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Hong SA, Armstrong AT, Snow K, Walker RJ, Massa ST. Association of adjuvant radiation and survival in human papilloma virus-positive oropharynx squamous cell carcinoma with lymphovascular invasion as the sole adverse pathologic feature. Head Neck 2024; 46:1043-1050. [PMID: 38511301 DOI: 10.1002/hed.27740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 02/18/2024] [Accepted: 03/08/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Postoperative radiotherapy radiation therapy (PORT) for early-stage human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) with positive lymphovascular invasion (LVI) has an unclear association with overall survival (OS). METHODS This retrospective cohort study queried the National Cancer Database for surgically treated, T1-2, N0-1 HPV+ OPSCC from 2010 to 2019. Primary exposures were LVI and PORT, and the main outcome was 5-year OS. Odds ratios and hazard ratios (HR) with 95% confidence intervals (CIs) were generated using multivariable models and Cox proportional hazard models, respectively. RESULTS Of 2768 patients, average age was 59.3 years, 2207 (79.7%) were male, and 386 (13.9%) had LVI. Of patients with LVI as their sole adverse pathologic feature, 220 (57.0%) received PORT, which was not associated with 5-year OS (HR, 1.13; CI, 0.65-1.19). CONCLUSIONS Patients with surgically treated, early-stage HPV+ OPSCC and positive LVI as their only pathologic adverse feature may not require PORT.
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Affiliation(s)
- Scott A Hong
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Austin T Armstrong
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Katherine Snow
- Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Ronald J Walker
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Sean T Massa
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
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2
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Faraji F, Kumar A, Voora R, Soliman SI, Cherry D, Courtney PT, Finegersh A, Guo T, Cohen E, Califano JA, Mell L, Rose B, Orosco RK. Transoral Surgery in HPV-Positive Oropharyngeal Carcinoma: Oncologic Outcomes in the Veterans Affairs System. Laryngoscope 2024; 134:207-214. [PMID: 37255050 PMCID: PMC10687307 DOI: 10.1002/lary.30784] [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: 12/17/2022] [Revised: 04/07/2023] [Accepted: 05/17/2023] [Indexed: 06/01/2023]
Abstract
OBJECTIVES Most transoral robotic surgery (TORS) literature for HPV-positive oropharyngeal squamous cell carcinoma (HPV-OPC) derives from high-volume tertiary-care centers. This study aims to describe long-term recurrence and survival outcomes among Veterans Health Administration patients. MATERIALS AND METHODS Using the US Veterans Affairs database, we identified patients with HPV-OPC treated with TORS between January 2010 and December 2016. Patients were stratified in risk categories: low (0-1 metastatic nodes, negative margins), intermediate (close margins, 2-4 metastatic nodes, lymphovascular or perineural invasion, pT3-pT4 tumor), or high (positive margins, extranodal extension (ENE), and/or ≥5 metastatic nodes). Primary outcomes included overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS). RESULTS The cohort included 161 patients of which 29 (18%) were low-risk, 45 (28%) intermediate-risk, and 87 (54%) high-risk. ENE was present in 41% of node-positive cases and 24% had positive margins. Median follow-up was 5.6 years (95% CI, 3.0-9.3). The 5-year DSS for low, intermediate, and high-risk groups were: 100%, 90.0% (95% CI, 75.4-96.1%), and 88.7% (95% CI, 78.3-94.2%). Pathologic features associated with poor DSS on univariable analysis included pT3-T4 tumors (HR 3.81, 95% CI, 1.31-11; p = 0.01), ≥5 metastatic nodes (HR 3.41, 95% CI, 1.20-11; p = 0.02), and ENE (HR 3.53, 95% CI, 1.06-12; p = 0.04). Higher 5-year cumulative incidences of recurrence were observed in more advanced tumors (pT3-T4, 33% [95% CI, 14-54%] versus pT1-T2, 13% [95% CI, 8-19%]; p = 0.01). CONCLUSIONS In this nationwide study, patients with HPV-OPC treated with TORS followed by adjuvant therapy at Veterans Affairs Medical Centers demonstrated favorable survival outcomes comparable to those reported in high-volume academic centers and clinical trials. LEVEL OF EVIDENCE 4 Laryngoscope, 134:207-214, 2024.
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Affiliation(s)
- Farhoud Faraji
- Department of Otolaryngology-Head and Neck Surgery, University of California San Diego Health, San Diego, CA, USA
- Moores Cancer Center, University of California San Diego Health, La Jolla, CA, USA
| | - Abhishek Kumar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego Health, La Jolla, CA, USA
- Department of Radiation Oncology, Duke University, Durham, NC, USA
| | - Rohith Voora
- Department of Otolaryngology-Head and Neck Surgery, University of California San Diego Health, San Diego, CA, USA
| | - Shady I. Soliman
- Department of Otolaryngology-Head and Neck Surgery, University of California San Diego Health, San Diego, CA, USA
| | - Daniel Cherry
- Department of Radiation Medicine and Applied Sciences, University of California San Diego Health, La Jolla, CA, USA
| | - P. Travis Courtney
- Department of Radiation Medicine and Applied Sciences, University of California San Diego Health, La Jolla, CA, USA
| | - Andrey Finegersh
- Department of Otolaryngology-Head and Neck Surgery, University of California San Diego Health, San Diego, CA, USA
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, CA, USA
| | - Theresa Guo
- Department of Otolaryngology-Head and Neck Surgery, University of California San Diego Health, San Diego, CA, USA
- Moores Cancer Center, University of California San Diego Health, La Jolla, CA, USA
| | - Ezra Cohen
- Moores Cancer Center, University of California San Diego Health, La Jolla, CA, USA
- Department of Medical Oncology, University of California, San Diego, CA, USA
| | - Joseph A. Califano
- Department of Otolaryngology-Head and Neck Surgery, University of California San Diego Health, San Diego, CA, USA
- Moores Cancer Center, University of California San Diego Health, La Jolla, CA, USA
| | - Loren Mell
- Moores Cancer Center, University of California San Diego Health, La Jolla, CA, USA
- Department of Radiation Medicine and Applied Sciences, University of California San Diego Health, La Jolla, CA, USA
| | - Brent Rose
- Moores Cancer Center, University of California San Diego Health, La Jolla, CA, USA
- Department of Radiation Medicine and Applied Sciences, University of California San Diego Health, La Jolla, CA, USA
| | - Ryan K. Orosco
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of New Mexico
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Shinomiya H, Nibu KI. Etiology, diagnosis, treatment, and prevention of human papilloma virus-associated oropharyngeal squamous cell carcinoma. Int J Clin Oncol 2023:10.1007/s10147-023-02336-8. [PMID: 37093464 PMCID: PMC10390603 DOI: 10.1007/s10147-023-02336-8] [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: 02/26/2023] [Accepted: 03/30/2023] [Indexed: 04/25/2023]
Abstract
Classical oropharyngeal squamous cell carcinoma (OPSCC) caused by alcohol consumption and smoking and HPV-associated OPSCC caused by human papillomavirus (HPV) infection have different etiologies, incidences, and prognoses. Therefore, the 8th American Joint committee on Cancer (AJCC) and Union for International Cancer Control (UICC) TNM classifications propose distinguishing HPV-associated OPSCC from classical OPSCC and classifying it as an independent disease. Therefore, this review provides an overview of HPV-associated OPSCC from the perspectives of epidemiology, carcinogenesis, development, diagnosis, treatment, and prevention. The incidence of HPV-associated OPSCC is increasing. Although HPV vaccination has been shown to be effective at reducing the incidence of cervical cancer, it is still unclear how it affects the incidence of HPV-associated OPSCC. Additionally, the prognosis of patients with HPV-associated OPSCC is extremely favorable compared to that of patients with classical OPSCC. Therefore, patients with HPV-associated OPSCC may undergo reduced-dose therapy, although attempts to reduce treatment intensity should be carefully planned to ensure they do not compromise oncological outcomes, and large-scale trials aimed at reducing treatment intensity are ongoing.
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Affiliation(s)
- Hirotaka Shinomiya
- Department of Otolaryngology-Head and Neck Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo, 650-0017, Japan.
| | - Ken-Ichi Nibu
- Department of Otolaryngology-Head and Neck Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo, 650-0017, Japan
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4
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Turner B, MacKay C, Taylor SM, Rigby MH. Five-year survival outcomes in oropharyngeal squamous cell carcinoma following transoral laser microsurgery. Laryngoscope Investig Otolaryngol 2023; 8:125-134. [PMID: 36846422 PMCID: PMC9948578 DOI: 10.1002/lio2.994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/12/2022] [Accepted: 11/27/2022] [Indexed: 12/15/2022] Open
Abstract
Objective To determine the 5-year survival outcomes of patients with oropharyngeal cancer treated with transoral laser microsurgery at our institution. Methods A prospective longitudinal cohort study of all cases of oropharyngeal squamous cell cancer or clinically unknown primaries diagnosed at our institution between September 1, 2014, to December 31, 2019, treated with primary transoral laser microsurgery were analyzed. Patients with a previous history of head and neck radiation were excluded from analysis. Kaplan-Meier survival curves were used to estimate 5-year overall survival, disease-specific survival, local control, and recurrence free survival rates in oropharyngeal squamous cell carcinoma. Results Of 142 patients identified, 135 met criteria and were included in the survival analysis. Five-year local control rates in p16 positive and negative disease were 99.2% and 100%, respectively, with one locoregional failure in the p16 positive cohort. Five-year overall survival, disease-specific survival, and recurrence free survival in p16 positive disease were 91%, 95.2%, and 87% respectively (n = 124). Five-year overall survival, disease-specific survival, and recurrence free survival in p16 negative disease were 39.8%, 58.3%, and 60%, respectively (n = 11). The permanent gastrostomy tube rate was 1.5% and zero patients received a tracheostomy at the time of surgery. One patient (0.74%) required a return to the OR for a post-operative pharyngeal bleed. Conclusion Transoral laser microsurgery is a safe primary treatment option for oropharyngeal squamous cell carcinoma with high 5-year survival outcomes, notably in p16 positive disease. More randomized trials are needed to compare survival outcomes and associated morbidity in transoral laser microsurgery compared to treatment with primary chemoradiation. Level of Evidence 3.
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Affiliation(s)
- Brooke Turner
- Department of Surgery, Division of Otolaryngology – Head and Neck SurgeryQueen Elizabeth II Health Science CentreHalifaxNova ScotiaCanada
| | - Colin MacKay
- Department of Surgery, Division of Otolaryngology – Head and Neck SurgeryQueen Elizabeth II Health Science CentreHalifaxNova ScotiaCanada
- Dalhousie UniversityHalifaxNova ScotiaCanada
| | - S. Mark Taylor
- Department of Surgery, Division of Otolaryngology – Head and Neck SurgeryQueen Elizabeth II Health Science CentreHalifaxNova ScotiaCanada
| | - Matthew Hall Rigby
- Department of Surgery, Division of Otolaryngology – Head and Neck SurgeryQueen Elizabeth II Health Science CentreHalifaxNova ScotiaCanada
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5
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Impact of AJCC 8th edition staging system and definitive treatment choice on the prognosis of complete responders with p16+ and p16− oropharyngeal squamous cell carcinomas. Oral Oncol 2022; 128:105861. [PMID: 35436712 PMCID: PMC9624219 DOI: 10.1016/j.oraloncology.2022.105861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 03/31/2022] [Accepted: 04/10/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To identify predictors of overall survival (OS) in oropharyngeal squamous cell carcinoma (OPSCC) patients who achieved complete response (CR). METHODS We performed a retrospective study of OPSCC patients who achieved CR from a single academic medical center. Associations between OS, AJCC 8th edition staging system, definitive treatment choice, smoking history, and p16 status were assessed. RESULTS p16+ status was associated with favorable prognosis for CR (p < 0.001) but not non-CR (p = 0.67) patients. For early stage, p16+ OPSCC patients who achieved CR, surgery + adjuvant radiation (RT) treatment was more durable compared to concurrent chemoradiation (CRT), particularly in smokers. CONCLUSIONS Curative intent treatment choice and smoking history has an impact on the long-term OS of the CR p16+ OPSCC cohort. Prospective studies to define the optimal multi-modality treatment option to manage p16+ OPSCC patients is needed.
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Robotic vs. transoral laser surgery of malignant oropharyngeal tumors-what is best for the patient? : A contemporary review. HNO 2022; 70:371-379. [PMID: 35419634 DOI: 10.1007/s00106-022-01165-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 12/23/2022]
Abstract
Human papillomavirus (HPV)-associated squamous cell carcinoma of the oropharynx is a malignancy of increasing prevalence. The oncologic community is currently evaluating the safety and efficacy of de-intensifying treatment without compromising oncologic outcomes. Paramount to these treatment algorithms is primary surgery through transoral approaches. This article reviews the literature and concepts pertaining to transoral surgery and describes the two most common techniques, transoral laser microsurgery (TLM) and transoral robotic surgery (TORS).
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Stepan K, Craig E, Skillington SA, Deutsch BC, Chen S, Wamkpah NS, Bollig CA, Kallogjeri D, Thorstad WL, Puram SV, Pipkorn P, Jackson RS. Development of second primary malignancies after transoral surgery in human papilloma virus-positive oropharyngeal squamous cell carcinoma. Head Neck 2022; 44:1069-1078. [PMID: 35175648 PMCID: PMC9112335 DOI: 10.1002/hed.27002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 12/08/2021] [Accepted: 02/01/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Little data exists regarding the incidence of oropharyngeal and upper aerodigestive tract (UADT) second primary malignancies (SPM) among human papilloma virus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC). Here we evaluate SPM rates among patients with HPV-related OPSCC. METHODS A retrospective cohort study of 412 patients with HPV-related OPSCC who underwent transoral resection +/- adjuvant therapy at a single center between 1996 and 2018. RESULTS Twenty patients (4.9%) developed SPM of the UADT, nine (2.2%) occurring in the oropharynx. Median time to diagnosis was 59.5 months (0-173 months). Risk of SPM was lower for patients receiving adjuvant radiation (aHR: 0.25, 95%CI: 0.08-0.78). There was no difference in overall or disease-free survival between those with and without SPM. CONCLUSION The rate of SPM among patients with HPV-positive OPSCC is lower than reported rates among HPV-negative OPSCC. To date, this is the largest study evaluating SPM in patients with surgically treated HPV-positive OPSCC.
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Affiliation(s)
- Katelyn Stepan
- Department of Otolaryngology - Head and Neck Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Ethan Craig
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Scott Andrew Skillington
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Brian C Deutsch
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Stephanie Chen
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Nneoma S Wamkpah
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Craig A Bollig
- Department of Otolaryngology - Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Dorina Kallogjeri
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Sidharth V Puram
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ryan S Jackson
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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8
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HPV-associated oropharyngeal cancer: epidemiology, molecular biology and clinical management. Nat Rev Clin Oncol 2022; 19:306-327. [PMID: 35105976 PMCID: PMC8805140 DOI: 10.1038/s41571-022-00603-7] [Citation(s) in RCA: 317] [Impact Index Per Article: 158.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 12/13/2022]
Abstract
Human papillomavirus (HPV)-positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC) has one of the most rapidly increasing incidences of any cancer in high-income countries. The most recent (8th) edition of the UICC/AJCC staging system separates HPV+ OPSCC from its HPV-negative (HPV−) counterpart to account for the improved prognosis seen in the former. Indeed, owing to its improved prognosis and greater prevalence in younger individuals, numerous ongoing trials are examining the potential for treatment de-intensification as a means to improve quality of life while maintaining acceptable survival outcomes. In addition, owing to the distinct biology of HPV+ OPSCCs, targeted therapies and immunotherapies have become an area of particular interest. Importantly, OPSCC is often detected at an advanced stage owing to a lack of symptoms in the early stages; therefore, a need exists to identify and validate possible diagnostic biomarkers to aid in earlier detection. In this Review, we provide a summary of the epidemiology, molecular biology and clinical management of HPV+ OPSCC in an effort to highlight important advances in the field. Ultimately, a need exists for improved understanding of the molecular basis and clinical course of this disease to guide efforts towards early detection and precision care, and to improve patient outcomes. The incidence of human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) is increasing rapidly in most developed countries. In this Review, the authors provide an overview of the epidemiology, molecular biology and treatment of HPV-positive OPSCC, including discussions of the role of treatment de-escalation and emerging novel therapies. The incidence of human papillomavirus-associated oropharyngeal cancer (HPV+ OPSCC) is expected to continue to rise over the coming decades until the benefits of gender-neutral prophylactic HPV vaccination begin to become manifest. The incidence of HPV+ OPSCC appears to be highest in high-income countries, although more epidemiological data are needed from low- and middle-income countries, in which HPV vaccination coverage remains low. The substantially better prognosis of patients with HPV+ OPSCC compared to those with HPV– OPSCC has been recognized in the American Joint Committee on Cancer TNM8 staging guidelines, which recommend stratification by HPV status to improve staging. The molecular biology and genomic features of HPV+ OPSCC are similar to those of other HPV-associated malignancies, with HPV oncogenes (E6 and E7) acting as key drivers of pathogenesis. Treatment de-intensification is being pursued in clinical trials, although identifying the ~15% of patients with HPV+ OPSCC who have recurrent disease, and who therefore require more intensive treatment, remains a key challenge.
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Ferris RL, Flamand Y, Weinstein GS, Li S, Quon H, Mehra R, Garcia JJ, Chung CH, Gillison ML, Duvvuri U, O'Malley BW, Ozer E, Thomas GR, Koch WM, Gross ND, Bell RB, Saba NF, Lango M, Méndez E, Burtness B. Phase II Randomized Trial of Transoral Surgery and Low-Dose Intensity Modulated Radiation Therapy in Resectable p16+ Locally Advanced Oropharynx Cancer: An ECOG-ACRIN Cancer Research Group Trial (E3311). J Clin Oncol 2022; 40:138-149. [PMID: 34699271 PMCID: PMC8718241 DOI: 10.1200/jco.21.01752] [Citation(s) in RCA: 197] [Impact Index Per Article: 98.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 07/30/2021] [Accepted: 09/17/2021] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Definitive or postoperative chemoradiation (CRT) is curative for human papillomavirus-associated (HPV+) oropharynx cancer (OPC) but induces significant toxicity. As a deintensification strategy, we studied primary transoral surgery (TOS) and reduced postoperative radiation therapy (RT) in intermediate-risk HPV+ OPC. METHODS E3311 is a phase II randomized trial of reduced- or standard-dose postoperative RT for resected stage III-IVa (American Joint Committee on Cancer-seventh edition) HPV+ OPC, determined by pathologic parameters. Primary goals were feasibility of prospective multi-institutional study of TOS for HPV+ OPC, and oncologic efficacy (2-year progression-free survival) of TOS and adjuvant therapy in intermediate-risk patients after resection. TOS plus 50 Gy was considered promising if the lower limit of the exact 90% binomial confidence intervals exceeded 85%. Quality of life and swallowing were measured by functional assessment of cancer therapy-head and neck and MD Anderson Dysphagia Index. RESULTS Credentialed surgeons performed TOS for 495 patients. Eligible and treated patients were assigned as follows: arm A (low risk, n = 38) enrolled 11%, intermediate risk arms B (50 Gy, n = 100) or C (60 Gy, n = 108) randomly allocated 58%, and arm D (high risk, n = 113) enrolled 31%. With a median 35.2-month follow-up for 359 evaluable (eligible and treated) patients, 2-year progression-free survival Kaplan-Meier estimate is 96.9% (90% CI, 91.9 to 100) for arm A (observation), 94.9% (90% CI, 91.3 to 98.6]) for arm B (50 Gy), 96.0% (90% CI, 92.8 to 99.3) for arm C (60 Gy), and 90.7% (90% CI, 86.2 to 95.4) for arm D (66 Gy plus weekly cisplatin). Treatment arm distribution and oncologic outcome for ineligible or step 2 untreated patients (n = 136) mirrored the 359 evaluable patients. Exploratory comparison of functional assessment of cancer therapy-head and neck total scores between arms B and C is presented. CONCLUSION Primary TOS and reduced postoperative RT result in outstanding oncologic outcome and favorable functional outcomes in intermediate-risk HPV+ OPC.
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Affiliation(s)
| | - Yael Flamand
- Dana Farber Cancer Institute-ECOG-ACRIN Biostatistics Center, Boston, MA
| | | | - Shuli Li
- Dana Farber Cancer Institute-ECOG-ACRIN Biostatistics Center, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | - Neil D. Gross
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | - Nabil F. Saba
- Winship Cancer Institute at Emory University, Atlanta, GA
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10
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Ryan WR, Xu MJ, Ochoa E, Plonowska-Hirschfeld KA, Zebolsky AL, Ha PK, Bewley AF, Mallen-St Clair J, Joshi AS, Coffey CS, Faraji F, MacDonald BV, Houlton JJ, Gobillot TA, Curry JM, Philips R, Hackman TG, Richmon JD, Holcomb AJ, Coughlin AM, Panwar A, Smith RB, Herberg ME, Fakhry C, Cognetti DM. Oncologic outcomes of human papillomavirus-associated oropharynx carcinoma treated with surgery alone: A 12-institution study of 344 patients. Cancer 2021; 127:3092-3106. [PMID: 33957701 DOI: 10.1002/cncr.33611] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/11/2021] [Accepted: 02/19/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The oncologic outcomes of surgery alone for patients with American Joint Committee on Cancer 7th edition (AJCC 7th) pN2a and pN2b human papillomavirus-associated oropharynx squamous cell carcinoma (HPV+OPSCC) are not clear. METHODS The authors performed a 12-institution retrospective study of 344 consecutive patients with HPV+OPSCC (AJCC 7th pT0-3 N3 M0) treated with surgery alone with 6 months or more of follow-up using univariate and multivariate analyses. RESULTS The 2-year outcomes for the entire cohort were 91% (182 of 200) disease-free survival (DFS), 100% (200 of 200) disease-specific survival (DSS), and 98% (200 of 204) overall survival (OS). The 18 recurrences within 2 years were 88.9% (16 of 18) local and/or regional recurrences and 11.1% (2 of 18) distant metastases. Recurrences were not significantly associated with smoking, pT stage, or pN stage. The 16 patients with locoregional recurrences within 2 years all underwent successful salvage treatments (median follow-up after salvage: 13.1 months), 43.8% (7 of 16) of whom underwent salvage surgery alone for a 2-year overall salvage radiation need of 4.5% (9 of 200). The 2-year outcomes for the 59 evaluable patients among the 109 AJCC 7th pT0-2 N2a-N2b patients with 1 to 3 pathologic lymph nodes (LNs) were as follows: local recurrence, 3.4% (2 of 59); regional recurrence, 8.4% (5 of 59); distant metastases, 0%; DFS, 88.1% (52 of 59); DSS, 100% (59 of 59); OS, 96.7% (59 of 61); and salvage radiation, 5.1% (3 of 59). CONCLUSIONS With careful selection, surgery alone for AJCC 7th pT0-T2N0-N2b HPV+OPSCC with zero to 3 pathologic LNs without perineural invasion, extranodal extension, or positive margins results in high DFS, DSS, OS, and salvage treatment success. Because of the short-term follow-up, these data support further investigation of treatment de-escalation in this population.
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Affiliation(s)
- William R Ryan
- Division of Head and Neck Oncologic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California
| | - Mary J Xu
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California
| | - Edgar Ochoa
- School of Medicine, University of California San Francisco, San Francisco, California
| | | | - Aaron L Zebolsky
- Homer Stryker MD School of Medicine, Western Michigan University, Kalamazoo, Michigan
| | - Patrick K Ha
- Division of Head and Neck Oncologic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California
| | - Arnaud F Bewley
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis Medical Center, Sacramento, California
| | | | - Arjun S Joshi
- Division of Head and Neck Oncologic Surgery, Department of Surgery, George Washington University School of Medicine, Washington, DC
| | - Charles S Coffey
- Division of Otolaryngology/Head and Neck Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Farhoud Faraji
- Division of Otolaryngology/Head and Neck Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Bridget V MacDonald
- School of Medicine, University of California San Diego, La Jolla, California
| | - Jeffrey J Houlton
- Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington
| | - Theodore A Gobillot
- School of Medicine, University of Washington Medical Center, Seattle, Washington
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ramez Philips
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Trevor G Hackman
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts
| | - Andrew J Holcomb
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts.,Head and Neck Surgical Oncology, Nebraska Methodist Health System, Omaha, Nebraska
| | - Andrew M Coughlin
- Head and Neck Surgical Oncology, Nebraska Methodist Health System, Omaha, Nebraska
| | - Aru Panwar
- Head and Neck Surgical Oncology, Nebraska Methodist Health System, Omaha, Nebraska
| | - Russell B Smith
- Section of Head and Neck Surgical Oncology, Baptist MD Anderson Cancer Physicians, Baptist Medical Center, Jacksonville, Florida
| | - Matthew E Herberg
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Carole Fakhry
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - David M Cognetti
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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11
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20 pack-year smoking history as strongest smoking metric predictive of HPV-positive oropharyngeal cancer outcomes. Am J Otolaryngol 2021; 42:102915. [PMID: 33482566 DOI: 10.1016/j.amjoto.2021.102915] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES While smoking is associated with worse outcomes in HPV-positive oropharyngeal squamous cell carcinoma (OPSCC), the magnitude of this association is unclear given the heterogenous smoking definitions and outcomes. Our objective was to investigate the association between smoking, survival, and recurrence in HPV-related OPSCC using multiple smoking metrics reported in the literature. MATERIALS AND METHODS This was a retrospective cohort study of 375 adults with p16+ OPSCC undergoing surgical resection (n = 272) or definitive chemoradiation (n = 103) at a tertiary academic institution from 2006 to 2017. The primary outcome was overall survival (OS). Secondary outcomes included disease-free survival (DFS), disease-specific survival (DSS), and recurrence. We used multiple smoking metrics commonly cited in previous studies, including ever versus never smokers, current versus former/never smokers, ≤10 versus >10 pack-year, ≤20 versus >20 pack-year, and continuous pack-year. RESULTS There were 375 patients, median age 58 years, with 326 (87%) males, and median follow-up of 52 months. Of all smoking metrics, >20 pack-year history was the strongest predictor of both OS (HR 2.24, 95% CI: 1.19-4.20) and DFS (HR 1.67, 95% CI: 1.04-2.66) on univariable and multivariable analysis after adjusting for age, overall stage, and comorbidities. Patients with >20 pack-year smoking history were also more likely to have recurrence (HR 1.59, 95% CI: 0.95-2.67) after adjusting for overall stage. CONCLUSION Heavier smoking >20 pack-years was the strongest smoking metric associated with 2-times worse survival and recurrence. Our findings suggest that >20 pack-year smoking history may be a more useful cutoff for risk stratification models but requires further validation.
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12
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Precision head and neck surgery: robotics and surgical vision technology. Curr Opin Otolaryngol Head Neck Surg 2021; 29:161-167. [PMID: 33664199 DOI: 10.1097/moo.0000000000000706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW As the molecular basis of head and neck cancer becomes more clearly defined, precision medicine has gradually refined the multidisciplinary treatment paradigm for patients with oropharyngeal cancer. Although precision medicine is often thought to refer to new molecular diagnostics or unique medical therapy, the recent adoption of robotic surgery has ushered in the era of 'precision' head and neck surgery. RECENT FINDINGS Surgeons now routinely utilize a virtual reality environment to reduce the morbidity of head and neck surgical care and improve oncologic and functional outcomes. The development and subsequent FDA approval of the da Vinci SP system, a single-arm system with a flexible camera, has allowed for improved visualization and access to the deep oropharynx and larynx. Groups investigating anti-EGFR antibodies tagged with fluorescent dye as well as inherent autofluorescence differences between normal and cancerous mucosal tissues show promise for improving positive surgical margin rates. SUMMARY The evolution of robotics and visualization for oropharyngeal cancer represents a novel and innovative utilization of new technology to improve care. Further advancements in techniques, from refinement of the robotic platform itself, to novel real-time tumour imaging options will be critical to further advance precision care for these patients.
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13
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Bauwens L, Baltres A, Fiani DJ, Zrounba P, Buiret G, Fleury B, Benzerdjeb N, Grégoire V. Prevalence and distribution of cervical lymph node metastases in HPV-positive and HPV-negative oropharyngeal squamous cell carcinoma. Radiother Oncol 2021; 157:122-129. [PMID: 33545255 DOI: 10.1016/j.radonc.2021.01.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/18/2021] [Accepted: 01/18/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE In oropharyngeal squamous cell carcinoma (OP-SCC), the prevalence and distribution of clinical and pathological lymph node metastasis in the neck have been extensively reported. It served as the basis for consensus recommendations on the selection of the lymph node levels in the neck requiring a treatment. The objective of the study is to compare the prevalence and distribution of neck node metastases in HPV+ and HPV- OP-SCC from a large series of patients with OP-SCC who underwent a cervical lymph-node dissection (LND) as part of their treatment. METHODS The study concentrated on OP-SCC patients treated by various neck node dissection (LND) procedures from January 2014 to December 2018 in 3 French institutions. Patients with prior head and neck cancer, prior neck surgery, the use of induction chemotherapy, or patients with carcinoma of unknown primary were excluded. HPV-status was assessed by p16 immunohistochemistry. For each patient, the clinical and the pathological nodal status, as well as the distribution of the positive nodes in each neck level (from Ia to V) were reported. RESULTS Two-hundred and sixty-three patients were included (126 p16-negative (p16-), and 137 p16-positive (p16+). The rate of clinical positive node (cN+) reached 54% and 88.3% in the p16- and p16+ groups, respectively (p < 0.001); the corresponding rate of pathological positive node (pN+) reached 61.9% and 91.2%, respectively (p < 0.001). Regarding the clinical lymph node distribution, in p16+ patients, more positive nodes were observed in the ipsilateral level IV (p = 0.003), and less positive nodes were observed in the contralateral levels III and IV (p = 0.003 and p = 0.045, respectively). Regarding the pathologic lymph node distribution in the ipsilateral neck, in the cN0 patients, no significant difference was observed between p16- and p16+ patients (p = 0.33 to 1); in the cN+ patients, the nodes were distributed in levels Ib, II, III, IV and V without differences between the p16- and the p16+ patients. In the contralateral neck of p16- patients, nodes metastases were mainly observed in levels II, III and IV, whereas for the p16+ patients, positive nodes were only observed in level II (p = 0.03). CONCLUSION This study demonstrated the higher prevalence of cN+ and pN+ in p16+ OP-SCC patients, but without meaningful difference in the distribution of the lymph node drainage between p16- and p16+ OP-SCC. It indicates that no difference should be made between p16- and p16+ patients regarding the extend of neck treatment.
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Affiliation(s)
| | - Aline Baltres
- Pathology Department, Centre Léon Bérard, Lyon, France
| | | | | | - Guillaume Buiret
- Surgical Department, Centre Hospitalier de Valence, Valence, France
| | - Bertrand Fleury
- Radiation Oncology Department, Centre Marie Curie, Valence, France
| | - Nazim Benzerdjeb
- Pathology Department, Centre Hopsitalier Lyon Sud, Pierre-Bénite, France
| | - Vincent Grégoire
- Radiation Oncology Department, Centre Léon Bérard, Lyon, France.
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14
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Carey RM, Shimunov D, Weinstein GS, Cannady SB, Lukens JN, Lin A, Swisher-McClure S, Bauml JM, Aggarwal C, Cohen RB, Newman JG, Chalian AA, Rassekh CH, Basu D, O'Malley BW, Rajasekaran K, Brody RM. Increased rate of recurrence and high rate of salvage in patients with human papillomavirus-associated oropharyngeal squamous cell carcinoma with adverse features treated with primary surgery without recommended adjuvant therapy. Head Neck 2020; 43:1128-1141. [PMID: 33325579 DOI: 10.1002/hed.26578] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/23/2020] [Accepted: 11/30/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Some patients with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) do not receive guideline-recommended postoperative radiation therapy (PORT) following primary transoral robotic surgery (TORS). METHODS Three-hundred and sixty-four patients with treatment-naïve, HPV-associated OPSCC were recommended to receive PORT based on clinicopathological features following TORS. Patients were stratified based on if they received PORT. Oncologic outcomes were compared. RESULTS The 3-year locoregional failure (LRF) was 32% in patients who did not receive PORT and 4% in patients who received PORT (P < .001). Despite increased LRF, avoiding PORT was not associated with increased 3-year distant metastasis rates (8% vs 4%, P = .56) or worse 3-year survival (95% vs 98%, P = .34). Recurrences in the surgery alone cohort varied between local and regional sites and were often successfully salvaged. CONCLUSIONS Patients with HPV-associated OPSCC who do not receive indicated PORT have an increased risk of LRF but similar survival due to high salvage rates.
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Affiliation(s)
- Ryan M Carey
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Shimunov
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory S Weinstein
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Cannady
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John N Lukens
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alexander Lin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Samuel Swisher-McClure
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Bauml
- Department of Internal Medicine, Division of Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charu Aggarwal
- Department of Internal Medicine, Division of Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Roger B Cohen
- Department of Internal Medicine, Division of Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason G Newman
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ara A Chalian
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher H Rassekh
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Devraj Basu
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bert W O'Malley
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert M Brody
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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15
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Dalton CL, Milinis K, Houghton D, Ridley P, Davies K, Williams R, Hamilton D, Wilkie MD, Markey A, Clarke K, Lofthouse M, Helliwell TR, Triantafyllou A, Rodrigues J, Bheemireddy K, Hanlon R, Wieshmann H, Haridass A, Brammer C, Husband D, Shenoy A, Loh C, Roland NJ, Bekiroglu F, Tandon S, Lancaster J, Jones TM. Transoral laser microsurgery and radiotherapy for oropharyngeal squamous cell carcinoma: Equitable survival and enhanced function compared with contemporary standards of care. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:2042-2049. [PMID: 32893045 DOI: 10.1016/j.ejso.2020.06.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 06/17/2020] [Accepted: 06/27/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION We describe the 5-year oncological and functional outcomes of transoral laser microsurgery, neck dissection (TLM + ND) and adjuvant radiotherapy (PORT) used to treat patients with oropharyngeal carcinoma. The effectiveness of external carotid artery (ECA) ligation in reducing post-operative bleeding, and fibrin glue following ND in reducing wound drainage and length of hospital stay is reported. MATERIALS AND METHODS This retrospective case review of consecutive patients undergoing TLM between 2006 and 2017 used the Kaplan-Meier Estimator and Log-Rank Test for univariate, time-to-event analyses, and Cox-Proportionate Hazard modelling for multivariate analysis. RESULTS 264 consecutive patients were included. Mean follow-up was 49.4 months. 219 (82.9%) patients received PORT. Five-year overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) rates were 74.9%, 73.7%, and 86.2%, respectively. Five-year locoregional control was 89.4%. 65.5% of cases were Human papillomavirus associated (HPV+), for whom OS, DFS and DSS was 85.6%, 84.7% and 92.7%, respectively, and demonstrated significantly higher OS (hazard ratio (HR) 0.28, CI 0.16-0.49, p < 0.0001), DFS (HR 0.28, CI 0.17-0.47, p < 0.0001) and DSS (HR 0.2, CI 0.09-0.44, <0.001). Post-operative oropharyngeal bleeding occurred in 23 patients (8.7%), of which 5 were major/severe, in patients without ECA ligation. Fibrin glue significantly reduced neck drain output (p < 0.001), and length of hospital stay (p < 0.001). One-year gastrostomy dependence rate was 2.3%. CONCLUSIONS TLM + ND + PORT results in favourable 5-year survival and locoregional control rates, and low feeding tube dependency rates. ECA ligation and fibrin glue appear to reduce major post-operative haemorrhage, wound drainage and length of hospital stay.
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Affiliation(s)
- C Lucy Dalton
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Kristijonas Milinis
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - David Houghton
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Oral and Maxillofacial Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Paul Ridley
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Katharine Davies
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Richard Williams
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - David Hamilton
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Mark D Wilkie
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Anne Markey
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Otorhinolaryngology-Head and Neck Surgery, Mid Cheshire Hospitals NHS Foundation Trust, Middlewich Road, Crewe, Cheshire, CW1 4QJ, United Kingdom
| | - Kim Clarke
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Matthew Lofthouse
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Timothy R Helliwell
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Cellular Pathology, Liverpool University Hospitals NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, United Kingdom
| | - Asterios Triantafyllou
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Cellular Pathology, Liverpool University Hospitals NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, United Kingdom
| | - Jennifer Rodrigues
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Anaesthesia, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Krishna Bheemireddy
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Anaesthesia, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Rebecca Hanlon
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Radiology, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Hulya Wieshmann
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Radiology, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Anoop Haridass
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Wirral, CH63 4JY, United Kingdom
| | - Caroline Brammer
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Wirral, CH63 4JY, United Kingdom
| | - David Husband
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Wirral, CH63 4JY, United Kingdom
| | - Aditya Shenoy
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Wirral, CH63 4JY, United Kingdom
| | - Christopher Loh
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Nicholas J Roland
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Fazilet Bekiroglu
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Oral and Maxillofacial Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Sankalap Tandon
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Jeffrey Lancaster
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Terence M Jones
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom.
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16
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Bollig CA, Lee DS, Mazul AL, Stepan K, Puram SV, Massa ST, Zenga J, Faden DL, Doering MM, Jackson RS, Pipkorn P. Systematic Review of Second Primary Oropharyngeal Cancers in Patients With p16+ Oropharyngeal Cancer. Otolaryngol Head Neck Surg 2020; 164:733-740. [PMID: 32928026 DOI: 10.1177/0194599820951175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To systematically review the literature to determine the prevalence and clinical outcomes of second primary oropharyngeal squamous cell carcinoma (OPSCC). DATA SOURCES Search strategies created with a medical librarian were implemented using multiple databases in October 2019. REVIEW METHODS The population of interest included adults age >18 years with a p16+ or human papillomavirus-positive OPSCC. The outcome was a synchronous or metachronous second primary OPSCC. Inclusion and exclusion criteria were designed to capture all study designs. In total, 685 records were identified by the search strategy. Two reviewers independently performed the review, extracted data, and performed a quality assessment. Primary Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A random-effects model was used for the meta-analysis. RESULTS A total of 2470 patients with 35 second primary OPSCCs from 15 studies were identified. The pooled prevalence of second primary OPSCC was 1.4% (range, 0%-14.3%). In the random-effects model, the prevalence was estimated at 1.3% (95% CI, 0.7%-2.3%; P = .51, I2 = 52%). Of the 30 patients with treatment information, 26 (86.7%) received surgical treatment, while 4 (13.3%) underwent nonsurgical therapy. Of the 29 patients with available survival information, 22 (75.9%) had no evidence of disease at last follow-up, 5 (17.2%) ultimately died of disease, and 2 (6.9%) were alive with disease. CONCLUSION Overall, the rate of second primary OPSCC in patients with an index p16+ OPSCC is low, and most patients are successfully treated. Insufficient evidence currently exists to recommend routine elective tonsillectomy during surgical treatment of p16+ OPSCC.
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Affiliation(s)
- Craig A Bollig
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - David S Lee
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Angela L Mazul
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA.,Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Katelyn Stepan
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA.,Department of Genetics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Sean T Massa
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Joseph Zenga
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Daniel L Faden
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Michelle M Doering
- Bernard Becker Medical Library, Washington University School of Medicine, St Louis, Missouri, USA
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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17
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Benchetrit L, Torabi SJ, Givi B, Haughey B, Judson BL. Prognostic Significance of Extranodal Extension in HPV-Mediated Oropharyngeal Carcinoma: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2020; 164:720-732. [PMID: 32838649 DOI: 10.1177/0194599820951176] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the prognostic role of extranodal extension (ENE) among patients with human papilloma virus-positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC) through a systematic review and meta-analysis of institutional studies. DATA SOURCES MEDLINE, Embase, Scopus, and PubMed. REVIEW METHODS Two independent authors searched the databases on December 3, 2019, to identify studies of HPV+ OPSCC comparing prognostic outcomes stratified by ENE. The I2 statistic was used to determine study heterogeneity. Fixed and random effects models were used to determine hazard ratios (HRs) with 95% CIs. RESULTS Eighteen observational studies met inclusion criteria, yielding 3603 patients with HPV+ OPSCC (1521 ENE+ and 2082 ENE-) with a median follow-up of 49 months. The presence of pathologic ENE (pENE) and radiologic ENE (rENE) was associated with decreased overall survival (pENE HR, 1.89 [95% CI, 1.15-3.13], I2 = 35%; rENE HR, 2.64 [95% CI, 1.46-4.78], I2 = 75%) and distant recurrence (pENE HR, 3.23 [95% CI, 1.25-8.33], I2 = 0%; rENE HR, 3.83 [95% CI, 1.88-7.80], I2 = 0%). Neither pENE nor rENE was associated with locoregional recurrence (pENE HR, 0.75 [95% CI, 0.20-2.84], I2 = 0%; rENE HR, 2.03 [95% CI, 0.86-4.79], I2 = 0%). pENE was not associated with disease-specific survival (pENE HR, 1.45 [95% CI, 0.84-2.49], I2 = 0%). CONCLUSION pENE and rENE are moderately associated with an increased risk of all-cause mortality and recurrence with distant metastasis in a cohort of patients with HPV+ OPSCC. These findings may be used to inform exclusion criteria for deintensification trials and assist in refined risk stratification.
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Affiliation(s)
| | - Sina J Torabi
- School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Babak Givi
- Department of Otolaryngology, School of Medicine, New York University, New York, New York, USA
| | - Bruce Haughey
- Otolaryngology-Head and Neck Surgery, Advent Health Celebration, Celebration, Florida, USA.,Department of Otolaryngology-Head and Neck Surgery (Collaborative), University of South Florida, Tampa, Florida, USA
| | - Benjamin L Judson
- Division of Otolaryngology, Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, USA.,Yale Cancer Center, New Haven, Connecticut, USA
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18
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Ference R, Liao D, Gao Q, Mehta V. Impact of Smoking on Survival Outcomes in HPV-Related Oropharyngeal Carcinoma: A Meta-analysis. Otolaryngol Head Neck Surg 2020; 163:1114-1122. [DOI: 10.1177/0194599820931803] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective Characterize the survival impact of smoking on HPV-related (human papillomavirus) oropharyngeal squamous cell carcinoma. Data Sources Articles from 2000 to 2019 in the PubMed, Embase, and Cochrane Library databases were systematically reviewed for content and inclusion/exclusion criteria. Review Methods Two reviewers independently analyzed the databases for eligibility and quality of the articles. Demographic data, smoking history, and survival outcomes were recorded. Hazard ratios and 95% CIs were collectively analyzed through a random effects meta-analysis model. Results Fifteen articles were included in the meta-analysis for overall survival, disease-specific survival, disease-free survival, progression-free survival, and locoregional recurrence outcomes. The overall survival hazard ratio was 2.4 for ever having smoked (95% CI, 1.4-4.0; P = .0006, I2 = .384) and 3.2 for current smoking (95% CI, 2.2-4.6; P < .0001, I2 = 0). The hazard ratio for disease-specific survival in current smokers was 6.3 (95% CI, 1.3-29.3; P = .0194, I2 = 0). Ever smoking had a larger impact on overall survival and disease-specific survival than the 10–pack year smoking threshold. Conclusion Smoking negatively affects survival in patients with HPV-related oropharyngeal carcinoma across all outcomes. Current smoking during treatment is associated with the greatest reduction in survival, possibly secondary to diminished radiation therapy efficacy.
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Affiliation(s)
- Ryan Ference
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - David Liao
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Qi Gao
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Vikas Mehta
- Department of Otorhinolaryngology–Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, USA
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19
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Machczyński P, Majchrzak E, Niewinski P, Marchlewska J, Golusiński W. A review of the 8th edition of the AJCC staging system for oropharyngeal cancer according to HPV status. Eur Arch Otorhinolaryngol 2020; 277:2407-2412. [PMID: 32342197 PMCID: PMC7410862 DOI: 10.1007/s00405-020-05979-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/10/2020] [Indexed: 12/20/2022]
Abstract
Background The incidence of oropharyngeal squamous cell carcinoma (OPSCC) has increased substantially in recent decades, particularly p16-positive human papillomavirus (HPV)-related OPSCC, which has risen by 50% in western countries. HPV-positivity is the most favourable non-anatomic predictor of oropharyngeal cancer outcomes, which underscores the importance of incorporating this variable into the cancer staging system. Methods In the present article, we review the differences between the 7th and 8th editions of the AJCC staging system, with particular focus on the role of HPV-positivity in patients with head and neck cancer. Results In the previous edition (7th edition) of the AJCC/UICC manual, HPV status and its correlation with nodal metastasis were not considered, thereby leading to incorrect lymph node (N) staging and, potentially, inadequate treatment and worse outcomes. The 8th edition of the AJCC manual addresses these issues, providing more accurate discrimination between groups and better risk stratification in patients with HPV-positive OPSCC. In the future, additional adjustments are likely to be needed, such as unification of the pathological and clinical staging models. Conclusions The new staging system is substantially more accurate than the previous system and should be widely adopted in routine clinical practice.
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Affiliation(s)
- Piotr Machczyński
- Head and Neck Surgery Department, The Greater Poland Cancer Centre, University of Medical Sciences Poznan, 15 Garbary St, 61-866, Poznan, Poland.
| | - Ewa Majchrzak
- Head and Neck Surgery Department, The Greater Poland Cancer Centre, University of Medical Sciences Poznan, 15 Garbary St, 61-866, Poznan, Poland
| | - Patryk Niewinski
- Head and Neck Surgery Department, The Greater Poland Cancer Centre, University of Medical Sciences Poznan, 15 Garbary St, 61-866, Poznan, Poland
| | - Joanna Marchlewska
- Head and Neck Surgery Department, The Greater Poland Cancer Centre, University of Medical Sciences Poznan, 15 Garbary St, 61-866, Poznan, Poland
| | - Wojciech Golusiński
- Head and Neck Surgery Department, The Greater Poland Cancer Centre, University of Medical Sciences Poznan, 15 Garbary St, 61-866, Poznan, Poland
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20
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Chidambaram S, Nakken ER, Kennedy W, Thorstad WL, Chen SY, Pipkorn P, Zevallos JP, Mazul AL. Prognostic Significance of Smoking in Human Papillomavirus-Positive Oropharyngeal Cancer Under American Joint Committee on Cancer Eighth Edition Stage. Laryngoscope 2020; 130:1961-1966. [PMID: 32293733 DOI: 10.1002/lary.28659] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 02/29/2020] [Accepted: 03/14/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the prognostic significance of smoking in human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) when considering American Joint Committee on Cancer eighth edition (AJCC-8) stage. STUDY DESIGN Retrospective cohort study. METHODS Three hundred seventeen HPV-positive OPSCC patients with known AJCC-8 stage and smoking status (<10 or ≥10 pack-years) seen at a tertiary center from 1997 to 2017 were studied. We used the Kaplan-Meier method to compare 5-year overall survival (OS) by smoking status and by clinical AJCC-8 stage and smoking status combined. Hazard ratios (HRs) were estimated with Cox proportional hazard regression for the independent effects of smoking and AJCC-8 stage. We also studied pathologic stage and estimated the combined effects of smoking and clinical stage. RESULTS The ≥10 pack-years smokers had worse 5-year OS than <10 pack-years smokers (93.6%; 95% confidence interval (CI): 89.7-97.8 vs. 82.3%; 95% CI: 76.0%-89.1%). When stratified by AJCC-8 clinical stage, only stage I <10 pack-years smokers (98.7%; 95% CI: 96.3%-100.0%) had significantly better 5-year OS than their ≥10 pack-years (84.8%; 95% CI: 76.4%-94.1%) counterparts. In a multivariable analysis, ≥10 pack-years smoking was associated with increased hazard of death when adjusting for AJCC-8 clinical (HR: 2.52; 95% CI: 1.16-5.46) and pathologic (HR: 5.21; 95% CI: 1.47-18.5) stage. In both analyses, stage III patients demonstrated worse survival than stage I, and smoking had greater impact at lower stages. CONCLUSIONS Smoking is a negative prognosticator in HPV-positive OPSCC and interacts with AJCC-8 clinical stage. It is important to understand the impact of smoking in HPV-positive disease when considering treatment plans and deintensification trials. LEVEL OF EVIDENCE 2b Laryngoscope, 130: 1961-1966, 2020.
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Affiliation(s)
- Smrithi Chidambaram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A.,St. Louis University School of Medicine, St. Louis, Missouri, U.S.A
| | - Erik R Nakken
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A.,Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - William Kennedy
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Stephanie Y Chen
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Jose P Zevallos
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Angela L Mazul
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A.,Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
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21
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Strober W, Shishido S, Wood B, Lewis JS, Kuhs K, Ferris RL, Faden DL. Two for the price of one: Prevalence, demographics and treatment implications of multiple HPV mediated Head and Neck Cancers. Oral Oncol 2020; 100:104475. [PMID: 31765835 PMCID: PMC7017724 DOI: 10.1016/j.oraloncology.2019.104475] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/08/2019] [Accepted: 11/09/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVES HPV mediated head and neck squamous cell carcinoma (HPVmHNSCC) is increasing in prevalence in the United States, as are reports of patients with multiple HPVmHNSCCs. The prevalence, demographics, and treatment implications of this emerging clinical entity are poorly understood. MATERIALS AND METHODS We performed a multitiered assessment of patients with multiple HPVmHNSCC including: 1. systematic review of the literature, 2. query of the 2017 Surveillance, Epidemiology and End Results (SEER) database and 3. institutional level reporting at two high volume academic centers. RESULTS Systematic literature review: 13 articles met inclusion criteria (48 patients with multiple HPVmHNSCC). Pooled prevalence rate of multiple HPVmHNSCC was 2.64%. SEER database: 60(0.95%) patients with HPVmHNSCC had two tumors. Patients with multiple HPVmHNSCC were more likely to be younger and present with a lower T and N stage (p < 0.025 for all). The second identified tumor was more likely to be contralateral, found synchronously, of smaller size, and to occur in the tonsil (p < 0.05 for all). Institutional reporting: 17(1.69%) patients with HPVmHNSCC had two primary tumors. Similar to the SEER database, patients with multiple HPVmHNSCC were more likely to present with a low T stage and tonsil location (p < 0.007 for both). CONCLUSION Multiple HPVmHNSCCs occur in a subset of HPVmHNSCC cases with distinct characteristics. Thorough interrogation of all oropharyngeal subsites should be performed as part of the initial workup for HPVmHNSCC, with consideration given to contralateral tonsillectomy at the time of surgical resection for HPV mediated tonsil cancers due to the prevalence of contralateral tonsil primaries.
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Affiliation(s)
- William Strober
- University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States
| | | | - Burton Wood
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - James S Lewis
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Krystle Kuhs
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Robert L Ferris
- University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States
| | - Daniel L Faden
- Massachusetts Eye and Ear, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
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22
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Swisher-McClure S, Lukens JN, Aggarwal C, Ahn P, Basu D, Bauml JM, Brody R, Chalian A, Cohen RB, Fotouhi-Ghiam A, Geiger G, Gershowitz J, Livolsi V, Mitra N, Montone K, Newman J, Ojerholm E, O'Malley B, Rajasekaran K, Tan E, Weinstein G, Lin A. A Phase 2 Trial of Alternative Volumes of Oropharyngeal Irradiation for De-intensification (AVOID): Omission of the Resected Primary Tumor Bed After Transoral Robotic Surgery for Human Papilloma Virus-Related Squamous Cell Carcinoma of the Oropharynx. Int J Radiat Oncol Biol Phys 2019; 106:725-732. [PMID: 31785337 DOI: 10.1016/j.ijrobp.2019.11.021] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/29/2019] [Accepted: 11/01/2019] [Indexed: 01/06/2023]
Abstract
PURPOSE This trial tested the safety and efficacy of a novel, deintensified radiation therapy (RT) approach after initial surgical resection for patients with human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC). METHODS AND MATERIALS This single-arm phase 2 prospective clinical trial enrolled 60 patients with stage pT1-pT2 N1-3 HPV-associated OPSCC treated with transoral robotic surgery (TORS) and selective neck dissection at a single institution between May 2014 and September 2017. Patients had favorable features at the primary site (negative surgical margins ≥2 mm, no perineural invasion, and no lymphovascular invasion) but required adjuvant therapy based on lymph node involvement. Surgeries were all performed at a high-volume head and neck cancer center with expertise in TORS. Patients received postoperative RT to at-risk areas in the involved neck (60-66 Gy) and uninvolved neck (54 Gy). The resected primary site was treated as an active avoidance structure in the treatment planning of postoperative RT. Concurrent chemotherapy was administered for patients with extranodal extension. RESULTS Median follow-up of the 60 patients enrolled was 2.4 years (range, 8.5-53.8 months). A single patient recurred at the primary site, for 2-year local control of 98.3%. One patient (1.7%) developed a regional neck recurrence, and 2 patients (3.3%) developed distant metastases. Measured 2-year local recurrence-free survival was 97.9% (95% confidence interval, 86.1%-99.7%). Overall survival was 100% at the time of analysis. The mean radiation dose to the primary site was 36.9 Gy (standard deviation, 10.3 Gy). Two patients (3.3%) experienced late soft tissue necrosis in the primary site surgical bed that resolved within 2 months. Feeding tube dependence rates were 0% during RT, 3.3% temporarily during follow-up, and 0% at last follow-up. CONCLUSIONS Deintensified postoperative RT that avoids the resected primary tumor site and targets only the at-risk neck after TORS for selected patients with HPV-associated OPSCC may be safe and is worthy of further study.
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Affiliation(s)
- Samuel Swisher-McClure
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John N Lukens
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charu Aggarwal
- Department of Medicine, Division of Hematology/Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter Ahn
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Devraj Basu
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Bauml
- Department of Medicine, Division of Hematology/Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert Brody
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ara Chalian
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roger B Cohen
- Department of Medicine, Division of Hematology/Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alireza Fotouhi-Ghiam
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Geoffrey Geiger
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jared Gershowitz
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Virginia Livolsi
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathleen Montone
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason Newman
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric Ojerholm
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bert O'Malley
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erik Tan
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory Weinstein
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania.
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23
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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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24
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Jackson RS, Chen S, Last A, Khan A, Kallogjeri D, Van Abel KM, Moore EJ, Pipkorn P. Multi-institutional analysis of outcomes following transoral surgery for HPV-positive oropharyngeal squamous cell carcinoma in elderly patients. Head Neck 2019; 41:3933-3939. [PMID: 31460691 DOI: 10.1002/hed.25946] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 07/12/2019] [Accepted: 08/15/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) is rising, even in elderly patients. The outcomes of transoral surgery (TOS) in this population are not entirely known. METHODS A retrospective review was performed at two institutions from October 2003 to September 2016 on patients 70 years or older with HPV-related OPSCC treated with TOS. RESULTS A total of 75 patients were included with a mean age of 74 years (70-87 years). At a median follow-up of 35.7 months, 3-year overall survival was 81.5% and disease-specific survival was 94.3%. Advanced cT stage (odds ratio, 2.74; 95% confidence interval, 1.13-6.64) negatively impacted OS. Conjunctive consolidation was performed to create a staging system with patients older than 80 years, severe comorbidity, and cT3-4 having worse survival. CONCLUSIONS Elderly patients with HPV-related OPSCC treated with TOS have excellent survival and therefore should not be excluded from such therapy based on age alone.
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Affiliation(s)
- Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Stephanie Chen
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Aisling Last
- Washington University School of Medicine, St. Louis, Missouri
| | - Amish Khan
- Washington University School of Medicine, St. Louis, Missouri
| | - Dorina Kallogjeri
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Eric J Moore
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
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25
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Faraji F, Fung N, Zaidi M, Gourin CC, Eisele DW, Rooper LM, Fakhry C. Tumor-infiltrating lymphocyte quantification stratifies early-stage human papillomavirus oropharynx cancer prognosis. Laryngoscope 2019; 130:930-938. [PMID: 31070246 DOI: 10.1002/lary.28044] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/25/2019] [Accepted: 04/15/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate if a simple method for assessing tumor-infiltrating lymphocytes (TIL) in primary tumor specimens improves the prognostic value of the American Joint Committee on Cancer, 8th Edition (AJCC8) cancer staging system in human papillomavirus-positive oropharyngeal squamous cell carcinoma (HPV-OPC). STUDY DESIGN Retrospective study. METHODS In this study, TIL density was quantified on hematoxylin and eosin (H&E)-stained specimens from patients presenting to Johns Hopkins Hospital between 2009 and 2017 who underwent primary surgical therapy and had primary tumor specimens available for analysis. The prognostic effect of TIL density was evaluated by Kaplan-Meier method and Cox proportional hazards models considering recurrence-free survival (RFS) as the primary outcome. RESULTS This study included 132 patients. Ninety-five percent were classified by clinical criteria with AJCC8 early-stage disease (stage I: 82%, stage II: 13%). After 84 months of follow-up, 15 recurrences were observed. Among clinically early-stage disease, TILhigh status was associated with improved RFS compared to TILlow (P = .002). Adjusted analysis showed TILhigh status was associated with 79% lower risk of recurrence than TILlow (adjusted hazard ratio [aHR]: 0.210, 95% confidence interval [CI]: 0.061-0.723). In clinical stage I disease, TILhigh status was associated with improved RFS compared to TILlow in both univariate and multivariate analyses (hazard ratio: 0.235, P = .021; aHR: 0.218; 95% CI: 0.058-0.822). TIL density similarly stratified risk in pathologically staged disease. CONCLUSIONS In patients with AJCC8 stage I disease, low TIL density was associated with diminished RFS. Our data suggest that assessing TIL density on H&E-stained primary tumor specimens may enhance the prognostic resolution of the AJCC8 staging criteria for HPV-OPC. LEVEL OF EVIDENCE 4 Laryngoscope, 130:930-938, 2020.
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Affiliation(s)
- Farhoud Faraji
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California San Diego Health, San Diego, California
| | - Nicholas Fung
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Munfarid Zaidi
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Christine C Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David W Eisele
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lisa M Rooper
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Carole Fakhry
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.,Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A
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26
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Gross JH, Townsend M, Hong HY, Miller E, Kallogjeri D, Zenga J, Pipkorn P, Jackson RS, Haughey B, Rich JT. Predictors of swallow function after transoral surgery for locally advanced oropharyngeal cancer. Laryngoscope 2019; 130:94-100. [DOI: 10.1002/lary.27856] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/21/2018] [Accepted: 01/22/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Jennifer H. Gross
- Department of OtolaryngologyWashington University School of Medicine Saint Louis Missouri U.S.A
| | | | - Helena Y. Hong
- Department of OtolaryngologyWashington University School of Medicine Saint Louis Missouri U.S.A
| | - Emily Miller
- University of Maryland Medical System Baltimore Maryland U.S.A
| | - Dorina Kallogjeri
- Department of OtolaryngologyWashington University School of Medicine Saint Louis Missouri U.S.A
| | - Joseph Zenga
- Medical College of Wisconsin Milwaukee Wisconsin U.S.A
| | - Patrik Pipkorn
- Department of OtolaryngologyWashington University School of Medicine Saint Louis Missouri U.S.A
| | - Ryan S. Jackson
- Department of OtolaryngologyWashington University School of Medicine Saint Louis Missouri U.S.A
| | - Bruce Haughey
- Florida ENT Surgical Specialists Celebration Florida U.S.A
| | - Jason T. Rich
- Department of OtolaryngologyWashington University School of Medicine Saint Louis Missouri U.S.A
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