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Embring A, Onjukka E, Mercke C, Lax I, Berglund A, Friesland S. Dose Escalation of Oropharyngeal Cancer: Long-Time Follow-Up and Side Effects. Cancers (Basel) 2023; 15:cancers15092580. [PMID: 37174046 PMCID: PMC10177133 DOI: 10.3390/cancers15092580] [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: 02/04/2023] [Revised: 04/13/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
Previous studies on dose-escalated radiotherapy in head and neck cancer have shown mixed results, and it is not established which patients would benefit from dose escalation. Further, while dose escalation does not appear to increase late toxicity, this needs to be confirmed with longer follow-up. In this study, we analysed treatment outcome and toxicity in 215 patients with oropharyngeal cancer treated with dose-escalated radiotherapy (>72 Gy, EQD2, α/β = 10 Gy, boost by brachytherapy or simultaneous integrated boost) and a matched cohort of 215 patients treated with standard dose external-beam radiotherapy (68 Gy) between 2011 and 2018 at our institution. The 5-year overall survival (OS) was 77.8% (72.4-83.6) and 73.7% (67.8-80.1) in the dose-escalated and standard dose group, respectively (p = 0.24). Median follow-up was 78.1 (49.2-98.4) and 60.2 (38.9-89.4) months in the dose-escalated and standard dose groups, respectively. Grade ≥3 osteoradionecrosis (ORN) and late dysphagia were more common in the dose-escalated group compared to the standard dose group, with 19 (8.8%) vs. 4 (1.9%) patients developing grade ≥3 ORN (p = 0.001), and 39 (18.1%) vs. 21 (9.8%) patients developing grade ≥3 dysphagia (p = 0.01). No predictive factors to help select patients for dose-escalated radiotherapy were found. However, the remarkably good OS in the dose-escalated cohort, despite a predominance of advanced tumour stages, encourages further attempts to identify such factors.
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Affiliation(s)
- Anna Embring
- Department of Oncology, Karolinska University Hospital, 17176 Stockholm, Sweden
- Karolinska Institute, Department of Oncology-Pathology, 17176 Stockholm, Sweden
| | - Eva Onjukka
- Karolinska Institute, Department of Oncology-Pathology, 17176 Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Claes Mercke
- Department of Oncology, Karolinska University Hospital, 17176 Stockholm, Sweden
- Karolinska Institute, Department of Oncology-Pathology, 17176 Stockholm, Sweden
| | - Ingmar Lax
- Karolinska Institute, Department of Oncology-Pathology, 17176 Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Anders Berglund
- Epistat Epidemiology and Statistics Consulting, 75655 Uppsala, Sweden
| | - Signe Friesland
- Department of Oncology, Karolinska University Hospital, 17176 Stockholm, Sweden
- Karolinska Institute, Department of Oncology-Pathology, 17176 Stockholm, Sweden
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Embring A, Onjukka E, Mercke C, Lax I, Berglund A, Friesland S. Dose escalation in oropharyngeal cancer: a comparison of simultaneous integrated boost and brachytherapy boost. Radiat Oncol 2023; 18:65. [PMID: 37029424 PMCID: PMC10082532 DOI: 10.1186/s13014-023-02256-x] [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: 10/21/2022] [Accepted: 04/03/2023] [Indexed: 04/09/2023] Open
Abstract
BACKGROUND Local recurrence is the most common pattern of failure in head and neck cancer. It can therefore be hypothesised that some of these patients would benefit from an intensified local treatment, such as radiation dose escalation of the primary tumour. This study compares treatment and toxicity outcomes from two different boost modalities in oropharyngeal cancer: simultaneous integrated boost (SIB) and brachytherapy boost. METHODS Two hundred and forty-four consecutive patients treated with > 72 Gy for oropharyngeal squamous cell carcinoma between 2011 and 2018 at our institution were retrospectively analysed. Data on side effects were collected from a local quality registry and supplemented with a review of medical records. Patients receiving a brachytherapy boost first had external beam radiotherapy consisting of 68 Gy in 2 Gy fractions to the gross tumour volume (GTV), and elective radiotherapy to the neck bilaterally. The brachytherapy boost was typically given using pulsed dose rate, 15 fractions and 0.56-0.66 Gy per fraction [total dose in EQD2 = 75.4-76.8 Gy (α/β = 10)]. The typical dose escalated radiotherapy with external beam radiotherapy only, was delivered using SIB with 74,8 Gy in 2.2 Gy fractions [EQD2 = 76.0 Gy (α/β = 10)] to the primary tumour, 68 Gy in 2 Gy fractions to GTV + 10 mm margin and elective radiotherapy to the neck bilaterally. RESULTS Dose escalation by SIB was given to 111 patients and brachytherapy boost to 134 patients. The most common type of cancer was base of tongue (55%), followed by tonsillar cancer (42%). The majority of patients had T3- or T4-tumours and 84% were HPV-positive. The 5-year OS was 72,4% (95% CI 66.9-78.3) and the median follow-up was 6.1 years. Comparing the two different dose escalation modalities we found no significant differences in OS or PFS and these results remained after a propensity-score matched analysis was performed. The analysis of grade ≥ 3 side effects showed no significant differences between the two different dose escalation techniques. CONCLUSIONS We found no significant differences in survival or grade ≥ 3 side effects comparing simultaneous integrated boost and brachytherapy boost as alternative dose escalation modalities in the treatment of oropharyngeal cancer.
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Affiliation(s)
- Anna Embring
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.
- Department of Oncology, Karolinska University Hospital, Anna Steckséns Gata 41, 171 76, Solna, Stockholm, Sweden.
| | - Eva Onjukka
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Claes Mercke
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Oncology, Karolinska University Hospital, Anna Steckséns Gata 41, 171 76, Solna, Stockholm, Sweden
| | - Ingmar Lax
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Berglund
- Epistat Epidemiology and Statistics Consulting, Uppsala, Sweden
| | - Signe Friesland
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Oncology, Karolinska University Hospital, Anna Steckséns Gata 41, 171 76, Solna, Stockholm, Sweden
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Platek A, Mix M, Chowdhry V, Farrugia M, Lacombe MA, Bogart JA, Degraaf L, Iovoli A, Arshad H, Wooten K, Gupta V, Hicks WL, Platek ME, Hahn SS, Singh AK. Evaluation of radiation treatment volumes for unknown primaries of the head and neck in the era of FDG PET. PLoS One 2020; 15:e0231042. [PMID: 32275670 PMCID: PMC7147765 DOI: 10.1371/journal.pone.0231042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/13/2020] [Indexed: 11/20/2022] Open
Abstract
Objectives Positron-emission tomography (PET) has improved identification of the primary tumor as well as occult nodal burden in cancer of the head and neck. Nevertheless, there are still patients where the primary tumor cannot be located. In these situations, the standard of care is comprehensive head and neck radiation therapy however it is unclear whether this is necessary. This study examines the effects of radiation treatment volume on outcomes among using data from two cancer centers in unknown primary carcinoma of the head and neck. Methods Patients received unilateral (n = 34), or bilateral radiation (n = 28). Patient factors such as age, gender, smoking history, and patterns of failure were compared using Mann Whitney U and Chi Square. Overall survival (OS) and disease free survival (DFS) trends were estimated using Kaplan-Meier survival curves. Effect of treatment volume on survival was examined using multivariate cox proportional hazard regression model. Results No significant differences were observed in the frequency of local (p = 0.32), regional (p = 0.50), or distant (p = 0.76) failures between unilateral and bilateral radiation therapy. By Kaplan-Meier estimates, OS (3-year OS bilateral = 71.67%, unilateral = 77.90%, p = 0.50) and DFS (3-year DFS bilateral = 77.92%, unilateral = 69.43%, p = 0.63) were similar between the two treatment approaches. Lastly, multivariate analysis did not demonstrate any significant differences in outcome by treatment volumes (OS: HR = 0.74, 95% CI: 0.31, 1.81, p = 0.51; DFS: HR: 0.68, 95% CI: 0.24, 1.93, p = 0.47). Conclusions Unilateral radiation therapy compared with bilateral produced similar survival.
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Affiliation(s)
- Alexis Platek
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, United States of America
| | - Michael Mix
- Department of Radiation Oncology, Upstate Medical University, Syracuse, NY, United States of America
| | - Varun Chowdhry
- Roswell Park Comprehensive Cancer Center, Department of Radiation Medicine, Buffalo, NY, United States of America
| | - Mark Farrugia
- Roswell Park Comprehensive Cancer Center, Department of Radiation Medicine, Buffalo, NY, United States of America
| | - Michael A Lacombe
- Department of Radiation Oncology, Upstate Medical University, Syracuse, NY, United States of America
| | - Jeffrey A Bogart
- Department of Radiation Oncology, Upstate Medical University, Syracuse, NY, United States of America
| | - Luke Degraaf
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, United States of America
| | - Austin Iovoli
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, United States of America
| | - Hassan Arshad
- Roswell Park Comprehensive Cancer Center, Department of Head and Neck/Plastic and Reconstructive Surgery, Buffalo, NY, United States of America
| | - Kimberly Wooten
- Roswell Park Comprehensive Cancer Center, Department of Head and Neck/Plastic and Reconstructive Surgery, Buffalo, NY, United States of America
| | - Vishal Gupta
- Roswell Park Comprehensive Cancer Center, Department of Head and Neck/Plastic and Reconstructive Surgery, Buffalo, NY, United States of America
| | - Wesley L Hicks
- Roswell Park Comprehensive Cancer Center, Department of Head and Neck/Plastic and Reconstructive Surgery, Buffalo, NY, United States of America
| | - Mary E Platek
- Roswell Park Comprehensive Cancer Center, Department of Biostatistics, Buffalo, New York, United States of America.,Department of Dietetics, D'Youville College, Buffalo, New York, United States of America
| | - Seung S Hahn
- Department of Radiation Oncology, Upstate Medical University, Syracuse, NY, United States of America
| | - Anurag K Singh
- Roswell Park Comprehensive Cancer Center, Department of Radiation Medicine, Buffalo, NY, United States of America
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Thompson LDR, Burchette R, Iganej S, Bhattasali O. Oropharyngeal Squamous Cell Carcinoma in 390 Patients: Analysis of Clinical and Histological Criteria Which Significantly Impact Outcome. Head Neck Pathol 2019; 14:666-688. [PMID: 31741151 PMCID: PMC7413975 DOI: 10.1007/s12105-019-01096-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/03/2019] [Indexed: 12/12/2022]
Abstract
This study evaluates the prognostic impact of several factors in oropharyngeal squamous cell carcinoma (OPSCC), controlling for human papillomavirus (HPV)-associated tumors and stage (American Joint Committee on Cancer 8th edition). All patients in Southern California Permanente Medical Group diagnosed with OPSCC between 2006 and 2012 tested for p16 immunohistochemistry were included. Review of all pathology materials was combined with central p16 testing. Multivariable analyses were performed. The cohort of 390 patients included 342 p16-positive and 48 p16-negative tumors. For all-comers, on univariate analysis, the following factors, when present, were associated with improved patient survival: p16-positive tumor (n = 324, p < 0.001); crypt versus surface tumor location (n = 312, p = 0.004); nonkeratinizing type (n = 309, p < 0.0001); nonkeratinizing with maturation type (n = 37, p < 0.0001); basaloid pattern (n = 284, p = 0.005); and a broad, pushing border of infiltration (n = 282, p = 0.004). Inferior survival outcomes were observed with: age ≥ 55 years (p < 0.0001); ≥ 10 pack-year smoking history (n = 183, p = 0.003); increasing tumor stage (p < 0.0001); overt radiographic extranodal extension (ORENE) (n = 58, p < 0.0001); low level IV/Vb lymph node involvement (n = 45, p = 0.0002); a jagged pattern of infiltration (n = 76, p = 0.0004); tumor ulceration (n = 76, p = 0.0004); absent lymphocytic infiltrate (p < 0.0001); and concurrent dysplasia (n = 125, p = 0.009). On multivariable analysis, accounting for patient age, smoking history ≥ 10 pack-years, and TNM stage, for patients with p16-positive disease, advanced TNM stage (p = 0.007), the presence of ORENE (p = 0.0002), and low-neck lymphadenopathy (p = 0.0001) were independent negative prognostic factors for disease free survival (DFS). Older age (p < 0.0001), smoking history ≥ 10 pack-years (p = 0.02), advanced TNM stage (p = 0.0002), ORENE (p = 0.004), and low-neck lymphadenopathy (p = 0.002) were independent negative prognostic factors for OS. Among patients with p16-positive OPSCC, older age, smoking history, advanced stage, ORENE, and low-neck lymphadenopathy were significant negative prognostic factors for DFS and/or OS. Further refinement of staging to incorporate additional lymph node findings may be warranted.
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Affiliation(s)
- Lester D. R. Thompson
- Department of Pathology, Southern California Permanente Medical Group, Woodland Hills Medical Center, 5601 De Soto Avenue, Woodland Hills, CA 91365 USA
| | - Raoul Burchette
- Research and Evaluation, Southern California Permanente Medical Group, Pasadena, CA USA
| | - Shawn Iganej
- Department of Radiation Oncology, Southern California Permanente Medical Group, Los Angeles, CA USA
| | - Onita Bhattasali
- Department of Radiation Oncology, Southern California Permanente Medical Group, Los Angeles, CA USA
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Bezerra NVF, Leite KLF, de Medeiros MMD, Martins ML, Cardoso AMR, Alves PM, Padilha WWN, Cavalcanti YW. Impact of the anatomical location, alcoholism and smoking on the prevalence of advanced oral cancer in Brazil. Med Oral Patol Oral Cir Bucal 2018; 23:e295-e301. [PMID: 29680854 PMCID: PMC5945237 DOI: 10.4317/medoral.22318] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 02/14/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To evaluate the prevalence of oral cancer in Brazil according to the clinical stage, anatomical location, alcoholism and smoking. MATERIAL AND METHODS Data referring to 31,217 cases of oral cancer, from 2000 to 2010, were obtained from the Integrator Module of the Hospital Registry of Cancer. Inconsistent data ("non-classified" cases) was eliminated and 21,160 cases were analyzed. The frequency distribution according to clinical stage, anatomical location, alcoholism and smoking was analyzed descriptively and through a binary logistic regression model (α<0.05). The clinical stage (dependent variable) was dichotomized in early stage (I and II) or advanced stage (III and IV). The year of diagnosis, anatomical location and deleterious habits (alcoholism and smoking) were considered independent variables. RESULTS The most frequent characteristics were: oropharynx location (n=3856, 18.41%), clinical stage IV (n=11924, 56.09%) and combined use of alcohol and tobacco (n=19226; 61.59%). The year 2009 (p<0.01, PR = 1.162, CI-95%=1.053-1.283) and location at the base of tongue (p<0.01, PR = 2.485, CI-95% = 2.182-2.807) presented a higher prevalence ratio for advanced stage oral cancer. The combined use of alcohol and tobacco showed a higher prevalence rate for the advanced clinical stage of cancer (p<0.01, PR =1.449, CI-95%=1.382-1.520) if compared to individuals without habits, or just alcoholics. CONCLUSIONS Higher prevalence of advanced stage of oral cancer is related to the localization at the base of the tongue and to the concomitant use of alcohol and tobacco. Therefore, it can be suggested that all these characteristics lead to a worse prognosis of oral cancer.
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Affiliation(s)
- N-V-F Bezerra
- Clinical and Social Dentistry Department, Health Sciences Center, Federal University of Paraiba, Campus I, Cidade Universitária. João Pessoa-PB, ZIP code: 58051-900,
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Singh AK, Mimikos C, Groman A, Dibaj S, Platek AJ, Cohan DM, Hicks WL, Gupta V, Arshad H, Kuriakose MA, Warren GW, Platek ME. Combined surgery and radiation improves survival of tonsil squamous cell cancers. Oncotarget 2017; 8:112442-112450. [PMID: 29348837 PMCID: PMC5762522 DOI: 10.18632/oncotarget.20122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 07/31/2017] [Indexed: 01/07/2023] Open
Abstract
Objective The study evaluated the addition of surgery (S) to radiation (RT) on survival of squamous cell carcinomas (SCC) of tonsillar-fossa (TF) in a modern cohort with similar epidemiology and treatment as current patients. Study Design Retrospective analysis utilizing Surveillance, Epidemiology, and End Results (SEER) Program data. Results For all stages combined TF patients who received S+RT had superior OS (p < 0.01) and DSS (p < 0.01). For each stage OS and DSS was superior for S+RT (p < 0.05). In multivariate analysis, HRs for OS were statistically significantly higher for TF patients (stage 2, 3, and 4) receiving RT alone (p < 0.001). Materials and Methods TF SCC patients treated with either S+RT or RT alone between 2004 and 2011 were examined (n = 6,476). Primary outcome measures included overall survival (OS) and disease specific survival (DSS). Cox proportional hazard ratios (HR) were estimated for patients treated with S+RT compared to RT alone. Conclusions OS and DSS were superior for all stages combined and for stages 2, 3, and 4 in TF patients who received S+RT compared to RT alone.
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Affiliation(s)
- Anurag K Singh
- Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Christina Mimikos
- Department of Head and Neck/Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Adrienne Groman
- Department of Biostatistics, Roswell Park Cancer Institute, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Shiva Dibaj
- Department of Biostatistics, Roswell Park Cancer Institute, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Alexis J Platek
- Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - David M Cohan
- Department of Head and Neck/Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Wesley L Hicks
- Department of Head and Neck/Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Vishal Gupta
- Department of Head and Neck/Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Hassan Arshad
- Department of Head and Neck/Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Moni A Kuriakose
- Department of Head and Neck/Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Graham W Warren
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC, USA.,Department of Cell and Molecular Pharmacology, Medical University of South Carolina, Charleston, SC, USA
| | - Mary E Platek
- Department of Head and Neck/Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA.,Department of Health, Nutrition and Dietetics, Buffalo State College (SUNY), Buffalo, NY, USA
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