C.L.)
| | - Taehwan Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (Y.J.K.); (S.Y.P.); (T.K.); (E.K.); (Y.H.); (C.L.)
| | - Eunhye Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (Y.J.K.); (S.Y.P.); (T.K.); (E.K.); (Y.H.); (C.L.)
| | - Yujin Heo
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (Y.J.K.); (S.Y.P.); (T.K.); (E.K.); (Y.H.); (C.L.)
| | - Changhee Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (Y.J.K.); (S.Y.P.); (T.K.); (E.K.); (Y.H.); (C.L.)
| | - Han-Sin Jeong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (Y.J.K.); (S.Y.P.); (T.K.); (E.K.); (Y.H.); (C.L.)
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5
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Bruening J. Robotic Surgery in the Head and Neck: Presurgical Considerations and Post-treatment Appearance. Semin Roentgenol 2023; 58:374-383. [PMID: 37507177 DOI: 10.1053/j.ro.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/24/2023] [Accepted: 05/30/2023] [Indexed: 07/30/2023]
Affiliation(s)
- Jennifer Bruening
- Department of Otolaryngology and Communication Sciences, Head and Neck Surgical Oncology and Reconstructive Surgery, Medical College of Wisconsin, Milwaukee, WI.
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