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Chen SY, Sinha P, Last A, Ettyreddy A, Kallogjeri D, Pipkorn P, Rich JT, Zevallos JP, Paniello R, Puram SV, Van Abel K, Moore EJ, Oppelt P, Palka K, Adkins D, Daly M, Gay H, Thorstad WL, Jackson RS. Outcomes of Patients With Single-Node Metastasis of Human Papillomavirus-Related Oropharyngeal Cancer Treated With Transoral Surgery. JAMA Otolaryngol Head Neck Surg 2021; 147:16-22. [PMID: 33151273 DOI: 10.1001/jamaoto.2020.3870] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance Regional lymph node metastasis remains an important prognostic factor in patients with oropharyngeal squamous cell carcinoma (OPSCC). Although survival among patients with regional metastasis in human papillomavirus (HPV)-related OPSCC is more favorable compared with patients who are HPV negative, prognostic variables associated with failure in patients with single-node metastasis are not known. Objective To evaluate recurrence and survival in patients with HPV-related OPSCC with single-lymph node metastasis treated with transoral surgery. Design, Setting, and Participants A retrospective cohort study was conducted of 207 adults with newly diagnosed p16-positive OPSCC and pathology-confirmed single-node disease who underwent surgical resection with or without adjuvant therapy at 2 tertiary academic medical centers from January 1, 2007, to December 31, 2016. Statistical analysis was performed from September 1, 2018, to September 1, 2020. Interventions Surgery alone (n = 59), surgery with adjuvant radiation (n = 75), or surgery with adjuvant chemoradiation (n = 73). Main Outcomes and Measures The primary outcome was regional recurrence. Secondary outcomes included overall survival, any recurrence, and identification of factors associated with regional recurrence and overall survival. Results Among 207 patients, 178 (86%) were men, with a median age of 57 years (range, 35-82 years) at the time of surgery. Median follow-up was 36.2 months (range, 7-127 months). Regional recurrence occurred in 11 patients (5%). Of these, 1 patient (9%) was lost to follow-up after diagnosis, 1 (9%) was treated with palliative chemotherapy, and 9 (82%) were treated with curative intent. Ultimately, 7 patients received successful salvage treatment, and 3 died with disease. Overall, there were 21 patients (10%) with any recurrence, with 4 patients (19%) experiencing local recurrence, 11 (52%) experiencing regional recurrence, and 6 (29%) experiencing distant metastasis. The 5-year overall survival was 95% (95% CI, 89%-98%) for all patients. Older age (odds ratio [OR], 1.2; 95% CI, 1.1-1.2), advanced T stage (OR, 3.5; 95% CI, 0.9-14.0), and positive margins (OR, 10.9; 95% CI, 1.8-67.5) were associated with increased regional recurrence. Extranodal extension (OR, 0.2; 95% CI, 0.04-0.8), lymph node size greater than 3 cm (OR, 0.2; 95% CI, 0.1-0.7), and adjuvant therapy (OR, 0.08; 95% CI, 0.02-0.4) were associated with decreased regional recurrence. Advanced comorbidities (hazard ratio, 6.20; 95% CI, 1.4-27.7), lymphovascular invasion (hazard ratio, 4.7; 95% CI, 1.0-21.2), and regional recurrence (hazard ratio, 16.0; 95% CI, 3.1-82.0) were associated with worse overall survival. Conclusions and Relevance The findings of this cohort study suggest that patients with HPV-related OPSCC and single-node disease undergoing surgical resection with or without adjuvant treatment have excellent survival. Adjuvant therapy appears to improve regional control. Among patients with regional recurrence of OPSCC, there is a high rate of successful salvage treatment.
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Affiliation(s)
- Stephanie Y Chen
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Parul Sinha
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Aisling Last
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Abhinav Ettyreddy
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Dorina Kallogjeri
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri.,Statistics Editor, JAMA Otolaryngology-Head & Neck Surgery
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Jason T Rich
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Jose P Zevallos
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Randal Paniello
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Katheryn Van Abel
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - Eric J Moore
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - Peter Oppelt
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Kevin Palka
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Douglas Adkins
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Mackenzie Daly
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Hiram Gay
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
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Oppelt P, Ley J, Daly M, Rich J, Paniello R, Jackson RS, Pipkorn P, Liu J, Gay H, Palka K, Neupane P, Powell S, Spanos WC, Gitau M, Zevallos J, Thorstad W, Adkins D. nab-Paclitaxel and cisplatin followed by cisplatin and radiation (Arm 1) and nab-paclitaxel followed by cetuximab and radiation (Arm 2) for locally advanced head and neck squamous-cell carcinoma: a multicenter, non-randomized phase 2 trial. Med Oncol 2021; 38:35. [PMID: 33683482 DOI: 10.1007/s12032-021-01479-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/13/2021] [Indexed: 10/22/2022]
Abstract
In locally advanced head and neck squamous-cell carcinoma (LA-HNSCC), clinical complete response (cCR) at the primary site, assessed by clinical examination, after induction chemotherapy predicts for a low relapse risk after subsequent chemoradiotherapy. Prior studies showed a cCR rate of 77% with induction nanoparticle albumin-bound (nab)-paclitaxel given with cisplatin and 5-fluorouracil (APF). The primary aims of this non-randomized phase 2 trial were to determine the cCR rate after induction nab-paclitaxel and cisplatin (Arm 1) and after nab-paclitaxel monotherapy (Arm 2). Eligibility required LA-HNSCC, T2-T4 stage classification, and suitable (Arm 1) or unsuitable (Arm 2) candidates for cisplatin. Arm 1 patients received nab-paclitaxel and cisplatin, then cisplatin with radiation. Arm 2 patients received nab-paclitaxel, then cetuximab with radiation. The primary endpoint was cCR after two cycles of induction chemotherapy. Each arm enrolled forty patients. cCR at the primary site occurred in 28 patients (70%) after nab-paclitaxel and cisplatin and in 8 patients (20%) after nab-paclitaxel monotherapy. The overall clinical response rate was 98% after nab-paclitaxel and cisplatin and 90% after nab-paclitaxel monotherapy. In subset analyses, cCR rates by T stage classifications (T2, T3, T4) were 54, 86, and 69% after nab-paclitaxel and cisplatin, and 14, 11, and 26% after nab-paclitaxel. cCR rates by human papillomavirus status (p16 positive oropharynx vs other) were 72 and 64% after nab-paclitaxel and cisplatin and 35 and 9% after nab-paclitaxel. The cCR rate after nab-paclitaxel and cisplatin was similar to APF; however, the cCR rate after nab-paclitaxel monotherapy was lower. The trial was registered at ClinicalTrials.gov NCT02573493 on October 9, 2015.
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Affiliation(s)
- Peter Oppelt
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.,Division of Medical Oncology, Washington University School of Medicine, 660 South Euclid, Campus, Box 8056, St. Louis, MO, 63110, USA
| | - Jessica Ley
- Division of Medical Oncology, Washington University School of Medicine, 660 South Euclid, Campus, Box 8056, St. Louis, MO, 63110, USA
| | - Mackenzie Daly
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.,Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jason Rich
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.,Department of Otolaryngology, Washington University School of Medicine, St. Louis, MO, USA
| | - Randal Paniello
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.,Department of Otolaryngology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ryan S Jackson
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.,Department of Otolaryngology, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrik Pipkorn
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.,Department of Otolaryngology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jingxia Liu
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Hiram Gay
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.,Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Kevin Palka
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.,Division of Medical Oncology, Washington University School of Medicine, 660 South Euclid, Campus, Box 8056, St. Louis, MO, 63110, USA
| | - Prakash Neupane
- Division of Oncology, University of Kansas School of Medicine, Kansas, MO, USA
| | - Steven Powell
- Sanford Cancer Center, Sanford Health, Sioux Falls, SD, USA
| | | | - Mark Gitau
- Sanford Cancer Center, Sanford Health, Fargo, ND, USA
| | - Jose Zevallos
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.,Department of Otolaryngology, Washington University School of Medicine, St. Louis, MO, USA
| | - Wade Thorstad
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.,Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Douglas Adkins
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA. .,Division of Medical Oncology, Washington University School of Medicine, 660 South Euclid, Campus, Box 8056, St. Louis, MO, 63110, USA.
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Last AS, Pipkorn P, Chen S, Kallogjeri D, Zenga J, Rich JT, Paniello R, Zevallos J, Chernock R, Adkins D, Oppelt P, Gay H, Daly M, Thorstad W, Jackson RS. Risk and Rate of Occult Contralateral Nodal Disease in Surgically Treated Patients With Human Papillomavirus-Related Squamous Cell Carcinoma of the Base of the Tongue. JAMA Otolaryngol Head Neck Surg 2021; 146:50-56. [PMID: 31697348 DOI: 10.1001/jamaoto.2019.3277] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Importance The optimal treatment strategy for patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) of the base of the tongue (BOT) has not been sufficiently studied. Objective To investigate the rate of and risk factors for occult contralateral nodal disease in patients with HPV-related BOT OPSCC undergoing transoral surgery and bilateral neck dissections. Design, Setting, and Participants This retrospective case series reviewed the medical records of patients with HPV-related BOT OPSCC who underwent transoral surgery and bilateral neck dissections from January 1, 2002, through December 31, 2018, at the tertiary care center of Washington University School of Medicine in St Louis. Patients had a median follow-up of 30.0 months (interquartile range, 11.0-60.4 months). Patients with recurrent disease or multiple synchronous OPSCC primary tumors were excluded for a total of 89 patients. Data were analyzed from January 1 through June 1, 2019. Main Outcomes and Measures The primary outcome was the rate of contralateral occult nodal disease. Secondary outcomes were potential risk factors for contralateral occult nodal disease and regional recurrence rates. Results Eighty-nine patients were included in the series, of whom 81 (91.0%) were men. The mean (SD) age was 60 (9) years. Overall, 34 patients (38.2%) had pathologic contralateral nodal metastases. Seventy patients had no clinical evidence of contralateral nodal disease. Of these 70, occult nodes were identified in 15 (21.4%). Risk of contralateral disease was higher when the primary tumor crossed midline (odds ratio, 6.23; 95% CI, 1.71-22.77). Of the 55 patients with no occult disease identified, only 2 (3.6%) received radiotherapy to the contralateral neck, and no regional recurrence of disease was noted. Conclusions and Relevance Given the rate of occult contralateral nodal disease of 21.4%, it appears that contralateral elective neck dissection or radiotherapy should be recommended in patients with HPV-related BOT OPSCC. Patients with a pathologically negative result of contralateral neck dissection may not benefit from radiotherapy to that nodal basin. Future prospective investigations should evaluate functional and oncologic outcomes of contralateral elective neck dissection compared with elective radiotherapy in the contralateral neck for HPV-related BOT OPSCC.
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Affiliation(s)
- Aisling S Last
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Stephanie Chen
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Dorina Kallogjeri
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Joseph Zenga
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee
| | - Jason T Rich
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Randal Paniello
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Jose Zevallos
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Rebecca Chernock
- Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Douglas Adkins
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Peter Oppelt
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Hiram Gay
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Mackenzie Daly
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Wade Thorstad
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
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Contreras JA, Spencer C, DeWees T, Haughey B, Henke LE, Chin RI, Paniello R, Rich J, Jackson R, Oppelt P, Pipkorn P, Zevallos J, Chernock R, Nussenbaum B, Daly M, Gay H, Adkins D, Thorstad W. Eliminating Postoperative Radiation to the Pathologically Node-Negative Neck: Long-Term Results of a Prospective Phase II Study. J Clin Oncol 2019; 37:2548-2555. [PMID: 31246526 DOI: 10.1200/jco.19.00186] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The volume treated with postoperative radiation therapy (PORT) is a mediator of toxicity, and reduced volumes result in improved quality of life (QOL). In this phase II trial, treatment volumes were reduced by omitting PORT to the pathologically negative (PN0) neck in patients with primary head and neck squamous cell carcinoma. METHODS Patients with head and neck squamous cell carcinoma who underwent surgical resection and neck dissection with a PN0 neck and high-risk features mandating PORT to the primary and/or involved neck were eligible. The primary end point was greater than 90% disease control in the unirradiated neck. QOL was evaluated using the MD Anderson Dysphagia Inventory and the University of Michigan patient-reported xerostomia questionnaire. RESULTS Seventy-three patients were enrolled, and 72 were evaluable. Median age was 56 years (range, 31 to 81 years); 58 patients were male, and 47 (65%) had a smoking history. Sites included oral cavity (n = 14), oropharynx (n = 37), hypopharynx (n = 4), larynx (n = 16), and unknown primary tumor (n = 1). According to the American Joint Committee on Cancer Staging Manual (7th edition), 67 patients (93%) had stage III/IV disease, and 71% of tumors involved or crossed midline. No patient had contralateral neck PORT. In 17 patients (24%), only the primary site was treated. At a median follow-up of 53 months, two patients experienced treatment failure of the PN0 unirradiated neck; they also experienced treatment failure locally. Unirradiated neck control was 97% (95% CI, 93.4% to 100.0%). Five-year rates of local control, regional control, progression-free survival, and overall survival were 84%, 93%, 60%, and 64%, respectively. QOL measures were not significantly different from baseline at 12 and 24 months post-PORT (P > .05). CONCLUSION Eliminating PORT to the PN0 neck resulted in excellent control rates in the unirradiated neck without long-term adverse effects on global QOL.
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Affiliation(s)
| | | | | | - Bruce Haughey
- Advent Health Celebration, Celebration; Morsani College of Medicine, Tampa, FL.,University of Auckland Faculty of Medicine and Health Sciences, Auckland, New Zealand
| | | | | | | | | | | | | | | | | | | | - Brian Nussenbaum
- American Board of Otolaryngology-Head and Neck Surgery, Houston, TX
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Bauer E, Mazul A, Chernock R, Rich J, Jackson RS, Paniello R, Pipkorn P, Oppelt P, Gay H, Daly M, El-Mofty S, Thorstad W, Adkins D, Zevallos J. Extranodal extension is a strong prognosticator in HPV-positive oropharyngeal squamous cell carcinoma. Laryngoscope 2019; 130:939-945. [PMID: 31077394 DOI: 10.1002/lary.28059] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/29/2019] [Accepted: 04/22/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To comprehensively examine the prognostic significance of extranodal extension (ENE) in human papillomavirus-positive oropharyngeal squamous cell carcinoma (HPV-positive OPSCC). METHODS Retrospective cohort of cases diagnosed with HPV-positive OPSCC from 2010 to 2015 in the National Cancer Database. Inclusion of all OPSCC HPV-positive cases with appropriate International Classification of Diseases-0-3 codes that received surgery with a neck dissection. Univariate and multivariable analyses were conducted. Hazard ratios (HR) for the independent effects of ENE and N stage on overall survival were estimated by Cox proportional hazards regression. RESULTS Cases that were ENE-negative had the highest 5-year survival (92.6%; 95% confidence interval [CI]: 90.5%-94.7%). ENE-positive cases had the lowest 5-year survival (84.0%; 95% CI: 80.7%-87.4%). After adjusting for confounding variables, ENE-positivity was associated with almost twice the hazard of death (HR = 1.90; 95% CI: 1.35-2.67) compared to ENE-negative cases. Nodal (N) category 1, ENE-positive status was associated with an increased risk of death (HR = 1.88; 95% CI: 1.26-2.80) compared with N1, ENE-negative status. Compared to N1/ENE-negative cases, N2/ENE-positive cases had the poorest survival (HR: 2.93; 95% CI: 1.94-4.43). Both microscopic and macroscopic ENE were associated with worse outcomes compared to node-positive/ENE-negative status. CONCLUSION The implementation of the American Joint Committee on Cancer 8th edition staging system provides a much-improved framework to develop and discuss treatment plans for HPV-positive OPSCC. We feel that careful consideration should be given to the importance of ENE in patients with HPV-positive OPSCC. LEVEL OF EVIDENCE 4 Laryngoscope, 130:939-945, 2020.
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Affiliation(s)
- Eric Bauer
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Angela Mazul
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Rebecca Chernock
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Jason Rich
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Randal Paniello
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Peter Oppelt
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Hiram Gay
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Mackenzie Daly
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Samir El-Mofty
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Wade Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Douglas Adkins
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Jose Zevallos
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
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Lin AJ, Gang M, Rao YJ, Campian J, Daly M, Gay H, Oppelt P, Jackson RS, Rich J, Paniello R, Zevallos J, Hallahan D, Adkins D, Thorstad W. Association of Posttreatment Lymphopenia and Elevated Neutrophil-to-Lymphocyte Ratio With Poor Clinical Outcomes in Patients With Human Papillomavirus-Negative Oropharyngeal Cancers. JAMA Otolaryngol Head Neck Surg 2019; 145:413-421. [PMID: 30920592 PMCID: PMC6537794 DOI: 10.1001/jamaoto.2019.0034] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/03/2019] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Better biomarkers are needed for human papillomavirus (HPV)-negative oropharyngeal cancer (OPC) to identify patients at risk of recurrence. Lymphopenia and an elevated ratio of neutrophils to lymphocytes (NLR) have been associated with poor disease outcomes in a number of solid tumors. OBJECTIVE To test the hypothesis that postradiotherapy lymphopenia and elevated NLR are associated with poor clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS This single-institution retrospective analysis included patients with HPV-negative OPC treated from January 1, 1997, through January 4, 2017. Median follow-up was 37 months (range, 2-197 months). A total of 108 patients with HPV-negative OPC and at least 1 complete blood cell count 2 to 12 months after the start of radiotherapy were included. Data were analyzed from August 26 to September 7, 2017. INTERVENTIONS Surgery followed by radiotherapy vs definitive radiotherapy, with or without chemotherapy. MAIN OUTCOMES AND MEASURES Absolute lymphocyte (ALC) and absolute neutrophil (ANC) counts were tested as variables affecting locoregional control, recurrence-free survival, and overall survival. RESULTS Of a total of 108 patients included in the analysis (87.0% male; mean age, 56 years [range, 35-84 years]), 57 received surgery followed by postoperative radiotherapy and 51 received definitive radiotherapy. During treatment, 67 of 79 patients (84.8%) had grades 3 to 4 lymphopenia and 17 of 79 (21.5%) had grade 4 lymphopenia. The ANC recovered by 6 months after radiotherapy, but ALC remained depressed to 1 year after radiotherapy. Posttreatment lymphopenia and elevated NLR were associated with worse recurrence-free and overall survival. The estimated 3-year LRC in patients with and without grades 3 to 4 lymphopenia at 3 months after radiotherapy start was 73% vs 82% (hazard ratio [HR], 0.58; 95% CI, 0.19-1.8); estimated 3-year recurrence-free survival, 36% vs 63% (HR, 0.45; 95% CI, 0.23-0.87); and estimated 3-year overall survival, 34% vs 64% (HR, 0.45; 95% CI, 0.23-0.88). In multivariable analysis, an association with worse overall survival was found for definitive radiotherapy (HR, 3.3; 95% CI, 1.6-7.1) and grades 3 to 4 lymphopenia (HR, 2.6; 95% CI, 1.3-5.5) at 3 months after radiotherapy. CONCLUSIONS AND RELEVANCE Lymphopenia and NLR as early as 3 months after treatment start may serve as biomarkers of clinical outcomes in patients with HPV-negative OPC. These patients may benefit from adjuvant treatment intensification or closer surveillance.
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Affiliation(s)
- Alexander J. Lin
- Department of Radiation Oncology, Washington University School of Medicine in Saint Louis, St Louis, Missouri
| | - Margery Gang
- Medical student at Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Yuan James Rao
- Department of Radiation Oncology, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jian Campian
- Division of Hematology and Oncology, Department of Internal Medicine, Washington University School of Medicine in Saint Louis, St Louis, Missouri
| | - Mackenzie Daly
- Department of Radiation Oncology, Washington University School of Medicine in Saint Louis, St Louis, Missouri
| | - Hiram Gay
- Department of Radiation Oncology, Washington University School of Medicine in Saint Louis, St Louis, Missouri
| | - Peter Oppelt
- Division of Hematology and Oncology, Department of Internal Medicine, Washington University School of Medicine in Saint Louis, St Louis, Missouri
| | - Ryan S. Jackson
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri
| | - Jason Rich
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri
| | - Randal Paniello
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri
| | - Jose Zevallos
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri
| | - Dennis Hallahan
- Department of Radiation Oncology, Washington University School of Medicine in Saint Louis, St Louis, Missouri
| | - Douglas Adkins
- Division of Hematology and Oncology, Department of Internal Medicine, Washington University School of Medicine in Saint Louis, St Louis, Missouri
| | - Wade Thorstad
- Department of Radiation Oncology, Washington University School of Medicine in Saint Louis, St Louis, Missouri
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7
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Lin AJ, Gabani P, Fischer-Valuck B, Rudra S, Gay H, Daly M, Oppelt P, Jackson R, Rich J, Paniello R, Zevallos J, Adkins D, Thorstad W. Patterns of care and survival outcomes for laryngeal small cell cancer. Head Neck 2019; 41:722-729. [PMID: 30785231 DOI: 10.1002/hed.25430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 07/19/2018] [Accepted: 09/21/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To determine practice patterns and outcomes of laryngeal small cell cancer (LSCC) across the United States. METHODS Patients with LSCC were identified in the National Cancer Database. Overall survival (OS) was compared with Kaplan-Meier analysis and Cox regression. RESULTS From 2004 to 2014, the 5-year OS for early stage (n = 47), locally advanced stage (n = 133), and metastatic disease (n = 53) was 34%, 26%, and 9%, respectively. Chemoradiation was given in 66% of cases. Chemotherapy was less likely given in early stage disease (P = .001), and definitive radiation was less likely given in metastatic disease (P < .001). Definitive radiation improved median OS in locally advanced LSCC (20 vs. 7 months, log-rank P = .04). In multivariable modeling, radiation dose ≥40 Gy was associated with better OS (P < .001). CONCLUSION Chemoradiation was the most common practice for treating locally advanced LSCC, and radiation dose ≥40 Gy was associated with improved OS.
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Affiliation(s)
- Alexander J Lin
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Prashant Gabani
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Ben Fischer-Valuck
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Soumon Rudra
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Hiram Gay
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Mackenzie Daly
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Peter Oppelt
- Division of Hematology and Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Ryan Jackson
- Division of Head and Neck Oncology Surgery, Department of Otolaryngology, Washington University School of Medicine, St. Louis, Missouri
| | - Jason Rich
- Division of Head and Neck Oncology Surgery, Department of Otolaryngology, Washington University School of Medicine, St. Louis, Missouri
| | - Randal Paniello
- Division of Head and Neck Oncology Surgery, Department of Otolaryngology, Washington University School of Medicine, St. Louis, Missouri
| | - Jose Zevallos
- Division of Head and Neck Oncology Surgery, Department of Otolaryngology, Washington University School of Medicine, St. Louis, Missouri
| | - Douglas Adkins
- Division of Hematology and Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Wade Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
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8
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Ludlow CL, Domangue R, Sharma D, Jinnah HA, Perlmutter JS, Berke G, Sapienza C, Smith ME, Blumin JH, Kalata CE, Blindauer K, Johns M, Hapner E, Harmon A, Paniello R, Adler CH, Crujido L, Lott DG, Bansberg SF, Barone N, Drulia T, Stebbins G. Consensus-Based Attributes for Identifying Patients With Spasmodic Dysphonia and Other Voice Disorders. JAMA Otolaryngol Head Neck Surg 2018; 144:657-665. [PMID: 29931028 PMCID: PMC6143004 DOI: 10.1001/jamaoto.2018.0644] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 03/20/2018] [Indexed: 11/14/2022]
Abstract
Importance A roadblock for research on adductor spasmodic dysphonia (ADSD), abductor SD (ABSD), voice tremor (VT), and muscular tension dysphonia (MTD) is the lack of criteria for selecting patients with these disorders. Objective To determine the agreement among experts not using standard guidelines to classify patients with ABSD, ADSD, VT, and MTD, and develop expert consensus attributes for classifying patients for research. Design, Setting and Participants From 2011 to 2016, a multicenter observational study examined agreement among blinded experts when classifying patients with ADSD, ABSD, VT or MTD (first study). Subsequently, a 4-stage Delphi method study used reiterative stages of review by an expert panel and 46 community experts to develop consensus on attributes to be used for classifying patients with the 4 disorders (second study). The study used a convenience sample of 178 patients clinically diagnosed with ADSD, ABSD, VT MTD, vocal fold paresis/paralysis, psychogenic voice disorders, or hypophonia secondary to Parkinson disease. Participants were aged 18 years or older, without laryngeal structural disease or surgery for ADSD and underwent speech and nasolaryngoscopy video recordings following a standard protocol. Exposures Speech and nasolaryngoscopy video recordings following a standard protocol. Main Outcomes and Measures Specialists at 4 sites classified 178 patients into 11 categories. Four international experts independently classified 75 patients using the same categories without guidelines after viewing speech and nasolaryngoscopy video recordings. Each member from the 4 sites also classified 50 patients from other sites after viewing video clips of voice/laryngeal tasks. Interrater κ less than 0.40 indicated poor classification agreement among rater pairs and across recruiting sites. Consequently, a Delphi panel of 13 experts identified and ranked speech and laryngeal movement attributes for classifying ADSD, ABSD, VT, and MTD, which were reviewed by 46 community specialists. Based on the median attribute rankings, a final attribute list was created for each disorder. Results When classifying patients without guidelines, raters differed in their classification distributions (likelihood ratio, χ2 = 107.66), had poor interrater agreement, and poor agreement with site categories. For 11 categories, the highest agreement was 34%, with no κ values greater than 0.26. In external rater pairs, the highest κ was 0.23 and the highest agreement was 38.5%. Using 6 categories, the highest percent agreement was 73.3% and the highest κ was 0.40. The Delphi method yielded 18 attributes for classifying disorders from speech and nasolaryngoscopic examinations. Conclusions and Relevance Specialists without guidelines had poor agreement when classifying patients for research, leading to a Delphi-based development of the Spasmodic Dysphonia Attributes Inventory for classifying patients with ADSD, ABSD, VT, and MTD for research.
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Affiliation(s)
- Christy L. Ludlow
- Department of Communication Sciences and Disorders, James Madison University, Harrisonburg, Virgina
| | - Rickie Domangue
- Department of Mathematics and Statistics, James Madison University, Harrisonburg, Virgina
| | - Dinesh Sharma
- Department of Mathematics and Statistics, James Madison University, Harrisonburg, Virgina
| | - H. A. Jinnah
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Joel S. Perlmutter
- Neurology, Radiology, Neuroscience, Physical Therapy and Occupational Therapy, Washington University School of Medicine, St Louis, Missouri
| | - Gerald Berke
- Head and Neck Surgery, Ronald Reagan University of California Los Angeles Medical Center, Los Angeles
| | - Christine Sapienza
- Communication Sciences and Disorders, Jacksonville University, Jacksonville, Florida
| | - Marshall E. Smith
- Division of Otolaryngology–Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City
| | - Joel H. Blumin
- Division of Laryngology and Professional Voice, Medical College of Wisconsin, Milwaukee
| | - Carrie E. Kalata
- Division of Laryngology and Professional Voice, Medical College of Wisconsin, Milwaukee
| | - Karen Blindauer
- Department of Neurology, Medical College of Wisconsin, Milwaukee
| | - Michael Johns
- Emory Voice Center, Department of Otolaryngology–Head and Neck Surgery, Emory Medicine, Emory University, Atlanta, Georgia
- Division of Laryngology, Keck Medicine of University of Southern California, Los Angeles
| | - Edie Hapner
- Emory Voice Center, Department of Otolaryngology–Head and Neck Surgery, Emory Medicine, Emory University, Atlanta, Georgia
- Division of Laryngology, Keck Medicine of University of Southern California, Los Angeles
| | - Archie Harmon
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Randal Paniello
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Charles H. Adler
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Lisa Crujido
- Department of Otolaryngology, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
| | - David G. Lott
- Department of Otolaryngology, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Stephen F. Bansberg
- Department of Otolaryngology, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Nicholas Barone
- Department of Communication Sciences and Disorders, James Madison University, Harrisonburg, Virgina
- Communication Sciences and Disorders, Curry School of Education, University of Virginia, Charlottesville
| | - Teresa Drulia
- Department of Communication Sciences and Disorders, James Madison University, Harrisonburg, Virgina
- Davies School of Communication Sciences and Disorders, Harris College of Nursing and Health Sciences, Texas Christian University, Fort Worth
| | - Glenn Stebbins
- Department of Neurological Sciences, Rush Medical College, Chicago, Illinois
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Uppaluri R, Zolkind P, Lin T, Nussenbaum B, Jackson RS, Rich J, Pipkorn P, Paniello R, Thorstad W, Michel L, Mudianto T, Oppelt PJ, Wildes TM, Dunn GP, Piccirillo JF, Kallogjeri D, Rodig S, Hagemann IS, Chernock R, Adkins D. Neoadjuvant pembrolizumab in surgically resectable, locally advanced HPV negative head and neck squamous cell carcinoma (HNSCC). J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.6012] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6012 Background: Pembrolizumab has efficacy in metastatic HNSCC. We hypothesized that treatment intensification in surgically resectable HPV-negative, Stage III/IV HNSCC with neoadjuvant plus post-operative adjuvant (POA) pembrolizumab would be safe and reduce 1-year locoregional recurrence/distant metastases (LRR/DM) from 35% (historical: Cooper and Bernier NEJM 2004) to 15%. Methods: Phase II trial where all eligible patients received 1 dose of pembrolizumab (200 mg) prior to surgery and only those with high-risk pathologic features (HRPF: extracapsular extension/positive margin) were given POA cisplatin and radiation followed by pembrolizumab. PD-L1 staining was assessed by immunohistochemistry (9A11 antibody). Results: The study continues to enroll. Characteristics of 21 enrolled patients (pts) were median age 59 (32-87) yrs, tobacco use 81% (17 pts), clinical T2 (n = 2), T3 (n = 1), T4 (n = 18), and cN0/1 (n = 8), cN2 (n = 13). Preliminary analyses revealed five important findings: 1) No serious study drug-related AEs or unexpected surgical delays/complications, 2) No LRR/DM events in the first 10 patients with > 1-year follow-up after surgery 3) HRPF rate of 38% (95% CI: 18%-62%) (expected: 80%), 4) 43% of pts (95% CI: 22%-66%) with pathologic treatment response to neoadjuvant pembrolizumab (definition: tumor necrosis and/or giant cell/histiocytic reaction to keratinous debris in > 10% of tumor area), and 5) 48% of pts (95% CI:26%-70%) with clinical-to-pathologic downstaging. Pathologic treatment effect (TE) in ≥ 70% of the resected tumor or lymph node tissue area occurred in 6/21 pts (29%). Baseline tumor biopsies were PD-L1 positive ( > 1% of tumor cells) in 11/19 (58%) evaluable samples and in 7/8 (88%) evaluable pathologic responders. A significant correlation existed between baseline PD-L1 expression on tumor cells and pathologic treatment effect in the tumor (correlation coefficient: 0.72 and p = 0.0005). Conclusions: Neoadjuvant and adjuvant pembrolizumab was safe and well tolerated. We observed several lines of evidence supporting an anti-tumor effect in these pts with a single dose of pre-operative pembrolizumab. Further evaluation of this strategy is warranted. Clinical trial information: NCT02296684.
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Affiliation(s)
- Ravindra Uppaluri
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA
| | - Paul Zolkind
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Tianxiang Lin
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian Nussenbaum
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Ryan S Jackson
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jason Rich
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Patrik Pipkorn
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Randal Paniello
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Loren Michel
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Peter John Oppelt
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Gavin P Dunn
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jay F Piccirillo
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Dorina Kallogjeri
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Scott Rodig
- Department of Pathology and Center for Immuno-Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ian S. Hagemann
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Rebecca Chernock
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Douglas Adkins
- Washington University School of Medicine in St. Louis and Siteman Cancer Center, St. Louis, MO
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10
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Adkins D, Ley J, Michel L, Wildes TM, Thorstad W, Gay HA, Daly M, Rich J, Paniello R, Uppaluri R, Jackson R, Trinkaus K, Nussenbaum B. nab-Paclitaxel, cisplatin, and 5-fluorouracil followed by concurrent cisplatin and radiation for head and neck squamous cell carcinoma. Oral Oncol 2016; 61:1-7. [PMID: 27688097 PMCID: PMC5105832 DOI: 10.1016/j.oraloncology.2016.07.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/21/2016] [Accepted: 07/22/2016] [Indexed: 01/22/2023]
Abstract
OBJECTIVES We previously reported the efficacy of nab-paclitaxel added to cisplatin, 5-FU, and cetuximab (APF-C) followed by concurrent high dose bolus cisplatin and radiation therapy (CRT) in patients with locally advanced head and neck squamous cell carcinoma (HNSCC). In this phase II trial, we determined the efficacy of APF (without cetuximab) followed by CRT in similar patients. MATERIALS AND METHODS Eligible patients had stage III-IV oropharynx (OP), larynx, or hypopharynx SCC and adequate organ function and performance status. T1 tumors were excluded. Patients were treated with three cycles of APF followed by CRT. Efficacy endpoints included two-year disease-specific survival (DSS), progression-free survival (PFS), overall survival (OS), and relapse rate. RESULTS Thirty patients were enrolled. Most patients were smokers (77%) with bulky T3/4 (73%) and N2/3 (83%) tumors. Analyses were stratified for human papilloma virus (HPV) status: HPV-related OPSCC (n=17; 57%) and HPV-unrelated HNSCC (n=13; 43%). With a minimum follow-up of 21months, relapse occurred in 1 (3%) patient. Two-year DSS was 94% in HPV-related OPSCC and 100% in HPV-unrelated HNSCC. Two-year PFS was 94% in HPV-related OPSCC and 100% in HPV-unrelated HNSCC. Two-year OS was 94% in HPV-related OPSCC and 92% in HPV-unrelated HNSCC. Causes of death were relapse (1), treatment-related mortality (1), and co-morbidity (1). Two patients with HPV-unrelated HNSCC treated with APF declined CRT and remained free of relapse at 36 and 28months of follow-up. CONCLUSION This phase II trial demonstrated favorable two-year DSS, PFS, and OS and a low relapse rate in HPV-unrelated HNSCC and HPV-related OPSCC treated with APF followed by CRT.
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Affiliation(s)
- Douglas Adkins
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, United States.
| | - Jessica Ley
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Loren Michel
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Tanya M Wildes
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Wade Thorstad
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Hiram A Gay
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Mackenzie Daly
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Jason Rich
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Department of Otolaryngology, Washington University School of Medicine, St. Louis, MO, United States
| | - Randal Paniello
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Department of Otolaryngology, Washington University School of Medicine, St. Louis, MO, United States
| | - Ravindra Uppaluri
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Department of Otolaryngology, Washington University School of Medicine, St. Louis, MO, United States
| | - Ryan Jackson
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Department of Otolaryngology, Washington University School of Medicine, St. Louis, MO, United States
| | - Kathryn Trinkaus
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, United States
| | - Brian Nussenbaum
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Department of Otolaryngology, Washington University School of Medicine, St. Louis, MO, United States
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11
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Uppaluri R, Winkler A, Lin T, Law J, Haughey B, Nussenbaum B, Paniello R, Rich J, Diaz J, Michel L, Wildes T, Dunn G, Kallogjeri D, Zolkind P, Dehdashti F, Siegel B, Chernock R, Lewis JS, Piccirillo J, Adkins D. Abstract CT070: Biomarker and clinical response of oral cavity squamous cell carcinoma to the MEK 1/2 inhibitor trametinib: A phase II neoadjuvant window of opportunity clinical trial. Cancer Res 2016. [DOI: 10.1158/1538-7445.am2016-ct070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Purpose: Ras/MEK/ERK pathway activation is common in oral cavity squamous cell carcinoma (OCSCC). To determine biomarker and clinical tumor response of MEK inhibition in patients with OCSCC, we performed a neoadjuvant window of opportunity trial in which the MEK inhibitor trametinib was administered before surgery (NCT01553851).
Patients and Methods: Patients with untreated Stage II-IV OCSCC were scheduled to receive trametinib 2 mg/day orally for 7-14 days prior to surgery (last dose 24 hours before surgery). Tumor specimens from the primary site obtained before and after trametinib underwent immunohistochemistry staining for p-ERK1/2 (a marker of Ras/MEK/ERK activation) and CD44 (a protein upregulated by ERK activation), which represented the primary endpoint. Secondary endpoints included comparison of changes in pre- and post-trametinib tumor measurement by clinical examination and in metabolic activity (SUVmax) by FDG-PET/CT (partial response: >25% reduction). Adverse events (AE) and surgical/wound complications were evaluated.
Results: Of the 20 enrolled patients, 17 (85%) completed the study as planned. Three patients withdrew from the study due to AE, two (nausea; duodenal perforation) related to trametinib and one (constipation) related to narcotics. The most common drug-related AE was mild rash (9/20 patients, 45%). Nineteen patients (95%) underwent surgery and neck dissection with no unexpected surgical/wound complications. Fifteen patients (75%) were evaluable for the primary biomarker endpoint. 5 (25%) patients either had insufficient pre- or post-treatment biopsies or did not complete the trial. Reduction in p-ERK1/2 expression occurred in 7/15 evaluable patients (47%), whereas a reduction in CD44 occurred in 3/15 (20%). Reduction in tumor size (median 40%, range -74 to +17%) assessed by clinical examination was observed in 12/17 (71%) evaluable patients, and partial metabolic tumor response assessed by FDG-PET/CT was observed in 5/13 (38%) patients.
Conclusions: Trametinib was safe to administer as a neoadjuvant treatment in patients with OCSCC and several patients displayed significant reduction in Ras/MEK/ERK pathway activation, and in clinical and metabolic tumor responses. Further exploration of trametinib response in OCSCC patients is warranted.
Citation Format: Ravindra Uppaluri, Ashley Winkler, Tianxiang Lin, Jonathan Law, Bruce Haughey, Brian Nussenbaum, Randal Paniello, Jason Rich, Jason Diaz, Loren Michel, Tanya Wildes, Gavin Dunn, Dorina Kallogjeri, Paul Zolkind, Farrokh Dehdashti, Barry Siegel, Rebecca Chernock, James S. Lewis, Jay Piccirillo, Douglas Adkins. Biomarker and clinical response of oral cavity squamous cell carcinoma to the MEK 1/2 inhibitor trametinib: A phase II neoadjuvant window of opportunity clinical trial. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr CT070.
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Uppaluri R, Zolkind P, Lin T, Nussenbaum B, Paniello R, Rich J, Jackson R, Thorstad W, Gay HA, Daly M, Kallogjeri D, Dunn GP, Wildes TM, Michel LS, Chernock R, Piccirillo JF, Griffith O, Adkins D. Immunotherapy with pembrolizumab in surgically resectable head and neck squamous cell carcinoma. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.tps6110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Paul Zolkind
- Washington University School of Medicine, St. Louis, MO
| | - Tianxiang Lin
- Washington University School of Medicine, St. Louis, MO
| | - Brian Nussenbaum
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Randal Paniello
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jason Rich
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Ryan Jackson
- Washington University School of Medicine, St. Louis, MO
| | | | - Hiram Alberto Gay
- Washington University in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | | | | | - Gavin P Dunn
- Washington University School of Medicine, St. Louis, MO
| | | | | | | | - Jay F Piccirillo
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Obi Griffith
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Douglas Adkins
- Washington University School of Medicine and Siteman Cancer Center, St. Louis, MO
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Adkins D, Ley JC, Wildes TM, Michel LS, Rich J, Paniello R, Uppaluri R, Thorstad WL, Gay HA, Trinkaus K, Rachocki T, Nussenbaum B. The role of cetuximab in induction chemotherapy: Comparison of APF-C (nab-paclitaxel, cisplatin, 5-FU + cetuximab) with APF, both followed by chemoradiation therapy (CRT), in patients with locally advanced head and neck squamous cell carcinoma (HNSCC). J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.6042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | - Jason Rich
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Randal Paniello
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Ravi Uppaluri
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Wade L. Thorstad
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Hiram Alberto Gay
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Toni Rachocki
- Washington University School of Medicine, St. Louis, MO
| | - Brian Nussenbaum
- Washington University School of Medicine in St. Louis, St. Louis, MO
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Ley JC, Nussenbaum B, Diaz J, Rich J, Paniello R, Uppaluri R, Thorstad WL, Gay HA, Rachocki T, Varges J, Wildes TM, Michel LS, Adkins D. Comparison of clinical primary tumor site (PTS) response to induction chemotherapy (IC) with APF ( nab-paclitaxel, cisplatin, and 5-FU) or APF plus cetuximab (APF+Cetux) in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN). J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.6013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jessica C. Ley
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian Nussenbaum
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jason Diaz
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jason Rich
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Randal Paniello
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Ravi Uppaluri
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Wade L. Thorstad
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Hiram Alberto Gay
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Jaisy Varges
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Loren S. Michel
- Division of Oncology, Washington University School of Medicine, St. Louis, MO
| | - Douglas Adkins
- Washington University School of Medicine in St. Louis, St. Louis, MO
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Adkins D, Ley J, Nussenbaum B, Diaz J, Paniello R, Thorstad WL, Gay HA, Subramanian J, Wildes TM, Mathai J, Rachocki T, Kuperman DI. Clinical response rate at primary tumor site (PTS) following a novel induction chemotherapy (IC) regimen of weekly nanoparticle albumin-bound (nab-)paclitaxel and cetuximab with every-3-week cisplatin and 5-FU (ACCF) versus docetaxel, cisplatin, 5-FU, and cetuximab (TPF + C) in patients with locally advanced head and neck squamous cell carcinoma (HNSCC). J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.5560] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Kuperman DI, Ley J, Nussenbaum B, Diaz J, Paniello R, Thorstad WL, Gay HA, Subramanian J, Wildes TM, Mathai J, Rachocki T, Adkins D. Safety analysis of a novel induction chemotherapy (IC) regimen of weekly nanoparticle albumin-bound (nab-)paclitaxel and cetuximab with every 3 week cisplatin and 5-FU in 30 patients (pts) with locally advanced nonmetastatic head and neck squamous cell carcinoma (HNSCC). J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.e16025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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17
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Xiao J, Bastian RW, Perlmutter JS, Racette BA, Tabbal SD, Karimi M, Paniello R, Blitzer A, Batish SD, Wszolek ZK, Uitti RJ, Van Gerpen JA, Hedera P, Simon DK, Tarsy D, Truong DD, Frei KP, Pfeiffer RF, Gong S, LeDoux MS. Novel human pathological mutations. Gene symbol: THAP1. Disease: dystonia 6. Hum Genet 2010; 127:470. [PMID: 21488298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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18
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Xiao J, Zhao Y, Bastian RW, Perlmutter JS, Racette BA, Tabbal SD, Karimi M, Paniello R, Blitzer A, Batish SD, Wszolek ZK, Uitti RJ, Van Gerpen JA, Hedera P, Simon DK, Tarsy D, Truong DD, Frei KP, Pfeiffer RF, Gong S, LeDoux MS. Novel human pathological mutations. Gene symbol: THAP1. Disease: dystonia 6. Hum Genet 2010; 127:470. [PMID: 21488297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Jianfeng Xiao
- Department of Neurology, UTHSC, Memphis, TN 38163, USA.
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Xiao J, Zhao Y, Bastian RW, Perlmutter JS, Racette BA, Tabbal SD, Karimi M, Paniello R, Blitzer A, Batish SD, Wszolek ZK, Uitti RJ, Van Gerpen JA, Hedera P, Simon DK, Tarsy D, Truong DD, Frei KP, Pfeiffer RF, Gong S, LeDoux MS. Novel human pathological mutations. Gene symbol: THAP1. Disease: dystonia 6. Hum Genet 2010; 127:469-470. [PMID: 21488296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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20
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Xiao J, Zhao Y, Bastian RW, Perlmutter JS, Racette BA, Tabbal SD, Karimi M, Paniello R, Blitzer A, Batish SD, Wszolek ZK, Uitti RJ, Van Gerpen JA, Hedera P, Simon DK, Tarsy D, Truong DD, Frei KP, Pfeiffer RF, Gong S, LeDoux MS. Novel human pathological mutations. Gene symbol: THAP1. Disease: dystonia 6. Hum Genet 2010; 127:469. [PMID: 21488277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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21
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Xiao J, Zhao Y, Bastian RW, Perlmutter JS, Racette BA, Tabbal SD, Karimi M, Paniello R, Blitzer A, Batish SD, Wszolek ZK, Uitti RJ, Van Gerpen JA, Hedera P, Simon DK, Tarsy D, Truong DD, Frei KP, Pfeiffer RF, Gong S, LeDoux MS. Novel human pathological mutations. Gene symbol: THAP1. Disease: dystonia 6. Hum Genet 2010; 127:470. [PMID: 21488252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Khosla S, Murugappan S, Paniello R, Ying J, Gutmark E. Role of vortices in voice production: Normal versus asymmetric tension. Laryngoscope 2009; 119:216-21. [DOI: 10.1002/lary.20026] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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23
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Virgo K, Paniello R, Johnson M, Clemente M, Johnson F. Surgical decision making in upper aerodigestive tract cancer patient follow-up. Int J Oncol 2002. [DOI: 10.3892/ijo.21.5.1101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Sclaroff A, Haughey B, Gay WD, Paniello R. Immediate mandibular reconstruction and placement of dental implants. At the time of ablative surgery. Oral Surg Oral Med Oral Pathol 1994; 78:711-7. [PMID: 7898907 DOI: 10.1016/0030-4220(94)90085-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The outcomes of surgical reconstruction for patients who have undergone extensive tumor resection of the mandible and associated soft tissue have been less than desirable for many reasons: lack of cancer cure, radiation problems, as well as inadequate functional reconstructive results. These patients traditionally have undergone multiple surgical procedures for restoration of the surgical deformity. With the advent of new donor sites and successful transfer of microvascular hard and soft tissue, one can restore the largest defects created during cancer excision. Combining these techniques with biocompatible dental implants and reconstructive bone plates, technology has advanced to the point of predictable outcomes. The restoration of appearance, mandibular function, and mastication is mandated by patients. Dental implants are now placed in vascularized bone reconstruction of the mandible immediately at the time of ablative surgery. This obviates the need for additional surgical reconstructive procedures, adjunctive hyperbaric oxygen therapy, and problems associated with the placement of dental implants in irradiated tissue.
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Affiliation(s)
- A Sclaroff
- Department of Otolaryngology, Washington University School of Medicine
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