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Billingsley S, Iyizoba Z, Frood R, Vaidyanathan S, Prestwich R, Scarsbrook A. Clinical Utility of Second-Look FDG PET-CT to Stratify Incomplete Metabolic Response Post (Chemo) Radiotherapy in Oropharyngeal Squamous Cell Carcinoma. Cancers (Basel) 2023; 15:464. [PMID: 36672413 PMCID: PMC9856733 DOI: 10.3390/cancers15020464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/07/2023] [Accepted: 01/08/2023] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Incomplete response on FDG PET-CT following (chemo)radiotherapy (CRT) for head and neck squamous cell carcinoma (HNSCC) hinders optimal management. The study assessed the utility of an interval (second look) PET-CT. METHODS Patients with oropharyngeal squamous cell carcinoma cancer (OPSCC) treated with CRT at a single centre between 2013 and 2020 who underwent baseline, response, and second-look PET-CT were included. Endpoints were conversion rate to complete metabolic response (CMR) and test characteristics of second-look PET-CT. RESULTS In total, 714 patients with OPSCC underwent PET-CT post-radiotherapy. In total, 88 patients with incomplete response underwent second-look PET-CT a median of 13 weeks (interquartile range 10-15 weeks) after the initial response assessment. In total, 27/88 (31%) second-look PET-CTs showed conversion to CMR, primary tumour CMR in 20/60 (30%), and nodal CMR in 13/37 (35%). In total, 1/34 (3%) with stable tumour/nodal uptake at the second-look PET-CT relapsed. Sensitivity, specificity, positive (PPV), and negative predictive value (NPV) of second-look PET-CT were 95%, 49%, 50%, and 95% for tumour and 92%, 50%, 50%, and 92% for nodes, respectively. Primary tumour progression following CMR occurred in one patient, two patients with residual nodal uptake at second-look PET-CT progressed locoregionally, and one patient developed metastatic disease following CMR in residual nodes. CONCLUSION Most patients undergoing second-look PET-CT converted to CMR or demonstrated stable PET signal. NPV was high, suggesting the potential to avoid unnecessary surgical intervention.
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Affiliation(s)
- Sarah Billingsley
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
| | - Zsuzsanna Iyizoba
- Leeds Institute of Health Research, Faculty of Medicine & Health, University of Leeds, Leeds LS9 7TF, UK
- Department of Clinical Oncology, Leeds Cancer Centre, Leeds LS9 7TF, UK
| | - Russell Frood
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
- Leeds Institute of Health Research, Faculty of Medicine & Health, University of Leeds, Leeds LS9 7TF, UK
| | - Sriram Vaidyanathan
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
| | - Robin Prestwich
- Department of Clinical Oncology, Leeds Cancer Centre, Leeds LS9 7TF, UK
| | - Andrew Scarsbrook
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
- Leeds Institute of Health Research, Faculty of Medicine & Health, University of Leeds, Leeds LS9 7TF, UK
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2
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Oldan JD, Beaty BM, Jewells VL, Muhleman MA, Benefield T, Chera B. Qualitative and quantitative methods in post-chemoradiation PET for head and neck cancer. Nucl Med Commun 2022; 43:710-716. [PMID: 35414636 DOI: 10.1097/mnm.0000000000001558] [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: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether quantitative methods could aid in the evaluation of post-treatment head and neck scans, particularly taking human papillomavirus status into account. METHODS Clinical readings of positron emission tomography/computed tomography scans as well as standardized uptake value (SUV)max (and other metrics) of nodes visible on PET conducted on a total of 172 patients with head and neck squamous cell cancer were examined. Locoregional recurrence at 2 years was assessed. In total 88 of these patients had close enough follow-up to determine whether individual nodes were positive or negative, and 233 nodes on these patients were compared to surgical pathology notes or follow-up (if no path was available). RESULTS General negative predictive value (NPV) of complete response was 93% and an equivocal response was 89%; focusing on nodal recurrence, NPV was found to be 97% and positive predictive value (PPV) 46% if equivocal reads were treated as negative and NPV 98% and PPV 16% if equivocal reads were treated as positive. Using SUVmax of the hottest node with a cutoff of 3.4 gave NPV 97% and PPV 26%; a direct re-read (using 2 observers) gave NPV 98% and PPV 32% if equivocal reads were treated as negative, and NPV 99% and PPV 18% if equivocal reads were treated as positive. Using other first-order radiomics data such as SD and skewness did not improve this. CONCLUSIONS Quantitative data such as SUVmax does not show additional value over qualitative evaluation of response to chemoradiation in head and neck tumors.
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Affiliation(s)
| | - Brian M Beaty
- Department of Radiation Oncology, University of North Carolina-Chapel Hill, 101 Manning Drive, Chapel Hill, NC 27514, USA
| | | | | | | | - Bhishamjit Chera
- Department of Radiation Oncology, University of North Carolina-Chapel Hill, 101 Manning Drive, Chapel Hill, NC 27514, USA
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3
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PET/Computed Tomography. PET Clin 2022; 17:319-326. [DOI: 10.1016/j.cpet.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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4
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Salzillo TC, Taku N, Wahid KA, McDonald BA, Wang J, van Dijk LV, Rigert JM, Mohamed ASR, Wang J, Lai SY, Fuller CD. Advances in Imaging for HPV-Related Oropharyngeal Cancer: Applications to Radiation Oncology. Semin Radiat Oncol 2021; 31:371-388. [PMID: 34455992 DOI: 10.1016/j.semradonc.2021.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
While there has been an overall decline of tobacco and alcohol-related head and neck cancer in recent decades, there has been an increased incidence of HPV-associated oropharyngeal cancer (OPC). Recent research studies and clinical trials have revealed that the cancer biology and clinical progression of HPV-positive OPC is unique relative to its HPV-negative counterparts. HPV-positive OPC is associated with higher rates of disease control following definitive treatment when compared to HPV-negative OPC. Thus, these conditions should be considered unique diseases with regards to treatment strategies and survival. In order to sufficiently characterize HPV-positive OPC and guide treatment strategies, there has been a considerable effort to diagnose, prognose, and track the treatment response of HPV-associated OPC through advanced imaging research. Furthermore, HPV-positive OPC patients are prime candidates for radiation de-escalation protocols, which will ideally reduce toxicities associated with radiation therapy and has prompted additional imaging research to detect radiation-induced changes in organs at risk. This manuscript reviews the various imaging modalities and current strategies for tackling these challenges as well as provides commentary on the potential successes and suggested improvements for the optimal treatment of these tumors.
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Affiliation(s)
- Travis C Salzillo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Nicolette Taku
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Kareem A Wahid
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Brigid A McDonald
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Jarey Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Lisanne V van Dijk
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Jillian M Rigert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Abdallah S R Mohamed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Jihong Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Stephen Y Lai
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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5
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Mathews F, Irizarry R, Rosenfeld R, Sundaram K. Systematic Review and Meta-Analysis of Post-Treatment PET/CT in HPV-Associated Oropharyngeal Cancer. Ann Otol Rhinol Laryngol 2021; 131:595-603. [PMID: 34353135 DOI: 10.1177/00034894211036842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To perform a systematic review with meta-analysis to investigate the utility of post-treatment PET/CT specifically in HPV-associated oropharyngeal squamous cell carcinoma following curative intent treatment. METHODS Random-effects meta-analysis was used to pool data from 7 observational studies (2013-2019) obtained from a database search of PubMed, Web of Science, and EMBASE using an a priori protocol with dual independent evaluation for inclusion, risk of bias assessment for acceptable methodology, and extraction of data for analysis. PET/CT results, treatment failure, imaging and interventions subsequent to PET/CT findings, and efficacy of salvage therapy were extracted. RESULTS Of the 907 post-treatment scans, PET/CT results were largely negative (76.2%; 95% CI, 63.4-85.6) and least often positive (11.3%; 95% CI, 8.8-14.4). PET/CT results were equivocal for 22.5% (95% CI, 12.5-36.9) and equivocal/positive for 34.2% of patients (95% CI, 25.1-44.5). Patients with an initial positive scan had the highest treatment failure rates (43.1%; 95% CI, 21.4-67.7) and those with an initial negative scan had the lowest rates (7.4%; 95% CI, 5.7-9.7). The equivocal and equivocal/positive scans had intermediate prevalence of 16.5% (95% CI, 9.4-27.6) and 16.7% (95% CI, 9.1-28.7), respectively. CONCLUSION The low treatment failure rate following a negative PET/CT scan is reassuring, but the data are consistent with treatment failure rates up to 9.7% suggesting follow-up of these patients is prudent. Additionally, the low positive predictive value for treatment failure observed alludes to use of post-treatment PET/CT in HPV-associated disease frequently leading to unnecessary subsequent imaging and intervention.
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Affiliation(s)
- Fasil Mathews
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Rachel Irizarry
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Richard Rosenfeld
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Krishnamurthi Sundaram
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY, USA.,Department of Otolaryngology, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
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6
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Fu TS, Scheffler P, Forner D, Noel CW, Huang SH, Gilbert RW, Goldstein DP, O'Sullivan B, Mehanna HM, Waldron J, de Almeida JR. A cost-utility analysis comparing CT surveillance, PET-CT surveillance, and planned postradiation neck dissection for advanced nodal HPV-positive oropharyngeal cancer. Cancer 2021; 127:3372-3380. [PMID: 34062618 DOI: 10.1002/cncr.33653] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/14/2021] [Accepted: 03/21/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND The cost utility of image-guided surveillance using computed tomography (CT) and positron emission tomography (PET)-CT to planned postradiation neck dissection (PRND) was compared for the management of advanced nodal human papillomavirus-positive oropharyngeal cancer following chemoradiation. METHODS A universal payer perspective was adopted. A Markov model was designed to simulate four treatment approaches with 3-month cycles over a lifetime horizon: 1) CT surveillance, 2) standard PET-CT surveillance, 3) a novel PET-CT approach with repeat PET at 6 months postchemoradiation for equivocal responders, and 4) PRND. Parameters including probabilities of CT nodal progression/resolution, PET avidity, recurrence, and survival were obtained from the literature. Costs were reported in 2019 Canadian dollars and utilities were expressed in quality-adjusted life years (QALYs). Deterministic and probabilistic sensitivity analyses were performed to evaluate model uncertainty. RESULTS PET-CT surveillance dominated CT surveillance and PRND in the base case scenario, and the novel PET-CT approach was the most cost-effective strategy across a wide range of variables tested in one-way sensitivity analysis. On probabilistic sensitivity analysis, novel PET-CT surveillance was the most cost-effective strategy in 78.1% of model iterations at a willingness-to-pay of $50,000/QALYs. Novel PET-CT surveillance resulted in a 49% lower rate of neck dissection compared with traditional PET-CT, and yielded an incremental benefit of 0.14 QALYs with average cost savings of $1309. CONCLUSIONS Image-guided surveillance including PET-CT and CT are more cost effective than PRND. The novel PET-CT approach with repeat PET for equivocal responders was the dominant strategy and yielded both higher benefit and lower costs compared with standard PET-CT surveillance.
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Affiliation(s)
- Terence S Fu
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Scheffler
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David Forner
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Christopher W Noel
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Shao Hui Huang
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Radiation Oncology, Princess Margaret Cancer Centre-University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ralph W Gilbert
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David P Goldstein
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Brian O'Sullivan
- Department of Radiation Oncology, Princess Margaret Cancer Centre-University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Hisham M Mehanna
- Institute of Head and Neck Studies and Education, University of Birmingham, Birmingham, United Kingdom
| | - John Waldron
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Radiation Oncology, Princess Margaret Cancer Centre-University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - John R de Almeida
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
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Chatfield-Reed K, Roche VP, Pan Q. cfDNA detection for HPV+ squamous cell carcinomas. Oral Oncol 2021; 115:104958. [PMID: 33582486 PMCID: PMC8331111 DOI: 10.1016/j.oraloncology.2020.104958] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 12/13/2022]
Abstract
High-risk human papillomavirus (HPV) is an etiologic factor in a spectrum of squamous cell carcinomas including anal, cervical, and oropharyngeal. HPV cell free DNA (cfDNA) is shed from the primary tumor into systemic circulation and can be detected using several platforms including quantitative PCR, digital droplet PCR, or next generation sequencing. Levels of HPV cfDNA at time of initial presentation is associated with known poor prognostic clinicopathologic variables, such as advanced stage and, locoregional and distant metastases. Moreover, longitudinal sampling revealed that persistent or increasing HPV cfDNA levels are indicative of treatment relapse and, in some studies, HPV cfDNA detection predicted treatment failures prior to routine post-treatment clinical imaging. A liquid biopsy platform using HPV cfDNA offers unique advantages over traditional approaches and may have clinical utility for detection of minimum residual disease, treatment response, and disease progression in patients with HPV+ cancers.
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Affiliation(s)
- Kate Chatfield-Reed
- University Hospitals Seidman Cancer Center, Cleveland, OH 44106, United States; Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, United States
| | - Veronique P Roche
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, United States; Case Comprehensive Cancer Center, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, United States
| | - Quintin Pan
- University Hospitals Seidman Cancer Center, Cleveland, OH 44106, United States; Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, United States; Case Comprehensive Cancer Center, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, United States.
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8
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Wong ET, Huang SH, O'Sullivan B, Persaud V, Su J, Waldron J, Goldstein DP, de Almeida J, Ringash J, Kim J, Hope A, Bratman S, Cho J, Giuliani M, Hosni A, Spreafico A, Hansen A, Tong L, Xu W, Yu E. Head and neck imaging surveillance strategy for HPV-positive oropharyngeal carcinoma following definitive (chemo)radiotherapy. Radiother Oncol 2021; 157:255-262. [PMID: 33600871 DOI: 10.1016/j.radonc.2021.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/01/2021] [Accepted: 02/01/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE To describe the utilization pattern of head and neck (HN) surveillance imaging and explore the optimal strategy for radiologic "residual" lymph node (LN) surveillance following definitive (chemo)radiotherapy (RT/CRT) in human papillomavirus (HPV)+ oropharyngeal carcinoma (OPC). METHODS All HPV+ OPC patients who completed RT/CRT from 2012 to 2015 were included. Schedule and rationale for post-treatment HN-CT/MRI were recorded. Imaging findings and oncologic outcomes were evaluated. RESULTS A total of 1036 scans in 412 patients were reviewed: 414 scans for first post-treatment response assessment and 622 scans for the following reasons: follow-up of radiologic "residual" LN(s) (293 scans/175 patients); local symptoms (227/146); other (17/16); unknown (85/66). Rate of scans with "unstated" reason varied significantly among clinicians (3-28%, p < 0.001) and none of them yielded any positive imaging findings. First post-treatment scans identified 192 (47%) patients with radiologic "residual" LNs. Neck dissection (ND) was performed in 28 patients: 16 immediately (6/16 positive), 10 after one follow-up scan (2/10 positive), and 2 after 2nd follow-up scan (1/2 positive). Thirty patients had >2 consecutive follow-up scans at 2-3-month intervals, and none showed subsequent imaging progression or regional failure. CONCLUSIONS Pattern of HN imaging utilization for surveillance varied significantly among clinicians. Imaging surveillance reduces the need for ND. However, routine HN-CT/MR surveillance without clinical symptoms/signs does not demonstrate proven value in identifying locoregional failure or toxicity. Radiologic "residual" LNs without adverse features are common. If two subsequent follow-up scans demonstrate stable/regressing radiologic "residual" LNs, clinical surveillance without further imaging appears to be safe in this population.
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Affiliation(s)
- Erin T Wong
- Department of Medical Imaging, University of Toronto, Canada
| | - Shao Hui Huang
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada; Department of Otolaryngology - Head and Neck Surgery, University Health Network, University of Toronto, Canada.
| | - Brian O'Sullivan
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada; Department of Otolaryngology - Head and Neck Surgery, University Health Network, University of Toronto, Canada
| | - Vincent Persaud
- Department of Medical Imaging, University of Toronto, Canada
| | - Jie Su
- Biostatistics Division, University of Toronto, Canada
| | - John Waldron
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada; Department of Otolaryngology - Head and Neck Surgery, University Health Network, University of Toronto, Canada
| | - David P Goldstein
- Department of Otolaryngology - Head and Neck Surgery, University Health Network, University of Toronto, Canada
| | - John de Almeida
- Department of Otolaryngology - Head and Neck Surgery, University Health Network, University of Toronto, Canada
| | - Jolie Ringash
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada; Department of Otolaryngology - Head and Neck Surgery, University Health Network, University of Toronto, Canada
| | - John Kim
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Andrew Hope
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Scott Bratman
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada
| | - John Cho
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Meredith Giuliani
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Ali Hosni
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Anna Spreafico
- Division of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Aaron Hansen
- Division of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Li Tong
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada; Department of Otolaryngology - Head and Neck Surgery, University Health Network, University of Toronto, Canada
| | - Wei Xu
- Biostatistics Division, University of Toronto, Canada
| | - Eugene Yu
- Department of Medical Imaging, University of Toronto, Canada; Department of Medical Imaging, Princess Margaret Cancer Centre, University of Toronto, Canada
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Wotman M, Ghaly M, Massaro L, Tham T, Seetharamu N, Kamdar D, Frank D, Kraus D, Teckie S. Improving post-CRT neck assessment in patients with HPV-associated OPSCC (Review). Mol Clin Oncol 2020; 13:24. [PMID: 32765872 DOI: 10.3892/mco.2020.2094] [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: 12/14/2019] [Accepted: 04/10/2020] [Indexed: 11/05/2022] Open
Abstract
The positive predictive value (PPV) of 12-week post-therapy FDG-PET/CT is low in patients with Human Papillomavirus (HPV)-associated Oropharyngeal Squamous Cell Carcinoma (OPSCC) after treatment with definitive chemoradiation (CRT). Moreover, the diagnostic performance of post-CRT fine needle aspiration (FNA) in detecting persistent disease is unknown in this population. Given these important shortcomings in post-CRT treatment assessment, head and neck oncologists are limited in appropriately selecting patients for consolidative neck dissection, which results in over-treatment of a favorable risk population. Using the PubMed database, we performed a literature review of published series in HPV-associated OPSCC to investigate potential strategies for improvement of post-CRT neck assessment. Several different approaches were found, including continued surveillance with PET/CT, delayed timing of restaging PET/CT, initial response evaluation with multimodality or alternative imaging, and detection of circulating HPV DNA. At present, the optimal approach to post-CRT treatment assessment is unclear; further investigation and incorporation of new technologies and surveillance protocols will be highly beneficial for patients with HPV-associated OPSCC.
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Affiliation(s)
- Michael Wotman
- Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY 11549, USA
| | - Maged Ghaly
- Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY 11549, USA
| | - Luke Massaro
- Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY 11549, USA
| | - Tristan Tham
- Department of Otolaryngology-Head and Neck Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY 11549, USA
| | - Nagashree Seetharamu
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY 11549, USA
| | - Dev Kamdar
- Department of Otolaryngology-Head and Neck Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY 11549, USA
| | - Douglas Frank
- Department of Otolaryngology-Head and Neck Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY 11549, USA
| | - Dennis Kraus
- Department of Otolaryngology-Head and Neck Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY 11549, USA
| | - Sewit Teckie
- Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY 11549, USA
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10
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Sivarajah S, Isaac A, Cooper T, Zhang H, Puttagunta L, Abele J, Biron V, Harris J, Seikaly H, O' Connell DA. Association of Fludeoxyglucose F 18-Labeled Positron Emission Tomography and Computed Tomography With the Detection of Oropharyngeal Cancer Recurrence. JAMA Otolaryngol Head Neck Surg 2019; 144:1037-1043. [PMID: 30242338 DOI: 10.1001/jamaoto.2018.2143] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Importance No guidelines at present describe when fludeoxyglucose F 18-labeled positron emission tomography and computed tomography (FDG PET-CT) should be used in the initial posttreatment period for evaluation of oropharyngeal squamous cell carcinoma treatment outcome and recurrence. Objective To compare accuracies of the initial posttreatment PET-CT between primary treatment groups and to define indicators of false-positive findings. Design, Setting, and Participants This retrospective cohort study identified adults with a new diagnosis of oropharyngeal squamous cell carcinoma who received treatment with curative intent from October 1, 2006, through November 30, 2016, using the Alberta Cancer Registry (n = 380). Patients who underwent PET-CT within 1 year of treatment completion were included (n = 190). Of these, 103 patients (54.2%) had PET-CT findings positive for residual or recurrent disease, and 61 (32.1%) had false-positive findings. Among the 61 patients, 42 (68.9%) had received chemoradiotherapy (CRT) and 19 (31.1%) had primary surgery. Forty-two patients had true-positive findings, indicating a prevalence rate of disease of 22.1%. Data were analyzed from July through October 2017. Exposures One of 2 primary treatment modalities (surgery with or without adjuvant therapy vs CRT). All patients had posttreatment FDG PET-CT. Main Outcomes and Measures Primary outcome measures included the diagnostic odds ratio, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PET-CT for detecting residual and/or recurrent disease. A multivariate analysis determined indicators of false-positive findings. Discriminative ability was assessed using receiver operating characteristic curve analysis of maximum standardized uptake value (SUVmax) metabolic data. Results Of the 190 participants, 77.9% were men, with a mean (SD) age at diagnosis of 58.5 (8.5) years. The diagnostic odds ratio was 19.3 (95% CI, 5.7-65.1); pooled sensitivity, 93.3% (95% CI, 80.7%-98.3%); and pooled specificity, 57.9% (95% CI, 49.4%-66.0%). The PPV of detecting disease was 54.7% (95% CI, 38.8%-69.8%) for primary surgery and 31.1% (95% CI, 20.2%-44.4%) for CRT. The NPV was 100% (95% CI, 94.7%-100%) for primary surgery and 96.6% (95% CI, 89.5%-99.1%) for CRT. Multivariate analysis identified treatment type, p16 disease, and smoking status as indicative of false-positive findings. In the receiver operating characteristic curve analysis for primary tumors, the optimal cutoff SUVmax for indicating true- vs false-positive results was 5.1 for surgically treated patients (area under the curve, 0.729; 95% CI, 0.570-0.888) and 5.3 for patients treated with CRT (area under the curve, 0.844; 95% CI, 0.700-0.989). Conclusions and Relevance The results indicate a higher specificity for FDG PET-CT for initial posttreatment surveillance imaging among patients treated with primary surgery compared with nonsurgical management. Both sets of patients with posttreatment FDG PET-CT findings with an SUVmax greater than 5.0 should undergo close evaluation for possible residual or recurrent disease.
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Affiliation(s)
| | - Andre Isaac
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Tim Cooper
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Han Zhang
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada.,Division of Otolaryngology-Head and Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Lakshmi Puttagunta
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Jonathan Abele
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada.,Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Vincent Biron
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada.,Otolaryngology-Head and Neck Research Laboratory of Alberta, University of Alberta, Edmonton, Alberta, Canada
| | - Jeffery Harris
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Hadi Seikaly
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel A O' Connell
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada
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11
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De Felice F, Tombolini V. [ 18F]PARPi-PET in locally advanced oral cavity carcinoma. Oral Oncol 2019; 98:160. [PMID: 31548129 DOI: 10.1016/j.oraloncology.2019.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 09/16/2019] [Accepted: 09/17/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Francesca De Felice
- Department of Radiotherapy, Policlinico Umberto I "Sapienza" University of Rome, Viale Regina Elena 326, 00161 Rome, Italy.
| | - Vincenzo Tombolini
- Department of Radiotherapy, Policlinico Umberto I "Sapienza" University of Rome, Viale Regina Elena 326, 00161 Rome, Italy
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12
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Wotman M, Ghaly M, Massaro L, Tham T, Seetharamu N, Kamdar D, Frank D, Kraus D, Teckie S. Management of the neck after definitive chemoradiation in patients with HPV-associated oropharyngeal cancer: An institutional experience. Am J Otolaryngol 2019; 40:684-690. [PMID: 31229365 DOI: 10.1016/j.amjoto.2019.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 06/12/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE To investigate the multidisciplinary management of patients with Human Papilloma Virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) and an incomplete nodal response on restaging PET/CT after definitive chemoradiation (CRT). MATERIALS AND METHODS A retrospective chart review was performed of patients diagnosed with node-positive HPV-associated OPSCC from 2012 to 2017, who underwent definitive upfront CRT, and had an incomplete response on post-therapy PET/CT according to NCCN criteria. Post-CRT PET/CT results, management decisions, and clinical outcomes were recorded. RESULTS Seventy-four patients with node-positive HPV-associated OPSCC were identified; 20 patients with incomplete neck response on PET/CT according to NCCN criteria were included in the final case series. Median follow-up time was 33 months. Patients were managed as follows: 8 underwent observation and surveillance imaging, 6 underwent ultrasound-guided fine needle aspiration (FNA), and 6 had immediate neck dissection. All the observed patients were disease-free at most recent follow-up. None of the patients who underwent immediate neck dissection had residual neck disease on pathological examination; two patients in this group ultimately developed metastatic disease. Among the 6 who underwent FNA, 1 individual had positive pathology, along with residual primary disease, for which the patient underwent salvage surgery. The 5 remaining individuals had negative FNA results, were subsequently observed, and remained free of disease. CONCLUSIONS This institutional experience supports the notion of a high threshold for neck dissection in this low-risk population; only 1 of 20 patients with suspicious PET/CT findings had residual disease in the neck. Moreover, these patients should be managed by a multidisciplinary tumor board (MTB) since current algorithms do not universally include HPV status. Finally, the use of restaging PET/CT to guide management of the neck can be improved with changes in terminology and consideration of FDG-avidity at the primary site and on pre-therapy scans.
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Affiliation(s)
- Michael Wotman
- Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Maged Ghaly
- Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Luke Massaro
- Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Tristan Tham
- Department of Otolaryngology - Head and Neck Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Nagashree Seetharamu
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Dev Kamdar
- Department of Otolaryngology - Head and Neck Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Douglas Frank
- Department of Otolaryngology - Head and Neck Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Dennis Kraus
- Department of Otolaryngology - Head and Neck Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Sewit Teckie
- Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA.
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13
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Prestwich RJD, Arunsingh M, Zhong J, Dyker KE, Vaidyanathan S, Scarsbrook AF. Second-look PET-CT following an initial incomplete PET-CT response to (chemo)radiotherapy for head and neck squamous cell carcinoma. Eur Radiol 2019; 30:1212-1220. [PMID: 31485835 DOI: 10.1007/s00330-019-06401-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 07/03/2019] [Accepted: 07/26/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The limited positive predictive value of an incomplete response on PET-CT following (chemo)radiotherapy for head and neck squamous cell carcinoma (HNSCC) means that the optimal management strategy remains uncertain. The aim of the study is to assess the utility of a 'second-look' interval PET-CT. METHODS Patients with HNSCC who were treated with (chemo)radiotherapy between 2008 and 2017 and underwent (i) baseline and (ii) response assessment PET-CT and (iii) second-look PET-CT following incomplete (positive or equivocal scan) response were included. Endpoints were conversion rate to complete response (CR) and test characteristics of the second-look PET-CT. RESULTS Five hundred sixty-two patients with HNSCC underwent response assessment PET-CT at a median of 17 weeks post-radiotherapy. Following an incomplete response on PET-CT, 40 patients underwent a second-look PET-CT at a median of 13 weeks (range 6-25) from the first response PET-CT. Thirty-four out of 40 (85%) patients had oropharyngeal carcinoma. Twenty-four out of 40 (60%) second-look PET-CT scans converted to a complete locoregional response. The primary tumour conversion rate was 15/27 (56%) and the lymph node conversion rate was 14/19 (74%). The sensitivity, specificity, positive predictive value and negative predictive value (NPV) of the second-look PET-CT were 75%, 75%, 25% and 96% for the primary tumour and 100%, 92%, 40% and 100% for lymph nodes. There were no cases of progression following conversion to CR in the primary site or lymph nodes. CONCLUSIONS The majority of patients who undergo a second-look PET-CT convert to a CR. The NPV of a second-look PET-CT is high, suggesting the potential to avoid surgical intervention. KEY POINTS • PET-CT is a useful tool for response assessment following (chemo)radiotherapy for head and neck squamous cell carcinoma. • An incomplete response on PET-CT has a limited positive predictive value and optimal management is uncertain. • These data show that with a 'second-look' interval PET-CT, the majority of patients convert to a complete metabolic response. When there is doubt about clinical and radiological response, a 'second-look' PET-CT can be used to spare patients unnecessary surgical intervention.
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Affiliation(s)
- Robin J D Prestwich
- Department of Clinical Oncology, Leeds Cancer Centre, Leeds, LS9 7TF, UK. .,Level 4, Leeds Cancer Centre, St. James's University Hospital, Beckett St., Leeds, LS9 7TF, UK.
| | - Moses Arunsingh
- Department of Clinical Oncology, Leeds Cancer Centre, Leeds, LS9 7TF, UK
| | - Jim Zhong
- Department of Nuclear Medicine and Radiology, Leeds Cancer Centre, Leeds, UK
| | - Karen E Dyker
- Department of Clinical Oncology, Leeds Cancer Centre, Leeds, LS9 7TF, UK
| | - Sriram Vaidyanathan
- Department of Nuclear Medicine and Radiology, Leeds Cancer Centre, Leeds, UK
| | - Andrew F Scarsbrook
- Department of Nuclear Medicine and Radiology, Leeds Cancer Centre, Leeds, UK.,Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
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14
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Wang K, Moon DH, Amdur RJ, Dagan R, Sheets NC, Shen CJ, Green R, Patel SN, Zanation AM, Thorp BD, Hackman TG, Weissler MC, Mendenhall WM, Chera BS. Shoulder symptoms and quality of life impact of limited neck dissection after de‐intensified chemoradiotherapy: Secondary analysis of two prospective trials. Head Neck 2018; 41:1213-1219. [DOI: 10.1002/hed.25535] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 08/07/2018] [Accepted: 10/06/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kyle Wang
- Department of Radiation OncologyUniversity of North Carolina Hospitals Chapel Hill North Carolina
| | - Dominic H. Moon
- Department of Radiation OncologyUniversity of North Carolina Hospitals Chapel Hill North Carolina
| | - Robert J. Amdur
- Department of Radiation OncologyUniversity of Florida Hospitals Gainesville Florida
| | - Roi Dagan
- Department of Radiation OncologyUniversity of Florida Hospitals Gainesville Florida
| | - Nathan C. Sheets
- Department of Radiation OncologyUniversity of North Carolina Hospitals Chapel Hill North Carolina
| | - Colette J. Shen
- Department of Radiation OncologyUniversity of North Carolina Hospitals Chapel Hill North Carolina
| | - Rebecca Green
- Department of Radiation OncologyUniversity of North Carolina Hospitals Chapel Hill North Carolina
| | - Samip N. Patel
- Department of Otolaryngology, Division of Head and Neck SurgeryUniversity of North Carolina Hospitals Chapel Hill North Carolina
| | - Adam M. Zanation
- Department of Otolaryngology, Division of Head and Neck SurgeryUniversity of North Carolina Hospitals Chapel Hill North Carolina
| | - Brian D. Thorp
- Department of Otolaryngology, Division of Head and Neck SurgeryUniversity of North Carolina Hospitals Chapel Hill North Carolina
| | - Trevor G. Hackman
- Department of Otolaryngology, Division of Head and Neck SurgeryUniversity of North Carolina Hospitals Chapel Hill North Carolina
| | - Mark C. Weissler
- Department of Otolaryngology, Division of Head and Neck SurgeryUniversity of North Carolina Hospitals Chapel Hill North Carolina
| | | | - Bhishamjit S. Chera
- Department of Radiation OncologyUniversity of North Carolina Hospitals Chapel Hill North Carolina
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15
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Corpman DW, Masroor F, Carpenter DM, Nayak S, Gurushanthaiah D, Wang KH. Posttreatment surveillance PET/CT for HPV-associated oropharyngeal cancer. Head Neck 2018; 41:456-462. [PMID: 30549345 DOI: 10.1002/hed.25425] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 08/26/2018] [Accepted: 09/14/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Surveillance positron emission tomography-computed tomography (PET/CT) is commonly used for treatment assessment of radiation therapy in head and neck cancer. However, human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+OPSCC) patients represent a unique subpopulation, for which the utility of surveillance PET/CT has not been well studied. METHODS In this retrospective chart review comprising 233 HPV+OPSCC patients, we evaluated surveillance PET/CT for diagnostic accuracy, downstream clinical impact, and survival. RESULTS Surveillance PET/CT demonstrated 100% negative predictive value and sensitivity, 59.9% specificity, and 13.4% positive predictive value. Surveillance PET/CT led to 90 imaging studies and 31 biopsies; 91.1% and 77.4% were negative for recurrence, respectively. Surveillance PET/CT led to meaningful salvage therapy in 1.6% of cases. PET/CT-detected recurrences did not have improved survival compared to clinically detected recurrences. CONCLUSION For HPV+OPSCC patients, surveillance PET/CTs frequently lead to unnecessary testing and rarely to meaningful disease salvage. They have no demonstrated survival benefit and should be interpreted cautiously to prevent patient harm.
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Affiliation(s)
- David W Corpman
- Department of Head and Neck Surgery, Kaiser Permanente Oakland Medical Center, Oakland, California.,University of California, San Francisco School of Medicine, San Francisco, California
| | - Farzad Masroor
- Department of Head and Neck Surgery, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Diane M Carpenter
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Sundeep Nayak
- Department of Radiology, Kaiser Permanente San Leandro Medical Center, San Leandro, California
| | - Deepak Gurushanthaiah
- Department of Head and Neck Surgery, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Kevin H Wang
- Department of Head and Neck Surgery, Kaiser Permanente Oakland Medical Center, Oakland, California
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16
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Cristaudo A, Hickman M, Fong C, Sanghera P, Hartley A. Assessing Novel Drugs and Radiation Technology in the Chemoradiation of Oropharyngeal Cancer. MEDICINES (BASEL, SWITZERLAND) 2018; 5:E65. [PMID: 29954154 PMCID: PMC6163293 DOI: 10.3390/medicines5030065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 06/21/2018] [Accepted: 06/25/2018] [Indexed: 01/21/2023]
Abstract
Integrating immunotherapy, proton therapy and biological dose escalation into the definitive chemoradiation of oropharyngeal cancer poses several challenges. Reliable and reproducible data must be obtained in a timely fashion. However, despite recent international radiotherapy contouring guidelines, controversy persists as to the applicability of such guidelines to all cases. Similarly, a lack of consensus exists concerning both the definition of the organ at risk for oral mucositis and the most appropriate endpoint to measure for this critical toxicity. Finally, the correlation between early markers of efficacy such as complete response on PET CT following treatment and subsequent survival needs elucidation for biological subsets of oropharyngeal cancer.
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Affiliation(s)
- Agostino Cristaudo
- Department of Radiation Oncology, University of Pisa, 56100 Pisa PI, Italy.
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
| | - Mitchell Hickman
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
| | - Charles Fong
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
| | - Paul Sanghera
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
| | - Andrew Hartley
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
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