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Chen AM. Translational risk-adapted approaches to de-escalated radiation for human papillomavirus-positive oropharyngeal cancer: Past, present, and future. Oral Oncol 2024; 154:106850. [PMID: 38749113 DOI: 10.1016/j.oraloncology.2024.106850] [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: 04/02/2024] [Revised: 05/05/2024] [Accepted: 05/11/2024] [Indexed: 06/11/2024]
Abstract
Interest in the use of de-escalated radiation to treat patients with newly diagnosed human papillomavirus (HPV)-positive oropharyngeal cancer has grown dramatically with the publication of prospective trials demonstrating the efficacy of such an approach. While the rationale for de-escalation--- namely to decrease treatment-related toxicity while maintaining the excellent rates of disease control historically observed in patients with this disease-is inherently obvious, uncertainty exists regarding how to best select patients for de-escalation. Consequently, risk-adapted strategies using a variety of translational and clinical platforms have been increasingly popularized to better refine treatment. These have integrated contemporary methods of mid-treatment response assessment using advanced technologies and molecular assays to customize the radiation dose. By monitoring the response as patients actively proceed through treatment, risk-adapted protocols have the potential to provide insight into the biological behavior of tumors and make individualized therapy possible. The purpose of this review is to summarize the evidence to date on risk-adapted approaches to de-escalated radiation-- highlighting the clinical, radiological, and biological data which may ultimately help usher the principles of precision medicine into practice for patients with HPV-positive oropharyngeal cancer.
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Affiliation(s)
- Allen M Chen
- Department of Radiation Oncology, Chao Family Comprehensive Cancer Center, University of California- Irvine, School of Medicine, Irvine, CA 92617, United states.
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2
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Garrido-Hernandez G, Henjum H, Winter RM, Alsaker MD, Danielsen S, Boer CG, Ytre-Hauge KS, Redalen KR. Interim 18F-FDG-PET based response-adaptive dose escalation of proton therapy for head and neck cancer: a treatment planning feasibility study. Phys Med 2024; 123:103404. [PMID: 38852365 DOI: 10.1016/j.ejmp.2024.103404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 05/06/2024] [Accepted: 06/05/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND Image-driven dose escalation to tumor subvolumes has been proposed to improve treatment outcome in head and neck cancer (HNC). We used 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) acquired at baseline and into treatment (interim) to identify biologic target volumes (BTVs). We assessed the feasibility of interim dose escalation to the BTV with proton therapy by simulating the effects to organs at risk (OARs). METHODS We used the semiautomated just-enough-interaction (JEI) method to identify BTVs in 18F-FDG-PET images from nine HNC patients. Between baseline and interim FDG-PET, patients received photon radiotherapy. BTV was identified assuming that high standardized uptake value (SUV) at interim reflected tumor radioresistance. Using Eclipse (Varian Medical Systems), we simulated a 10% (6.8 Gy(RBE1.1)) and 20% (13.6 Gy(RBE1.1)) dose escalation to the BTV with protons and compared results with proton plans without dose escalation. RESULTS At interim 18F-FDG-PET, radiotherapy resulted in reduced SUV compared to baseline. However, spatial overlap between high-SUV regions at baseline and interim allowed for BTV identification. Proton therapy planning demonstrated that dose escalation to the BTV was feasible, and except for some 20% dose escalation plans, OAR doses did not significantly increase. CONCLUSION Our in silico analysis demonstrated the potential for interim 18F-FDG-PET response-adaptive dose escalation to the BTV with proton therapy. This approach may give more efficient treatment to HNC with radioresistant tumor subvolumes without increasing normal tissue toxicity. Studies in larger cohorts are required to determine the full potential for interim 18F-FDG-PET-guided dose escalation of proton therapy in HNC.
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Affiliation(s)
| | - Helge Henjum
- Department of Physics and Technology, University of Bergen, Bergen, Norway
| | - René Mario Winter
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway
| | - Mirjam Delange Alsaker
- Department of Radiotherapy, Cancer Clinic, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Signe Danielsen
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | | | | | - Kathrine Røe Redalen
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway
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3
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Fujimoto K, Shiinoki T, Kawazoe Y, Yuasa Y, Mukaidani W, Manabe Y, Kajima M, Tanaka H. Biomechanical imaging biomarker during chemoradiotherapy predicts treatment response in head and neck squamous cell carcinoma. Phys Med Biol 2024; 69:055033. [PMID: 38359451 DOI: 10.1088/1361-6560/ad29b9] [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: 06/23/2023] [Accepted: 02/15/2024] [Indexed: 02/17/2024]
Abstract
Objective. For response-adapted adaptive radiotherapy (R-ART), promising biomarkers are needed to predict post-radiotherapy (post-RT) responses using routine clinical information obtained during RT. In this study, a patient-specific biomechanical model (BM) of the head and neck squamous cell carcinoma (HNSCC) was proposed using the pre-RT maximum standardized uptake value (SUVmax) of18F-fluorodeoxyglucose (FDG) and tumor structural changes during RT as evaluated using computed tomography (CT). In addition, we evaluated the predictive performance of BM-driven imaging biomarkers for the treatment response of patients with HNSCC who underwent concurrent chemoradiotherapy (CCRT).Approach. Patients with histologically confirmed HNSCC treated with definitive CCRT were enrolled in this study. All patients underwent CT two times as follows: before the start of RT (pre-RT) and 3 weeks after the start of RT (mid-RT). Among these patients, 67 patients who underwent positron emission tomography/CT during the pre-RT period were included in the final analysis. The locoregional control (LC), progression-free survival (PFS), and overall survival (OS) prediction performances of whole tumor stress change (TS) between pre- and mid-RT computed using BM were assessed using univariate, multivariate, and Kaplan-Meier survival curve analyses, respectively. Furthermore, performance was compared with the pre and post-RT SUVmax, tumor volume reduction rate (TVRR) during RT, and other clinical prognostic factors.Main results. For both univariate, multivariate, and survival curve analyses, the significant prognostic factors were as follows (p< 0.05): TS and TVRR for LC; TS and pre-RT FDG-SUVmaxfor PFS; and TS only for OS. In addition, for 2 year LC, PFS, and OS prediction, TS showed a comparable predictive performance to post-RT FDG-SUVmax.Significance. BM-driven TS is an effective prognostic factor for tumor treatment response after CCRT. The proposed method can be a feasible functional imaging biomarker that can be acquired during RT using only routine clinical data and may provide useful information for decision-making during R-ART.
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Affiliation(s)
- Koya Fujimoto
- Department of Radiation Oncology, Graduate School of Medicine, Yamaguchi University, Ube, Japan
| | - Takehiro Shiinoki
- Department of Radiation Oncology, Graduate School of Medicine, Yamaguchi University, Ube, Japan
| | - Yusuke Kawazoe
- Department of Radiation Oncology, Graduate School of Medicine, Yamaguchi University, Ube, Japan
- Department of Radiological Technology, Yamaguchi University Hospital, Ube, Japan
| | - Yuki Yuasa
- Department of Radiological Technology, Yamaguchi University Hospital, Ube, Japan
| | - Wataru Mukaidani
- Department of Radiological Technology, Yamaguchi University Hospital, Ube, Japan
| | - Yuki Manabe
- Department of Radiation Oncology, Graduate School of Medicine, Yamaguchi University, Ube, Japan
| | - Miki Kajima
- Department of Radiation Oncology, Graduate School of Medicine, Yamaguchi University, Ube, Japan
| | - Hidekazu Tanaka
- Department of Radiation Oncology, Graduate School of Medicine, Yamaguchi University, Ube, Japan
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4
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Allen SG, Rosen BS, Aryal M, Cao Y, Schipper MJ, Wong KK, Casper KA, Chinn SB, Malloy KM, Prince ME, Rosko AJ, Shuman AG, Spector ME, Stucken CL, Swiecicki PL, Worden FP, Brenner JC, Schonewolf CA, Elliott DA, Mierzwa ML, Shah JL. Initial Feasibility and Acute Toxicity Outcomes From a Phase 2 Trial of 18F-Fluorodeoxyglucose Positron Emission Tomography Response-Based De-escalated Definitive Chemoradiotherapy for p16+ Oropharynx Cancer: A Planned Interim Analysis. Int J Radiat Oncol Biol Phys 2023; 117:171-180. [PMID: 36931572 DOI: 10.1016/j.ijrobp.2023.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 03/04/2023] [Accepted: 03/08/2023] [Indexed: 03/17/2023]
Abstract
PURPOSE 18F-Fluorodeoxyglucose positron emission tomography (FDG-PET) parameters are prognostic of oncologic outcomes in human papillomavirus-associated oropharyngeal squamous cell carcinoma (OPSCC). We used FDG-PET imaging biomarkers to select patients for de-escalated chemoradiotherapy (CRT), hypothesizing that acute toxicity will be improved with de-escalation. METHODS AND MATERIALS This is a planned interim initial feasibility and acute toxicity report from a phase 2, prospective, nonrandomized study, which enrolled patients with stage I-II p16+ OPSCC. All patients started definitive CRT to 70 Gy in 35 fractions, and those who met de-escalation criteria on midtreatment FDG-PET at fraction 10 completed treatment at 54 Gy in 27 fractions. We report the acute toxicity and patient-reported outcomes for 59 patients with a minimum follow-up of 3 months. RESULTS There were no statistically significant differences between baseline patient characteristics in the standard and de-escalated cohorts. There were 28 of 59 (47.5%) patients who met FDG-PET de-escalation criteria and collectively received 20% to 30% less dose to critical organs at risk known to affect toxicity. At 3 months posttreatment, patients who received de-escalated CRT lost significantly less weight (median, 5.8% vs 13.0%; P < .001), had significantly less change from baseline in penetration-aspiration scale score (median, 0 vs 1; P = .018), and had significantly fewer aspiration events on repeat swallow study (8.0% vs 33.3%, P = .037) compared with patients receiving standard CRT. CONCLUSIONS Approximately half of patients with early-stage p16+ OPSCC are selected for de-escalation of definitive CRT using midtreatment FDG-PET biomarkers, which resulted in significantly improved rates of observed acute toxicity. Further follow-up is ongoing and will be required to determine whether this de-escalation approach preserves the favorable oncologic outcomes for patients with p16+ OPSCC before adoption.
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Affiliation(s)
- Steven G Allen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Benjamin S Rosen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Madhava Aryal
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Matthew J Schipper
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Ka Kit Wong
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kelly M Malloy
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Mark E Prince
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew J Rosko
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew G Shuman
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan; Surgery Services-ENT Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Chaz L Stucken
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Paul L Swiecicki
- Department of Internal Medicine, Division of Medical Oncology, University of Michigan, Ann Arbor, Michigan
| | - Francis P Worden
- Department of Internal Medicine, Division of Medical Oncology, University of Michigan, Ann Arbor, Michigan
| | - J Chad Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - David A Elliott
- Radiation Oncology Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Michelle L Mierzwa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Jennifer L Shah
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Radiation Oncology Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.
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5
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Garcia DA, Jeans EB, Morris LK, Shiraishi S, Laughlin BS, Rong Y, Rwigema JCM, Foote RL, Herman MG, Qian J. A Radiomics-Based Classifier for the Progression of Oropharyngeal Cancer Treated with Definitive Radiotherapy. Cancers (Basel) 2023; 15:3715. [PMID: 37509376 PMCID: PMC10377821 DOI: 10.3390/cancers15143715] [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: 06/19/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
In this study, we investigated whether radiomics features from pre-treatment positron emission tomography (PET) images could be used to predict disease progression in patients with HPV-positive oropharyngeal cancer treated with definitive proton or x-ray radiotherapy. Machine learning models were built using a dataset from Mayo Clinic, Rochester, Minnesota (n = 72) and tested on a dataset from Mayo Clinic, Phoenix, Arizona (n = 22). A total of 71 clinical and radiomics features were considered. The Mann-Whitney U test was used to identify the top 2 clinical and top 20 radiomics features that were significantly different between progression and progression-free patients. Two dimensionality reduction methods were used to define two feature sets (manually filtered or machine-driven). A forward feature selection scheme was conducted on each feature set to build models of increased complexity (number of input features from 1 to 6) and evaluate model robustness and overfitting. The machine-driven features had superior performance and were less prone to overfitting compared to the manually filtered features. The four-variable Gaussian Naïve Bayes model using the 'Radiation Type' clinical feature and three machine-driven features achieved a training accuracy of 79% and testing accuracy of 77%. These results demonstrate that radiomics features can provide risk stratification beyond HPV-status to formulate individualized treatment and follow-up strategies.
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Affiliation(s)
- Darwin A Garcia
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN 55905, USA
| | - Elizabeth B Jeans
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Lindsay K Morris
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Satomi Shiraishi
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Brady S Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | | | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Michael G Herman
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Jing Qian
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
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6
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Rosen BS, Vaishampayan N, Cao Y, Mierzwa ML. The Utility of Interim Positron Emission Tomography Imaging to Inform Adaptive Radiotherapy for Head and Neck Squamous Cell Carcinoma. Cancer J 2023; 29:243-247. [PMID: 37471616 DOI: 10.1097/ppo.0000000000000669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
ABSTRACT In this article, as part of this special issue on biomarkers of early response, we review the current evidence to support the use of positron emission tomography (PET) imaging during chemoradiation therapy to inform biologically adaptive radiotherapy for head and neck squamous cell carcinoma. We review literature covering this topic spanning nearly 3 decades, including the use of various radiotracers and discoveries of novel predictive PET biomarkers. Through understanding how observational trials have informed current interventional clinical trials, we hope that this review will encourage researchers and clinicians to incorporate PET response criteria in new trial designs to advance biologically optimized radiotherapy.
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Affiliation(s)
- Benjamin S Rosen
- From the Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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Ger RB, Wei L, Naqa IE, Wang J. The Promise and Future of Radiomics for Personalized Radiotherapy Dosing and Adaptation. Semin Radiat Oncol 2023; 33:252-261. [PMID: 37331780 PMCID: PMC11214660 DOI: 10.1016/j.semradonc.2023.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Quantitative image analysis, also known as radiomics, aims to analyze large-scale quantitative features extracted from acquired medical images using hand-crafted or machine-engineered feature extraction approaches. Radiomics has great potential for a variety of clinical applications in radiation oncology, an image-rich treatment modality that utilizes computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) for treatment planning, dose calculation, and image guidance. A promising application of radiomics is in predicting treatment outcomes after radiotherapy such as local control and treatment-related toxicity using features extracted from pretreatment and on-treatment images. Based on these individualized predictions of treatment outcomes, radiotherapy dose can be sculpted to meet the specific needs and preferences of each patient. Radiomics can aid in tumor characterization for personalized targeting, especially for identifying high-risk regions within a tumor that cannot be easily discerned based on size or intensity alone. Radiomics-based treatment response prediction can aid in developing personalized fractionation and dose adjustments. In order to make radiomics models more applicable across different institutions with varying scanners and patient populations, further efforts are needed to harmonize and standardize the acquisition protocols by minimizing uncertainties within the imaging data.
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Affiliation(s)
- Rachel B Ger
- Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medicine, Baltimore, MD
| | - Lise Wei
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Issam El Naqa
- Department of Machine Learning, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jing Wang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX..
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Lin Fracp P, Holloway L, Min Franzcr M, Lee Franzcr M, Fowler Franzcr A. Prognostic and predictive values of baseline and mid-treatment FDG-PET in oropharyngeal carcinoma treated with primary definitive (chemo)radiation and impact of HPV status: review of current literature and emerging roles. Radiother Oncol 2023; 184:109686. [PMID: 37142128 DOI: 10.1016/j.radonc.2023.109686] [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: 07/29/2022] [Revised: 04/16/2023] [Accepted: 04/24/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND AND PURPOSE This study provides a review of the literature assessing whether semiquantitative PET parameters acquired at baseline and/or during definitive (chemo)radiotherapy ("prePET" and "iPET") can predict survival outcomes in patients with oropharyngeal squamous cell carcinoma (OPC), and the impact of human papilloma virus (HPV) status. MATERIAL AND METHODS A literature search was carried out using PubMed and Embase between 2001 to 2021 in accordance with PRISMA. RESULTS The analysis included 22 FDG-PET/CT studies1-22, 19 pre-PET and 3 both pre-PET and iPET14,18,20,. The analysis involved 2646 patients, of which 1483 are HPV-positive (17 studies: 10 mixed and 7 HPV-positive only), 589 are HPV-negative, and 574 have unknown HPV status. Eighteen studies found significant correlations of survival outcomes with pre-PET parameters, most commonly primary or "Total" (combined primary and nodal) metabolic tumour volume and/or total lesional glycolysis. Two studies could not establish significant correlations and both employed SUVmax only. Two studies also could not establish significant correlations when taking into account of the HPV-positive population only. Because of the heterogeneity and lack of standardized methodology, no conclusions on optimal cut-off values can be drawn. Ten studies specifically evaluated HPV-positive patients: five showed positive correlation of pre-PET parameters and survival outcomes, but four of these studies did not include advanced T or N staging in multivariate analysis1,6,15,22, and two studies only showed positive correlations after excluding high risk patients with smoking history7 or adverse CT features22. Two studies found that prePET parameters predicted treatment outcomes only in HPV-negative but not HPV-positive patients10,16. Two studies found that iPET parameters could predict outcomes in HPV-positive patients but not prePET parameters14,18. CONCLUSION The current literature supports high pre-treatment metabolic burden prior to definitive (chemo)radiotherapy can predict poor treatment outcomes for HPV-negative OPC patients. Evidence is conflicting and currently does not support correlation in HPV-positive patients.
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Affiliation(s)
- Peter Lin Fracp
- Department of Nuclear Medicine and PET, Liverpool Hospital, Liverpool, NSW, Australia; South Western Sydney Clinical School, University of New South Wales, NSW, Australia; School of Medicine, Western Sydney University, NSW, Australia.
| | - Lois Holloway
- South Western Sydney Clinical School, University of New South Wales, NSW, Australia; School of Medicine, Western Sydney University, NSW, Australia; Cancer Therapy Centre, Liverpool Hospital, Liverpool, NSW, Australia; Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia
| | - Myo Min Franzcr
- Department of Radiation Oncology, Sunshine Coast University Hospital, Queensland, Australia; Faculty of Science, Health, Education and Engineering, University of Sunshine Coast, Queensland, Australia
| | - Mark Lee Franzcr
- South Western Sydney Clinical School, University of New South Wales, NSW, Australia; Cancer Therapy Centre, Liverpool Hospital, Liverpool, NSW, Australia
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Kang JJ, Yu Y, Chen L, Zakeri K, Gelblum DY, McBride SM, Riaz N, Tsai CJ, Kriplani A, Hung T, Fetten JV, Dunn LA, Ho A, Boyle JO, Ganly IS, Singh B, Sherman EJ, Pfister DG, Wong RJ, Lee NY. Consensuses, controversies, and future directions in treatment deintensification for human papillomavirus-associated oropharyngeal cancer. CA Cancer J Clin 2023; 73:164-197. [PMID: 36305841 PMCID: PMC9992119 DOI: 10.3322/caac.21758] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/03/2022] [Accepted: 08/09/2022] [Indexed: 01/19/2023] Open
Abstract
The most common cancer caused by human papillomavirus (HPV) infection in the United States is oropharyngeal cancer (OPC), and its incidence has been rising since the turn of the century. Because of substantial long-term morbidities with chemoradiation and the favorable prognosis of HPV-positive OPC, identifying the optimal deintensification strategy for this group has been a keystone of academic head-and-neck surgery, radiation oncology, and medical oncology for over the past decade. However, the first generation of randomized chemotherapy deintensification trials failed to change the standard of care, triggering concern over the feasibility of de-escalation. National database studies estimate that up to one third of patients receive nonstandard de-escalated treatments, which have subspecialty-specific nuances. A synthesis of the multidisciplinary deintensification data and current treatment standards is important for the oncology community to reinforce best practices and ensure optimal patient outcomes. In this review, the authors present a summary and comparison of prospective HPV-positive OPC de-escalation trials. Chemotherapy attenuation compromises outcomes without reducing toxicity. Limited data comparing transoral robotic surgery (TORS) with radiation raise concern over toxicity and outcomes with TORS. There are promising data to support de-escalating adjuvant therapy after TORS, but consensus on treatment indications is needed. Encouraging radiation deintensification strategies have been reported (upfront dose reduction and induction chemotherapy-based patient selection), but level I evidence is years away. Ultimately, stage and HPV status may be insufficient to guide de-escalation. The future of deintensification may lie in incorporating intratreatment response assessments to harness the powers of personalized medicine and integrate real-time surveillance.
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Affiliation(s)
- Jung Julie Kang
- Yale University School of Medicine, Department of Therapeutic Radiology
| | - Yao Yu
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology
| | - Linda Chen
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology
| | - Kaveh Zakeri
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology
| | | | | | - Nadeem Riaz
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology
| | - C. Jillian Tsai
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology
| | - Anuja Kriplani
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | - Tony Hung
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | - James V. Fetten
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | - Lara A. Dunn
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | - Alan Ho
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | - Jay O. Boyle
- Memorial Sloan Kettering Cancer Center, Department of Surgery
| | - Ian S. Ganly
- Memorial Sloan Kettering Cancer Center, Department of Surgery
| | - Bhuvanesh Singh
- Memorial Sloan Kettering Cancer Center, Department of Surgery
| | - Eric J. Sherman
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | | | - Richard J. Wong
- Memorial Sloan Kettering Cancer Center, Department of Surgery
| | - Nancy Y. Lee
- Memorial Sloan Kettering Cancer Center, Department of Medicine
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10
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Mierzwa ML, Aryal M, Lee C, Schipper M, VanTil M, Rivera KM, Swiecicki PL, Casper KA, Malloy KM, Spector ME, Shuman AG, Chinn SB, Prince ME, Stucken CL, Rosko AJ, Lawrence TS, Brenner JC, Rosen B, Schonewolf CA, Shah J, Eisbruch A, Worden FP, Cao Y. Randomized Phase II Study of Physiologic MRI-Directed Adaptive Radiation Boost in Poor Prognosis Head and Neck Cancer. Clin Cancer Res 2022; 28:5049-5057. [PMID: 36107219 PMCID: PMC9773159 DOI: 10.1158/1078-0432.ccr-22-1522] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/06/2022] [Accepted: 09/13/2022] [Indexed: 01/24/2023]
Abstract
PURPOSE We conducted a randomized phase II multicenter clinical trial to test the hypothesis that physiologic MRI-based radiotherapy (RT) dose escalation would improve the outcome of patients with poor prognosis head and neck cancer. PATIENTS AND METHODS MRI was acquired at baseline and at RT fraction 10 to create low blood volume/apparent diffusion coefficient maps for RT boost subvolume definition in gross tumor volume. Patients were randomized to receive 70 Gy (standard RT) or 80 Gy to the boost subvolume (RT boost) with concurrent weekly platinum. The primary endpoint was disease-free survival (DFS) with significance defined at a one-sided 0.1 level, and secondary endpoints included locoregional failure (LRF), overall survival (OS), comparison of adverse events and patient reported outcomes (PRO). RESULTS Among 81 randomized patients, neither the primary endpoint of DFS (HR = 0.849, P = 0.31) nor OS (HR = 1.19, P = 0.66) was significantly improved in the RT boost arm. However, the incidence of LRF was significantly improved with the addition of the RT boost (HR = 0.43, P = 0.047). Two-year estimates [90% confidence interval (CI)] of the cumulative incidence of LRF were 40% (27%-53%) in the standard RT arm and 18% (10%-31%) in the RT boost arm. Two-year estimates (90% CI) for DFS were 48% (34%-60%) in the standard RT arm and 57% (43%-69%) in the RT boost arm. There were no significant differences in toxicity or longitudinal differences seen in EORTC QLQ30/HN35 subscales between treatment arms in linear mixed-effects models. CONCLUSIONS Physiologic MRI-based RT boost decreased LRF without a significant increase in grade 3+ toxicity or longitudinal PRO differences, but did not significantly improve DFS or OS. Additional improvements in systemic therapy are likely necessary to realize improvements in DFS and OS.
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Affiliation(s)
- Michelle L Mierzwa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Madhava Aryal
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Choonik Lee
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Matthew Schipper
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Monica VanTil
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | | | - Paul L. Swiecicki
- Department of Internal Medicine, Medical Oncology, University of Michigan, Ann Arbor, Michigan
| | - Keith A. Casper
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Kelly M. Malloy
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Matthew E. Spector
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Andrew G. Shuman
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Steven B. Chinn
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Mark E.P. Prince
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Chaz L. Stucken
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Andrew J. Rosko
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | | | - J Chad Brenner
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Benjamin Rosen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Jennifer Shah
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Francis P. Worden
- Department of Internal Medicine, Medical Oncology, University of Michigan, Ann Arbor, Michigan
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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Gordis TM, Cagle JL, Nguyen SA, Newman JG. Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis of Clinical Trial Demographics. Cancers (Basel) 2022; 14:cancers14164061. [PMID: 36011055 PMCID: PMC9406828 DOI: 10.3390/cancers14164061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/02/2022] [Accepted: 08/08/2022] [Indexed: 11/18/2022] Open
Abstract
Simple Summary HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) is unique amongst oropharyngeal cancers in its high responsiveness to treatment and its lower mortality rate. As a result, numerous clinical trials have been conducted to identify treatment modalities and protocols. In order for these trials to have meaningful impact on HPV-associated OPSCC patients, proper demographic representation by trial participants is essential. The aim of our systematic review and meta-analysis was to assess the demographics of trial participants for HPV-associated OPSCC clinical trials and compare them with those reported by national databases. We determined that clinical-trial participants were predominately non-smoking white men, with tonsils as the primary tumor site. These findings reflect the demographics reported by the National Cancer Database. Our results imply that HPV-associated OPSCC clinical trials appropriately represent the target population and offer immense benefit. Abstract The objective of our paper was to answer the following question: how do patients with HPV-related oropharyngeal squamous cell carcinoma OPSCC (Population) enrolled in clinical trials (Intervention), compared with national database reports of HPV-associated OPSCC patients (Comparison), present demographically (Outcome)? We conducted a systematic review and meta-analysis of studies pertaining to clinical trials of HPV-associated OPSCC and participant demographics in the United States. PubMed, Scopus, CINAHL, and the Cochrane Library were searched from inception to 2 February 2022. Studies of overlapping participant cohorts and/or studies conducted outside of the United States were excluded. Primary outcomes were patient age, sex, and race. Secondary outcomes were smoking history, alcohol history, history of prior cancer, and tumor origin site. Meta-analysis of single means (mean, N for each study, and standard deviation) for age, pack years, and smoking years was performed. Pooled prevalence rates of gender, race, alcohol history, tobacco history, and tumor origin site were expressed as a percentage, with 95% confidence intervals. Meta-analysis found patients to be predominately non-smoking white males, with tumors originating from the tonsil. Our findings reflected the demographics reported by the National Cancer Database (NCDB) for HPV-associated OPSCC. This indicates that HPV-associated OPSCC patients are appropriately represented in clinical trial demographics.
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Ji H, Lafata K, Mowery Y, Brizel D, Bertozzi AL, Yin FF, Wang C. Post-Radiotherapy PET Image Outcome Prediction by Deep Learning Under Biological Model Guidance: A Feasibility Study of Oropharyngeal Cancer Application. Front Oncol 2022; 12:895544. [PMID: 35646643 PMCID: PMC9135979 DOI: 10.3389/fonc.2022.895544] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/11/2022] [Indexed: 01/03/2023] Open
Abstract
PurposeTo develop a method of biologically guided deep learning for post-radiation 18FDG-PET image outcome prediction based on pre-radiation images and radiotherapy dose information.MethodsBased on the classic reaction–diffusion mechanism, a novel biological model was proposed using a partial differential equation that incorporates spatial radiation dose distribution as a patient-specific treatment information variable. A 7-layer encoder–decoder-based convolutional neural network (CNN) was designed and trained to learn the proposed biological model. As such, the model could generate post-radiation 18FDG-PET image outcome predictions with breakdown biological components for enhanced explainability. The proposed method was developed using 64 oropharyngeal patients with paired 18FDG-PET studies before and after 20-Gy delivery (2 Gy/day fraction) by intensity-modulated radiotherapy (IMRT). In a two-branch deep learning execution, the proposed CNN learns specific terms in the biological model from paired 18FDG-PET images and spatial dose distribution in one branch, and the biological model generates post-20-Gy 18FDG-PET image prediction in the other branch. As in 2D execution, 718/233/230 axial slices from 38/13/13 patients were used for training/validation/independent test. The prediction image results in test cases were compared with the ground-truth results quantitatively.ResultsThe proposed method successfully generated post-20-Gy 18FDG-PET image outcome prediction with breakdown illustrations of biological model components. Standardized uptake value (SUV) mean values in 18FDG high-uptake regions of predicted images (2.45 ± 0.25) were similar to ground-truth results (2.51 ± 0.33). In 2D-based Gamma analysis, the median/mean Gamma Index (<1) passing rate of test images was 96.5%/92.8% using the 5%/5 mm criterion; such result was improved to 99.9%/99.6% when 10%/10 mm was adopted.ConclusionThe developed biologically guided deep learning method achieved post-20-Gy 18FDG-PET image outcome predictions in good agreement with ground-truth results. With the breakdown biological modeling components, the outcome image predictions could be used in adaptive radiotherapy decision-making to optimize personalized plans for the best outcome in the future.
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Affiliation(s)
- Hangjie Ji
- Department of Mathematics, North Carolina State University, Raleigh, NC, United States
| | - Kyle Lafata
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States
- Department of Radiology, Duke University Medical Center, Durham, NC, United States
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, United States
| | - Yvonne Mowery
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States
| | - David Brizel
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States
| | - Andrea L. Bertozzi
- Mechanical and Aerospace Engineering Department, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Mathematics, University of California, Los Angeles, Los Angeles, CA, United States
| | - Fang-Fang Yin
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States
| | - Chunhao Wang
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States
- *Correspondence: Chunhao Wang,
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13
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Witek ME, Kimple RJ, Avey GD, Burr AR, Chandereng T, Yu M, Hu R, Wieland AM, Labby ZE, Bruce JY, Brower JV, Hartig GK, Harari PM. Prospective Study of PET/MRI Tumor Response During Chemoradiotherapy for Patients With Low-risk and Intermediate-risk p16-positive Oropharynx Cancer. Am J Clin Oncol 2022; 45:202-207. [PMID: 35446279 PMCID: PMC9623610 DOI: 10.1097/coc.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to examine tumor response with positron emission tomography (PET)/magnetic resonance imaging (MRI) during chemoradiotherapy as a predictor of outcome in patients with p16-positive oropharynx cancer. MATERIALS AND METHODS Patients with p16-positive oropharynx cancer were treated with chemoradiotherapy. Low-risk (LR) disease was defined as T1-T3 and N0-2b and ≤10 pack-years and intermediate-risk (IR) disease as T4 or N2c-3 or >10 pack-years. Patients underwent a PET/MRI scan pretreatment and at fraction 10. Change in value of imaging means were analyzed by analysis of variance. K-means clustering with Euclidean distance functions were used for patient clustering. Silhouette width was used to determine the optimal number of clusters. Linear regression was performed on all radiographic metrics using patient and disease characteristics. RESULTS Twenty-four patients were enrolled with 7 LR and 11 IR patients available for analysis. Pretreatment imaging characteristics between LR and IR patients were similar. Patients with LR disease exhibited a larger reduction in maximum standardized uptake value (SUV) compared with IR patients (P<0.05). Cluster analysis defined 2 cohorts that exhibited a similar intratreatment response. Cluster 1 contained 7 of 7 LR patients and 8 of 11 IR patients. Cluster 2 contained 3 of 11 IR patients. Cluster 2 exhibited significant differences compared with cluster 1 in the change in primary tumor peak SUV and largest lymph node median SUV. CONCLUSIONS We identified that IR p16-positive oropharynx cancers exhibit heterogeneity in their PET/MRI response to chemoradiotherapy. These data support further study of intratreatment imaging response as a potential mechanism to identify patients with IR oropharynx cancer suitable for treatment deintensification.
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Affiliation(s)
- Matthew E. Witek
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI, USA
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Randall J. Kimple
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI, USA
- UW Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Gregory D. Avey
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Adam R. Burr
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI, USA
| | | | - Menggang Yu
- UW Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Rong Hu
- UW Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Aaron M. Wieland
- Deparmtent of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Zacariah E. Labby
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI, USA
| | - Justine Y. Bruce
- UW Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jeffrey V. Brower
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI, USA
| | - Gregory K. Hartig
- Deparmtent of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Paul M. Harari
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, WI, USA
- UW Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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14
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PET/CT. PET Clin 2022; 17:297-305. [DOI: 10.1016/j.cpet.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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15
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Cao Y, Haring CT, Brummel C, Bhambhani C, Aryal M, Lee C, Heft Neal M, Bhangale A, Gu W, Casper K, Malloy K, Sun Y, Shuman A, Prince ME, Spector ME, Chinn S, Shah J, Schonewolf C, McHugh JB, Mills RE, Tewari M, Worden FP, Swiecicki PL, Mierzwa M, Brenner JC. Early HPV ctDNA Kinetics and Imaging Biomarkers Predict Therapeutic Response in p16+ Oropharyngeal Squamous Cell Carcinoma. Clin Cancer Res 2022; 28:350-359. [PMID: 34702772 PMCID: PMC8785355 DOI: 10.1158/1078-0432.ccr-21-2338] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/11/2021] [Accepted: 10/20/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE In locally advanced p16+ oropharyngeal squamous cell carcinoma (OPSCC), (i) to investigate kinetics of human papillomavirus (HPV) circulating tumor DNA (ctDNA) and association with tumor progression after chemoradiation, and (ii) to compare the predictive value of ctDNA to imaging biomarkers of MRI and FDG-PET. EXPERIMENTAL DESIGN Serial blood samples were collected from patients with AJCC8 stage III OPSCC (n = 34) enrolled on a randomized trial: pretreatment; during chemoradiation at weeks 2, 4, and 7; and posttreatment. All patients also had dynamic-contrast-enhanced and diffusion-weighted MRI, as well as FDG-PET scans pre-chemoradiation and week 2 during chemoradiation. ctDNA values were analyzed for prediction of freedom from progression (FFP), and correlations with aggressive tumor subvolumes with low blood volume (TVLBV) and low apparent diffusion coefficient (TVLADC), and metabolic tumor volume (MTV) using Cox proportional hazards model and Spearman rank correlation. RESULTS Low pretreatment ctDNA and an early increase in ctDNA at week 2 compared with baseline were significantly associated with superior FFP (P < 0.02 and P < 0.05, respectively). At week 4 or 7, neither ctDNA counts nor clearance were significantly predictive of progression (P = 0.8). Pretreatment ctDNA values were significantly correlated with nodal TVLBV, TVLADC, and MTV pre-chemoradiation (P < 0.03), while the ctDNA values at week 2 were correlated with these imaging metrics in primary tumor. Multivariate analysis showed that ctDNA and the imaging metrics performed comparably to predict FFP. CONCLUSIONS Early ctDNA kinetics during definitive chemoradiation may predict therapy response in stage III OPSCC.
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Affiliation(s)
- Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Catherine T Haring
- Department of Otolaryngology Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Collin Brummel
- Department of Otolaryngology Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Chandan Bhambhani
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Madhava Aryal
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Choonik Lee
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Molly Heft Neal
- Department of Otolaryngology Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Apurva Bhangale
- Department of Otolaryngology Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Wenjin Gu
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
| | - Keith Casper
- Department of Otolaryngology Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Kelly Malloy
- Department of Otolaryngology Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Yilun Sun
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Andrew Shuman
- Department of Otolaryngology Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Mark E Prince
- Department of Otolaryngology Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Matthew E Spector
- Department of Otolaryngology Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Steven Chinn
- Department of Otolaryngology Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Jennifer Shah
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Caitlin Schonewolf
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Jonathan B McHugh
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - Ryan E Mills
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
| | - Muneesh Tewari
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Francis P Worden
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Paul L Swiecicki
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Michelle Mierzwa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - J Chad Brenner
- Department of Otolaryngology Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
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Brodin NP, Velten C, Lubin J, Eichler J, Zhu S, Saha S, Guha C, Kalnicki S, Tomé WA, Garg MK, Kabarriti R. A positron emission tomography radiomic signature for distant metastases risk in oropharyngeal cancer patients treated with definitive chemoradiotherapy. Phys Imaging Radiat Oncol 2022; 21:72-77. [PMID: 35243035 PMCID: PMC8867118 DOI: 10.1016/j.phro.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 11/07/2022] Open
Abstract
The wavelet_LHL_GLDZM_LILDE feature was found to be associated with progression-free survival. A binary radiomics risk score was strongly associated with distant metastases for patients with HPV p16-negtive disease. Improved risk stratification could identify high-risk patients as potential candidates for adjuvant immunotherapy.
Background and purpose Disease recurrence and distant metastases (DM) are major concerns for oropharyngeal cancer (OPC) patients receiving definitive chemo-radiotherapy. Here, we investigated whether pre-treatment primary tumor positron emission tomography (PET) features could predict progression-free survival (PFS) or DM. Methods and materials Primary tumors were delineated on pre-treatment PET scans for patients treated between 2005 and 2018 using gradient-based segmentation. Radiomic image features were extracted, along with SUV metrics. Features with zero variance and strong correlation to tumor volume, stage, p16 status, age or smoking were excluded. A random forest model was used to identify features associated with PFS. Kaplan-Meier methods, Cox regression and logistic regression with receiver operating characteristics (ROC) and 5-fold cross-validated areas-under-the-curve (CV-AUCs) were used. Results A total of 114 patients were included. With median follow-up 40 months (range: 3–138 months), 14 patients had local recurrence, 21 had DM and 38 died. Two-year actuarial local control, distant control, PFS and overall survival was 89%, 84%, 70% and 84%, respectively. The wavelet_LHL_GLDZM_LILDE feature slightly improved PFS prediction compared to clinical features alone (CV-AUC 0.73 vs. 0.71). Age > 65 years (HR = 2.64 (95%CI: 1.36–5.2), p = 0.004) and p16-negative disease (HR = 3.38 (95%CI: 1.72–6.66), p < 0.001) were associated with poor PFS. A binary radiomic classifier strongly predicted DM with multivariable HR = 3.27 (95%CI: 1.15–9.31), p = 0.027, specifically for patients with p16-negative disease with 2-year DM-free survival 83% for low-risk vs. 38% for high-risk patients (p = 0.004). Conclusions A radiomics signature strongly associated with DM risk could provide a tool for improved risk stratification, potentially adding adjuvant immunotherapy for high-risk patients.
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Lin P, Min M, Lai K, Lee M, Holloway L, Xuan W, Bray V, Fowler A, Lee CS, Yong J. Mid-treatment Fluorodeoxyglucose Positron Emission Tomography in Human Papillomavirus-related Oropharyngeal Squamous Cell Carcinoma Treated with Primary Radiotherapy: Nodal Metabolic Response Rate can Predict Treatment Outcomes. Clin Oncol (R Coll Radiol) 2021; 33:e586-e598. [PMID: 34373179 DOI: 10.1016/j.clon.2021.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 06/05/2021] [Accepted: 07/16/2021] [Indexed: 11/26/2022]
Abstract
AIMS To evaluate whether biomarkers derived from fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) performed prior to (prePET) and during the third week (interim PET; iPET) of radiotherapy can predict treatment outcomes in human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPC). MATERIALS AND METHODS This retrospective analysis included 46 patients with newly diagnosed OPC treated with definitive (chemo)radiation and all patients had confirmed positive HPV status (HPV+OPC) based on p16 immunohistochemistry. The maximum standardised uptake value (SUVmax), metabolic tumour volume (MTV) and total lesional glycolysis (TLG) of primary, index node (node with the highest TLG) and total lymph nodes and their median percentage (≥50%) reductions in iPET were analysed, and correlated with 5-year Kaplan-Meier and multivariable analyses (smoking, T4, N2b-3 and AJCC stage IV), including local failure-free survival, regional failure-free survival, locoregional failure-free survival (LRFFS), distant metastatic failure-free survival (DMFFS), disease-free survival (DFS) and overall survival. RESULTS There was no association of outcomes with prePET parameters observed on multivariate analysis. A complete metabolic response of primary tumour was seen in 13 patients; the negative predictive value for local failure was 100%. More than a 50% reduction in total nodal MTV provided the best predictor of outcomes, including LRFFS (88% versus 47.1%, P = 0.006, hazard ratio = 0.153) and DFS (78.2% versus 41.2%, P = 0.01, hazard ratio = 0.234). More than a 50% reduction in index node TLG was inversely related to DMFFS: a better nodal response was associated with a higher incidence of distant metastatic failure (66.7% versus 100%, P = 0.009, hazard ratio = 3.0). CONCLUSION The reduction (≥50%) of volumetric nodal metabolic burden can potentially identify a subgroup of HPV+OPC patients at low risk of locoregional failure but inversely at higher risk of distant metastatic failure and may have a role in individualised adaptive radiotherapy and systemic therapy.
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Affiliation(s)
- P Lin
- Department of Nuclear Medicine and PET, Liverpool Hospital, Liverpool, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales, New South Wales, Australia; School of Medicine, Western Sydney University, New South Wales, Australia.
| | - M Min
- Department of Radiation Oncology, Sunshine Coast University Hospital, Queensland, Australia; Faculty of Science, Health, Education and Engineering, University of Sunshine Coast, Queensland, Australia; Cancer Therapy Centre, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - K Lai
- Department of Nuclear Medicine and PET, Liverpool Hospital, Liverpool, New South Wales, Australia; School of Medicine, Western Sydney University, New South Wales, Australia
| | - M Lee
- South Western Sydney Clinical School, University of New South Wales, New South Wales, Australia; Cancer Therapy Centre, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - L Holloway
- South Western Sydney Clinical School, University of New South Wales, New South Wales, Australia; School of Medicine, Western Sydney University, New South Wales, Australia; Cancer Therapy Centre, Liverpool Hospital, Liverpool, New South Wales, Australia; Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - W Xuan
- South Western Sydney Clinical School, University of New South Wales, New South Wales, Australia; Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - V Bray
- Cancer Therapy Centre, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - A Fowler
- Cancer Therapy Centre, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - C S Lee
- South Western Sydney Clinical School, University of New South Wales, New South Wales, Australia; School of Medicine, Western Sydney University, New South Wales, Australia; Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia; Department of Anatomical Pathology, Liverpool Hospital, Liverpool, New South Wales, Australia; Central Clinical School, University of Sydney, New South Wales, Australia
| | - J Yong
- Department of Anatomical Pathology, Liverpool Hospital, Liverpool, New South Wales, Australia
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Connor S, Sit C, Anjari M, Lei M, Guerrero-Urbano T, Szyszko T, Cook G, Bassett P, Goh V. The ability of post-chemoradiotherapy DWI ADC mean and 18F-FDG SUV max to predict treatment outcomes in head and neck cancer: impact of human papilloma virus oropharyngeal cancer status. J Cancer Res Clin Oncol 2021; 147:2323-2336. [PMID: 34159420 PMCID: PMC8236463 DOI: 10.1007/s00432-021-03662-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/10/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the ability of post-chemo-radiotherapy (CRT) diffusion-weighted-MRI apparent diffusion coefficient (ADCmean) and 18F-FDG PET maximum standardized uptake value (SUVmax) to predict disease-free survival (DFS) in head and neck squamous cell carcinoma (HNSCC), and to determine whether this ability is influenced by human papillomavirus oropharyngeal cancer (HPV-OPC) status. METHODS This prospective cohort observational study included 65 participants (53 male, mean ± SD age 59.9 ± 7.9 years, 46 HPV-OPC) with stage III or IV HNSCC. Primary tumour and nodal ADCmean (pre-treatment, 6- and 12-weeks post-CRT) and SUVmax (12-weeks post-CRT) were measured. Variables were compared with 2-year DFS (independent t-test/Mann-Whitney test) and overall DFS (Cox regression), before and after accounting for HPV-OPC status. Variables were also compared between HPV-OPC and other HNSCC subgroups after stratifying for DFS. RESULTS Absolute post-CRT ADCmean values predicted 2-year DFS and overall DFS for all participants (p = 0.03/0.03, 6-week node; p = 0.02/0.03 12-week primary tumour) but not in the HPV-OPC subgroup. In participants with DFS, percentage interval changes in primary tumour ADCmean at 6- and 12-weeks were higher in HPV-OPC than other HNSCC (p = 0.01, 6 weeks; p = 0.005, 12 weeks). The 12-week post-CRT SUVmax did not predict DFS. CONCLUSION Absolute post-CRT ADCmean values predicted DFS in HNSCC but not in the HPV-OPC subgroup. Amongst participants with DFS, post-CRT percentage interval changes in primary tumour ADCmean were significantly higher in HPV-OPC than in other HNSCC. Knowledge of HPV-OPC status is crucial to the clinical utilisation of post-CRT DWI-MRI for the prediction of outcomes.
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Affiliation(s)
- S Connor
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College, London, SE1 7EH, UK.
- Department of Neuroradiology, Ruskin Wing, Kings College Hospital, Denmark Hill, London, SE5 9RS, UK.
- Department of Radiology, Guy's Hospital, 2nd Floor, Tower Wing, Great Maze Pond, London, SE1 9RT, UK.
| | - C Sit
- Department of Radiology, Guy's Hospital, 2nd Floor, Tower Wing, Great Maze Pond, London, SE1 9RT, UK
| | - M Anjari
- Department of Radiology, Guy's Hospital, 2nd Floor, Tower Wing, Great Maze Pond, London, SE1 9RT, UK
| | - M Lei
- Department of Oncology, Guy's Hospital, 2nd Floor, Tower Wing, Great Maze Pond, London, SE1 9RT, UK
| | - T Guerrero-Urbano
- Department of Oncology, Guy's Hospital, 2nd Floor, Tower Wing, Great Maze Pond, London, SE1 9RT, UK
| | - T Szyszko
- King's College London & Guy's and St. Thomas' PET Centre, London, SE1 7EH, UK
| | - G Cook
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College, London, SE1 7EH, UK
- King's College London & Guy's and St. Thomas' PET Centre, London, SE1 7EH, UK
| | - P Bassett
- Department of Oncology, Guy's Hospital, 2nd Floor, Tower Wing, Great Maze Pond, London, SE1 9RT, UK
| | - V Goh
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College, London, SE1 7EH, UK
- Department of Radiology, Guy's Hospital, 2nd Floor, Tower Wing, Great Maze Pond, London, SE1 9RT, UK
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19
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Boeke S, Mönnich D, van Timmeren JE, Balermpas P. MR-Guided Radiotherapy for Head and Neck Cancer: Current Developments, Perspectives, and Challenges. Front Oncol 2021; 11:616156. [PMID: 33816247 PMCID: PMC8017313 DOI: 10.3389/fonc.2021.616156] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 02/01/2021] [Indexed: 02/06/2023] Open
Abstract
Based on the development of new hybrid machines consisting of an MRI and a linear accelerator, magnetic resonance image guided radiotherapy (MRgRT) has revolutionized the field of adaptive treatment in recent years. Although an increasing number of studies have been published, investigating technical and clinical aspects of this technique for various indications, utilizations of MRgRT for adaptive treatment of head and neck cancer (HNC) remains in its infancy. Yet, the possible benefits of this novel technology for HNC patients, allowing for better soft-tissue delineation, intra- and interfractional treatment monitoring and more frequent plan adaptations appear more than obvious. At the same time, new technical, clinical, and logistic challenges emerge. The purpose of this article is to summarize and discuss the rationale, recent developments, and future perspectives of this promising radiotherapy modality for treating HNC.
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Affiliation(s)
- Simon Boeke
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - David Mönnich
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | | | - Panagiotis Balermpas
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
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20
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Mierzwa ML, Gharzai LA, Li P, Wilkie JR, Hawkins PG, Aryal MP, Lee C, Rosen B, Lyden T, Blakely A, Chapman CH, Thamarus J, Schonewolf C, Shah J, Eisbruch A, Schipper MJ, Cao Y. Early MRI Blood Volume Changes in Constrictor Muscles Correlate With Postradiation Dysphagia. Int J Radiat Oncol Biol Phys 2020; 110:566-573. [PMID: 33346093 DOI: 10.1016/j.ijrobp.2020.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 12/01/2020] [Accepted: 12/13/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Predicting individual patient sensitivity to radiation therapy (RT) for tumor control or normal tissue toxicity is necessary to individualize treatment planning. In head and neck cancer, radiation doses are limited by many nearby critical structures, including structures involved in swallowing. Previous efforts showed that imaging parameters correlate with RT dose; here, we investigate the role of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) blood volume (BV) changes in predicting dysphagia. METHODS AND MATERIALS This study included 32 patients with locally advanced oropharyngeal squamous cell carcinoma treated with definitive chemoradiation on an institutional protocol incorporating baseline and early midtreatment DCE-MRI. BV maps of the pharyngeal constrictor muscles (PCM) were created, and BV increases midtreatment were correlated with the following parameters at 3 and 12 months post-RT: RT dose, Dynamic Imaging Grade of Swallowing Toxicity swallow score, aspiration frequency, European Organisation for Research and Treatment of Cancer HN35 patient-reported outcomes, physician-reported dysphagia, and feeding tube (FT) dependence. RESULTS The mean BV to the PCMs increased from baseline to fraction 10, which was significant for the superior PCM (P = .006) and middle PCM (P < .001), with a trend in the inferior PCM where lower mean doses were seen (P = .077). The factors associated with FT dependence at 3 months included BV increases in the total PCM (correlation, 0.48; P = .006) and middle PCM (correlation, 0.50; P = .004). A post-RT increase in aspiration was associated with a BV increase in the superior PCM (correlation, 0.44; P = .013),and the increase in the total PCMs was marginally significant (correlation, 0.34; P = .06). The best-performing models of FT dependence (area under the receiver operating curve [AUC] = 0.84) and aspiration increases (AUC = 0.78) included BV increases as well as a mean RT dose to middle PCM. CONCLUSIONS Our results suggest that midtreatment BV increases derived from DCE-MRI are an early predictor of dysphagia. Further investigation of these promising imaging markers to assess individual patient sensitivity to treatment and the patient's subsequent risk of toxicities is warranted to improve personalization of RT planning.
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Affiliation(s)
- Michelle L Mierzwa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Laila A Gharzai
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Pin Li
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Joel R Wilkie
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Madhava P Aryal
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Choonik Lee
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Benjamin Rosen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Teresa Lyden
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Anna Blakely
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Christina H Chapman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Jennifer Thamarus
- Department of Speech and Language Pathology, Veterans Affairs Hospital, Ann Arbor, Michigan
| | - Caitlin Schonewolf
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Jennifer Shah
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Matthew J Schipper
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Radiology, University of Michigan, Ann Arbor, Michigan; Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
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