Volumetric staging (VS) is superior to TNM and AJCC staging in predicting outcome of head and neck cancer treated with IMRT

Surgery enhances the effectiveness of peptide receptor radionuclide therapy in metastatic gastroenteropancreatic neuroendocrine tumors

BACKGROUND

With the advent of peptide receptor radionuclide therapy, the timing and sequence of surgery in the treatment of metastatic gastroenteropancreatic neuroendocrine tumors merits further study. We hypothesized that surgery before peptide receptor radionuclide therapy might enhance its effectiveness in patients with metastatic gastroenteropancreatic neuroendocrine tumors.

METHODS

Eighty-nine patients with metastatic well-differentiated gastroenteropancreatic neuroendocrine tumors treated with 177Lutetium-dotatate peptide receptor radionuclide therapy between 2018 and 2023 were included. Fifty-six patients underwent surgery (primary tumor resection and/or liver debulking) before peptide receptor radionuclide therapy and 33 patients did not. Primary outcome was progression-free survival according to Response Evaluation Criteria in Solid Tumors. Pretreatment dotatate positron emission tomography/computed tomography was used to calculate tumor volumes.

RESULTS

The surgery and no-surgery groups were well-matched. Median progression-free survival after peptide receptor radionuclide therapy was 15.6 months (interquartile range, 9.1-22.7 months) in the no-surgery group compared with 26.1 months (interquartile range, 12.7-38.1 months) in the surgery group (P = .04). On subgroup analysis, median progression-free survival was 18.1 months (interquartile range, 11.9-38.4 months) in patients who underwent primary tumor resection only compared with 26.2 months (interquartile range, 14.0-38.1 months) in patients who underwent liver debulking (P = .04). Tumor volume was lowest in patients who underwent liver debulking (median 146.07 mL3) compared with no surgery (median 626.42 mL3) (P = .001). On univariable analysis, a tumor volume <138.8 mL3 was associated with longer progression-free survival (hazard ratio, 2.03; 95% confidence interval, 0.95-4.34, P = .05), with a median progression-free survival of 38.1 months (interquartile range, 16.9-41.3 months) compared with 17.8 months (interquartile range, 10.8-28.7 months).

CONCLUSION

Surgery may enhance the effectiveness of 177Lutetium-dotatate in the treatment of metastatic well-differentiated gastroenteropancreatic neuroendocrine tumors. This positive effect may be the result of a lower tumor volume in patients after surgery. Our findings fortify the concept of using surgical debulking to improve systemic therapies such as peptide receptor radionuclide therapy.

Establishment of head and neck squamous cell carcinoma mouse models for cetuximab resistance and sensitivity

Aim: Acquired resistance to the targeted agent cetuximab poses a significant challenge in finding effective anti-cancer treatments for head and neck squamous cell carcinoma (HNSCC). To accurately study novel combination treatments, suitable preclinical mouse models for cetuximab resistance are key yet currently limited. This study aimed to optimize an acquired cetuximab-resistant mouse model, with preservation of the innate immunity, ensuring intact antibody-dependent cellular cytotoxicity (ADCC) functionality. Methods: Cetuximab-sensitive and acquired-resistant HNSCC cell lines, generated in vitro, were subcutaneously engrafted in Rag2 knock-out (KO), BALB/c Nude and CB17 Scid mice with/without Matrigel or Geltrex. Once tumor growth was established, mice were intraperitoneally injected twice a week with cetuximab for a maximum of 3 weeks. In addition, immunohistochemistry was used to evaluate the tumor and its microenvironment. Results: Despite several adjustments in cell number, cell lines and the addition of Matrigel, Rag2 KO and BALB/C Nude mice proved to be unsuitable for xenografting our HNSCC cell lines. Durable tumor growth of resistant SC263-R cells could be induced in CB17 Scid mice. However, these cells had lost their resistance phenotype in vivo. Immunohistochemistry revealed a high infiltration of macrophages in cetuximab-treated SC263-R tumors. FaDu-S and FaDu-R cells successfully engrafted into CB17 Scid mice and maintained their sensitivity/resistance to cetuximab. Conclusion: We have established in vivo HNSCC mouse models with intact ADCC functionality for cetuximab resistance and sensitivity using the FaDu-R and FaDu-S cell lines, respectively. These models serve as valuable tools for investigating cetuximab resistance mechanisms and exploring novel drug combination strategies.

Tumor Volume Staging Provides a Comparable Stratifying for Laryngeal Squamous Cell Cancer According to T Stages

The prognostic significance of tumor volume (TV) in laryngeal squamous cell cancer (LSCC) has been demonstrated previously. Still, its clinical use is uncertain, and a method for accurate staging for TV is lacking. This study aimed to develop an objective staging and determine the effect of tumor volume on disease outcome after surgical treatment for LSCC. This study was designed retrospectively. Patients with LSCC who underwent laryngectomy were identified. Discretization for optimal scaling level of Tumor Volume (TV) was performed by Catreg Version 3.0. The rate of cancer recurrence, disease-free survival (DFS), and overall survival (OS) rate were calculated and compared between T stage and TV staging. Kaplan-Meier survival analysis was performed for comparison. 206 LSCC patients enrolled in the study. TV was found significantly higher in patients with cartilage invasion, contralateral nodal metastasis, and extranodal extension (p = 0.004, 0.010, and 0.021, respectively). TV and lymph node density LND showed a low significant positive correlation (p = 0.015, r = 0.169). TV was 7.25 + 7.53 ml on average, and TV above the mean value was found to be an independent risk factor for OS and DFS (p = 0.043, HR = 1.8; CI95% for HR: 1.02-3.44 and p < 0.001, HR = 3.7; CI95% for HR: 1.8-7.3, respectively). The optimal scaling level of TV was found in three-level; group 1: TV ≤ 7.07, group 2: 7.07 < TV ≤ 14.09, and group 3: TV ≥ 14.10. This categorization of TV has obtained significant discretization between patients for DFS and OS (Long-Rank = 0.038 and < 0.001). This classification may provide better performance in addition to helping the T stage in determining prognosis, especially in patients with advanced laryngeal SCC.

The influence of tumor volume on the risk of distant metastases in head and neck squamous cell carcinomas

BACKGROUND AND PURPOSE

Distant metastases (DM) in head and neck squamous cell carcinomas (HNSCC) are in most circumstances non-curable. The TNM staging system is insufficient to predict the risk of DM. This study investigates if the DM risk can be predicted using a multivariate model including pre-treatment total tumor volume for both p16-positive oropharyngeal squamous cell carcinoma (OPSCC) and all other sites (other HNSCC).

MATERIALS AND METHODS

The study includes patients with localized pharyngeal and laryngeal squamous cell carcinomas treated with primary radiotherapy from 2008-2017 from three head and neck cancer centers. Patients were identified in the Danish Head and Neck Cancer (DAHANCA) database. Total (nodal and primary) tumor volume (Gross Tumor Volume, GTV) was extracted from local treatment planning systems. The GTV was grouped by volume (cm3) in four intervals and included in a multivariate Cox proportional hazard regression controlled for pre-selected clinical values incl. stage.

RESULTS

The study includes 2,865 patients, of which 321 (11 %) had DM post-treatment. The risk of DM was assessed in a multivariate model based on 2,751 patients (p16-positive OPSCC: 1,032; and other HNSCC: 1,719). There was a significant association between GTV and the risk of DM, and in tumor volumes ≥ 50 cm3 hazard ratios of 7.6 (2.5-23.4) for p16-positive OPSCC and 4.1 (2.3-7.2) in other HNSCC were observed.

CONCLUSION

Tumor volume is an independent risk factor for DM. The addition of total tumor volume to a predictive model is important to identify subgroups of HNSCC patients at high risk of DM.

Prognosticating Gross Tumor Volume in Head-and-Neck Cancer - Redefining Gross Tumor Volume Beyond Contouring

Purpose

Precision radiotherapy (RT) requires accurate delineation of gross tumor volumes (GTVs) for targeted dose delivery. Volumetric measurement of this GTV can predict the treatment outcomes. This volume has been limited for mere contouring and its potential as the prognostic factor is less explored.

Materials and Methods

The data of 150 patients with oropharynx, hypopharynx, and larynx cancer undergoing curative intensity-modulated RT and weekly cisplatin between April 2015 and December 2019 were retrospectively evaluated. GTV-P (primary), GTV-N (nodal), and GTV-P+N were defined, and volumetric parameters were generated. Volume thresholds were defined as per the receiver operating characteristics, and the prognostic value of these tumor volumes (TVs) with respect to treatment outcomes was analyzed.

Results

All patients completed 70 Gy, median chemotherapy cycles were six. Mean GTV-P, GTV-N, and GTV-P+N were 44.5 cc, 13.4 cc, and 57.9 cc, respectively. Oropharynx constituted 45% of cases. Forty-nine percent had Stage III disease. Sixty-six percent had complete response (CR). As per the defined cutoff values, GTV-P <30cc, GTV-N <4 cc, and GTV-P+N <50 cc had better CR rates with P < 0.05 (82.6% vs. 51.9%; 74% vs. 58.4% and 81.5% vs. 47.8%, respectively). At median follow-up of 21.4 months, overall survival (OS) was 60% and median OS was 32.3 months. The median OS in patients with GTV-P <30 cc, GTV-N <4 cc, and GTV-P+N <50 cc was better with P < 0.05 (59.2 vs. 21.4; 59.2 vs. 22.2, and 59.2 vs. 19.8 months, respectively).

Conclusion

GTV should not just be limited for contouring but its role as an important prognostic factor has to be recognized.

Tumour volume and radiotherapy prolongation in locally advanced head and neck cancer patients treated with radical IMRT

AIMS

The relationship of tumour volume, radiotherapy treatment time and other prognostic factors affecting prognosis was evaluated.

METHODS

184 patients with locally advanced head and neck cancer were treated with radical intensity modulated radiotherapy (IMRT) and compared retrospectively.

RESULTS

In the multivariate analysis the overall survival was dependent on gross tumour volume (GTV), clinical stage (CS), radiotherapy treatment time (RTT) and p16 status. Local control was influenced by GTV, overall RTT and age. DFS was significantly affected by GTV, CS, RTT, p16 status and concomitant chemotherapy (CHT).

CONCLUSIONS

The tumour volume and the radiotherapy treatment time were the most significant prognostic factors with the best outcomes in patients with GTV ≤ 55 cc and RTT ≤ 48 days (mean LC 8.1, DFS 7.1 and OS 6.4 years) and worst outcomes with GTV > 55 cc and RTT >48 days (mean LC 4.4, mean DFS 3.2 and mean OS 2.6 years).

Tumor Cell Extrinsic Synaptogyrin 3 Expression as a Diagnostic and Prognostic Biomarker in Head and Neck Cancer

Over 70% of oropharyngeal head and neck squamous cell carcinoma (HNSC) cases in the United States are positive for human papillomavirus (HPV) yet biomarkers for stratifying oropharyngeal head and neck squamous cell carcinoma (HNSC) patient risk are limited. We used immunogenomics to identify differentially expressed genes in immune cells of HPV(+) and HPV(-) squamous carcinomas. Candidate genes were tested in clinical specimens using both quantitative RT-PCR and IHC and validated by IHC using the Carolina Head and Neck Cancer Study (CHANCE) tissue microarray of HNSC cases. We performed multiplex immunofluorescent staining to confirm expression within the immune cells of HPV(+) tumors, receiver operating characteristic (ROC) curve analyses, and assessed survival outcomes. The neuronal gene Synaptogyrin-3 (SYNGR3) is robustly expressed in immune cells of HPV(+) squamous cancers. Multiplex immunostaining and single cell RNA-seq analyses confirmed SYNGR3 expression in T cells, but also unexpectedly in B cells of HPV(+) tumors. ROC curve analyses revealed that combining SYNGR3 and p16 provides more sensitivity and specificity for HPV detection compared to p16 IHC alone. SYNGR3-high HNSC patients have significantly better prognosis with five-year OS and DSS rates of 60% and 71%, respectively. Moreover, combining p16 localization and SYNGR3 expression can further risk stratify HPV(+) patients such that high cytoplasmic, low nuclear p16 do significantly worse (Hazard Ratio, 8.6; P = 0.032) compared to patients with high cytoplasmic, high nuclear p16. SYNGR3 expression in T and B cells is associated with HPV status and enhanced survival outcomes of HNSC patients.

Primary tumor volume and prognosis for patients with p16-positive and p16-negative oropharyngeal squamous cell carcinoma treated with radiation therapy

BACKGROUND

The prescribed radiation dose to patients with oropharyngeal squamous cell carcinoma (OPSCC) is standardized, even if the prognosis for individual patients may differ. Easy-at-hand pre-treatment risk stratification methods are valuable to individualize therapy. In the current study we assessed the prognostic impact of primary tumor volume for p16-positive and p16-negative tumors and in relationship to other prognostic factors for outcome in patients with OPSCC treated with primary radiation therapy (RT).

METHODS

Five hundred twenty-three OPSCC patients with p16-status treated with primary RT (68.0 Gy to 73.1 Gy in 7 weeks, or 68.0 Gy in 4.5 weeks), with or without concurrent chemotherapy, within three prospective trials were included in the study. Local failure (LF), progression free survival (PFS) and overall survival (OS) in relationship to the size of the primary gross tumor volume (GTV-T) and other prognostic factors were investigated. Efficiency of intensified RT (RT with total dose 73.1 Gy or given within 4.5 weeks) was analyzed in relationship to tumor volume.

RESULTS

The volume of GTV-T and p16-status were found to be the strongest prognostic markers for LF, PFS and OS. For p16-positive tumors, an increase in tumor volume had a significantly higher negative prognostic impact compared with p16-negative tumors. Within a T-classification, patients with a smaller tumor, compared with a larger tumor, had a better prognosis. The importance of tumor volume remained after adjusting for nodal status, age, performance status, smoking status, sex, and hemoglobin-level. The adjusted hazard ratio for OS per cm3 increase in tumor volume was 2.3% (95% CI 0-4.9) for p16-positive and 1.3% (95% 0.3-2.2) for p16-negative. Exploratory analyses suggested that intensified RT could mitigate the negative impact of a large tumor volume.

CONCLUSIONS

Outcome for patients with OPSCC treated with RT is largely determined by tumor volume, even when adjusting for other established prognostic factors. Tumor volume is significantly more influential for patients with p16-positive tumors. Patients with large tumor volumes might benefit by intensified RT to improve survival.

The COMPLETE trial: HolistiC early respOnse assessMent for oroPharyngeaL cancEr paTiEnts; Protocol for an observational study

INTRODUCTION

The locoregional failure (LRF) rate in human papilloma virus (HPV)-negative oropharyngeal squamous cell carcinoma (OPSCC) remains disappointingly high and toxicity is substantial. Response prediction prior to or early during treatment would provide opportunities for personalised treatment. Currently, there are no accurate predictive models available for correct OPSCC patient selection. Apparently, the pivotal driving forces that determine how a OPSCC responds to treatment, have yet to be elucidated. Therefore, the holistiC early respOnse assessMent for oroPharyngeaL cancer paTiEnts study focuses on a holistic approach to gain insight in novel potential prognostic biomarkers, acquired before and early during treatment, to predict response to treatment in HPV-negative patients with OPSCC.

METHODS AND ANALYSIS

This single-centre prospective observational study investigates 60 HPV-negative patients with OPSCC scheduled for primary radiotherapy (RT) with cisplatin or cetuximab, according to current clinical practice. A holistic approach will be used that aims to map the macroscopic (with Intra Voxel Incoherent Motion Diffusion Kurtosis Imaging (IVIM-DKI); before, during, and 3 months after RT), microscopic (with biopsies of the primary tumour acquired before treatment and irradiated ex vivo to assess radiosensitivity), and molecular landscape (with circulating tumour DNA (ctDNA) analysed before, during and 3 months after treatment). The main end point is locoregional control (LRC) 2 years after treatment. The primary objective is to determine whether a relative change in the mean of the diffusion coefficient D (an IVIM-DKI parameter) in the primary tumour early during treatment, improves the performance of a predictive model consisting of tumour volume only, for 2 years LRC after treatment. The secondary objectives investigate the potential of other IVIM-DKI parameters, ex vivo sensitivity characteristics, ctDNA, and combinations thereof as potential novel prognostic markers.

ETHICS AND DISSEMINATION

The study was approved by the Medical Ethical Committee of Erasmus Medical Center. The main results of the trial will be presented in international meetings and medical journals.

TRIAL REGISTRATION NUMBER

NL8458.

Does Tumor Volume Have a Prognostic Role in Oropharyngeal Squamous Cell Carcinoma? A Systematic Review and Meta-Analysis

The aim of this study was to assess the prognostic value of tumor volume in oropharyngeal squamous cell carcinoma (OPSCC). The study was performed according to the PRISMA guidelines. A total of 1417 patients with a median age of 59.3 years (IQR 57.5−60) were included. The combined Hazard Ratios (HRs) for overall survival (OS) were 1.02 (95% CI, 0.99−1.05; p = 0.21) for primary tumor volume (pTV) and 1.01 (95% CI, 1.00−1.02; p = 0.15) for nodal tumor volume (nTV). Regarding locoregional control (LRC), the pooled HRs were 1.07 (95% CI, 0.99−1.17; p = 0.10) for pTV and 1.02 (95% CI, 1.01−1.03; p < 0.05) for nTV. Finally, the pooled HRs for disease-free survival (DFS) were 1.01 (95% CI, 1.00−1.03; p < 0.05) for pTV and 1.02 (95% CI, 1.01−1.03; p < 0.05) for nTV. In conclusion, pTV and nTV seem not to behave as reliable prognostic factors in OPSCC.

Adding value to tumor staging in head and neck cancer: The role of metabolic parameters as prognostic factors

BACKGROUND

Validated biomarkers in head and neck squamous cell carcinoma (HNSCC) are scarce.

METHODS

We retrospectively analyzed 62 patients with HNSCC treated with radiotherapy +/- concurrent chemotherapy. Pretreatment metabolic tumor volume (MTV) and total lesion glycolysis (TLG) were measured in a ¹⁸ F-FDG positron emission tomography using a liver dependent standardized uptake value threshold. Cox regression analyses were performed to find associations with disease-free survival (DFS) and overall survival (OS).

RESULTS

High values of MTV (>37 ml) were independently associated with a worse DFS (hazard ratio [HR] = 3.45; 95% confidence interval [CI], 1.52-7.84) and OS (HR = 3.27; 95% CI, 1.41-7.57). Similar results were found for high values of TLG (>247 g) for DFS (HR = 3.32; 95% CI, 1.44-7.65) and OS (HR = 3.42; 95% CI, 1.45-8.07).

CONCLUSIONS

MTV and TLG can be considered as independent prognostic factors for DFS and OS in patients with HNSCC. Considering how easily obtainable they are, they may be useful for predicting clinical outcomes in these patients.

Prognostic value of pathological tumor size in patients with supraglottic carcinoma

BACKGROUND

The association between pathological tumor size and predictive value in patients with supraglottic carcinoma who receive surgery is poorly understood. To gain further insight into this association, the influence of postoperative tumor size assessed via pathological evaluation on survival outcomes in patients with supraglottic carcinoma was fully analyzed.

MATERIALS AND METHODS

This study collected data from 375 consecutive supraglottic carcinoma patients who underwent primary surgical treatment between 2005 and 2010. The parameters of tumor size, including tumor diameter, tumor area, and tumor volume, were used to analyze the prognostic abilities of overall survival (OS) and disease-free survival (DFS) in supraglottic carcinoma.

RESULTS

Twelve women and 363 men were included, with a mean age of 61.2 years. The 5-year OS and DFS rates were 65.4% and 56.2%, respectively. The mean tumor diameter, tumor area, and tumor volume of all patients was 3.1 cm, 8.6 cm², and 9.1 cm³, respectively. Tumors with higher pT stages had a larger tumor diameter, tumor area, and tumor volume. These three factors were significantly correlated with pT stage, and tumor volume was the strongest factor contributing to pT stage. Patients with a larger tumor diameter, tumor area, and tumor volume had worse OS and DFS. Tumor area and tumor volume were independent prognostic factors of OS and DFS in supraglottic carcinoma patients.

CONCLUSIONS

Patients with a larger tumor size have inferior survival outcomes, and tumor area and tumor volume are independent predictive parameters of survival in supraglottic carcinoma patients who are treated with primary surgery.

Implications of limited exolaryngeal disease and cricoarytenoid joint involvement in organ conservation protocols for laryngopharyngeal cancers: Results from a prospective study

BACKGROUND

To identify clinicoradiological factors that determine functional outcomes in laryngopharyngeal cancers treated with chemoradiotherapy.

METHODS

One hundred patients of locally advanced laryngopharyngeal cancers who were treated with chemoradiotherapy were accrued in this prospective study. The coprimary endpoint of the study was local control (LC) and functional larynx preservation survival (FLPS).

RESULTS

The median follow-up was 39 months. Thirty-nine patients had a local failure of which 17 underwent a salvage laryngectomy. A dysfunctional larynx with clinic-radiologically disease was seen in only 1 patient. Factors significant for LC were thyroid cartilage erosion/lysis and cricoarytenoid joint involvement. Within the T4a subset, patients with exolaryngeal disease through the soft tissue framework had significantly better LC and FLPS than those with cartilage erosion/lysis.

CONCLUSIONS

Patients with limited exolaryngeal disease through the soft-tissue framework can be considered for functional organ preservation, while those with thyroid cartilage involvement and cricoarytenoid joint involvement are not suitable.

Tumor volume as a prognostic factor of locally advanced laryngeal cancer

PURPOSE

The TNM tumor staging system is the most widely used for laryngeal cancer. However, in the same T stage, lesions with different primary tumor volumes (TV) can be found, impacting treatment outcomes.

METHODS

145 patients with T3 and T4a laryngeal cancer, according to Union for International Cancer Control, who underwent surgical treatment from 2008 to 2017, were analyzed. TV measurements were collected and compared to different outcomes.

RESULTS

The mean TV was 23.0 ± 16.4 cm³. A cutoff point for TV of 14.2 cm³ was established. Cumulative sample 5-year overall survival (OS) was 62.1%, while 5-years disease-free survival (DFS) was 65.5%. In univariate analysis, TV ≥ 14.2 cm³ was associated with a higher risk of distant metastases (p = 0.045), and worse rates of OS (p = 0.009) and DFS (p = 0.035). In multivariate analysis, TV was not an independent risk factor of worse DFS (p = 0.569) or OS (p = 0.094).

CONCLUSION

Primary lesion TV showed significant association, in univariate analysis, with worse rates of recurrence and survival in advanced laryngeal cancer undergoing surgical treatment and can be a promising prognostic for these patients.

Magnetic resonance imaging-derived radiomic signature predicts locoregional failure after organ preservation therapy in patients with hypopharyngeal squamous cell carcinoma

•

The first study to develop and validate an MRI-derived radiomic signature (RS) for the prediction of 1-year locoregional failure in HPSCC patients receiving OPT.

•

The RS-based model (RS of 0.0326 as the cut-off value) provides a novel and convenient approach for the prediction of the 1-year clinical outcomes.

•

The proposed RS-based model can help physicians characterize and facilitate decision-making for the clinical management of patients with locally advanced HPSCC.

Background and purpose

To develop and validate a magnetic resonance imaging (MRI)-derived radiomic signature (RS) for the prediction of 1-year locoregional failure (LRF) in patients with hypopharyngeal squamous cell carcinoma (HPSCC) who received organ preservation therapy (OPT)

Material and methods

A total of 800 MRI-based features of pretreatment tumors were obtained from 116 patients with HPSCC who received OPT from two independent cohorts. The least absolute shrinkage and selection operator regression model were used to select the features used to develop the RS. Harrell’s C-index and corrected C-index were used to evaluate the discriminative ability of RS. The Youden index was used to select the optimal cut-point for risk category.

Results

The RS yielded 1000 times bootstrapping corrected C-index of 0.8036 and 0.78235 in the experimental (n = 82) and validation cohorts (n = 34), respectively. With respect to the subgroup of patients with stage III/IV and cT4 disease, the RS also showed good predictive performance with corrected C-indices of 0.760 and 0.754, respectively. The dichotomized risk category using an RS of 0.0326 as the cut-off value yielded a 1-year LRF predictive accuracy of 79.27%, 79.41%, 76.74%, and 71.15% in the experimental, validation, stage III/IV, and cT4a cohorts, respectively. The low-risk group was associated with a significantly better progression-free laryngectomy-free and overall survival outcome in two independent institutions, stage III/IV, and cT4a cohorts.

Conclusion

The RS-based model provides a novel and convenient approach for the prediction of the 1-year LRF and survival outcome in patients with HPSCC who received OPT.

Pathologic Tumor Size as a Predictor of the Survival Outcomes of Patients With Glottic Carcinoma

OBJECTIVES

The purpose of this study was to evaluate the potential predictor of tumor size on rates of overall and disease-free survival (OS and DFS) as determined by postoperative pathologic examination in patients with glottic carcinoma.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care university hospital.

SUBJECTS AND METHODS

In this study, 1337 consecutive patients with glottic carcinoma who underwent surgical treatment from 2005 to 2010 were retrospectively reviewed. The influence of tumor size that was evaluated by tumor area (tumor length × tumor width) on OS and DFS outcomes was assessed by Cox regression analyses.

RESULTS

In all, 1303 (97.5%) patients were male, and 34 (2.5%) were female, with a mean ± SD age of 60.4 ± 10 years. The 10-year OS and DFS rates were 72.9% and 69.9%, respectively. The tumor area cutoff values that best discriminated OS and DFS rates were both 1.80 cm². Patients with glottic carcinoma with a larger tumor area had inferior OS and DFS rates. Based on the results of multivariate analyses, tumor area was an independent prognostic factor for rates of OS (hazard ratio, 1.87; 95% CI, 1.37-2.56; P < .001) and DFS (hazard ratio, 1.79; 95% CI, 1.34-2.38; P < .001) in patients with glottic carcinoma.

CONCLUSIONS

The results of this study indicate that patients with glottic carcinoma with a tumor area >1.8 cm² have inferior survival outcomes, and this factor independently predicts survival outcomes in these patients.

Consolidation cetuximab after concurrent triplet radiochemotherapy+cetuximab in patients with advanced head and neck cancer: A randomized phase II study

BACKGROUND AND PURPOSE

Preclinical data suggest that cetuximab should be continued after end of concurrent radiotherapy+cetuximab due to its efficacy against residual tumor cells in the irradiated tumor bed. Based on this concept the phase II add-on cetuximab (AOC) study was designed.

MATERIALS AND METHODS

Altogether 63 patients with advanced head and neck cancer were treated with radiochemotherapy (70 Gy, cisplatin 40 mg/m² weekly) in combination with concurrent cetuximab (loading dose 400 mg/m², then 250 mg/m² weekly). Thereafter patients were randomized to cetuximab consolidation (500 mg/m² biweekly × 6) or no further treatment. The primary endpoint was the 2-year locoregional control (LRC) rate. As translational research endpoints serum markers were analyzed before and during treatment and CT-based quantitative image analysis (radiomics) was performed.

RESULTS

Median follow-up was 24 months. The 2-year LRC rates were 67.9% and 67.7% in the treatment arms with and without consolidation cetuximab, respectively. Higher than median levels of three serum markers were negatively associated with the 2-year LRC rate in the overall patient cohort: Osteopontin, IL8 and FasL2 (p ≤ 0.05). A radiomics model consisting of two radiomics features could be built showing that higher entropy and higher complexity of tumor Hounsfield unit distribution indicates worse LRC (concordance index 0.66). No correlation was found between biological and imaging markers.

CONCLUSIONS

There was no evidence that consolidation cetuximab would improve the 2-year LRC rate. Prognostic biological and imaging markers could be identified for the overall patient cohort. Studies with larger patient numbers are needed to correlate biological and imaging markers.

Altered fractionation diminishes importance of tumor volume in oropharyngeal cancer: Subgroup analysis of ARTSCAN-trial

BACKGROUND

A large tumor volume negatively impacts the outcome of radiation therapy (RT). Altered fractionation (AF) can improve local control (LC) compared with conventional fractionation (CF). The aim of the present study was to investigate if response to AF differs with tumor volume in oropharyngeal cancer.

METHODS

Three hundred and twenty four patients with oropharyngeal cancer treated in a randomized, phase III trial comparing CF (2 Gy/d, 5 d/wk, 7 weeks, total dose 68 Gy) to AF (1.1 Gy + 2 Gy/d, 5 d/wk, 4.5 weeks, total dose 68 Gy) were analyzed.

RESULTS

Tumor volume had less impact on LC for patients treated with AF. There was an interaction between tumor volume and fractionation schedule (P = .039). This differential response was in favor of CF for small tumors and of AF for large tumors.

CONCLUSION

AF diminishes the importance of tumor volume for local tumor control in oropharyngeal cancer.

Dosiomics improves prediction of locoregional recurrence for intensity modulated radiotherapy treated head and neck cancer cases

OBJECTIVES

To investigate whether dosiomics can benefit to IMRT treated patient's locoregional recurrences (LR) prediction through a comparative study on prediction performance inspection between radiomics methods and that integrating dosiomics in head and neck cancer cases.

MATERIALS AND METHODS

A cohort of 237 patients with head and neck cancer from four different institutions was obtained from The Cancer Imaging Archive and utilized to train and validate the radiomics-only prognostic model and integrate the dosiomics prognostic model. For radiomics, the radiomics features were initially extracted from images, including CTs and PETs, and selected on the basis of their concordance index (CI) values, then condensed via principle component analysis. Lastly, multivariate Cox proportional hazards regression models were constructed with class-imbalance adjustment as the LR prediction models by inputting those condensed features. For dosiomics integration model establishment, the initial features were similar, but with additional 3-dimensional dose distribution from radiation treatment plans. The CI and the Kaplan-Meier curves with log-rank analysis were used to assess and compare these models.

RESULTS

Observed from the independent validation dataset, the CI of the model for dosiomics integration (0.66) was significantly different from that for radiomics (0.59) (Wilcoxon test, p=5.9×10^-31). The integrated model successfully classified the patients into high- and low-risk groups (log-rank test, p=2.5×10^-02), whereas the radiomics model was not able to provide such classification (log-rank test, p=0.37).

CONCLUSION

Dosiomics can benefit in predicting the LR in IMRT-treated patients and should not be neglected for related investigations.

The Role of Prognostic Factors in Salivary Gland Tumors Treated by Surgery and Adjuvant Radio- or Chemoradiotherapy - A Single Institution Experience

Purpose

Salivary gland neoplasms are rare cancers of the head and neck region. Radical treatment in tumors of large salivary glands is surgery. Adjuvant treatment depends on the presence of risk factors that worsen the prognosis, but the role of these factors in patients treated by surgery with radio- or radiochemotherapy still remains unclear. The aim of the study is assessment of treatment results and identification of the risk factors affecting the prognosis in patients with tumors of large salivary glands subjected to adjuvant radio- or radiochemotherapy.

Patients and Methods

The study included 126 patients with local stage large salivary gland cancer who were treated surgically with adjuvant radio- or radiochemotherapy. The study excluded inoperable patients, patients with distant metastases, patients in a poor general condition and patients with contraindications to adjuvant treatment. They were treated between 2006 and 2016 and evaluated in terms of OS (overall survival), CSS (cancer-specific survival), RFS (relapse-free survival) and LRFS (local relapse-free survival).

Results

During a 44-month follow-up, 5-OS, CSS, RFS and LRFS were 55%, 68%, 60% and 73%, respectively. Multivariate analysis showed that OS was influenced by the following parameters: WHO performance status, TNM stage (T and N parameters), radicality of surgery, histopathological type, applied method of radiotherapy planning and tumor volume. WHO performance status, T and N parameters of the TNM stage and large volume of elective area influenced CSS, and the T parameter of the TNM stage, the dose below 60Gy and tumor volume influenced RFS and LRFS. Chemoradiotherapy can be used in N-positive patients.

Conclusion

The analysis indicates that the TNM grade, histopathological type, patient’s condition, radicality of the procedure, technique and dose of radiotherapy are the most important prognostic factors in these patients.

Prognostic role of primary tumor, nodal neck, and retropharyngeal GTVs for unresectable sinonasal cancers treated with IMRT and chemotherapy

Background:

We evaluated the prognostic role of gross tumor volumes (GTVs) of primary tumor and positive lymph nodes on overall survival (OS) and progression-free survival (PFS) in locally advanced unresectable sinonasal cancer (SNC) treated with definitive intensity-modulated radiotherapy (IMRT) with or without chemotherapy.

Methods:

Primary tumor GTV (GTV-T), pathologic neck nodes GTV (GTV-N), and positive retropharyngeal nodes GTV (GTV-RPN) of 34 patients with epithelial nonglandular SNC receiving IMRT with or without chemotherapy were retrospectively measured. The GTV variables were analyzed in relation with OS and PFS. Survival curves were estimated using the Kaplan-Meier method and compared with the log-rank test. We also estimated the crude cumulative incidence of locoregional relapses only. The optimal volume cutoff value was determined using an outcome-oriented method among the observed values.

Results:

GTV-T was significantly associated with decreased OS ( P=0.003) and PFS ( P=0.003). Moreover, patients with disease total volumes (GTV) smaller than 149.44 cm³ had better OS and PFS than patients with higher volumes ( P<0.0001 for both). Neck nodal metastasis impacted on OS and PFS ( P=0.030 and P=0.033, respectively), but GTV-N did not ( P=0.961; P=0.958). Retropharyngeal nodes metastasis was not associated with prognosis (OS: P=0.400; PFS: P=0.104). When GTV-RPN was added to GTV-N (GTV-TN), a relation with PFS ( P=0.041) and a trend toward significance for OS ( P=0.075) were found.

Conclusions:

Our results show that tumor volume is a powerful predictor of outcome in SNC. This could be useful to identify patients with worse prognosis deserving different treatment strategies.

The Relationship between Primary Gross Tumor Volume and Tumor Response of Locally Advanced Rectal Cancer: pGTV as a More Accurate Tumor Size Indicator

Purpose: To identify the clinical predictive factors of tumor response and to evaluate the significance of primary gross tumor volume (pGTV), obtained from radiotherapy planning, in predicting tumor response. Materials and Methods: We retrospectively analyzed data of consecutive locally advanced rectal cancer (LARC) patients who were treated with neoadjuvant chemoradiotherapy (nCRT) followed by radical surgery at our institution between March 2009 and December 2017. We identify independent predictors of tumor response to nCRT by statistical analysis. Disease-free survival (DFS) starting from the time of surgery was calculated by the Kaplan-Meier method, and log-rank tests were performed to compare DFS between patients with superior and inferior tumor response. Results: Overall, 185 LARC patients received nCRT, of whom 89 (48.11%) achieved superior tumor response. Diminutive pGTV (p = 0.038) and distance from the anal verge (DAV) (p = 0.006) were independent predictive factors of superior tumor response. Meanwhile, pGTV can be regarded as an independent predictor of pathologic complete response (pCR) (p = 0.036). The log-rank test revealed that DFS was longer in the diminutive pGTV group than in the giant pGTV group (p = 0.001). Conclusions: pGTV, as a measure of tumor size, is not only an important prognostic indicator but also an independent predictive factor of tumor response, even pCR.

Recategorization of tumor stage in patients with node-negative oral tongue cancer: Impact of the eighth edition American Joint Committee staging system

BACKGROUND

To evaluate recategorization of pT1-3N0 oral tongue cancer, from seventh to eighth editions of the American Joint Committee on Cancer (AJCC) staging classification, and impact on overall survival (OS).

METHODS

Using the National Cancer Database, 1277 patients were categorized using tumor size and depth of invasion with seventh and eighth AJCC staging systems and evaluated for OS.

RESULTS

Tumor-category was unchanged in 82.9% and upstaged in 17.1% patients with eighth AJCC. The 3-year OS was 85.3%, 76.6%, and 77.0% with seventh AJCC compared to 87.1%, 75.1%, and 81% with eighth AJCC, for patients with pT1N0, pT2N0, and pT3N0 disease, respectively. Improved discrimination of pT1N0 vs pT2N0 for OS on multivariate analysis was seen for eighth AJCC (hazard ratio [HR] = 1.43, 95% confidence interval [CI]: 1.03-1.98, P = .03) but not for patients with pT3N0, with seventh AJCC (HR = 1.02, 95% CI:0.53-1.98, P = .95), and eighth AJCC (HR = 0.86, 95% CI: 0.52-1.42, P = .55).

CONCLUSION

Eighth edition AJCC staging leads to improved discrimination of OS between pT1N0 and pT2N0 but not for patients with pT3N0.

Tumor volume as a prognostic marker in p16-positive and p16-negative oropharyngeal cancer patients treated with definitive intensity-modulated radiotherapy

PURPOSE

To investigate the impact of primary gross tumor volume (pGTV) and nodal gross tumor volume (nGTV) in oropharyngeal squamous cell carcinoma (OPSCC) and the difference in their role between human papillomavirus (HPV)-positive and HPV-negative patients.

METHODS

The patient cohort consists of 91 OPSCC patients treated with definitive radiochemotherapy or radiotherapy using intensity-modulated radiotherapy (IMRT). All patients had a minimum follow-up of 31 months. Volume measurements were made from computer tomography (CT) scans and HPV status was assessed by p16 immunohistochemistry. The end points were as follows: overall survival (OS), disease-free survival (DFS) and locoregional control (LRC).

RESULTS

pGTV was a significant independent prognostic factor for overall survival (OS; p = 0.020) in p16-negative patients. nGTV of p16-negative tumors had significant prognostic value in all end points in multivariate analyses. High-stage (III-IVc) p16-negative tumors were only associated with significantly poorer OS (p = 0.046) but not with poorer LRC or DFS when compared with the low-stage (I-II) tumors. nGTV of p16-positive tumors was an independent prognostic factor for DFS (p = 0.005) and LRC (p = 0.007) in multivariate analyses.

CONCLUSION

pGTV may serve as an independent prognostic factor in p16-negative patients and nGTV may serve as an independent prognostic factor both in p16-positive and p16-negative patients treated with radiochemotherapy or radiotherapy using IMRT. Tumor volume may have an impact on selecting patients for de-escalation protocols in the future, both in p16-positive and p16-negative patients.

Predictive value of 1H MR spectroscopy and 18F-FDG PET/CT for local control of advanced oropharyngeal and hypopharyngeal squamous cell carcinoma receiving chemoradiotherapy: a prospective study

Purpose

To determine whether pretreatment in vivo 1H magnetic resonance (MR) spectroscopy at 3 Tesla (T) and 18F-FDG PET/CT can offer predictive power regarding the local control of oropharyngeal or hypopharyngeal squamous cell carcinoma (OHSCC) patients.

Materials and Methods

¹H MR spectroscopy was performed in addition to conventional MR imaging before definitive chemoradiotherapy in 58 patients with advanced OHSCC. The relationship of local control with the ¹H MR spectroscopy and ¹⁸F-FDG PET/CT parameters was analyzed.

Results

With a median follow-up of 17.6 months, 13 (22.4%) patients exhibited local failure; whereas the remaining 45 achieved local control. Kaplan-Meier analysis identified age > 60 years, creatine level on MRS ≦ 6.02 mM, glutamine and glutamate (Glx) level on MRS > 3.31 mM, and total lesion glycolysis (TLG) on ¹⁸F-FDG PET/CT > 217.18 g/mL × mL as significant adverse predictors for 2-year local control. Multivariate Cox regression analysis showed that age (p=0.017), Glx level on MRS (p=0.021), and TLG on ¹⁸F-FDG PET/CT (p=0.028) retained their independent prognostic significance. A scoring system was constructed based on the sum of these three factors. We found that patients with scores of 2-3 had significantly poorer local control rates than patients with scores of 0-1 (33.3% versus 86.8%, p=0.003).

Conclusion

We conclude that Glx on ¹H MR spectroscopy at 3 T was the independent prognostic factor for local control of OHSCC patients treated with chemoradiotherapy, and its combination with age and TLG may help identify a subgroup of patients at high risk for developing local failure.

CT Texture Analysis Potentially Predicts Local Failure in Head and Neck Squamous Cell Carcinoma Treated with Chemoradiotherapy

BACKGROUND AND PURPOSE

The accurate prediction of prognosis and failure is crucial for optimizing treatment strategies for patients with cancer. The purpose of this study was to assess the performance of pretreatment CT texture analysis for the prediction of treatment failure in primary head and neck squamous cell carcinoma treated with chemoradiotherapy.

MATERIALS AND METHODS

This retrospective study included 62 patients diagnosed with primary head and neck squamous cell carcinoma who underwent contrast-enhanced CT examinations for staging, followed by chemoradiotherapy. CT texture features of the whole primary tumor were measured using an in-house developed Matlab-based texture analysis program. Histogram, gray-level co-occurrence matrix, gray-level run-length, gray-level gradient matrix, and Laws features were used for texture feature extraction. Receiver operating characteristic analysis was used to identify the optimal threshold of any significant texture parameter. We used multivariate Cox proportional hazards models to examine the association between the CT texture parameter and local failure, adjusting for age, sex, smoking, primary tumor stage, primary tumor volume, and human papillomavirus status.

RESULTS

Twenty-two patients (35.5%) developed local failure, and the remaining 40 (64.5%) showed local control. Multivariate analysis revealed that 3 histogram features (geometric mean [hazard ratio = 4.68, P = .026], harmonic mean [hazard ratio = 8.61, P = .004], and fourth moment [hazard ratio = 4.56, P = .048]) and 4 gray-level run-length features (short-run emphasis [hazard ratio = 3.75, P = .044], gray-level nonuniformity [hazard ratio = 5.72, P = .004], run-length nonuniformity [hazard ratio = 4.15, P = .043], and short-run low gray-level emphasis [hazard ratio = 5.94, P = .035]) were significant predictors of outcome after adjusting for clinical variables.

CONCLUSIONS

Independent primary tumor CT texture analysis parameters are associated with local failure in patients with head and neck squamous cell carcinoma treated with chemoradiotherapy.

Neutrophil-lymphocyte ratio complements volumetric staging as prognostic factor in patients treated with definitive radiotherapy for oropharyngeal cancer

Background

Volumetric tumor staging has been shown as superior prognostic tool compared to the conventional TNM system in patients undergoing definitive intensity-modulated radiotherapy (IMRT) for head and neck cancer. Recently, clinical immunoscores such as the neutrophil-lymphocyte ratio (NLR) have been investigated as prognostic markers in several tumor entities. The aim of this study was to assess the combined prognostic value of NLR and tumor volume in patients treated with IMRT for oropharyngeal cancer (OC).

Methods

Data on all consecutive patients treated for locally advanced or inoperable OC with IMRT from 2002–2011 was prospectively collected. Tumor volume was assessed based on the total gross tumor volume (tGTV) calculated by the treatment planning system volume algorithm. The NLR was collected by a retrospective analysis of differential blood count before initiation of therapy.

Results

Overall, 187 eligible patients were treated with a median IMRT dose of 69.6 Gy. Three-year recurrence-free survival (RFS) for low, intermediate, high and very high tumor volume groups was 88%, 74%, 62% and 25%, respectively (p = 0.007). Patients with elevated NLR (>4.68) showed a significantly decreased 3-year RFS of 44% vs. 81% (p < 0.001) and 3-year OS of 56% vs. 84% (p < 0.001). The NLR remained a significant prognostic factor for RFS and OS when tested among tumor volume groups. Univariate and multivariate regression analysis confirmed both tumor volume and NLR as independent prognostic factors. The NLR offered further statistically significant prognostic differentiation of the small/intermediate/large tumor volume groups.

Conclusion

The NLR remains an independent prognostic factor for patients with OC undergoing radiotherapy independent of the tumor volume.

Quantitative pretreatment CT volumetry: Association with oncologic outcomes in patients with T4a squamous carcinoma of the larynx

BACKGROUND

The purpose of this study was to determine the impact of CT-determined pretreatment primary tumor volume on survival and disease control in T4a laryngeal squamous cell carcinoma (SCC).

METHODS

We retrospectively reviewed 124 patients with T4a laryngeal cancer from 2000-2011. Tumor volume measurements were collected and correlated with outcomes.

RESULTS

Five-year overall survival (OS) for patients with tumor volume ≥21 cm³ treated with larynx preservation (n = 26 of 41) was significantly inferior compared to <21 cm³ (42% vs 64%, respectively; P = .003). Five-year OS for patients with tumor volumes ≥21 cm³ in the cohort treated with total laryngectomy followed by radiotherapy (RT; n = 42 of 83) was not statistically significant when compared to <21 cm³ (50% vs 63%, respectively; P = .058). On multivariate analysis, tumor volume ≥21 cm³ was a significant independent correlate of worse disease-specific survival (DSS; P = .004), event-free survival (P = .005), recurrence-free survival (RFS; P = .04), noncancer cause-specific survival (P = .02), and OS (P = .0002).

CONCLUSION

Pretreatment CT-based tumor volume is an independent prognostic factor of outcomes in T4a laryngeal cancer.

External validation of sTWEAK as a prognostic noninvasive biomarker for head and neck squamous cell carcinoma

BACKGROUND

The main purpose of this study was to validate the prognostic significance of tumor necrosis factor (TNF)-like weak inducer of apoptosis (TWEAK) in head and neck squamous cell carcinoma (HNSCC) using an independent cohort.

METHODS

Data were evaluated from 153 patients with HNSCC in stages III to IV, who received radiotherapy (RT) or chemoradiotherapy. We quantified soluble TWEAK (sTWEAK) in pretreatment samples using enzyme-linked immunosorbent assay.

RESULTS

The classification tree revealed a cutoff value of 322 pg/mL for sTWEAK to be ideal for discriminating between patients' disease control. Kaplan-Meier curves indicate that the disease-free survival rate in patients with high sTWEAK was significantly higher than in patients with low levels (p = .006, log-rank test). An independent link was identified between low sTWEAK and poor clinical outcome in Cox regression multivariate analysis (hazard ratio = 1.866; 95% confidence interval [CI] = 1.114-3.125; p = .001).

CONCLUSION

Our study highlights the significance of this noninvasive biomarker in the discrimination according to the disease control achieved by patients who received a nonsurgical organ-preservation treatment. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1358-E1363, 2016.

Tumor volume as a predictor of survival in human papillomavirus-positive oropharyngeal cancer

BACKGROUND

Increasing evidence exists that tumor volume may be a superior prognostic model than traditional TNM staging. It has been observed that oropharyngeal squamous cell carcinoma (oropharyngeal SCC) in the setting of human papillomavirus (HPV) positivity have a greater propensity for cystic nodal metastases, and, thus, presumably larger volume with relatively smaller primary tumors. The influence of HPV status on the predictive value of tumor volume is unknown.

METHODS

Fifty-three patients with HPV-positive oropharyngeal SCC were treated with definitive chemotherapy and intensity-modulated radiotherapy (IMRT).

RESULTS

The estimated 2-year overall survival (OS) and disease-free survival (DFS) was 92.2% and 83.6%, respectively. Nodal classification did not predict OS (p = .096) or DFS (p = .170). Similarly, T classification did not predict OS (p = .057) or DFS (p = .309). Lower nodal volume was associated with greater DFS (p = .001).

CONCLUSION

Nodal tumor volume was found to be predictive of DFS. DFS was best predicted by nodal gross tumor volume (GTV) at 24 months. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1613-E1617, 2016.

Tumor Volumes and Prognosis in Laryngeal Cancer

Tumor staging systems for laryngeal cancer (LC) have been developed to assist in estimating prognosis after treatment and comparing treatment results across institutions. While the laryngeal TNM system has been shown to have prognostic information, varying cure rates in the literature have suggested concern about the accuracy and effectiveness of the T-classification in particular. To test the hypothesis that tumor volumes are more useful than T classification, we conducted a retrospective review of 78 patients with laryngeal cancer treated with radiation therapy at our institution. Using multivariable analysis, we demonstrate the significant prognostic value of anatomic volumes in patients with previously untreated laryngeal cancer. In this cohort, primary tumor volume (GTV_P), composite nodal volumes (GTV_N) and composite total volume (GTV_P + GTV_N = GTV_C) had prognostic value in both univariate and multivariate cox model analysis. Interestingly, when anatomic volumes were measured from CT scans after a single cycle of induction chemotherapy, all significant prognosticating value for measured anatomic volumes was lost. Given the literature findings and the results of this study, the authors advocate the use of tumor anatomic volumes calculated from pretreatment scans to supplement the TNM staging system in subjects with untreated laryngeal cancer. The study found that tumor volume assessment after induction chemotherapy is not of prognostic significance.

Approximation of head and neck cancer volumes in contrast enhanced CT

Background

Tumor volume may serve as a predictor of response to radiochemotherapy (RCT) in head and neck squamous cell carcinoma (HNSCC). Computer assisted tumor volumetry requires time-consuming slice-by-slice manual or semi-automated segmentation. We questioned how accurately primary tumor and suspect cervical lymph node (LN) volumes can be approximated by the maximum tumor diameters in three dimensions.

Methods

In contrast-enhanced diagnostic CT scans of 74 patients with incident advanced HNSCC, manual slice-by-slice segmentation volumetry of primary tumor, total- and largest suspect cervical LN served as the reference method. In the same scans, maximum orthogonal diameters were measured using the distance measurement tool in standard visualization software in axial and coronal sections. From these diameters, approximate volumes were calculated using the cubic and ellipsoid formula. A second segmentation volumetry was performed in contrast enhanced radiotherapy-planning CT scans obtained prior to primary concurrent RCT 24 days (+/− 13 days) following the initial diagnostic CT scans. Intraclass correlation coefficients and Bland-Altman analyses were used to compare results.

Results

Slice-by-slice manual segmentation volumetry of primary and LN volumes revealed a lognormal distribution and ranged from 0 to 86 ml and 0 to 129 ml, respectively. Volume approximations in diagnostic CT scans with the ellipsoid formula resulted in an −8 % underestimation of tumor volumes (95 % CI −14 % to −1 %; p = 0.022) and an −18 % underestimation of suspect cervical LN volumes (95 % CI −25 % to −12 %; p = 0.001). Inter rater intraclass correlation for primaries was 0.95 (95 % CI +0.92 to +0.97; p = 0.001), and intra rater intraclass correlation was 0.99 (95 % CI +0.98 to +0.99; p = 0.001). The cubic formula resulted in pronounced overestimation of primary and LN volumes. Primary tumor volumes obtained by the second segmentation volumetry in radiotherapy-planning CT scans obtained on average 24 days following the initial volumetry resulted in larger primary tumor volumes (mean bias +28 %, 95 % CI +14 % to +41 %; p = 0.001). Tumor volume increase correlated with time between the diagnostic and planning CTs (r = 0.24, p = 0.05) and was approximately 1 % per day.

Discussion

Ellipsoid approximations of tumor and lymph node volumes in HNSCC using maximum orthogonal diameters underestimates volumes based on segmentation in multiple slices. Due to time difference and safety margins, segmented volumes in radiotherapy-planning CT scans tend to be larger than in diagnostic CT scans.

Conclusion

Ellipsoid approximations of tumor and lymph node volumes in HNSCC are easily available from diagnostic CT scans. Volume estimates are applicable over a wide range of tumor and LN sizes and may be useful in clinical decision-making and oncologic research.

A prognostic volumetric threshold of gross tumor volume in head and neck cancer patients treated with radiotherapy

OBJECTIVES

To determine the prognostic utility of a volumetric threshold for gross tumor volume (GTV) of the primary and nodal disease when accounting for the TNM classification in head and neck cancer (HNC) patients treated with definitive radiotherapy (RT).

MATERIALS AND METHODS

From 2004 to 2011, 79 HNC patients were treated to a median dose of 70 Gy, using intensity-modulated RT in 78.5% and 3-dimensional conformal RT in 21.5% with 83.5% receiving concurrent chemotherapy. Primary (GTV-P) and nodal (GTV-N) GTVs were derived from computed tomography (CT)-based contours for RT planning, of which 89.7% were aided by positron emission tomography-computed tomography. Local (LC), nodal (NC), distant (DC) control, and overall survival (OS) were assessed using the Kaplan-Meier product-limit method.

RESULTS

With a median follow-up of 27.1 months GTV-P, threshold of <32.9 mL (mean value) compared with ≥32.9 mL, correlated with improved 2-year LC (96.2% vs. 63.9%, P<0.0001), NC (100% vs. 69.2%, P<0.0001), DC (87.9% vs. 64.2%, P=0.001), and OS (88.4% vs. 58.6%, P=0.001). GTV-P demonstrated its prognostic utility in multivariate analyses when adjusted for tumor category, cancer site, and chemotherapy regimen. Nodal GTV (mean, 34.0 mL) was not predictive of nodal control and survival.

CONCLUSIONS

A volumetric threshold of the primary tumor may be used as an independent prognostic factor in patients with HNC undergoing definitive RT.

Clinical utility of multimodality imaging with dynamic contrast-enhanced MRI, diffusion-weighted MRI, and 18F-FDG PET/CT for the prediction of neck control in oropharyngeal or hypopharyngeal squamous cell carcinoma treated with chemoradiation

The clinical usefulness of pretreatment imaging techniques for predicting neck control in patients with oropharyngeal or hypopharyngeal squamous cell carcinoma (OHSCC) treated with chemoradiation remains unclear. In this prospective study, we investigated the role of pretreatment dynamic contrast-enhanced perfusion MR imaging (DCE-PWI), diffusion-weighted MR imaging (DWI), and [¹⁸F]fluorodeoxyglucose-positron emission tomography (¹⁸F-FDG PET)/CT derived imaging markers for the prediction of neck control in OHSCC patients treated with chemoradiation. Patients with untreated OHSCC scheduled for chemoradiation between August, 2010 and July, 2012 were eligible for the study. Clinical variables and the following imaging parameters of metastatic neck lymph nodes were examined in relation to neck control: transfer constant, volume of blood plasma, and volume of extracellular extravascular space (V_e) on DCE-PWI; apparent diffusion coefficient (ADC) on DWI; maximum standardized uptake value, metabolic tumor volume, and total lesion glycolysis on ¹⁸F-FDG PET/CT. There were 69 patients (37 with oropharynx SCC and 32 with hypopharynx SCC) with successful pretreatment DCE-PWI and DWI available for analysis. After a median follow-up of 31 months, 25 (36.2%) participants had neck failure. Multivariate analysis identified hemoglobin level <14.3 g/dL (P = 0.019), V_e <0.23 (P = 0.040), and ADC >1.14×10⁻³ mm²/s (P = 0.003) as independent prognostic factors for 3-year neck control. A prognostic scoring system was formulated by summing up the three significant predictors of neck control. Patients with scores of 2–3 had significantly poorer neck control and overall survival rates than patients with scores of 0–1. We conclude that hemoglobin levels, V_e, and ADC are independent pretreatment prognostic factors for neck control in OHSCC treated with chemoradiation. Their combination may identify a subgroup of patients at high risk of developing neck failure.

Predicting oropharyngeal tumor volume throughout the course of radiation therapy from pretreatment computed tomography data using general linear models

PURPOSE

The purpose of this work was to develop and evaluate the accuracy of several predictive models of variation in tumor volume throughout the course of radiation therapy.

METHODS

Nineteen patients with oropharyngeal cancers were imaged daily with CT-on-rails for image-guided alignment per an institutional protocol. The daily volumes of 35 tumors in these 19 patients were determined and used to generate (1) a linear model in which tumor volume changed at a constant rate, (2) a general linear model that utilized the power fit relationship between the daily and initial tumor volumes, and (3) a functional general linear model that identified and exploited the primary modes of variation between time series describing the changing tumor volumes. Primary and nodal tumor volumes were examined separately. The accuracy of these models in predicting daily tumor volumes were compared with those of static and linear reference models using leave-one-out cross-validation.

RESULTS

In predicting the daily volume of primary tumors, the general linear model and the functional general linear model were more accurate than the static reference model by 9.9% (range: -11.6%-23.8%) and 14.6% (range: -7.3%-27.5%), respectively, and were more accurate than the linear reference model by 14.2% (range: -6.8%-40.3%) and 13.1% (range: -1.5%-52.5%), respectively. In predicting the daily volume of nodal tumors, only the 14.4% (range: -11.1%-20.5%) improvement in accuracy of the functional general linear model compared to the static reference model was statistically significant.

CONCLUSIONS

A general linear model and a functional general linear model trained on data from a small population of patients can predict the primary tumor volume throughout the course of radiation therapy with greater accuracy than standard reference models. These more accurate models may increase the prognostic value of information about the tumor garnered from pretreatment computed tomography images and facilitate improved treatment management.

Race disparities attributed to volumetric tumor burden in patients with head and neck cancer treated with radiotherapy

BACKGROUND

The purpose of this study was to evaluate how gross tumor volume (GTV) affects treatment outcome among different race/ethnic groups in patients with head and neck cancer receiving definitive radiotherapy (RT).

METHODS

Ninety-one patients with head and neck cancer were treated to a median RT dose of 69.96 Gy in 33 fractions. The patient's self-reported race/ethnicity, primary tumor, and nodal GTV were obtained. Two-year actuarial local, nodal, and distant control, and overall and disease-free survival were calculated.

RESULTS

The patients were categorized as white (n = 43) or non-white (n = 48), which included 29 African Americans, 11 Hispanics, 5 Asians, and 3 others. The mean primary GTV was 21.0 cc and 39.9 cc for whites and non-whites, respectively (p = .011). White patients reported improved overall survival of 85.4% compared to non-whites (65.8%; p = .006). Improvements in local and nodal control and disease-free survival rates were also observed.

CONCLUSION

White patients demonstrated improved treatment outcomes compared with non-whites, which may be reflective of tumor volume.

The relative prognostic utility of standardized uptake value, gross tumor volume, and metabolic tumor volume in oropharyngeal cancer patients treated with platinum based concurrent chemoradiation with a pre-treatment [(18)F] fluorodeoxyglucose positron emission tomography scan

OBJECTIVES

This study compared the relative prognostic utility of the Gross Tumor Volume (GTV), maximum Standardized Uptake Value (SUVmax), and Metabolic Tumor Volume (MTV) in a uniform cohort of oropharyngeal squamous cell carcinoma (OPSCC) patients treated with platinum-based concurrent chemoradiation therapy (CCRT).

METHODS AND MATERIALS

One-hundred OPSCC with a pretreatment [(18)F] fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) were treated with CCRT. Kaplan-Meier curves and Cox proportional hazard models were generated.

RESULTS

When dichotomized by the median, a smaller MTV correlated with improved 5year locoregional control (LRC) (98.0% versus 87.0%, p=0.049), freedom from distant metastasis (FDM) (91.7% versus 65.0%, p=0.005), progression-free survival (PFS) (80.3% versus 56.7%, p=0.015), and overall survival (OS) (84.1% versus 57.8%, p=0.008), whereas a smaller GTV correlated with improved PFS (80.3% versus 57.4%, p=0.040) and OS (82.1% versus 60.1%, p=0.025). SUVmax failed to correlate with any outcome. On multivariate analysis, when adjusted for GTV, T-stage, and N-stage a smaller MTV remained independently correlated with improved FDM, PFS, and OS. GTV failed to reach significance in the multivariate model.

CONCLUSIONS

A smaller MTV correlates with improved LRC, FDM, PFS, and OS in OPSCC patients undergoing platinum-based CCRT.

The role of tumor volume in radiotherapy of patients with head and neck cancer

The assumption that the larger tumor contains a higher number of clonogenic cells what may deteriorate prognosis of patients treated with RT has been confirmed in many clinical studies. Significant prognostic influence of tumor volume (TV) on radiotherapy (RT) outcome has been found for tumors of different localizations including patients with head and neck cancer (HNC). Although TV usually is a stronger prognostic factor than T stage, commonly used TNM classification system dose not incorporate TV data. The aim of the paper is to refresh clinical data regarding the role of TV in RT of patients with HNC. At present somehow new meaning of TV could be employed in the aspect of modern RT techniques and combined treatment strategies. For larger TV more aggressive treatment options may be considered. In modern RT techniques escalated dose could be provided highly conformal or RT can be combined with systemic treatment increasing therapeutic ratio. In the study several reports estimating prognostic value of TV for patients with HNC treated with RT has been reviewed.Due to substantially various reported groups of patients as to tumor site, stage of disease or treatment strategies, precise cut-off value could not be establish in general, but the significant association between TV and treatment outcome had been found in almost all studies. There is a strong suggestion that TV should supplement clinical decision in the choice of optimal treatment strategy for patients with HNC.

Prognostic factors in patients with head and neck squamous cell carcinoma with cN3 neck disease: a retrospective case-control study

OBJECTIVE

This study examined prognostic factors in patients with head and neck squamous cell carcinoma with advanced neck disease.

STUDY DESIGN

The records of 191 patients with previously untreated head and neck squamous cell carcinoma and metastatic cervical lymph node (LN) >6 cm (cN, n = 70) and 3.01 to 6 cm (control, n = 121) in the greatest dimension were reviewed. Univariate and multivariate analyses were used to identify factors associated with disease-free survival (DFS) and locoregional control (LRC).

RESULTS

In the cN3 group, independent variables for DFS were age, active drinking, LN size, and extranodal extension (P < .05), and that for LRC was age (P = .025). In the control group, independent variables for DFS were tumor location and differentiation and LN bilaterality (P < .05), and that for LRC was LN bilaterality (P = .011).

CONCLUSIONS

The survival of cN3 patients is affected by host and nodal characteristics including age, drinking, nodal size, and extranodal extension.