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Chang KW, Mazul AL, Lander DP, Wahle BM, Yan EZ, Thorstad WL, Puram SV, Jackson RS, Pipkorn P, Paniello RC, Zolkind PA, Olshan AF, Zevallos JP. Poor Dental Health as a Risk Factor for Alveolar Ridge Malignancies. Otolaryngol Head Neck Surg 2024; 170:1081-1090. [PMID: 38219743 DOI: 10.1002/ohn.647] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/15/2023] [Accepted: 05/01/2023] [Indexed: 01/16/2024]
Abstract
OBJECTIVE To determine the association between poor dental health and risk of oral cavity squamous cell cancer (OCSCC) at individual tumor subsites. STUDY DESIGN Case-control and cross-sectional METHODS: A case-control study was performed using a population-based cohort in North Carolina (Carolina Head and Neck Cancer Epidemiology Study [CHANCE]). A secondary cross-sectional analysis was performed with an institutional cohort (WashU/Siteman). Cases were adults with primary OCSCC and an identifiable tumor subsite. In the CHANCE cohort, controls were adults without head and neck cancer. In the Washington University/Siteman cohort, patients with tongue cancer served as the comparator group. We used number of missing teeth (categorized 0-6, 7-24, 25-28) as a surrogate for poor dental health, which was self-reported in CHANCE and measured on a pretreatment computed tomography scan in the WashU/Siteman study. Adjusted odds ratios (aORs) for missing teeth were estimated for each tumor subsite using binomial logistic regression models. RESULTS Near complete tooth loss (25-28 teeth) was associated with a 3.5-fold increased risk of alveolar ridge malignancy (aOR: 3.51; 95% confidence interval [CI]: 1.14-11.01, P = .03) in the CHANCE study. This association was confirmed in our cross-sectional analysis (WashU/Siteman study) where missing 25-28 teeth was associated with an increased risk of alveolar ridge compared to tongue cancer (aOR: 4.60; 95% CI: 1.97-11.10, P = .001). CONCLUSIONS This study suggests an association between poor dental health and risk of alveolar ridge cancer independent of smoking, alcohol use, age, race, and sex. Future prospective and translational studies are needed to confirm this association and elucidate the mechanism of dental disease in alveolar ridge malignancies.
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Affiliation(s)
- Katherine W Chang
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Angela L Mazul
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel P Lander
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin M Wahle
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Emily Z Yan
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Genetics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Randal C Paniello
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Paul A Zolkind
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Andrew F Olshan
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jose P Zevallos
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburg, Pennsylvania, USA
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Lee DS, Travis EY, Wong SK, Collopy C, McClannahan KS, Ortmann AJ, Rich JT, Pipkorn P, Puram SV, Jackson RS, Paniello RC, Adkins DR, Oppelt P, Thorstad WL, Wick CC, Zevallos JP, Mazul AL. Audiologic Follow-up in Patients With Head and Neck Cancer Treated With Cisplatin and Radiation. Laryngoscope 2023; 133:3161-3168. [PMID: 36995150 PMCID: PMC10544674 DOI: 10.1002/lary.30682] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/27/2023] [Accepted: 03/17/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVES Evaluate factors associated with adherence to ototoxicity monitoring among patients with head and neck cancer treated with cisplatin and radiation therapy at a tertiary care center. METHODS We performed a single-institution retrospective cohort study on adults with head and neck cancer treated with cisplatin and radiation therapy who participated in an ototoxicity monitoring program. The primary outcomes were rates of post-treatment audiograms at the following time points: one, three, six, 12, and greater than 12 months. Multivariable logistic regression was performed to identify risk factors associated with complete loss of follow-up after pre-treatment evaluation. RESULTS Two hundred ninety-four head and neck cancer patients were analyzed. Overall, 220 (74.8%) patients had at least one post-treatment audiogram; 58 (20.0%) patients had more than one audiogram. The time point with the highest follow-up rate was at 3 months (n = 170, 57.8%); rates at the remaining times ranged from 7.1% to 14.3%. When controlling for covariates, patients without insurance and those with stage IV cancers were associated with complete loss of audiologic follow-up (aOR = 7.18, 95% CI = 2.75-19.90; aOR = 1.96, 95% CI = 1.02-3.77, respectively). Among 156 patients recommended for a hearing aid, only 39 (24.8%) patients received one. CONCLUSIONS Head and neck cancer patients enrolled in an ototoxicity monitoring program demonstrate moderately high follow-up rates for at least one post-treatment audiogram. However, follow-up tapers dramatically after 6 months, and overall hearing aid utilization is low. Further research is needed to understand barriers to long-term audiologic follow-up and hearing aid utilization to decrease untreated hearing loss in cancer survivorship. LEVEL OF EVIDENCE Level 3 Laryngoscope, 133:3161-3168, 2023.
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Affiliation(s)
- David S Lee
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Emma Y Travis
- Division of Adult Audiology, Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Susan K Wong
- Division of Adult Audiology, Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Cathryn Collopy
- Division of Adult Audiology, Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Katrina S McClannahan
- Division of Adult Audiology, Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Amanda J Ortmann
- Division of Adult Audiology, Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jason T Rich
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sidharth V Puram
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Genetics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ryan S Jackson
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Randal C Paniello
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Douglas R Adkins
- Division of Medical Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Peter Oppelt
- Division of Medical Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Cameron C Wick
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jose P Zevallos
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Angela L Mazul
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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3
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Puram SV, Mints M, Pal A, Qi Z, Reeb A, Gelev K, Barrett TF, Gerndt S, Liu P, Parikh AS, Ramadan S, Law T, Mroz EA, Rocco JW, Adkins D, Thorstad WL, Gay HA, Ding L, Paniello RC, Pipkorn P, Jackson RS, Wang X, Mazul A, Chernock R, Zevallos JP, Silva-Fisher J, Tirosh I. Cellular states are coupled to genomic and viral heterogeneity in HPV-related oropharyngeal carcinoma. Nat Genet 2023; 55:640-650. [PMID: 37012457 PMCID: PMC10191634 DOI: 10.1038/s41588-023-01357-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [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: 09/16/2021] [Accepted: 02/27/2023] [Indexed: 04/05/2023]
Abstract
Head and neck squamous cell carcinoma (HNSCC) includes a subset of cancers driven by human papillomavirus (HPV). Here we use single-cell RNA-seq to profile both HPV-positive and HPV-negative oropharyngeal tumors, uncovering a high level of cellular diversity within and between tumors. First, we detect diverse chromosomal aberrations within individual tumors, suggesting genomic instability and enabling the identification of malignant cells even at pathologically negative margins. Second, we uncover diversity with respect to HNSCC subtypes and other cellular states such as the cell cycle, senescence and epithelial-mesenchymal transitions. Third, we find heterogeneity in viral gene expression within HPV-positive tumors. HPV expression is lost or repressed in a subset of cells, which are associated with a decrease in HPV-associated cell cycle phenotypes, decreased response to treatment, increased invasion and poor prognosis. These findings suggest that HPV expression diversity must be considered during diagnosis and treatment of HPV-positive tumors, with important prognostic ramifications.
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Affiliation(s)
- Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA.
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA.
- Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA.
| | - Michael Mints
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Ananya Pal
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Zongtai Qi
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ashley Reeb
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Kyla Gelev
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Thomas F Barrett
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sophie Gerndt
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ping Liu
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Anuraag S Parikh
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Salma Ramadan
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Travis Law
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Edmund A Mroz
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, OH, USA
| | - James W Rocco
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, OH, USA
| | - Doug Adkins
- Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Wade L Thorstad
- Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Hiram A Gay
- Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Li Ding
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- McDonnell Genome Institute, Washington University in St. Louis, St. Louis, MO, USA
| | - Randal C Paniello
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
| | - Xiaowei Wang
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Department of Pharmacology and Regenerative Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Angela Mazul
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Rebecca Chernock
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jose P Zevallos
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
| | - Jessica Silva-Fisher
- Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Itay Tirosh
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel.
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4
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Yan EZ, Wahle BM, Nakken ER, Chidambaram S, Getz K, Thorstad WL, Zevallos JP, Mazul AL. No survival benefit in never-smoker never-drinker patients with oral cavity cancer. Head Neck 2023; 45:567-577. [PMID: 36524736 PMCID: PMC9898183 DOI: 10.1002/hed.27266] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/01/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Although strongly associated with tobacco and alcohol use, many oral cavity squamous cell carcinoma (OCSCC) cases occur in patients without exposure to either, known as "never-smoker, never-drinkers" (NSND). We aimed to compare clinical outcomes between NSND and tobacco/alcohol-exposed populations and to define demographic characteristics of NSND. METHODS We performed a retrospective, single-institution cohort study of 672 OCSCC patients. Cox models were used to estimate differences in overall survival (OS) and recurrence-free survival (RFS) between NSND and tobacco/alcohol-exposed patients while adjusting for confounders. RESULTS NSND represented 25.6% of our cohort and were older, more female, and more economically advantaged. Among NSND, oral tongue tumors dominated in younger patients, while alveolar ridge tumors dominated in elderly patients. Multivariate survival analysis revealed no differences in OS or RFS between NSND and tobacco/alcohol-exposed patients. CONCLUSION When adjusted for independent biologic features, clinical outcomes in OCSCC are similar between NSND and tobacco/alcohol-exposed patients.
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Affiliation(s)
- Emily Z. Yan
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin M. Wahle
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Erik R. Nakken
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Smrithi Chidambaram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
- Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Kayla Getz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Wade L. Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jose P. Zevallos
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Angela L. Mazul
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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5
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Lee DS, Lee JJ, Sinha P, Puram SV, Jackson RS, Adkins DR, Oppelt P, Brenneman R, Thorstad WL, Pipkorn P. Risk Factors for Functional Outcomes in Advanced Laryngeal Squamous Cell Carcinoma. Laryngoscope 2023; 133:594-600. [PMID: 35611799 PMCID: PMC9691786 DOI: 10.1002/lary.30166] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/23/2022] [Accepted: 04/13/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Chemoradiation for patients with laryngeal squamous cell carcinoma (SCC) may achieve organ preservation, but appropriate patient selection remains unknown. This study investigates pre-treatment risk factors associated with functional and survival outcomes after radiation-based therapy in patients with advanced laryngeal SCC. METHODS A retrospective cohort study was performed on 75 adult patients with stage III or IV laryngeal SCC receiving definitive radiation-based therapy from 1997 to 2016 at a tertiary care center. Tracheostomy and gastrostomy dependence were the primary functional outcomes. Multivariable logistic regressions were performed to evaluate relationships between pre-treatment factors and tracheostomy and gastrostomy dependence. Time-to-event analyses were performed to determine risk factors associated with overall survival. RESULTS Among 75 patients included in the analysis, 30 (40%) patients were tracheostomy dependent and 31 (41%) were gastrostomy tube dependent. The median length of follow-up was 31 months (range = 1 to 142 months). Pre-treatment tracheostomy was a significant predictor of post-treatment tracheostomy (aOR = 13.9, 95% CI = 3.35 to 57.5) and moderate-severe comorbidity was a significant predictor of post-treatment gastrostomy dependence (aOR = 2.96, 95% CI = 1.04 to 8.43). The five-year overall survival was 51% (95% CI = 38 to 64%). Pre-treatment gastrostomy tube dependence was associated with an increased risk of death (aHR = 2.45, 95% CI = 1.09 to 5.53). CONCLUSIONS Baseline laryngeal functional status and overall health in advanced laryngeal SCC are associated with poor functional outcomes after radiation-based therapy, highlighting the importance of patient selection when deciding between surgical and non-surgical treatment plans. Laryngoscope, 133:594-600, 2023.
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Affiliation(s)
- David S. Lee
- Department of Otolaryngology – Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jake J. Lee
- Department of Otolaryngology – Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Parul Sinha
- Department of Otolaryngology – Head and Neck Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Sidharth V. Puram
- Department of Otolaryngology – Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ryan S Jackson
- Department of Otolaryngology – Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Douglas R. Adkins
- Department of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Peter Oppelt
- Department of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Randall Brenneman
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Wade L. Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology – Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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6
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Subramaniam RM, DeMora L, Yao M, Yom SS, Gillison M, Caudell JJ, Waldron J, Xia P, Chung CH, Truong MT, Echevarria M, Chan JW, Geiger JL, Mell L, Seaward S, Thorstad WL, Beitler JJ, Sultanem K, Blakaj D, Le QT. 18F-FDG PET/CT Prediction of Treatment Outcomes in Human Papillomavirus-Positive, Locally Advanced Oropharyngeal Cancer Patients Receiving Deintensified Therapy: Results from NRG-HN002. J Nucl Med 2023; 64:362-367. [PMID: 36215572 PMCID: PMC10071810 DOI: 10.2967/jnumed.122.264424] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/24/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022] Open
Abstract
The purpose of this study was to determine the negative predictive value (NPV) of a 12- to 14-wk posttreatment PET/CT for 2-y progression-free survival (PFS) and locoregional control (LRC) in patients with p16-positive locoregionally advanced oropharyngeal cancer (LA-OPC). Study was a secondary endpoint in NRG-HN002, a noncomparative phase II trial in p16-positive LA-OPC, stage T1-T2, N1-N2b or T3, N0-N2b, and ≤10 pack-year smoking. Patients were randomized in a 1:1 ratio to reduced-dose intensity-modulated radiotherapy (IMRT) with or without cisplatin. Methods: PET/CT scans were reviewed centrally. Tumor response evaluations for the primary site, right neck, and left neck were performed using a 5-point ordinal scale (Hopkins criteria). Overall scores were then assigned as negative, positive, or indeterminate. Patients with a negative score for all 3 evaluation sites were given an overall score of negative. The hypotheses were NPV for PFS and LRC at 2-y posttreatment ≤ 90% versus >90% (1-sided P value, 0.10). Results: A total of 316 patients were enrolled, of whom 306 were randomized and eligible. Of these, 131 (42.8%) patients consented to a posttherapy PET/CT, and 117 (89.3%) patients were eligible for PET/CT analysis. The median time from the end of treatment to PET/CT scan was 94 d (range, 52-139 d). Estimated 2-y PFS and LRC rates in the analysis subgroup were 91.3% (95% CI, 84.6, 95.8%) and 93.8% (95% CI, 87.6, 97.5%), respectively. Posttreatment scans were negative for residual tumor for 115 patients (98.3%) and positive for 2 patients (1.7%). NPV for 2-y PFS was 92.0% (90% lower confidence bound [LCB] 87.7%; P = 0.30) and for LRC was 94.5% (90% LCB 90.6%; P = 0.07). Conclusion: In the context of deintensification with reduced-dose radiation, the NPV of a 12- to 14-wk posttherapy PET/CT for 2-y LRC is estimated to be >90%, similar to that reported for patients receiving standard chemoradiation. However, there is insufficient evidence to conclude that the NPV is >90% for PFS.
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Affiliation(s)
- Rathan M Subramaniam
- Otago Medical School, University of Otago, Otago, New Zealand;
- Duke University, Durham, North Carolina
| | - Lyudmila DeMora
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Min Yao
- University Hospitals Cleveland, Cleveland, Ohio
| | - Sue S Yom
- University of California, San Francisco, California
| | - Maura Gillison
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - John Waldron
- Princess Margaret Hospital, Toronto, Oneida, Canada
| | - Ping Xia
- Cleveland Clinic, Cleveland, Ohio
| | | | | | | | - Jason W Chan
- University of California, San Francisco, California
| | | | - Loren Mell
- UC San Diego Moores Cancer Center, San Diego, California
| | - Samantha Seaward
- Kaiser Permanente NCI Community Oncology Research Program, Vallejo, California
| | - Wade L Thorstad
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Diagjin Blakaj
- Ohio State University Comprehensive Cancer Center, Columbus, Ohio; and
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7
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Lee DS, Mahal RS, Tharakan T, Cathryn Collopy, Kallogjeri D, Thorstad WL, Adkins DR, Oppelt P, Ley J, Wick CC, Zevallos J. Hearing Outcomes in a Deintensification Trial of Adjuvant Therapy for HPV-Related Oropharyngeal Squamous Cell Carcinoma. Otolaryngol Head Neck Surg 2023; 168:1089-1096. [PMID: 36939390 DOI: 10.1002/ohn.182] [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: 07/25/2022] [Revised: 09/27/2022] [Accepted: 10/08/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To explore whether deintensification of adjuvant therapy reduces ototoxicity among patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC). STUDY DESIGN Retrospective cohort study. SETTING Single academic center. METHODS The ototoxicity rate among adult patients with HPV-related OPSCC enrolled in the Minimalist Trial (MINT), a prospective phase 2 trial of surgery followed by risk-adjusted deintensified adjuvant therapy (42 Gy radiation given alone or with a single 100 mg/m2 dose of cisplatin), was compared to that among a historical cohort treated with standard adjuvant therapy (60-66 Gy radiation with up to three 100 mg/m2 doses of cisplatin). Ototoxicity was defined as Common Terminology Criteria for Adverse Events v5.0 ≥ Grade 2. Mixed model analysis was performed to investigate the association between deintensified adjuvant therapy and treatment-related hearing loss. RESULTS A total of 29 patients (58 ears) were analyzed in the MINT cohort, and 27 patients (54 ears) in the historical cohort. The ototoxicity rate was 5% (n = 3/58 ears) in the MINT cohort and 46% (n = 25/54 ears) in the historical cohort (difference, 41%; 95% confidence interval [CI] = 27%-56%). Patients in the MINT cohort demonstrated a 95% decrease in risk of ototoxicity compared to those in the historical cohort (adjusted odds ratio: 0.05, 95% CI = 0.01-0.31). Differences in estimated marginal mean threshold shifts were statistically and clinically significant at frequencies ≥ 3 kHz. CONCLUSION The deintensified adjuvant therapy given in MINT led to less ototoxicity than standard adjuvant therapy among patients with HPV-related OPSCC.
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Affiliation(s)
- David S Lee
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Rajwant S Mahal
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Theresa Tharakan
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Cathryn Collopy
- Department of Otolaryngology-Head and Neck Surgery, Division of Adult Audiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Dorina Kallogjeri
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Douglas R Adkins
- Department of Medical Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Peter Oppelt
- Department of Medical Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jessica Ley
- Department of Medical Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Cameron C Wick
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jose Zevallos
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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8
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Koyuncu CF, Nag R, Lu C, Corredor G, Viswanathan VS, Sandulache VC, Fu P, Yang K, Pan Q, Zhang Z, Xu J, Chute DJ, Thorstad WL, Faraji F, Bishop JA, Mehrad M, Castro PD, Sikora AG, Thompson LD, Chernock RD, Lang Kuhs KA, Wasman JK, Luo JR, Adelstein DJ, Koyfman SA, Lewis Jr JS, Madabhushi A. Image analysis reveals differences in tumor multinucleations in Black and White patients with human papillomavirus-associated oropharyngeal squamous cell carcinoma. Cancer 2022; 128:3831-3842. [PMID: 36066461 PMCID: PMC9782693 DOI: 10.1002/cncr.34446] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/17/2022] [Accepted: 06/28/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Understanding biological differences between different racial groups of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) patients, who have differences in terms of incidence, survival, and tumor morphology, can facilitate accurate prognostic biomarkers, which can help develop personalized treatment strategies. METHODS This study evaluated whether there were morphologic differences between HPV-associated tumors from Black and White patients in terms of multinucleation index (MuNI), an image analysis-derived metric that measures density of multinucleated tumor cells within epithelial regions on hematoxylin-eosin images and previously has been prognostic in HPV-associated OPSCC patients. In this study, the authors specifically evaluated whether the same MuNI cutoff that was prognostic of overall survival (OS) and disease-free survival in their previous study, TTR , is valid for Black and White patients, separately. We also evaluated population-specific cutoffs, TB for Blacks and TW for Whites, for risk stratification. RESULTS MuNI was statistically significantly different between Black (mean, 3.88e-4; median, 3.67e-04) and White patients (mean, 3.36e-04; median, 2.99e-04), with p = .0078. Using TTR , MuNI was prognostic of OS in the entire population with hazard ratio (HR) of 1.71 (p = .002; 95% confidence interval [CI], 1.21-2.43) and in White patients with HR of 1.72 (p = .005; 95% CI, 1.18-2.51). Population-specific cutoff, TW , yielded improved HR of 1.77 (p = .003; 95% CI, 1.21-2.58) for White patients, whereas TB did not improve risk-stratification in Black patients with HR of 0.6 (p = .3; HR, 0.6; 95% CI, 0.2-1.80). CONCLUSIONS Histological difference between White and Black patient tumors in terms of multinucleated tumor cells suggests the need for considering population-specific prognostic biomarkers for personalized risk stratification strategies for HPV-associated OPSCC patients.
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Affiliation(s)
- Can F. Koyuncu
- Wallace H. Coulter Department of Biomedical EngineeringGeorgia Institute of Technology and Emory UniversityAtlantaGeorgiaUSA,Louis Stokes Cleveland Veterans Affairs Medical CenterClevelandOhioUSA
| | - Reetoja Nag
- Wallace H. Coulter Department of Biomedical EngineeringGeorgia Institute of Technology and Emory UniversityAtlantaGeorgiaUSA
| | - Cheng Lu
- Wallace H. Coulter Department of Biomedical EngineeringGeorgia Institute of Technology and Emory UniversityAtlantaGeorgiaUSA
| | - Germán Corredor
- Wallace H. Coulter Department of Biomedical EngineeringGeorgia Institute of Technology and Emory UniversityAtlantaGeorgiaUSA,Louis Stokes Cleveland Veterans Affairs Medical CenterClevelandOhioUSA
| | - Vidya S. Viswanathan
- Wallace H. Coulter Department of Biomedical EngineeringGeorgia Institute of Technology and Emory UniversityAtlantaGeorgiaUSA
| | - Vlad C. Sandulache
- Baylor College of MedicineHoustonTexasUSA,Otolaryngology‐Head and Neck SurgeryOperative Care Line, Michael E. DeBakey Veterans Affairs Medical CenterHoustonTexasUSA
| | - Pingfu Fu
- Department of Population and Quantitative Health SciencesCase Western Reserve UniversityClevelandOhioUSA
| | | | - Quintin Pan
- Case Comprehensive Cancer CenterCase Western Reserve UniversityClevelandOhioUSA
| | - Zelin Zhang
- Wallace H. Coulter Department of Biomedical EngineeringGeorgia Institute of Technology and Emory UniversityAtlantaGeorgiaUSA
| | - Jun Xu
- Nanjing University of Information Science and TechnologyNanjingChina
| | | | | | - Farhoud Faraji
- University of California San DiegoSan DiegoCaliforniaUSA
| | | | - Mitra Mehrad
- Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | | | | | | | | | | | - Jay K. Wasman
- School of MedicineCase Western Reserve UniversityClevelandOhioUSA
| | | | | | | | | | - Anant Madabhushi
- Wallace H. Coulter Department of Biomedical EngineeringGeorgia Institute of Technology and Emory UniversityAtlantaGeorgiaUSA,Atlanta Veterans Administration Medical CenterAtlantaGeorgiaUSA,Louis Stokes Cleveland Veterans Affairs Medical CenterClevelandOhioUSA
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9
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Udupa JK, Liu T, Jin C, Zhao L, Odhner D, Tong Y, Agrawal V, Pednekar G, Nag S, Kotia T, Goodman M, Wileyto EP, Mihailidis D, Lukens JN, Berman AT, Stambaugh J, Lim T, Chowdary R, Jalluri D, Jabbour SK, Kim S, Reyhan M, Robinson CG, Thorstad WL, Choi JI, Press R, Simone CB, Camaratta J, Owens S, Torigian DA. Combining natural and artificial intelligence for robust automatic anatomy segmentation: Application in neck and thorax auto-contouring. Med Phys 2022; 49:7118-7149. [PMID: 35833287 PMCID: PMC10087050 DOI: 10.1002/mp.15854] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 01/05/2022] [Revised: 06/20/2022] [Accepted: 06/30/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Automatic segmentation of 3D objects in computed tomography (CT) is challenging. Current methods, based mainly on artificial intelligence (AI) and end-to-end deep learning (DL) networks, are weak in garnering high-level anatomic information, which leads to compromised efficiency and robustness. This can be overcome by incorporating natural intelligence (NI) into AI methods via computational models of human anatomic knowledge. PURPOSE We formulate a hybrid intelligence (HI) approach that integrates the complementary strengths of NI and AI for organ segmentation in CT images and illustrate performance in the application of radiation therapy (RT) planning via multisite clinical evaluation. METHODS The system employs five modules: (i) body region recognition, which automatically trims a given image to a precisely defined target body region; (ii) NI-based automatic anatomy recognition object recognition (AAR-R), which performs object recognition in the trimmed image without DL and outputs a localized fuzzy model for each object; (iii) DL-based recognition (DL-R), which refines the coarse recognition results of AAR-R and outputs a stack of 2D bounding boxes (BBs) for each object; (iv) model morphing (MM), which deforms the AAR-R fuzzy model of each object guided by the BBs output by DL-R; and (v) DL-based delineation (DL-D), which employs the object containment information provided by MM to delineate each object. NI from (ii), AI from (i), (iii), and (v), and their combination from (iv) facilitate the HI system. RESULTS The HI system was tested on 26 organs in neck and thorax body regions on CT images obtained prospectively from 464 patients in a study involving four RT centers. Data sets from one separate independent institution involving 125 patients were employed in training/model building for each of the two body regions, whereas 104 and 110 data sets from the 4 RT centers were utilized for testing on neck and thorax, respectively. In the testing data sets, 83% of the images had limitations such as streak artifacts, poor contrast, shape distortion, pathology, or implants. The contours output by the HI system were compared to contours drawn in clinical practice at the four RT centers by utilizing an independently established ground-truth set of contours as reference. Three sets of measures were employed: accuracy via Dice coefficient (DC) and Hausdorff boundary distance (HD), subjective clinical acceptability via a blinded reader study, and efficiency by measuring human time saved in contouring by the HI system. Overall, the HI system achieved a mean DC of 0.78 and 0.87 and a mean HD of 2.22 and 4.53 mm for neck and thorax, respectively. It significantly outperformed clinical contouring in accuracy and saved overall 70% of human time over clinical contouring time, whereas acceptability scores varied significantly from site to site for both auto-contours and clinically drawn contours. CONCLUSIONS The HI system is observed to behave like an expert human in robustness in the contouring task but vastly more efficiently. It seems to use NI help where image information alone will not suffice to decide, first for the correct localization of the object and then for the precise delineation of the boundary.
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Affiliation(s)
- Jayaram K. Udupa
- Medical Image Processing GroupDepartment of RadiologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Tiange Liu
- Medical Image Processing GroupDepartment of RadiologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- School of Information Science and EngineeringYanshan UniversityQinhuangdaoChina
| | - Chao Jin
- Medical Image Processing GroupDepartment of RadiologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Liming Zhao
- Medical Image Processing GroupDepartment of RadiologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Dewey Odhner
- Medical Image Processing GroupDepartment of RadiologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Yubing Tong
- Medical Image Processing GroupDepartment of RadiologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Vibhu Agrawal
- Medical Image Processing GroupDepartment of RadiologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Gargi Pednekar
- Quantitative Radiology SolutionsPhiladelphiaPennsylvaniaUSA
| | - Sanghita Nag
- Quantitative Radiology SolutionsPhiladelphiaPennsylvaniaUSA
| | - Tarun Kotia
- Quantitative Radiology SolutionsPhiladelphiaPennsylvaniaUSA
| | | | - E. Paul Wileyto
- Department of Biostatistics and EpidemiologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Dimitris Mihailidis
- Department of Radiation OncologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - John Nicholas Lukens
- Department of Radiation OncologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Abigail T. Berman
- Department of Radiation OncologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Joann Stambaugh
- Department of Radiation OncologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Tristan Lim
- Department of Radiation OncologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Rupa Chowdary
- Department of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Dheeraj Jalluri
- Department of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Salma K. Jabbour
- Department of Radiation OncologyRutgers UniversityNew BrunswickNew JerseyUSA
| | - Sung Kim
- Department of Radiation OncologyRutgers UniversityNew BrunswickNew JerseyUSA
| | - Meral Reyhan
- Department of Radiation OncologyRutgers UniversityNew BrunswickNew JerseyUSA
| | | | - Wade L. Thorstad
- Department of Radiation OncologyWashington UniversitySt. LouisMissouriUSA
| | | | | | | | - Joe Camaratta
- Quantitative Radiology SolutionsPhiladelphiaPennsylvaniaUSA
| | - Steve Owens
- Quantitative Radiology SolutionsPhiladelphiaPennsylvaniaUSA
| | - Drew A. Torigian
- Medical Image Processing GroupDepartment of RadiologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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10
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Wahle BM, Zolkind P, Ramirez RJ, Skidmore ZL, Anderson SR, Mazul A, Hayes DN, Sandulache VC, Thorstad WL, Adkins D, Griffith OL, Griffith M, Zevallos JP. Integrative genomic analysis reveals low T-cell infiltration as the primary feature of tobacco use in HPV-positive oropharyngeal cancer. iScience 2022; 25:104216. [PMID: 35494251 PMCID: PMC9044176 DOI: 10.1016/j.isci.2022.104216] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/20/2021] [Accepted: 04/05/2022] [Indexed: 11/15/2022] Open
Abstract
Although tobacco use is an independent adverse prognostic feature in HPV(+) oropharyngeal squamous cell carcinoma (OPSCC), the biologic features associated with tobacco use have not been systematically investigated. We characterized genomic and immunologic features associated with tobacco use through whole exome sequencing, mRNA hybridization, and immunohistochemical staining in 47 HPV(+) OPSCC tumors. Low expression of transcripts in a T cell-inflamed gene expression profile (TGEP) was associated with tobacco use at diagnosis and lower overall and disease-free survival. Tobacco use was associated with an increased proportion of T > C substitutions and a lower proportion of expected mutational signatures, but not with increases in mutational burden or recurrent oncogenic mutations. Our findings suggest that rather than increased mutational burden, tobacco's primary and clinically relevant association in HPV(+) OPSCC is immunosuppression of the tumor immune microenvironment. Quantitative assays of T cell infiltration merit further study as prognostic markers in HPV(+) OPSCC.
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Affiliation(s)
- Benjamin M. Wahle
- Department of Otolaryngology – Head and Neck Surgery, Washington University School of Medicine, Campus Box 8115, 660 South Euclid Avenue, St. Louis, MO 63110, USA
| | - Paul Zolkind
- Department of Otolaryngology – Head and Neck Surgery, Washington University School of Medicine, Campus Box 8115, 660 South Euclid Avenue, St. Louis, MO 63110, USA
| | - Ricardo J. Ramirez
- Department of Otolaryngology – Head and Neck Surgery, Washington University School of Medicine, Campus Box 8115, 660 South Euclid Avenue, St. Louis, MO 63110, USA
| | - Zachary L. Skidmore
- McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO 63108, USA
| | - Sydney R. Anderson
- McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO 63108, USA
| | - Angela Mazul
- Department of Otolaryngology – Head and Neck Surgery, Washington University School of Medicine, Campus Box 8115, 660 South Euclid Avenue, St. Louis, MO 63110, USA
| | - D. Neil Hayes
- Department of Medicine, Division of Hematology-Oncology, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Vlad C. Sandulache
- Bobby R. Alford Department of Otolaryngology Head and Neck Surgery, Baylor College of Medicine, Houston, TX 77030, USA
- ENT Section, Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX 77030
- Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX 77030
| | - Wade L. Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO 63108, USA
| | - Douglas Adkins
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Obi L. Griffith
- McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO 63108, USA
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Department of Genetics, Washington University School of Medicine, St Louis, Missouri
| | - Malachi Griffith
- McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO 63108, USA
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Department of Genetics, Washington University School of Medicine, St Louis, Missouri
| | - Jose P. Zevallos
- Department of Otolaryngology – Head and Neck Surgery, Washington University School of Medicine, Campus Box 8115, 660 South Euclid Avenue, St. Louis, MO 63110, USA
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11
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Stepan K, Craig E, Skillington SA, Deutsch BC, Chen S, Wamkpah NS, Bollig CA, Kallogjeri D, Thorstad WL, Puram SV, Pipkorn P, Jackson RS. Development of second primary malignancies after transoral surgery in human papilloma virus-positive oropharyngeal squamous cell carcinoma. Head Neck 2022; 44:1069-1078. [PMID: 35175648 PMCID: PMC9112335 DOI: 10.1002/hed.27002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 12/08/2021] [Accepted: 02/01/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Little data exists regarding the incidence of oropharyngeal and upper aerodigestive tract (UADT) second primary malignancies (SPM) among human papilloma virus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC). Here we evaluate SPM rates among patients with HPV-related OPSCC. METHODS A retrospective cohort study of 412 patients with HPV-related OPSCC who underwent transoral resection +/- adjuvant therapy at a single center between 1996 and 2018. RESULTS Twenty patients (4.9%) developed SPM of the UADT, nine (2.2%) occurring in the oropharynx. Median time to diagnosis was 59.5 months (0-173 months). Risk of SPM was lower for patients receiving adjuvant radiation (aHR: 0.25, 95%CI: 0.08-0.78). There was no difference in overall or disease-free survival between those with and without SPM. CONCLUSION The rate of SPM among patients with HPV-positive OPSCC is lower than reported rates among HPV-negative OPSCC. To date, this is the largest study evaluating SPM in patients with surgically treated HPV-positive OPSCC.
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Affiliation(s)
- Katelyn Stepan
- Department of Otolaryngology - Head and Neck Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Ethan Craig
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Scott Andrew Skillington
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Brian C Deutsch
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Stephanie Chen
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Nneoma S Wamkpah
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Craig A Bollig
- Department of Otolaryngology - Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Dorina Kallogjeri
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Sidharth V Puram
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ryan S Jackson
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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12
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Chin RI, Schiff JP, Brenneman RJ, Gay HA, Thorstad WL, Lin AJ. A Rational Approach to Unilateral Neck RT for Head and Neck Cancers in the Era of Immunotherapy. Cancers (Basel) 2021; 13:5269. [PMID: 34771432 PMCID: PMC8582444 DOI: 10.3390/cancers13215269] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/08/2021] [Accepted: 10/14/2021] [Indexed: 11/16/2022] Open
Abstract
Radiotherapy plays an important role in the definitive and adjuvant treatment of head and neck squamous cell carcinoma (HNSCC). However, standard courses of radiation therapy may contribute to the depletion of circulating lymphocytes and potentially attenuate optimal tumor antigen presentation that may be detrimental to the efficacy of novel immunotherapeutic agents. This review explores the advantages of restricting radiation to the primary tumor/tumor bed and ipsilateral elective neck as it pertains to the evolving field of immunotherapy.
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Affiliation(s)
| | | | | | | | | | - Alexander J. Lin
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MI 63110, USA; (R.-I.C.); (J.P.S.); (R.J.B.); (H.A.G.); (W.L.T.)
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13
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Liu X, Liu P, Chernock RD, Kuhs KAL, Lewis JS, Li H, Gay HA, Thorstad WL, Wang X. Impact of human papillomavirus on the tumor microenvironment in oropharyngeal squamous cell carcinoma. Int J Cancer 2021; 150:521-531. [PMID: 34655477 PMCID: PMC8665085 DOI: 10.1002/ijc.33849] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 04/15/2021] [Revised: 09/27/2021] [Accepted: 09/30/2021] [Indexed: 02/03/2023]
Abstract
Increasing evidence has elucidated the clinicopathological significance of tumor microenvironment (TME) cells. However, TME differences associated with human papillomavirus (HPV) infection in oropharyngeal squamous cell carcinoma (OPSCC) have not been well characterized. In our study, we comprehensively determined the TME infiltration patterns in 315 OPSCC patients, and systematically correlated the TME phenotypes with genomic characteristics and clinical features of OPSCCs. In this way, we observed the enrichment of high endothelial cells and adaptive immune cells in HPV-positive (HPV+) OPSCCs, in contrast to the enrichment of fibroblasts and capillary endothelial cells in HPV- negative (HPV-) OPSCCs. By focusing on immune checkpoint genes, we constructed a coexpression network using genes that were differentially expressed between HPV+ and HPV- OPSCCs. Functional analysis of the network indicated that HPV+ OPSCCs had elevated immune activities by promoting adaptive immune response and suppressing activities related to extracellular matrix organization. Subsequently, clinical analysis showed that identified TME-relevant genes were closely associated with the prognosis and therapy response in OPSCC. Importantly, results from the TME analysis were further validated using an independent OPSCC cohort.
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Affiliation(s)
- Xinyi Liu
- Department of Pharmacology and Regenerative Medicine, University of Illinois at Chicago,University of Illinois Cancer Center, Chicago, IL
| | - Ping Liu
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Rebecca D. Chernock
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
| | - Krystle A. Lang Kuhs
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY
| | - James S. Lewis
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Hua Li
- Department of Bioengineering, University of Illinois at Urbana-Champaign, Urbana, IL,Carle Foundation Hospital, Urbana, IL,Cancer Center at Illinois, Urbana, IL
| | - Hiram A. Gay
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Wade L. Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Xiaowei Wang
- Department of Pharmacology and Regenerative Medicine, University of Illinois at Chicago,University of Illinois Cancer Center, Chicago, IL
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14
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Andruska N, Fischer-Valuck BW, Mahapatra L, Brenneman RJ, Gay HA, Thorstad WL, Fields RC, MacArthur KM, Baumann BC. Association Between Surgical Margins Larger Than 1 cm and Overall Survival in Patients With Merkel Cell Carcinoma. JAMA Dermatol 2021; 157:540-548. [PMID: 33760021 DOI: 10.1001/jamadermatol.2021.0247] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Current recommendations regarding the size of local excision (LE) margins for Merkel cell carcinoma (MCC) have not been well established. Objective To assess whether larger clinical LE margins and receipt of adjuvant radiotherapy are associated with improvements in overall survival (OS) among patients with localized MCC. Design, Setting, and Participants This large multicenter retrospective cohort study used records from the National Cancer Database to identify adult patients with localized stage I or stage II MCC who underwent LE between January 1, 2004, and December 31, 2015. Data were analyzed from August 1, 2020, to January 25, 2021. Exposures Local excision margin size and adjuvant radiotherapy. Main Outcomes and Measures Overall and net survival were assessed using Cox multivariable regression analysis. Results A total of 6156 patients with localized MCC (median age at diagnosis, 77 years [range, 27-90 years]; 2500 women [40.6%]). In the multivariable regression analysis, LE clinical margins larger than 1.0 cm were associated with improvements in OS (HR, 0.88; 95% CI, 0.81-0.95; P < .001) compared with margins of 1.0 cm or smaller, regardless of tumor subsite. At 5 years after surgery, LE margins of 1.0 cm or smaller were associated with a net survival of 76.7%, while LE margins larger than 1.0 cm were associated with a net survival of 89.8% (P < .001). Stratification of LE margins into 3 subgroups indicated that LE margins of 1.1 to 2.0 cm (HR, 0.87; 95% CI, 0.76-0.99; P = .047) and larger than 2.0 cm (HR, 0.84; 95% CI, 0.72-0.98; P = .03) were associated with improvements in OS compared with margins of 1.0 cm or smaller. In patients with less aggressive disease (ie, those who were immunocompetent and had tumors ≤1.0 cm, no lymphovascular invasion, and negative pathologic margins), LE margins larger than 1.0 cm were also associated with improvements in OS (HR, 0.87; 95% CI, 0.78-0.97; P = .01). Among patients who received adjuvant radiotherapy, larger LE margins were associated with improvements in OS (HR, 0.87; 95% CI, 0.76-0.98; P = .03). Receipt of adjuvant radiotherapy was also associated with improvements in OS within the 3 LE margin subgroups. Patients who received adjuvant radiotherapy and had LE margins of 1.0 cm or smaller (HR, 0.81; 95% CI, 0.74-0.89; P < .001) experienced OS that was comparable to that in patients who did not receive adjuvant radiotherapy and had LE margins larger than 1.0 cm (HR, 0.80; 95% CI, 0.71-0.89; P = .87). Conclusions and Relevance In this study, LE clinical margins larger than 1.0 cm were associated with improvements in OS, and these improvements were independent of tumor subsite, receipt of adjuvant radiotherapy, positive pathologic margins, or adverse pathologic features for stage I to stage II MCC. Patients with LE margins of 1.0 cm or smaller who received adjuvant radiotherapy experienced OS that was similar to that of patients with larger LE margins who did not receive radiotherapy. The combination of LE clinical margins larger than 1.0 cm and adjuvant radiotherapy was associated with the highest OS.
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Affiliation(s)
- Neal Andruska
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | | | - Lily Mahapatra
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Randall J Brenneman
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Hiram A 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 C Fields
- Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Kelly M MacArthur
- Division of Dermatology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Brian C Baumann
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, Missouri.,Department of Radiation Oncology, University of Pennsylvania, Philadelphia
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15
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Shinn JR, Davis SJ, Lang-Kuhs KA, Rohde S, Wang X, Liu P, Dupont WD, Plummer WD, Thorstad WL, Chernock RD, Mehrad M, Lewis JS. Oropharyngeal Squamous Cell Carcinoma With Discordant p16 and HPV mRNA Results: Incidence and Characterization in a Large, Contemporary United States Cohort. Am J Surg Pathol 2021; 45:951-961. [PMID: 33739785 PMCID: PMC8192336 DOI: 10.1097/pas.0000000000001685] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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] [Indexed: 11/26/2022]
Abstract
Early studies estimate that 5% to 10% of oropharyngeal squamous cell carcinomas overexpress p16 but are unassociated with transcriptionally-active high-risk human papillomavirus (HPV). Patients with discordant HPV testing may experience clinical outcomes that differ from traditional expectations. To document the rate of p16 and HPV mRNA positivity, characterize patients with discordant testing, and identify features that may warrant selective use of HPV-specific testing after p16 IHC, a multi-institutional, retrospective review of oropharyngeal squamous cell carcinoma patients with p16 IHC and HPV mRNA testing by reverse transcriptase polymerase chain reaction was performed. Of the 467 patients, most had T1 or T2 tumors (71%), 82% were p16 positive, and 84% were HPV mRNA positive. Overall, most tumors were nonkeratinizing (378, 81%), which was strongly associated with p16 and HPV positivity (93% and 95%, respectively). Overall, 81% of patients were double positive, 14% double negative, and 4.9% discordant (3.4% p16 negative/HPV mRNA positive and 1.5% p16 positive/HPV mRNA negative). The survival rates of these discordant patient groups fell squarely between the 2 concordant groups, although in multivariate analysis for both disease-free survival and overall survival, discordant patients were not found to have statistically significantly different outcomes. Reclassifying patients by applying HPV mRNA testing when p16 results and morphology do not match, or when p16 results are equivocal, improved prognostication slightly over p16 or HPV mRNA testing alone. Patients with discordant testing demonstrate a borderline significant trend toward survival differences from those with concordant tests. When evaluated independently, patients who were p16 negative but HPV mRNA positive had a prognosis somewhat closer to double-positive patients, while those who were p16 positive, but HPV mRNA negative had a prognosis closer to that of double-negative patients. We suggest an algorithm whereby confirmatory HPV mRNA testing is performed in patients where p16 status is not consistent with tumor morphology. This captures a majority of discordant patients and improves, albeit modestly, the prognostication.
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Affiliation(s)
- Justin R. Shinn
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA
| | - Seth J. Davis
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Krystle A. Lang-Kuhs
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY
| | - Sarah Rohde
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Xiaowei Wang
- Department of Pharmacology and Regenerative Medicine, The University of Illinois at Chicago, IL
| | - Ping Liu
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
| | - William D Dupont
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - W. Dale Plummer
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Wade L. Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Rebecca D. Chernock
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
| | - Mitra Mehrad
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - James S. Lewis
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN
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16
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Liu X, Liu P, Chernock RD, Yang Z, Lang Kuhs KA, Lewis JS, Luo J, Li H, Gay HA, Thorstad WL, Wang X. A MicroRNA Expression Signature as Prognostic Marker for Oropharyngeal Squamous Cell Carcinoma. J Natl Cancer Inst 2021; 113:752-759. [PMID: 33057626 PMCID: PMC8168274 DOI: 10.1093/jnci/djaa161] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 06/09/2020] [Revised: 08/05/2020] [Accepted: 09/28/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Improved prognostication of oropharyngeal squamous cell carcinoma (OPSCC) may facilitate individualized patient management. The goal of this study was to develop and validate a prognostic signature based on microRNA sequencing (miRNA-seq) analysis. METHODS We collected tumor specimens for miRNA-seq analysis from OPSCC patients treated at Washington University in St Louis (n = 324) and Vanderbilt University (n = 130). OPSCC patients (n = 79) from The Cancer Genome Atlas Program were also included for independent validation. Univariate and multivariable Cox regression analyses were performed to identify miRNAs associated with disease outcomes. All statistical tests were 2-sided. RESULTS By miRNA-seq profiling analysis, we identified a 26-miRNA signature. Based on computed risk scores of the signature, we classified the patients into low- and high-risk groups. In the training cohort, the high-risk group had much shorter overall survival compared with the low-risk group (hazard ratio [HR] = 3.80, 95% confidence interval [CI] = 2.37 to 6.10, P < .001). Subgroup analysis further revealed that the signature was prognostic for HPV-positive OPSCCs (HR = 3.07, 95% CI = 1.65 to 5.71, P < .001). Multivariable analysis indicated that the signature was independent of common clinicopathologic factors for OPSCCs. Importantly, the miRNA signature was a statistically significant predictor of overall survival in independent validation cohorts (The Cancer Genome Atlas Program cohort: HR = 6.05, 95% CI = 2.10 to 17.37, P < .001; Vanderbilt cohort: HR = 7.98, 95% CI = 3.99 to 15.97, P < .001; Vanderbilt HPV-positive cohort: HR = 8.71, 95% CI = 2.70 to 28.14, P < .001). CONCLUSIONS The miRNA signature is a robust and independent prognostic tool for risk stratification of OPSCCs including HPV-positive OPSCCs.
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Affiliation(s)
- Xinyi Liu
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - Ping Liu
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - Rebecca D Chernock
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, MO, USA
| | - Zhenming Yang
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - Krystle A Lang Kuhs
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James S. Lewis
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jingqin Luo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hua Li
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - Hiram A Gay
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - Xiaowei Wang
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO, USA
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17
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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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18
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Koyuncu CF, Lu C, Bera K, Zhang Z, Xu J, Toro P, Corredor G, Chute D, Fu P, Thorstad WL, Faraji F, Bishop JA, Mehrad M, Castro PD, Sikora AG, Thompson LD, Chernock RD, Lang Kuhs KA, Luo J, Sandulache V, Adelstein DJ, Koyfman S, Lewis JS, Madabhushi A. Computerized tumor multinucleation index (MuNI) is prognostic in p16+ oropharyngeal carcinoma. J Clin Invest 2021; 131:145488. [PMID: 33651718 DOI: 10.1172/jci145488] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 11/04/2020] [Accepted: 02/25/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUNDPatients with p16+ oropharyngeal squamous cell carcinoma (OPSCC) are potentially cured with definitive treatment. However, there are currently no reliable biomarkers of treatment failure for p16+ OPSCC. Pathologist-based visual assessment of tumor cell multinucleation (MN) has been shown to be independently prognostic of disease-free survival (DFS) in p16+ OPSCC. However, its quantification is time intensive, subjective, and at risk of interobserver variability.METHODSWe present a deep-learning-based metric, the multinucleation index (MuNI), for prognostication in p16+ OPSCC. This approach quantifies tumor MN from digitally scanned H&E-stained slides. Representative H&E-stained whole-slide images from 1094 patients with previously untreated p16+ OPSCC were acquired from 6 institutions for optimization and validation of the MuNI.RESULTSThe MuNI was prognostic for DFS, overall survival (OS), or distant metastasis-free survival (DMFS) in p16+ OPSCC, with HRs of 1.78 (95% CI: 1.37-2.30), 1.94 (1.44-2.60), and 1.88 (1.43-2.47), respectively, independent of age, smoking status, treatment type, or tumor and lymph node (T/N) categories in multivariable analyses. The MuNI was also prognostic for DFS, OS, and DMFS in patients with stage I and stage III OPSCC, separately.CONCLUSIONMuNI holds promise as a low-cost, tissue-nondestructive, H&E stain-based digital biomarker test for counseling, treatment, and surveillance of patients with p16+ OPSCC. These data support further confirmation of the MuNI in prospective trials.FUNDINGNational Cancer Institute (NCI), NIH; National Institute for Biomedical Imaging and Bioengineering, NIH; National Center for Research Resources, NIH; VA Merit Review Award from the US Department of VA Biomedical Laboratory Research and Development Service; US Department of Defense (DOD) Breast Cancer Research Program Breakthrough Level 1 Award; DOD Prostate Cancer Idea Development Award; DOD Lung Cancer Investigator-Initiated Translational Research Award; DOD Peer-Reviewed Cancer Research Program; Ohio Third Frontier Technology Validation Fund; Wallace H. Coulter Foundation Program in the Department of Biomedical Engineering; Clinical and Translational Science Award (CTSA) program, Case Western Reserve University; NCI Cancer Center Support Grant, NIH; Career Development Award from the US Department of VA Clinical Sciences Research and Development Program; Dan L. Duncan Comprehensive Cancer Center Support Grant, NIH; and Computational Genomic Epidemiology of Cancer Program, Case Comprehensive Cancer Center. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH, the US Department of VA, the DOD, or the US Government.
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Affiliation(s)
- Can F Koyuncu
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA.,Louis Stokes Cleveland Veterans Affairs (VA) Medical Center, Cleveland, Ohio, USA
| | - Cheng Lu
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Kaustav Bera
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Zelin Zhang
- Nanjing University of Information Science and Technology, Nanjing, China
| | - Jun Xu
- Nanjing University of Information Science and Technology, Nanjing, China
| | - Paula Toro
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - German Corredor
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA.,Louis Stokes Cleveland Veterans Affairs (VA) Medical Center, Cleveland, Ohio, USA
| | | | - Pingfu Fu
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Wade L Thorstad
- Washington University in St. Louis, St. Louis, Missouri, USA
| | | | - Justin A Bishop
- University of Texas (UT) Southwestern Medical Center, Dallas, Texas, USA
| | - Mitra Mehrad
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patricia D Castro
- Department of Otolaryngology, Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Andrew G Sikora
- Department of Otolaryngology, Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA.,ENT Section, Operative Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | | | - R D Chernock
- Washington University in St. Louis, St. Louis, Missouri, USA
| | | | - Jingqin Luo
- Washington University in St. Louis, St. Louis, Missouri, USA
| | - Vlad Sandulache
- Department of Otolaryngology, Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA.,ENT Section, Operative Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | | | | | - James S Lewis
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anant Madabhushi
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA.,Louis Stokes Cleveland Veterans Affairs (VA) Medical Center, Cleveland, Ohio, USA
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19
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Awan MJ, Gittleman H, Barnholtz-Sloan J, Machtay M, Nguyen-Tan PF, Rosenthal DI, Schultz C, Huth BJ, Thorstad WL, Frank SJ, Kim H, Foote RL, Lango MN, Shenouda G, Suntharalingam M, Harris J, Zhang Q, Le QT, Yao M. Risk groups of laryngeal cancer treated with chemoradiation according to nomogram scores - A pooled analysis of RTOG 0129 and 0522. Oral Oncol 2021; 116:105241. [PMID: 33640577 DOI: 10.1016/j.oraloncology.2021.105241] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 06/11/2020] [Revised: 02/05/2021] [Accepted: 02/14/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To develop nomograms predicting overall survival (OS), freedom from locoregional recurrence (FFLR), and freedom from distant metastasis (FFDM) for patients receiving chemoradiation for laryngeal squamous cell carcinoma (LSCC). MATERIAL AND METHODS Clinical and treatment data for patients with LSCC enrolled on NRG Oncology/RTOG 0129 and 0522 were extracted from the RTOG database. The dataset was partitioned into 70% training and 30% independent validation datasets. Significant predictors of OS, FFLR, and FFDM were obtained using univariate analysis on the training dataset. Nomograms were built using multivariate analysis with four a priori variables (age, gender, T-stage, and N-stage) and significant predictors from the univariate analyses. These nomograms were internally and externally validated using c-statistics (c) on the training and validation datasets, respectively. RESULTS The OS nomogram included age, gender, T stage, N stage, and number of cisplatin cycles. The FFLR nomogram included age, gender, T-stage, N-stage, and time-equivalent biologically effective dose. The FFDM nomogram included age, gender, N-stage, and number of cisplatin cycles. Internal validation of the OS nomogram, FFLR nomogram, and FFDM nomogram yielded c = 0.66, c = 0.66 and c = 0.73, respectively. External validation of these nomograms yielded c = 0.59, c = 0.70, and c = 0.73, respectively. Using nomogram score cutoffs, three risk groups were separated for each outcome. CONCLUSIONS We have developed and validated easy-to-use nomograms for LSCC outcomes using prospective cooperative group trial data.
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Affiliation(s)
- Musaddiq J Awan
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States.
| | - Haley Gittleman
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Jill Barnholtz-Sloan
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Mitchell Machtay
- Department of Radiation Oncology, Case Western Reserve University, Cleveland, OH, United States
| | - Phuc Felix Nguyen-Tan
- Department of Radiation Oncology, Centre Hospitalier de l'Universite de Montreal Hopital Notre Dame, Montreal, Quebec, Canada
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Christopher Schultz
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Bradley J Huth
- Department of Radiation Oncology, University of Cincinatti, Cincinatti, OH, United States; Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Harold Kim
- Department of Radiation Oncology, Wayne State University, Detroit, MI, United States
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Miriam N Lango
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, United States
| | - George Shenouda
- Department of Radiation Oncology, McGill University Healthcare, Toronto, Ontario, Canada
| | - Mohan Suntharalingam
- Department of Radiation Oncology, University of Maryland, Baltimore, MD, United States
| | - Jonathan Harris
- NRG Oncology Statistics and Data Management Center, American College of Radiology, Philadelphia, PA, United States
| | - Qiang Zhang
- NRG Oncology Statistics and Data Management Center, American College of Radiology, Philadelphia, PA, United States
| | - Quynh-Thu Le
- Department of Radiation Oncology, Stanford University, Palo Alto, CA, United States
| | - Min Yao
- Department of Radiation Oncology, Case Western Reserve University, Cleveland, OH, United States
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20
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Sample RA, Wood CB, Mazul AL, Barrett TF, Paniello RC, Rich JT, Kang SY, Zevallos J, Daly MD, Thorstad WL, Chen SY, Pipkorn P, Jackson RS, Puram SV. Low-risk human papilloma virus positive oropharyngeal cancer with one positive lymph node: Equivalent outcomes in patients treated with surgery and radiation therapy versus surgery alone. Head Neck 2021; 43:1759-1768. [PMID: 33586842 DOI: 10.1002/hed.26642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 08/13/2020] [Revised: 11/20/2020] [Accepted: 02/01/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND For human papilloma virus positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC), management recommendations for patients with a single metastatic lymph node <6 cm in diameter remain nebulous, leading to treatment heterogeneity in this common subgroup of patients. METHODS We utilized the National Cancer Database to perform survival and multivariable analyses of patients with HPV+ OPSCC with one positive lymph node <6 cm and negative surgical margins. RESULTS We found that 5-year survival is comparable between patients who receive surgery and adjuvant radiation versus surgery alone. In multivariable analyses, we found no significant difference in the hazard ratio of overall survival after adjusting for various potential confounders. CONCLUSIONS These data suggest that patients with margin-negative HPV+ OPSCC with a single positive lymph node <6 cm have comparable survival with or without adjuvant radiation. Future studies exploring outcomes for this specific group in randomized-controlled trials will be critical for further evaluating these initial observations.
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Affiliation(s)
- Reilly A Sample
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA.,Clinical Research Training Center, Institute of Clinical and Translational Sciences, Washington University School of Medicine, St Louis, Missouri, USA
| | - Carey Burton Wood
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Angela L Mazul
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA.,Division of Public Health Sciences, Department of Surgery, Washington University, St Louis, Missouri, USA
| | - Thomas F Barrett
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Randal C Paniello
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jason T Rich
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Stephen Y Kang
- Department of Otolaryngology - Head and Neck Surgery, The James Cancer Hospital, Solove Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Jose Zevallos
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Mackenzie D Daly
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Stephanie Y Chen
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Ryan S Jackson
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Sidharth V Puram
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA.,Department of Genetics, Washington University School of Medicine, St Louis, Missouri, USA
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21
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Yom SS, Torres-Saavedra P, Caudell JJ, Waldron JN, Gillison ML, Xia P, Truong MT, Kong C, Jordan R, Subramaniam RM, Yao M, Chung CH, Geiger JL, Chan JW, O'Sullivan B, Blakaj DM, Mell LK, Thorstad WL, Jones CU, Banerjee RN, Lominska C, Le QT. Reduced-Dose Radiation Therapy for HPV-Associated Oropharyngeal Carcinoma (NRG Oncology HN002). J Clin Oncol 2021; 39:956-965. [PMID: 33507809 PMCID: PMC8078254 DOI: 10.1200/jco.20.03128] [Citation(s) in RCA: 178] [Impact Index Per Article: 59.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Reducing radiation treatment dose could improve the quality of life (QOL) of patients with good-risk human papillomavirus–associated oropharyngeal squamous cell carcinoma (OPSCC). Whether reduced-dose radiation produces disease control and QOL equivalent to standard chemoradiation is not proven.
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Affiliation(s)
- Sue S Yom
- University of California San Francisco, San Francisco, CA
| | | | | | - John N Waldron
- University Health Network-Princess Margaret Hospital, Toronto, ON, Canada
| | | | | | | | | | - Richard Jordan
- University of California San Francisco, San Francisco, CA
| | | | - Min Yao
- University Hospitals Cleveland, Cleveland, OH
| | | | | | - Jason W Chan
- University of California San Francisco, San Francisco, CA
| | - Brian O'Sullivan
- University Health Network-Princess Margaret Hospital, Toronto, ON, Canada
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22
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Andruska N, Mahapatra L, Brenneman RJ, Rich JT, Baumann BC, Compton L, Thorstad WL, Daly MD. Reduced Wide Local Excision Margins are Associated with Increased Risk of Relapse and Death from Merkel Cell Carcinoma. Ann Surg Oncol 2020; 28:3312-3319. [PMID: 33073342 DOI: 10.1245/s10434-020-09145-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/03/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Current recommendations regarding the size of wide local excision (WLE) margins for Merkel cell carcinoma (MCC) are not well established. METHODS WLE and pathologic margins were respectively reviewed from 79 patients with stage I or II MCC, who underwent WLE at Washington University in St Louis from 2005 to 2019. Outcomes included local recurrence-free survival (LRFS), regional recurrence-free survival (RRFS), distant recurrence-free survival (DRFS), disease-free survival (DFS), and disease-specific survival (DSS). RESULTS Thirty-two percent of patients received adjuvant radiotherapy (aRT). At 1 year, DFS was 51.3%, 71.4%, and 87.8% for patients with WLE margins < 1 cm, 1-1.9 cm, and ≥ 2 cm, respectively (p = 0.02). At 3 years, the DSS was 57.7%, 82.6%, and 100% for patients with WLE margins < 1 cm, 1-1.9 cm, and ≥ 2 cm, respectively (p = 0.02). Multivariable Cox analysis demonstrated that every 1-cm increase in WLE margins was associated with improved RRFS [hazard ratio (HR) = 0.28, 95% confidence interval (CI): 0.11-0.75], DRFS (HR 0.30, CI 0.08-0.99), DFS (HR 0.42, CI 0.21-0.86), and DSS (HR 0.16, CI 0.04-0.61). WLE and pathologic margin size were moderately-to-strongly correlated (r = 0.66). Close or positive pathologic margins (< 3 mm) were associated with reduced DRFS (HR 6.83, CI 1.80-25.9), DFS (HR 2.98, CI 1.31-6.75), and DSS (HR 3.52, CI 1.14-10.9). CONCLUSION Reduced WLE and pathologic margins were associated with higher risk of relapse and death from MCC. Larger WLE margins are important in populations with lower rates of adjuvant radiation.
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Affiliation(s)
- Neal Andruska
- Department of Radiation Oncology, Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO, USA
| | - Lily Mahapatra
- Department of Pathology and Immunology, Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO, USA
| | - Randall J Brenneman
- Department of Radiation Oncology, Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jason T Rich
- Department of Otolaryngology, Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO, USA
| | - Brian C Baumann
- Department of Radiation Oncology, Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO, USA
| | - Leigh Compton
- Department of Pathology and Immunology, Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO, USA.,Division of Dermatology, Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO, USA
| | - Wade L Thorstad
- Department of Radiation Oncology, Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO, USA
| | - Mackenzie D Daly
- Department of Radiation Oncology, Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO, USA.
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23
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Liu X, Liu P, Chernock RD, Kuhs KA, Lewis JS, Luo J, Gay HA, Thorstad WL, Wang X. A prognostic gene expression signature for oropharyngeal squamous cell carcinoma. EBioMedicine 2020; 61:102805. [PMID: 33038770 PMCID: PMC7648117 DOI: 10.1016/j.ebiom.2020.102805] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Robust prognostic stratification of patients with oropharyngeal squamous cell carcinoma (OPSCC) is important for developing individualized treatment plans. This study was conducted to develop and validate a clinically feasible prognostic classifier based on transcriptome-wide gene expression profiles. METHODS Tumor tissues were collected from 208 OPSCC patients treated at Washington University in St. Louis and 130 OPSCC patients treated at Vanderbilt University, used for model training and validation, respectively. OPSCC patients (n = 70) from the TCGA cohort were also included for independent validation. Based on RNA-seq profiling data, Cox proportional hazards regression analysis was performed to identify genes associated with disease outcomes. Then, Lasso-penalized multivariate survival models were constructed to identify biomarker genes for developing a prognostic gene signature. FINDINGS A 60-gene signature was identified by RNA-seq profiling analysis. Computed risk score of the gene signature was significantly predictive of 5-year overall survival of the training cohort (Hazard ratio (HR) 28·32, P = 4·3E-41). Subgroup analysis stratified by HPV status revealed that the signature was prognostic in HPV-positive OPSCC patients (HR 30·55, P = 7·0E-37) and was independent of clinical features. Importantly, the gene signature was validated in two independent patient cohorts, including the TCGA cohort (HR 3·94, P = 0·0018) and the Vanderbilt cohort (HR 8·50, P = 5·7E-09) for overall survival. INTERPRETATION The prognostic gene signature is a robust tool for risk stratification of OPSCC patients. The signature remains prognostic among HPV-positive OPSCC patients. FUNDING National Institutes of Health.
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Affiliation(s)
- Xinyi Liu
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ping Liu
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Rebecca D. Chernock
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Krystle A.Lang Kuhs
- Department of Otolaryngology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James S. Lewis
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jingqin Luo
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Hiram A. Gay
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Wade L. Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Xiaowei Wang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA.
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24
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Baumann BC, MacArthur KM, Brewer JD, Mendenhall WM, Barker CA, Etzkorn JR, Jellinek NJ, Scott JF, Gay HA, Baumann JC, Manian FA, Devlin PM, Michalski JM, Lee NY, Thorstad WL, Wilson LD, Perez CA, Miller CJ. Management of primary skin cancer during a pandemic: Multidisciplinary recommendations. Cancer 2020; 126:3900-3906. [PMID: 32478867 PMCID: PMC7301000 DOI: 10.1002/cncr.32969] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 04/21/2020] [Accepted: 04/28/2020] [Indexed: 12/13/2022]
Abstract
During the coronavirus disease 2019 (COVID‐19) pandemic, providers and patients must engage in shared decision making regarding the pros and cons of early versus delayed interventions for localized skin cancer. Patients at highest risk of COVID‐19 complications are older; are immunosuppressed; and have diabetes, cancer, or cardiopulmonary disease, with multiple comorbidities associated with worse outcomes. Physicians must weigh the patient's risk of COVID‐19 complications in the event of exposure against the risk of worse oncologic outcomes from delaying cancer therapy. Herein, the authors have summarized current data regarding the risk of COVID‐19 complications and mortality based on age and comorbidities and have reviewed the literature assessing how treatment delays affect oncologic outcomes. They also have provided multidisciplinary recommendations regarding the timing of local therapy for early‐stage skin cancers during this pandemic with input from experts at 11 different institutions. For patients with Merkel cell carcinoma, the authors recommend prioritizing treatment, but a short delay can be considered for patients with favorable T1 disease who are at higher risk of COVID‐19 complications. For patients with melanoma, the authors recommend delaying the treatment of patients with T0 to T1 disease for 3 months if there is no macroscopic residual disease at the time of biopsy. Treatment of tumors ≥T2 can be delayed for 3 months if the biopsy margins are negative. For patients with cutaneous squamous cell carcinoma, those with Brigham and Women's Hospital T1 to T2a disease can have their treatment delayed for 2 to 3 months unless there is rapid growth, symptomatic lesions, or the patient is immunocompromised. The treatment of tumors ≥T2b should be prioritized, but a 1‐month to 2‐month delay is unlikely to worsen disease‐specific mortality. For patients with squamous cell carcinoma in situ and basal cell carcinoma, treatment can be deferred for 3 months unless the individual is highly symptomatic. During the coronavirus disease 2019 (COVID‐19) pandemic, providers must help patients to make informed decisions regarding skin cancer management and assess the risk of potential COVID‐19–associated morbidity and/or mortality versus primary skin cancer morbidity and/or mortality. In this article, the authors summarize current data regarding the risk of COVID‐19 complications and mortality based on age and comorbidities, and review the literature assessing how treatment delays affect oncologic outcomes. They provide multidisciplinary recommendations regarding the timing of local therapy for patients with early‐stage skin cancers.
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Affiliation(s)
- Brian C Baumann
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri, USA.,Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kelly M MacArthur
- Division of Dermatologic Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jerry D Brewer
- Division of Dermatologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida at Gainesville, Gainesville, Florida, USA
| | - Christopher A Barker
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jeremy R Etzkorn
- Division of Dermatologic Surgery, Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nathaniel J Jellinek
- Dermatology Professionals Inc, East Greenwich, Rhode Island, USA.,Division of Dermatologic Surgery, Department of Dermatology, Brown University, Providence, Rhode Island, USA.,Division of Dermatologic Surgery, Department of Dermatology, University of Massachusetts, Worcester, Massachusetts, USA
| | - Jeffrey F Scott
- Division of Dermatologic Surgery, Department of Dermatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Hiram A Gay
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - John C Baumann
- Princeton Radiation Oncology, Princeton, New Jersey, USA
| | - Farrin A Manian
- Department of Internal Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Phillip M Devlin
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Lynn D Wilson
- Department of Therapeutic Radiology, Yale University, New Haven, Connecticut, USA
| | - Carlos A Perez
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Christopher J Miller
- Division of Dermatologic Surgery, Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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25
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Mazul AL, Stepan KO, Barrett TF, Thorstad WL, Massa S, Adkins DR, Daly MD, Rich JT, Paniello RC, Pipkorn P, Zevallos JP, Jackson RS, Kang SY, Puram SV. Duration of radiation therapy is associated with worse survival in head and neck cancer. Oral Oncol 2020; 108:104819. [PMID: 32485609 DOI: 10.1016/j.oraloncology.2020.104819] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 03/24/2020] [Revised: 04/22/2020] [Accepted: 05/22/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Delays in radiation are multifactorial, frequent, and associated with poor outcomes. This study investigates the effect of both primary and adjuvant radiation therapy duration and their interaction with other measures of treatment delay on survival in head and neck squamous cell carcinoma (HNSCC). METHODS We built a retrospective cohort using the National Cancer Database, consisting of primary oral cavity, hypopharynx, larynx and oropharynx squamous cell carcinoma without distant metastasis and with at least six weeks of radiation. The primary exposure was the duration of radiation therapy (DRT), and the primary outcome was death. We estimated the association between DRT and 5-year overall survival (OS) using Kaplan-Meier curves and hazard ratios (HRs) with Cox proportional hazard regression. RESULTS In both primary (definitive) and adjuvant (post-surgical) radiation settings, increased DRT results in decreased survival. In the primary radiation cohort, 5-year OS was 59.7% [59.1%-60.3%] among those with 47-53 days DRT, which decreased significantly with each subsequent week to completion (81+ days: 38.4% [36.2%-40.7%]). In the surgical cohort, survival decreased 16.5% when DRT extended beyond 75 days (40-46 days: 68.2% [67.3%-69.1%] vs. 75+ days: 53.3% [50.1%-56.7%]). Multivariate analyses showed increased hazard of death with increased DRT (primary radiation: 81+ days HR: 1.69 [1.58-1.81]); surgical: 75+ days HR: 1.61 [1.37-1.88]), with effects intensifying when restricting to those receiving full-dose radiation. CONCLUSION A prolonged DRT was associated with worse OS in head and neck cancer. Radiation treatment delays of even a week lead to a significant survival disadvantage. DRT had a stronger association with survival than time to initiation of postoperative adjuvant radiotherapy.
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Affiliation(s)
- Angela L Mazul
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, MO, United States; Division of Public Health Sciences, Department of Surgery, Washington University, St Louis, MO, United States
| | - Katelyn O Stepan
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, MO, United States
| | - Thomas F Barrett
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, MO, United States
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO, United States
| | - Sean Massa
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, MO, United States
| | - Douglas R Adkins
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, MO, United States
| | - Mackenzie D Daly
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO, United States
| | - Jason T Rich
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, MO, United States
| | - Randal C Paniello
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, MO, United States
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, MO, United States
| | - Jose P Zevallos
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, MO, United States
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, MO, United States
| | - Stephen Y Kang
- Department of Otolaryngology - Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, United States
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, MO, United States; Department of Genetics, Washington University School of Medicine, St Louis, MO, United States.
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26
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Chidambaram S, Nakken ER, Kennedy W, Thorstad WL, Chen SY, Pipkorn P, Zevallos JP, Mazul AL. Prognostic Significance of Smoking in Human Papillomavirus-Positive Oropharyngeal Cancer Under American Joint Committee on Cancer Eighth Edition Stage. Laryngoscope 2020; 130:1961-1966. [PMID: 32293733 DOI: 10.1002/lary.28659] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 01/14/2020] [Revised: 02/29/2020] [Accepted: 03/14/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the prognostic significance of smoking in human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) when considering American Joint Committee on Cancer eighth edition (AJCC-8) stage. STUDY DESIGN Retrospective cohort study. METHODS Three hundred seventeen HPV-positive OPSCC patients with known AJCC-8 stage and smoking status (<10 or ≥10 pack-years) seen at a tertiary center from 1997 to 2017 were studied. We used the Kaplan-Meier method to compare 5-year overall survival (OS) by smoking status and by clinical AJCC-8 stage and smoking status combined. Hazard ratios (HRs) were estimated with Cox proportional hazard regression for the independent effects of smoking and AJCC-8 stage. We also studied pathologic stage and estimated the combined effects of smoking and clinical stage. RESULTS The ≥10 pack-years smokers had worse 5-year OS than <10 pack-years smokers (93.6%; 95% confidence interval (CI): 89.7-97.8 vs. 82.3%; 95% CI: 76.0%-89.1%). When stratified by AJCC-8 clinical stage, only stage I <10 pack-years smokers (98.7%; 95% CI: 96.3%-100.0%) had significantly better 5-year OS than their ≥10 pack-years (84.8%; 95% CI: 76.4%-94.1%) counterparts. In a multivariable analysis, ≥10 pack-years smoking was associated with increased hazard of death when adjusting for AJCC-8 clinical (HR: 2.52; 95% CI: 1.16-5.46) and pathologic (HR: 5.21; 95% CI: 1.47-18.5) stage. In both analyses, stage III patients demonstrated worse survival than stage I, and smoking had greater impact at lower stages. CONCLUSIONS Smoking is a negative prognosticator in HPV-positive OPSCC and interacts with AJCC-8 clinical stage. It is important to understand the impact of smoking in HPV-positive disease when considering treatment plans and deintensification trials. LEVEL OF EVIDENCE 2b Laryngoscope, 130: 1961-1966, 2020.
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Affiliation(s)
- Smrithi Chidambaram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A.,St. Louis University School of Medicine, St. Louis, Missouri, U.S.A
| | - Erik R Nakken
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A.,Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - William Kennedy
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Stephanie Y Chen
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Jose P Zevallos
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Angela L Mazul
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A.,Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
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27
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Altenhofen B, DeWees TA, Ahn JW, Yeat NC, Goddu S, Chen I, Lewis JS, Thorstad WL, Chole RA, Gay HA. Childhood tonsillectomy alters the primary distribution of HPV-related oropharyngeal squamous cell carcinoma. Laryngoscope Investig Otolaryngol 2020; 5:210-216. [PMID: 32337351 PMCID: PMC7178443 DOI: 10.1002/lio2.342] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/25/2019] [Accepted: 12/10/2019] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES We investigated how tonsillectomy during childhood may influence the distribution of human papillomavirus (HPV) positive cancer of the tonsils in adult life using p16 as a surrogate marker for HPV infection. STUDY DESIGN Retrospective observational study. METHODS A total of 280 patients diagnosed with oropharyngeal squamous cell carcinoma (OPSCC) and known p16 status were eligible for this study. Each participant was called to obtain the childhood tonsillectomy history. Respondents were subgrouped by p16 status and the primary tumor location. Patient demographic and clinical information was analyzed for association with Fisher's exact and Wilcoxon rank sum tests. Location of tumor was modeled using univariate (UVA) and multivariate (MVA) logistic regression with associated odds ratios (OR) and 95% confidence intervals. RESULTS Of the 280 patients, 115 (41%) were respondents: 104 (90.4%) were p16 positive and 11 (9.6%) were p16 negative. For p16 positive patients, we observed a majority (93%) of intact tonsils in those with tonsil cancer, compared to 45% of intact tonsils in patients with p16 positive cancer elsewhere in the oropharynx (P < .001). MVA logistic regression showed that female gender (OR = 4.16, P = .0675), prior smoking history (OR = 2.6, P = .0367), and intact tonsils (OR = 15.2, P < .0001) were associated with tonsillar OPSCC. CONCLUSION We found that patients with p16 positive OPSCC at a non-tonsil site were much more likely to have had prior tonsillectomy vs those with p16 positive OPSCC arising within the tonsil. Nevertheless, we do not advocate tonsillectomies as a public health policy to reduce HPV-related OPSCC. LEVEL OF EVIDENCE 6.
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Affiliation(s)
- Brannon Altenhofen
- Department of Anesthesia and Perioperative MedicineUCLALos AngelesCalifornia
| | - Todd A. DeWees
- Division of Health Sciences ResearchMayo ClinicScottsdaleArizona
| | - Ji W. Ahn
- Department of DermatologyUniversity of Michigan HospitalsAnn ArborMichigan
| | - Nai C. Yeat
- Department of Internal MedicineMontefiore Medical CenterBronxNew York
| | - Shreya Goddu
- Washington University in St. LouisSt. LouisMissouri
| | - Ishita Chen
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | - James S. Lewis
- Department of Pathology, Microbiology and ImmunologyVanderbilt University School of MedicineNashvilleTennessee
- Department of OtolaryngologyVanderbilt University School of MedicineNashvilleTennessee
| | - Wade L. Thorstad
- Department of Radiation OncologyWashington University School of Medicine in St. LouisSt. LouisMissouri
| | - Richard A. Chole
- Department of Otolaryngology–Head and Neck SurgeryWashington University School of Medicine in St. LouisSt. LouisMissouri
| | - Hiram A. Gay
- Department of Radiation OncologyWashington University School of Medicine in St. LouisSt. LouisMissouri
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28
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Mell LK, Shen H, Nguyen-Tân PF, Rosenthal DI, Zakeri K, Vitzthum LK, Frank SJ, Schiff PB, Trotti AM, Bonner JA, Jones CU, Yom SS, Thorstad WL, Wong SJ, Shenouda G, Ridge JA, Zhang QE, Le QT. Nomogram to Predict the Benefit of Intensive Treatment for Locoregionally Advanced Head and Neck Cancer. Clin Cancer Res 2019; 25:7078-7088. [PMID: 31420360 DOI: 10.1158/1078-0432.ccr-19-1832] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/09/2019] [Accepted: 08/13/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Previous studies indicate that the benefit of therapy depends on patients' risk for cancer recurrence relative to noncancer mortality (ω ratio). We sought to test the hypothesis that patients with head and neck cancer (HNC) with a higher ω ratio selectively benefit from intensive therapy. EXPERIMENTAL DESIGN We analyzed 2,688 patients with stage III-IVB HNC undergoing primary radiotherapy (RT) with or without systemic therapy on three phase III trials (RTOG 9003, RTOG 0129, and RTOG 0522). We used generalized competing event regression to stratify patients according to ω ratio and compared the effectiveness of intensive therapy as a function of predicted ω ratio (i.e., ω score). Intensive therapy was defined as treatment on an experimental arm with altered fractionation and/or multiagent concurrent systemic therapy. A nomogram was developed to predict patients' ω score on the basis of tumor, demographic, and health factors. Analysis was by intention to treat. RESULTS Decreasing age, improved performance status, higher body mass index, node-positive status, P16-negative status, and oral cavity primary predicted a higher ω ratio. Patients with ω score ≥0.80 were more likely to benefit from intensive treatment [5-year overall survival (OS), 70.0% vs. 56.6%; HR of 0.73, 95% confidence interval (CI): 0.57-0.94; P = 0.016] than those with ω score <0.80 (5-year OS, 46.7% vs. 45.3%; HR of 1.02, 95% CI: 0.92-1.14; P = 0.69; P = 0.019 for interaction). In contrast, the effectiveness of intensive therapy did not depend on risk of progression. CONCLUSIONS Patients with HNC with a higher ω score selectively benefit from intensive treatment. A nomogram was developed to help select patients for intensive therapy.
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Affiliation(s)
- Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California.
| | - Hanjie Shen
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Phuc Felix Nguyen-Tân
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montreal, Montreal, Quebec, Canada
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kaveh Zakeri
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Lucas K Vitzthum
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peter B Schiff
- Department of Radiation Oncology, New York University School of Medicine, New York, New York
| | - Andy M Trotti
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - James A Bonner
- Department of Radiation Oncology, Hazelrig-Salter Radiation Oncology Center, The University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Sue S Yom
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Stuart J Wong
- Division of Hematology Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - George Shenouda
- Department of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - John A Ridge
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Qiang E Zhang
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Quynh-Thu Le
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
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29
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Fakhry C, Zhang Q, Gillison ML, Nguyen-Tân PF, Rosenthal DI, Weber RS, Lambert L, Trotti AM, Barrett WL, Thorstad WL, Yom SS, Wong SJ, Ridge JA, Rao SSD, Spencer S, Fortin A, Raben D, Harris J, Le QT. Validation of NRG oncology/RTOG-0129 risk groups for HPV-positive and HPV-negative oropharyngeal squamous cell cancer: Implications for risk-based therapeutic intensity trials. Cancer 2019; 125:2027-2038. [PMID: 30913305 PMCID: PMC6594017 DOI: 10.1002/cncr.32025] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [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: 10/25/2018] [Revised: 12/07/2018] [Accepted: 01/10/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Radiation Therapy Oncology Group (RTOG)-0129 recursive partitioning analysis was the basis for risk-based therapeutic intensification trials for oropharyngeal cancer (OPC). To the authors' knowledge, the question of whether RTOG-0129 overall survival (OS) estimates for low-risk, intermediate-risk, and high-risk groups are similar in other data sets or applicable to progression-free survival (PFS) is unknown. Therefore, the authors evaluated whether survival differences between RTOG-0129 risk groups persist at 5 years, are reproducible in an independent clinical trial, and are applicable to PFS, and whether toxicities differ across risk groups. METHODS Prospective randomized clinical trials were analyzed retrospectively. RTOG-0129 evaluated standard versus accelerated fractionation radiotherapy concurrent with cisplatin. RTOG-0522 compared the combination of cisplatin and accelerated fractionation with or without cetuximab. Patients with OPC with available p16 status and tobacco history were eligible. RESULTS There was a total of 260 patients and 287 patients, respectively, from RTOG-0129 and RTOG-0522, with median follow-ups for surviving patients of 7.9 years (range, 1.7-9.9 years) and 4.7 years (range, 0.1-7.0 years), respectively. Previous OS differences in RTOG-0129 persisted at 5 years. In RTOG-0522, the 5-year OS rates for the low-risk, intermediate-risk, and high-risk groups were 88.1%, 69.9%, and 45.1%, respectively (P for trend, <.001). The 5-year PFS rates for the same 3 groups were 72.9%, 56.1%, and 42.2%, respectively. In RTOG-0522 among a subgroup of patients considered to be at very good risk (p16-positive disease, smoking history of ≤10 pack-years, and classified with T1-T2 disease with ipsilateral lymph nodes measuring ≤6 cm or T3 disease without contralateral or >6 cm lymph nodes), the 5-year OS and PFS rates were 93.8% and 82.2%, respectively. Overall rates of acute and late toxicities were similar by risk group. CONCLUSIONS RTOG-0129 risk groups persisted at 5 years and were reproducible in RTOG-0522. However, there was variability in the estimates. These data underscore the importance of long-term follow-up and appropriate patient selection in therapeutic deintensification trials.
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Affiliation(s)
| | - Qiang Zhang
- NRG Oncology Statistics and Data Management Center, American College of Radiology, Philadelphia, PA
| | - Maura L Gillison
- University of Texas MD Anderson Cancer Center, Houston, TX Center
| | | | | | - Randal S Weber
- University of Texas MD Anderson Cancer Center, Houston, TX Center
| | - Louise Lambert
- Centre Hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | - Andy M Trotti
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | - William L Barrett
- University of Cincinnati Cancer Institute, Cincinnati, OH (accruals under Thomas Jefferson University Hospital)
| | | | - Sue S Yom
- University of California San Francisco, San Francisco, CA
| | | | | | | | - Sharon Spencer
- University of Alabama at Birmingham Medical Center, Birmingham, AL
| | - Andre Fortin
- L’Hotel-Dieu de Quebec, Ville de Québec, QC, Canada
| | | | - Jonathan Harris
- NRG Oncology Statistics and Data Management Center, American College of Radiology, Philadelphia, PA
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Gabani P, Lin AJ, Barnes J, Oppelt P, Adkins DR, Rich JT, Zevallos JP, Daly MD, Gay HA, Thorstad WL. Radiation therapy dose de-escalation compared to standard dose radiation therapy in definitive treatment of HPV-positive oropharyngeal squamous cell carcinoma. Radiother Oncol 2019; 134:81-88. [PMID: 31005228 DOI: 10.1016/j.radonc.2019.01.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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: 10/25/2018] [Revised: 01/09/2019] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Despite existing evidence that human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) has a favorable prognosis compared to HPV-negative OPSCC, randomized studies have yet to report the effect of de-escalating radiation therapy (RT) dose for definitive treatment. The aim of this study was to assess the effectiveness of dose de-escalated RT (DDRT) vs. standard dose RT (SDRT) in patients with HPV-positive OPSCC. METHODS This was an observational study using the National Cancer Database (Year 2010-2014) to identify patients who had HPV-positive OPSCC and were treated with definitive RT or chemo-RT. Patients undergoing surgery were excluded. Patients receiving ≥50 Gy, but <66 Gy were categorized as receiving DDRT. Patients receiving ≥66 Gy were categorized as receiving SDRT. Inverse probability of treatment weighting (IPTW) using propensity scores was used to balance the two groups. Kaplan-Meier analysis was used to estimate overall survival (OS). Subset analyses in patients receiving RT alone and concurrent chemo-RT were also performed. Multivariable Cox proportional hazards modeling was used to evaluate factors associated with OS. RESULTS 759 patients with HPV-positive OPSCC were identified: 104 received DDRT and 655 received SDRT. The median follow-up was 30.5 (2.4-81.4) months. After IPTW-adjusted analysis, there was no difference in the 3-yr OS between the two groups (82.2% vs. 79.3%; P = 0.85). In the subset of patients receiving concurrent chemoradiotherapy, IPTW-adjusted analysis also did not show a difference in the 3-yr OS between the two groups (83.1% vs. 79.6%; P = 0.83). On multivariable analysis, DDRT was not associated with an inferior OS (HR 0.88; 95% CI, 0.53-1.47; P = 0.63). CONCLUSIONS In this study, DDRT was not associated with an inferior OS compared to SDRT in patients with HPV-positive OPSCC. Randomized clinical trials to address DDRT in this patient population are currently ongoing.
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Affiliation(s)
- Prashant Gabani
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States
| | - Alexander J Lin
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States
| | - Justin Barnes
- Saint Louis University School of Medicine, Saint Louis, United States
| | - Peter Oppelt
- Division of Medical Oncology, Washington University School of Medicine, Saint Louis, United States
| | - Douglas R Adkins
- Division of Medical Oncology, Washington University School of Medicine, Saint Louis, United States
| | - Jason T Rich
- Department of Otolaryngology, Washington University School of Medicine, Saint Louis, United States
| | - Jose P Zevallos
- Department of Otolaryngology, Washington University School of Medicine, Saint Louis, United States
| | - Mackenzie D Daly
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States
| | - Hiram A Gay
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States.
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31
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Fakhry C, Nguyen-Tân PF, Lambert L, Rosenthal DI, Weber RS, Gillison ML, Trotti AM, Barrett WL, Thorstad WL, Jones CU, Yom SS, Wong SJ, Ridge JA, Rao SSD, Bonner JA, Vigneault E, Raben D, Kudrimoti MR, Harris J, Le QT. In Regard to Bossi et al. Int J Radiat Oncol Biol Phys 2018; 102:669-670. [PMID: 30238902 DOI: 10.1016/j.ijrobp.2018.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 05/21/2018] [Accepted: 06/13/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Carole Fakhry
- Department of Otolaryngology Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | | | - Louise Lambert
- Centre Hospitalier de l'Université de Montréal, Montreal, Quebec City, Canada
| | | | | | | | - Andy M Trotti
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - William L Barrett
- University of Cincinnati Cancer Institute, Cincinnati, Ohio, (accruals under Thomas Jefferson University Hospital)
| | | | - Christopher U Jones
- Sutter General Hospital, Sacramento, California, (accruals under Radiologic Associates of Sacramento)
| | - Sue S Yom
- University of California San Francisco, San Francisco, California
| | | | - John A Ridge
- Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | | | - James A Bonner
- University of Alabama at Birmingham Medical Center, Birmingham, Alabama
| | - Eric Vigneault
- L'Hotel-Dieu de Quebec, Ville de Québec, Quebec City, Canada
| | | | - Mahesh R Kudrimoti
- University of Kentucky, Lexington, Kentucky, (accrual under University of Maryland Medical Systems)
| | - Jonathan Harris
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
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32
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Gay HA, Oh JH, Apte AP, Daly MD, Adkins DR, Rich J, Oppelt PJ, Dyk PT, Mullen DF, Eschen L, Chin RI, Nussenbaum B, Haughey BH, Thorstad WL, Deasy JO. Predictors of acute throat or esophageal patient reported pain during radiation therapy for head and neck cancer. Clin Transl Radiat Oncol 2018; 13:1-6. [PMID: 30211324 PMCID: PMC6134163 DOI: 10.1016/j.ctro.2018.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 11/29/2022] Open
Abstract
Background and purpose Acute pain during weekly radiotherapy (RT) to the head and neck is not well characterized. We studied dose-volume metrics and clinical variables that are plausibly associated with throat or esophageal pain as measured with a weekly questionnaire during RT. Materials and methods We prospectively collected weekly patient-reported outcomes from 122 head and neck cancer patients during RT. The pain score for each question consisted of a four-level scale: none (0), mild (1), moderate (2), and severe (3). Univariate and multivariate ordinal logistic regression analyses were performed to investigate associations between both esophageal and throat pain and clinical as well as dosimetric variables. Results In multivariate analysis, age was significantly associated with both types of pain, leading to odds ratio (OR) = 0.95 (p = 0.008) and OR = 0.95 (p = 0.007) for esophageal and throat pain, respectively. For throat pain, sex (OR = 4.12; p = 0.010), with females at higher risk, and fractional organ at risk (OAR) mean dose (OR = 3.30; p = 0.014) were significantly associated with throat pain. Conclusions A fractional OAR mean dose of 1.1 Gy seems a reasonable cutoff for separating no or mild pain from moderate to severe esophageal and throat pain. Younger patients who received RT experienced more esophageal and throat pain. Females experienced more throat pain, but not esophageal pain.
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Affiliation(s)
- Hiram A Gay
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Jung Hun Oh
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Aditya P Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Mackenzie D Daly
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Douglas R Adkins
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, United States.,Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States
| | - Jason Rich
- Department of Otolaryngology, Washington University School of Medicine, St. Louis, MO, United States
| | - Peter J Oppelt
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Pawel T Dyk
- Department of Radiation Oncology, Missouri Baptist Cancer Center, St. Louis, MO, United States
| | - Daniel F Mullen
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Laura Eschen
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Re-I Chin
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | | | - Bruce H Haughey
- Head and Neck Surgery, Florida Hospital Celebration Health, Celebration, FL, United States
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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Floberg JM, DeWees TA, Chin RI, Garsa AA, Dehdashti F, Nussenbaum B, Oppelt PJ, Adkins DR, Gay HA, Thorstad WL. Pretreatment metabolic tumor volume as a prognostic factor in HPV-associated oropharyngeal cancer in the context of AJCC 8th edition staging. Head Neck 2018; 40:2280-2287. [DOI: 10.1002/hed.25337] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/30/2018] [Accepted: 05/03/2018] [Indexed: 12/31/2022] Open
Affiliation(s)
- John M. Floberg
- Washington University School of Medicine, Department of Radiation Oncology; St Louis MO
| | - Todd A. DeWees
- Mayo Clinic, Department of Biomedical Statistics and Informatics Scottsdale; AZ
| | - Re-I Chin
- St Louis University School of Medicine; St Louis MO
| | - Adam A. Garsa
- Keck School of Medicine of University of Southern California, Department of Radiation Oncology; Los Angeles CA
| | - Farrokh Dehdashti
- Washington University School of Medicine, Mallinckrodt Institute of Radiology Division of Nuclear Medicine; St Louis MO
| | | | - Peter J. Oppelt
- Washington University School of Medicine, Department of Internal Medicine, Division of Oncology; St Louis MO
| | - Douglas R. Adkins
- Washington University School of Medicine, Department of Internal Medicine, Division of Oncology; St Louis MO
| | - Hiram A. Gay
- Washington University School of Medicine, Department of Radiation Oncology; St Louis MO
| | - Wade L. Thorstad
- Washington University School of Medicine, Department of Radiation Oncology; St Louis MO
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Gabani P, Barnes J, Lin AJ, Rudra S, Oppelt P, Adkins D, Rich JT, Zevallos JP, Daly MD, Gay HA, Thorstad WL. Induction chemotherapy in the treatment of nasopharyngeal carcinoma: Clinical outcomes and patterns of care. Cancer Med 2018; 7:3592-3603. [PMID: 30008178 PMCID: PMC6089177 DOI: 10.1002/cam4.1626] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 05/17/2018] [Accepted: 05/25/2018] [Indexed: 11/09/2022] Open
Abstract
The role of induction chemotherapy in nasopharyngeal carcinoma (NPC) remains controversial. The primary aim of this study was to use the National Cancer Database to evaluate the patterns of care of induction chemotherapy in NPC and its impact on overall survival (OS). Patients with NPC from 2004 to 2014 were obtained from the NCDB. Patients were considered to have received induction chemotherapy if it was started ≥43 days before the start of RT and concurrent CRT if chemotherapy started within 21 days after the start of RT. Propensity score matching was used to control for selection bias. Cox proportional hazards model was used to determine significant predictors of OS. Logistic regression model was used to determine predictors of the use of induction chemotherapy. Significance was defined as a P value <.05. A total of 4857 patients were identified: 4041 patients (87.2%) received concurrent CRT and 816 patients (16.8%) received induction chemotherapy. The use of induction therapy remained stable between 2004 and 2014. Younger patients and those with higher T- and N-stage had a higher likelihood of being treated with induction chemotherapy. The 5-year OS in patients treated with induction chemotherapy and CRT was 66.3% vs 69.1%, respectively (P = .25). There was no difference in OS when these two groups were analyzed after propensity score matching. No differences in OS existed between these treatment groups in patients with T3-T4N1 or TanyN2-3 disease (P = .76). Propensity score matching also did not reveal any difference in OS in patients with T3-T4N1 or TanyN2-3 disease. The use of induction chemotherapy has remained stable in the last decade. In this study of patients with NPC, induction chemotherapy was not associated with improved OS compared to CRT alone.
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Affiliation(s)
- Prashant Gabani
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Justin Barnes
- Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Alexander J Lin
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Soumon Rudra
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Peter Oppelt
- Division of Medical Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Douglas Adkins
- Division of Medical Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jason T Rich
- Department of Otolaryngology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jose P Zevallos
- Department of Otolaryngology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Mackenzie D Daly
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Hiram A Gay
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
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Chin RI, Rao YJ, Hwang MY, Spencer CR, Pierro M, DeWees T, Patel P, Sinha P, Gay HA, Daly M, Haughey BH, Nussenbaum B, Adkins DR, Lewis JS, Thorstad WL. Comparison of unilateral versus bilateral intensity-modulated radiotherapy for surgically treated squamous cell carcinoma of the palatine tonsil. Cancer 2017; 123:4594-4607. [DOI: 10.1002/cncr.30931] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/28/2017] [Accepted: 07/05/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Re-I Chin
- Department of Radiation Oncology; Washington University School of Medicine; St. Louis Missouri
| | - Yuan James Rao
- Department of Radiation Oncology; Washington University School of Medicine; St. Louis Missouri
| | - Michael Y. Hwang
- Department of Internal Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | - Christopher R. Spencer
- Department of Radiation Oncology; Washington University School of Medicine; St. Louis Missouri
| | - Michael Pierro
- Department of Internal Medicine; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Todd DeWees
- Department of Radiation Oncology; Washington University School of Medicine; St. Louis Missouri
| | - Pranav Patel
- Department of Internal Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Parul Sinha
- Division of Head and Neck Surgery; Department of Otolaryngology, Washington University School of Medicine; St. Louis Missouri
| | - Hiram A. 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
| | - Bruce H. Haughey
- Head and Neck Surgery, Florida Hospital Celebration Health, Celebration; Florida
| | - Brian Nussenbaum
- Division of Head and Neck Surgery; Department of Otolaryngology, Washington University School of Medicine; St. Louis Missouri
| | - Douglas R. Adkins
- Division of Hematology and Oncology; Department of Internal Medicine, Washington University School of Medicine; St. Louis Missouri
| | - James S. Lewis
- Department of Pathology; Microbiology, and Immunology, Vanderbilt University School of Medicine; Nashville Tennessee
| | - Wade L. Thorstad
- Department of Radiation Oncology; Washington University School of Medicine; St. Louis Missouri
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Fakhry C, Zhang Q, Nguyen-Tân PF, Rosenthal DI, Weber RS, Lambert L, Trotti AM, Barrett WL, Thorstad WL, Jones CU, Yom SS, Wong SJ, Ridge JA, Rao SSD, Bonner JA, Vigneault E, Raben D, Kudrimoti MR, Harris J, Le QT, Gillison ML. Development and Validation of Nomograms Predictive of Overall and Progression-Free Survival in Patients With Oropharyngeal Cancer. J Clin Oncol 2017; 35:4057-4065. [PMID: 28777690 DOI: 10.1200/jco.2016.72.0748] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Purpose Treatment of oropharyngeal squamous cell carcinoma (OPSCC) is evolving toward risk-based modification of therapeutic intensity, which requires patient-specific estimates of overall survival (OS) and progression-free survival (PFS). Methods To develop and validate nomograms for OS and PFS, we used a derivation cohort of 493 patients with OPSCC with known p16 tumor status (surrogate of human papillomavirus) and cigarette smoking history (pack-years) randomly assigned to clinical trials using platinum-based chemoradiotherapy (NRG Oncology Radiation Therapy Oncology Group [RTOG] 0129 and 0522). Nomograms were created from Cox models and internally validated by use of bootstrap and cross-validation. Model discrimination was measured by calibration plots and the concordance index. Nomograms were externally validated in a cohort of 153 patients with OPSCC randomly assigned to a third trial, NRG Oncology RTOG 9003. Results Both models included age, Zubrod performance status, pack-years, education, p16 status, and T and N stage; the OS model also included anemia and age × pack-years interaction; and the PFS model also included marital status, weight loss, and p16 × Zubrod interaction. Predictions correlated well with observed 2-year and 5-year outcomes. The uncorrected concordance index was 0.76 (95% CI, 0.72 to 0.80) for OS and 0.70 (95% CI, 0.66 to 0.74) for PFS, and bias-corrected indices were similar. In the validation set, OS and PFS models were well calibrated, and OS and PFS were significantly different across tertiles of nomogram scores (log-rank P = .003;< .001). Conclusion The validated nomograms provided useful prediction of OS and PFS for patients with OPSCC treated with primary radiation-based therapy.
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Affiliation(s)
- Carole Fakhry
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - Qiang Zhang
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - Phuc Felix Nguyen-Tân
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - David I Rosenthal
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - Randal S Weber
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - Louise Lambert
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - Andy M Trotti
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - William L Barrett
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - Wade L Thorstad
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - Christopher U Jones
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - Sue S Yom
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - Stuart J Wong
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - John A Ridge
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - Shyam S D Rao
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - James A Bonner
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - Eric Vigneault
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - David Raben
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - Mahesh R Kudrimoti
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - Jonathan Harris
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - Quynh-Thu Le
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
| | - Maura L Gillison
- Carole Fakhry, Johns Hopkins University, Baltimore, MD; Qiang Zhang and Jonathan Harris, NRG Oncology Statistics and Data Management Center, American College of Radiology; John A. Ridge, Fox Chase Cancer Center, Philadelphia, PA; Phuc Felix Nguyen-Tân and Louise Lambert, Centre Hospitalier de l'Université de Montréal, Montreal; Eric Vigneault, L'Hotel-Dieu de Quebec, Ville de Québec, Quebec, Canada; David I. Rosenthal, Randal S. Weber, and Maura L. Gillison, MD Anderson Cancer Center, Houston, TX; Andy M. Trotti III, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; William L. Barrett, University of Cincinnati Cancer Institute, Cincinnati, OH; Wade L. Thorstad, Washington University, St Louis, MO; Christopher U. Jones, Sutter General Hospital, Sacramento; Sue S. Yom, University of California San Francisco, San Francisco; Shyam S.D. Rao, University of California Davis, Davis; Quynh-Thu Le, Stanford University, Stanford, CA; Stuart J. Wong, Medical College of Wisconsin, Milwaukee, WI; James A. Bonner, University of Alabama at Birmingham Medical Center, Birmingham, AL; David Raben, University of Colorado, Aurora, CO; and Mahesh R. Kudrimoti, University of Kentucky, Lexington, KY
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Folkert MR, Setton J, Apte AP, Grkovski M, Young RJ, Schöder H, Thorstad WL, Lee NY, Deasy JO, Oh JH. Predictive modeling of outcomes following definitive chemoradiotherapy for oropharyngeal cancer based on FDG-PET image characteristics. Phys Med Biol 2017; 62:5327-5343. [PMID: 28604368 DOI: 10.1088/1361-6560/aa73cc] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In this study, we investigate the use of imaging feature-based outcomes research ('radiomics') combined with machine learning techniques to develop robust predictive models for the risk of all-cause mortality (ACM), local failure (LF), and distant metastasis (DM) following definitive chemoradiation therapy (CRT). One hundred seventy four patients with stage III-IV oropharyngeal cancer (OC) treated at our institution with CRT with retrievable pre- and post-treatment 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) scans were identified. From pre-treatment PET scans, 24 representative imaging features of FDG-avid disease regions were extracted. Using machine learning-based feature selection methods, multiparameter logistic regression models were built incorporating clinical factors and imaging features. All model building methods were tested by cross validation to avoid overfitting, and final outcome models were validated on an independent dataset from a collaborating institution. Multiparameter models were statistically significant on 5 fold cross validation with the area under the receiver operating characteristic curve (AUC) = 0.65 (p = 0.004), 0.73 (p = 0.026), and 0.66 (p = 0.015) for ACM, LF, and DM, respectively. The model for LF retained significance on the independent validation cohort with AUC = 0.68 (p = 0.029) whereas the models for ACM and DM did not reach statistical significance, but resulted in comparable predictive power to the 5 fold cross validation with AUC = 0.60 (p = 0.092) and 0.65 (p = 0.062), respectively. In the largest study of its kind to date, predictive features including increasing metabolic tumor volume, increasing image heterogeneity, and increasing tumor surface irregularity significantly correlated to mortality, LF, and DM on 5 fold cross validation in a relatively uniform single-institution cohort. The LF model also retained significance in an independent population.
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Affiliation(s)
- Michael R Folkert
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States of America
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38
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Zenga J, Haughey BH, Jackson RS, Adkins DR, Aranake-Chrisinger J, Bhatt N, Gay HA, Kallogjeri D, Martin EJ, Moore EJ, Paniello RC, Rich JT, Thorstad WL, Nussenbaum B. Outcomes of surgically treated human papillomavirus-related oropharyngeal squamous cell carcinoma with N3 disease. Laryngoscope 2016; 127:2033-2037. [PMID: 28008626 DOI: 10.1002/lary.26455] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 10/29/2016] [Accepted: 11/14/2016] [Indexed: 01/20/2023]
Affiliation(s)
- Joseph Zenga
- Department of Otolaryngology-Head and Neck Surgery; Washington University; St. Louis Missouri U.S.A
| | - Bruce H. Haughey
- Department of Surgery; University of Auckland Faculty of Medicine; Auckland New Zealand
- Head and Neck Surgery Center of Florida; Celebration Hospital, Celebration; Florida U.S.A
| | - Ryan S. Jackson
- Department of Otolaryngology-Head and Neck Surgery; Washington University; St. Louis Missouri U.S.A
| | - Douglas R. Adkins
- Department of Medical Oncology; Washington University; St. Louis Missouri U.S.A
| | | | - Neel Bhatt
- Department of Otolaryngology-Head and Neck Surgery; Washington University; St. Louis Missouri U.S.A
| | - Hiram A. Gay
- Department of Radiation Oncology; Washington University; St. Louis Missouri U.S.A
| | - Dorina Kallogjeri
- Department of Otolaryngology-Head and Neck Surgery; Washington University; St. Louis Missouri U.S.A
| | - Eliot J. Martin
- Department of Otolaryngology-Head and Neck Surgery; Mayo Clinic; Rochester Minnesota U.S.A
| | - Eric J. Moore
- Department of Otolaryngology-Head and Neck Surgery; Mayo Clinic; Rochester Minnesota U.S.A
| | - Randal C. Paniello
- Department of Otolaryngology-Head and Neck Surgery; Washington University; St. Louis Missouri U.S.A
| | - Jason T. Rich
- Department of Otolaryngology-Head and Neck Surgery; Washington University; St. Louis Missouri U.S.A
| | - Wade L. Thorstad
- Department of Radiation Oncology; Washington University; St. Louis Missouri U.S.A
| | - Brian Nussenbaum
- Department of Otolaryngology-Head and Neck Surgery; Washington University; St. Louis Missouri U.S.A
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39
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Zenga J, Jackson RS, Graboyes EM, Sinha P, Lindberg M, Martin EJ, Ma D, Thorstad WL, Rich JT, Moore EJ, Haughey BH. Oncologic outcomes of selective neck dissection in HPV-related oropharyngeal squamous cell carcinoma. Laryngoscope 2016; 127:623-630. [DOI: 10.1002/lary.26272] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 07/01/2016] [Accepted: 07/21/2016] [Indexed: 01/29/2023]
Affiliation(s)
- Joseph Zenga
- Department of Otolaryngology-Head and Neck Surgery; Washington University; Saint Louis Missouri U.S.A
| | - Ryan S. Jackson
- Department of Otolaryngology-Head and Neck Surgery; Washington University; Saint Louis Missouri U.S.A
| | - Evan M. Graboyes
- Department of Otolaryngology-Head and Neck Surgery; Washington University; Saint Louis Missouri U.S.A
| | - Parul Sinha
- Department of Otolaryngology-Head and Neck Surgery; Washington University; Saint Louis Missouri U.S.A
| | - Miranda Lindberg
- Washington University School of Medicine; Saint Louis Missouri U.S.A
| | - Eliot J. Martin
- Department of Otolaryngology-Head and Neck Surgery; Mayo Clinic; Rochester Minnesota U.S.A
| | - Daniel Ma
- Department of Radiation Oncology; Mayo Clinic; Rochester Minnesota U.S.A
| | - Wade L. Thorstad
- Department of Radiation Oncology; Washington University; Saint Louis Missouri U.S.A
| | - Jason T. Rich
- Department of Otolaryngology-Head and Neck Surgery; Washington University; Saint Louis Missouri U.S.A
| | - Eric J. Moore
- Department of Otolaryngology-Head and Neck Surgery; Mayo Clinic; Rochester Minnesota U.S.A
| | - Bruce H. Haughey
- Head and Neck Surgery Center of Florida; Celebration Hospital; Celebration Florida U.S.A
- Department of Surgery; University of Auckland Faculty of Medicine; Auckland New Zealand
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40
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Divi V, Harris J, Harari PM, Cooper JS, McHugh J, Bell D, Sturgis EM, Cmelak AJ, Suntharalingam M, Raben D, Kim H, Spencer SA, Laramore GE, Trotti A, Foote RL, Schultz C, Thorstad WL, Zhang QE, Le QT, Holsinger FC. Establishing quality indicators for neck dissection: Correlating the number of lymph nodes with oncologic outcomes (NRG Oncology RTOG 9501 and RTOG 0234). Cancer 2016; 122:3464-3471. [PMID: 27419843 DOI: 10.1002/cncr.30204] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [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: 04/08/2016] [Revised: 06/08/2016] [Accepted: 06/13/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Prospective quality metrics for neck dissection have not been established for patients with head and neck squamous cell carcinoma. The purpose of this study was to investigate the association between lymph node counts from neck dissection, local-regional recurrence, and overall survival. METHODS The number of lymph nodes counted from neck dissection in patients treated in 2 NRG Oncology trials (Radiation Therapy Oncology Group [RTOG] 9501 and RTOG 0234) was evaluated for its prognostic impact on overall survival with a multivariate Cox model adjusted for demographic, tumor, and lymph node data and stratified by the postoperative treatment group. RESULTS Five hundred seventy-two patients were analyzed at a median follow-up of 8 years. Ninety-eight percent of the patients were pathologically N+. The median numbers of lymph nodes recorded on the left and right sides were 24 and 25, respectively. The identification of fewer than 18 nodes was associated with worse overall survival in comparison with 18 or more nodes (hazard ratio [HR], 1.38; 95% confidence interval [CI], 1.09-1.74; P = .007). The difference appeared to be driven by local-regional failure (HR, 1.46; 95% CI, 1.02-2.08; P = .04) but not by distant metastases (HR, 1.08; 95% CI, 0.77-1.53; P = .65). When the analysis was limited to NRG Oncology RTOG 0234 patients, adding the p16 status to the model did not affect the HR for dissected nodes, and the effect of nodes did not differ with the p16 status. CONCLUSIONS The removal and identification of 18 or more lymph nodes was associated with improved overall survival and lower rates of local-regional failure, and this should be further evaluated as a measure of quality in neck dissections for mucosal squamous cell carcinoma. Cancer 2016;122:3464-71. © 2016 American Cancer Society.
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Affiliation(s)
- Vasu Divi
- Stanford University, Stanford, California
| | - Jonathan Harris
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | | | | | | | - Diana Bell
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Erich M Sturgis
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Mohan Suntharalingam
- Marlene & Stewart Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland
| | - David Raben
- University of Colorado Denver, Aurora, Colorado
| | - Harold Kim
- Academic Radiation Oncology, Wayne State University, Detroit, Michigan
| | | | | | - Andy Trotti
- H. Lee Moffitt Cancer Center, Tampa, Florida
| | | | | | - Wade L Thorstad
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Qiang Ed Zhang
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
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Li H, Dolly S, Chen HC, Anastasio MA, Low DA, Li HH, Michalski JM, Thorstad WL, Gay H, Mutic S. A comparative study based on image quality and clinical task performance for CT reconstruction algorithms in radiotherapy. J Appl Clin Med Phys 2016; 17:377-390. [PMID: 27455472 PMCID: PMC5690061 DOI: 10.1120/jacmp.v17i4.5763] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 03/12/2016] [Accepted: 03/02/2016] [Indexed: 11/23/2022] Open
Abstract
CT image reconstruction is typically evaluated based on the ability to reduce the radiation dose to as‐low‐as‐reasonably‐achievable (ALARA) while maintaining acceptable image quality. However, the determination of common image quality metrics, such as noise, contrast, and contrast‐to‐noise ratio, is often insufficient for describing clinical radiotherapy task performance. In this study we designed and implemented a new comparative analysis method associating image quality, radiation dose, and patient size with radiotherapy task performance, with the purpose of guiding the clinical radiotherapy usage of CT reconstruction algorithms. The iDose4iterative reconstruction algorithm was selected as the target for comparison, wherein filtered back‐projection (FBP) reconstruction was regarded as the baseline. Both phantom and patient images were analyzed. A layer‐adjustable anthropomorphic pelvis phantom capable of mimicking 38–58 cm lateral diameter‐sized patients was imaged and reconstructed by the FBP and iDose4 algorithms with varying noise‐reduction‐levels, respectively. The resulting image sets were quantitatively assessed by two image quality indices, noise and contrast‐to‐noise ratio, and two clinical task‐based indices, target CT Hounsfield number (for electron density determination) and structure contouring accuracy (for dose‐volume calculations). Additionally, CT images of 34 patients reconstructed with iDose4 with six noise reduction levels were qualitatively evaluated by two radiation oncologists using a five‐point scoring mechanism. For the phantom experiments, iDose4 achieved noise reduction up to 66.1% and CNR improvement up to 53.2%, compared to FBP without considering the changes of spatial resolution among images and the clinical acceptance of reconstructed images. Such improvements consistently appeared across different iDose4 noise reduction levels, exhibiting limited interlevel noise (<5 HU) and target CT number variations (<1 HU). The radiation dose required to achieve similar contouring accuracy decreased when using iDose4 in place of FBP, up to 32%. Contouring accuracy improvement for iDose4 images, when compared to FBP, was greater in larger patients than smaller‐sized patients. Overall, the iDose4 algorithm provided superior radiation dose control while maintaining or improving task performance, when compared to FBP. The reader study on image quality improvement of patient cases shows that physicians preferred iDose4‐reconstructed images on all cases compared to those from FBP algorithm with overall quality score: 1.21 vs. 3.15, p=0.0022. However, qualitative evaluation strongly indicated that the radiation oncologists chose iDose4 noise reduction levels of 3–4 with additional consideration of task performance, instead of image quality metrics alone. Although higher iDose4 noise reduction levels improved the CNR through the further reduction of noise, there was pixelization of anatomical/tumor structures. Very‐low‐dose scans yielded severe photon starvation artifacts, which decreased target visualization on both FBP and iDose4 reconstructions, especially for the 58 cm phantom size. The iDose4 algorithm with a moderate noise reduction level is hence suggested for CT simulation and treatment planning. Quantitative task‐based image quality metrics should be further investigated to accommodate additional clinical applications. PACS number(s): 87.57.C‐, 87,57.Q‐
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Affiliation(s)
- Hua Li
- Department of Radiation Oncology, Washington University School of Medicine 4921 Parkview Place Saint Louis, MO 63110.
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Chin RI, Spencer CR, DeWees T, Hwang MY, Patel P, Sinha P, Gay HA, Haughey BH, Nussenbaum B, Adkins DR, Lewis JS, Thorstad WL. Reevaluation of postoperative radiation dose in the management of human papillomavirus-positive oropharyngeal cancer. Head Neck 2016; 38:1643-1649. [PMID: 27152851 DOI: 10.1002/hed.24486] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 09/12/2015] [Revised: 02/29/2016] [Accepted: 03/17/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to compare outcomes of patients with p16-positive oropharyngeal squamous cell carcinoma (SCC) treated with postoperative intensity-modulated radiotherapy (IMRT) before and after an institutional dose reduction policy effective on February 2009. METHODS Between 1998 and 2013, 175 consecutive patients with p16-positive oropharyngeal SCC with extracapsular extension (ECE) and/or close or positive margins were treated postoperatively to 66 Gy (n = 109) or 60 Gy (n = 66) in 2 Gy/fx. RESULTS Between the 66 and 60 Gy groups, there was no difference in tumor classification (pT4 vs pT1-T3; p = .181) and nodal classification (pN2c-N3 vs pN0-N2b; p = .704), and American Joint Committee on Cancer (AJCC) group stage (IV vs I-III; p = .473). Median follow-up was 5.9 years overall (66 Gy: 7.4 years; 60 Gy: 4.0 years). There was no difference in locoregional recurrence-free survival (2-year: 98.1% vs 98.5%; p = .421). CONCLUSION This study suggests that treating p16-positive oropharyngeal SCC with ECE and/or close or positive margins with postoperative IMRT to 60 Gy may not compromise locoregional recurrence-free survival compared to 66 Gy. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.
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Affiliation(s)
- Re-I Chin
- Saint Louis University School of Medicine, St. Louis, Missouri
| | - Christopher R Spencer
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Todd DeWees
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | | | - Pranav Patel
- Saint Louis University School of Medicine, St. Louis, Missouri
| | - Parul Sinha
- Department of Otolaryngology Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Hiram A Gay
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Bruce H Haughey
- Department of Otolaryngology Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri.,Department of Surgery, University of Auckland School of Medicine, Auckland, New Zealand
| | - Brian Nussenbaum
- Department of Otolaryngology Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Douglas R Adkins
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - James S Lewis
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri.
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Zenga J, Wilson M, Adkins DR, Gay HA, Haughey BH, Kallogjeri D, Michel LS, Paniello RC, Rich JT, Thorstad WL, Nussenbaum B. Treatment Outcomes for T4 Oropharyngeal Squamous Cell Carcinoma. JAMA Otolaryngol Head Neck Surg 2016; 141:1118-27. [PMID: 25902372 DOI: 10.1001/jamaoto.2015.0764] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Little is known about treatment outcomes for T4 oropharyngeal squamous cell carcinoma (OPSCC), particularly in the era of human papillomavirus (HPV)-related disease. OBJECTIVE To evaluate oncologic outcomes for T4 OPSCC treated with primary surgical and nonsurgical therapies. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 131 patients from a single academic hospital, who were treated for T4a or T4b OPSCC (with any N stage and without distant metastatic disease at presentation) between 1998 and 2012 and had a minimum 2-year follow-up (the median follow-up time was 34.6 months). This study was conducted between January 1, 1998, and November 1, 2012. INTERVENTIONS Sixty-nine patients underwent nonsurgical therapy, 47 (68%) of whom had p16-positive tumors. Nonsurgical treatment paradigms included induction chemotherapy followed by chemoradiotherapy (n = 36 [54%]), concurrent chemoradiotherapy (n = 29 [43%]), and induction chemotherapy followed by radiation therapy alone (n = 2 [3%]). Sixty-two patients underwent surgical treatment, 50 (81%) of whom had p16-positive tumors. Fifty-seven surgical patients (92%) received adjuvant therapy. MAIN OUTCOMES AND MEASURES Overall survival (OS) was the primary outcome measure. Secondary outcome measures included disease-specific survival (DSS), disease-free survival (DFS), 2-year gastrostomy and tracheostomy tube rates, and major complication rates. RESULTS Significant baseline differences between the surgical vs nonsurgical groups included age (mean 59.8 vs 55.4 years [P = .005]), sex (male, 95% vs 84% [P = .04]), body mass index (<18.5 [calculated as weight in kilograms divided by height in meters squared], 3% vs 16% [P = .02]), and smoking history of 10 or more pack-years (48% vs 77% [P = .003]). For p16-positive patients, Kaplan-Meier estimates of OS, DSS, and DFS were significantly higher for surgically treated patients than for the nonsurgical group (χ(2)(1) = 7.335 for log-rank P = .007, χ(2)(1) = 8.607 for log-rank P = .003, and χ(2)(1) = 7.763 for log-rank P = .005, respectively). For p16-negative patients, Kaplan-Meier estimates of OS and DSS were higher for the surgical group but did not reach statistical significance (χ(2)(1) = 2.649 for log-rank P = .10 and χ(2)(1) = 2.077 for log-rank P = .15, respectively), while estimates of DFS were significantly higher for patients treated with primary surgery (χ(2)(1)= 3.869 for log-rank P = .049. In a multivariable Cox survival analysis, p16-positive immunohistochemical status had a significant positive association with OS (hazard ratio [HR], 0.55; 95% CI, 0.32-0.95 [P = .03]), DSS (HR, 0.45; 95% CI, 0.22-0.92 [P = .03]), and DFS (HR, 0.55; 95% CI, 0.32-0.95 [P = .03]), and nonsurgical treatment had a significant negative association with OS (HR, 2.79; 95% CI, 1.51-5.16 [P = .001]), DSS (HR, 3.38; 95% CI, 1.59-7.16 [P = .002]), and DFS (HR, 2.59; 95% CI, 1.51-4.45 [P = .001]). CONCLUSIONS AND RELEVANCE Primary surgical treatment may be associated with improved outcomes in patients with T4 OPSCC. p16 Immunohistochemical status remains a strong prognostic indicator even in patients with locally advanced disease.
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Affiliation(s)
- Joseph Zenga
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St Louis, Missouri
| | - Michael Wilson
- medical student at Washington University, School of Medicine, St Louis, Missouri
| | - Douglas R Adkins
- Department of Medical Oncology, Washington University, St Louis, Missouri
| | - Hiram A Gay
- Department of Radiation Oncology, Washington University, St Louis, Missouri
| | - Bruce H Haughey
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St Louis, Missouri
| | - Dorina Kallogjeri
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St Louis, Missouri
| | - Loren S Michel
- Department of Medical Oncology, Washington University, St Louis, Missouri
| | - Randal C Paniello
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St Louis, Missouri
| | - Jason T Rich
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St Louis, Missouri
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University, St Louis, Missouri
| | - Brian Nussenbaum
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St Louis, Missouri
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Bichakjian CK, Olencki T, Aasi SZ, Alam M, Andersen JS, Berg D, Bowen GM, Cheney RT, Daniels GA, Glass LF, Grekin RC, Grossman K, Higgins SA, Ho AL, Lewis KD, Lydiatt DD, Nehal KS, Nghiem P, Olsen EA, Schmults CD, Sekulic A, Shaha AR, Thorstad WL, Tuli M, Urist MM, Wang TS, Wong SL, Zic JA, Hoffmann KG, Engh A. Basal Cell Skin Cancer, Version 1.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2016; 14:574-97. [PMID: 27160235 DOI: 10.6004/jnccn.2016.0065] [Citation(s) in RCA: 154] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Basal cell carcinoma (BCC) of the skin is the most common cancer, with a higher incidence than all other malignancies combined. Although it is rare to metastasize, patients with multiple or frequently recurring BCC can suffer substantial comorbidity and be difficult to manage. Assessment of risk is a key element of management needed to inform treatment selection. The overall management of BCC primarily consists of surgical approaches, with radiation therapy as an alternate or adjuvant option. Many superficial therapies for BCC have been explored and continue to be developed, including topicals, cryosurgery, and photodynamic therapy. Two hedgehog pathway inhibitors were recently approved by the FDA for systemic treatment of advanced and metastatic BCC, and others are in development. The NCCN Guidelines for Basal Cell Skin Cancer, published in full herein, include recommendations for selecting among the various surgical approaches based on patient-, lesion-, and disease-specific factors, as well as guidance on when to use radiation therapy, superficial therapies, and hedgehog pathway inhibitors.
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45
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Wong N, Khwaja SS, Baker CM, Gay HA, Thorstad WL, Daly MD, Lewis JS, Wang X. Prognostic microRNA signatures derived from The Cancer Genome Atlas for head and neck squamous cell carcinomas. Cancer Med 2016; 5:1619-28. [PMID: 27109697 PMCID: PMC4944889 DOI: 10.1002/cam4.718] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/24/2016] [Accepted: 03/07/2016] [Indexed: 12/24/2022] Open
Abstract
Identification of novel prognostic biomarkers typically requires a large dataset which provides sufficient statistical power for discovery research. To this end, we took advantage of the high‐throughput data from The Cancer Genome Atlas (TCGA) to identify a set of prognostic biomarkers in head and neck squamous cell carcinomas (HNSCC) including oropharyngeal squamous cell carcinoma (OPSCC) and other subtypes. In this study, we analyzed miRNA‐seq data obtained from TCGA patients to identify prognostic biomarkers for OPSCC. The identified miRNAs were further tested with an independent cohort. miRNA‐seq data from TCGA was also analyzed to identify prognostic miRNAs in oral cavity squamous cell carcinoma (OSCC) and laryngeal squamous cell carcinoma (LSCC). Our study identified that miR‐193b‐3p and miR‐455‐5p were positively associated with survival, and miR‐92a‐3p and miR‐497‐5p were negatively associated with survival in OPSCC. A combined expression signature of these four miRNAs was prognostic of overall survival in OPSCC, and more importantly, this signature was validated in an independent OPSCC cohort. Furthermore, we identified four miRNAs each in OSCC and LSCC that were prognostic of survival, and combined signatures were specific for subtypes of HNSCC. A robust 4‐miRNA prognostic signature in OPSCC, as well as prognostic signatures in other subtypes of HNSCC, was developed using sequencing data from TCGA as the primary source. This demonstrates the power of using TCGA as a potential resource to develop prognostic tools for improving individualized patient care.
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Affiliation(s)
- Nathan Wong
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri.,Department of Biomedical Engineering, Washington University, St. Louis, Missouri
| | - Shariq S Khwaja
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Callie M Baker
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Hiram A Gay
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Mackenzie D Daly
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - James S Lewis
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Xiaowei Wang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri.,Department of Biomedical Engineering, Washington University, St. Louis, Missouri
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Zenga J, Graboyes EM, Haughey BH, Paniello RC, Mehrad M, Lewis JS, Thorstad WL, Nussenbaum B, Rich JT. Definitive Surgical Therapy after Open Neck Biopsy for HPV-Related Oropharyngeal Cancer. Otolaryngol Head Neck Surg 2016; 154:657-66. [PMID: 26861231 DOI: 10.1177/0194599815627642] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 12/29/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine the impact of prior open neck biopsy on the prognosis of patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) who are subsequently treated with a definitive surgical paradigm, including adjuvant therapy when indicated. STUDY DESIGN Retrospective cohort. SETTING Tertiary care university hospital. SUBJECTS AND METHODS Patients with open neck biopsies who were treated with definitive surgery, with or without adjuvant therapy, for HPV-related OPSCC between 1998 and 2012 were compared with a matched control group who did not undergo open neck biopsy. Outcomes were disease-free survival, overall survival, disease-specific survival, incidence of tumor deposit in dermal scar, patterns of recurrence, and neck dissection complications. RESULTS Forty-five patients who underwent open neck biopsy were compared with 90 matched controls. Tumor deposits in dermal scars from the prior open neck biopsy were found in 3 patients (7%) during completion neck dissection. Overall complications of the neck dissection were not significantly increased in the open biopsy group over matched controls (20% vs 12%, respectively; P > .05). Five-year Kaplan-Meier estimates for disease-free survival, overall survival, and disease-specific survival were not significantly different between the open biopsy and control groups (93% vs 91%, 98% vs 97%, 98% vs 99%, respectively; all P > .05). Recurrence rates were also not significantly different between groups. CONCLUSIONS Patients with HPV-related OPSCC who have undergone a prior open neck biopsy can be successfully treated with a definitive surgical paradigm. Although needle biopsy is preferable to establish a diagnosis, previous open neck biopsy does not affect prognosis in these patients.
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Affiliation(s)
- Joseph Zenga
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Bruce H Haughey
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Randal C Paniello
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Mitra Mehrad
- Department of Pathology, Washington University School of Medicine, St Louis, Missouri, USA
| | - James S Lewis
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Brian Nussenbaum
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jason T Rich
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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Altman MB, Kavanaugh JA, Wooten HO, Green OL, DeWees TA, Gay H, Thorstad WL, Li H, Mutic S. A framework for automated contour quality assurance in radiation therapy including adaptive techniques. Phys Med Biol 2015; 60:5199-209. [DOI: 10.1088/0031-9155/60/13/5199] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Divi V, Harris J, Harari PM, Cooper JS, McHugh JB, Bell D, Sturgis EM, Cmelak A, Suntharalingam M, Raben D, Kim HE, Spencer S, Laramore GE, Trotti A, Foote RL, Schultz CJ, Thorstad WL, Zhang Q, Le QT, Holsinger FC. Establishing quality indicators for neck dissection: Correlating the number of lymph nodes with oncologic outcomes, NRG Oncology/RTOG 9501-0234. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.6011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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)
| | | | | | | | | | - Diana Bell
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Mohan Suntharalingam
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD
| | | | | | | | | | | | | | | | - Wade L. Thorstad
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Quynh-Thu Le
- Stanford University Medical Center, Stanford, CA
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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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50
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Sinha P, Kallogjeri D, Gay H, Thorstad WL, Lewis JS, Chernock R, Nussenbaum B, Haughey BH. High metastatic node number, not extracapsular spread or N-classification is a node-related prognosticator in transorally-resected, neck-dissected p16-positive oropharynx cancer. Oral Oncol 2015; 51:514-20. [PMID: 25771076 DOI: 10.1016/j.oraloncology.2015.02.098] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [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: 01/19/2015] [Revised: 02/18/2015] [Accepted: 02/19/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Due to unique biology and prognosis, precise identification of predictive parameters is critical for p16+ oropharyngeal squamous cell carcinoma (OPSCC). Prior studies showing absence of prognostication from extracapsular spread (ECS) and/or high N-classification in surgically-treated p16+ OPSCC necessitate new, evidence-based prognosticators. METHODS A prospectively assembled cohort of 220, transoral surgery+neck dissection±adjuvant therapy-treated, p16+ OPSCC patients was analyzed. Disease recurrence and disease-specific survival (DSS) were primary endpoints. RESULTS Median follow-up was 59 (12-189) months. Distribution of metastatic node numbers was: 0 in 9.5% (n=21), 1 in 33.6% (n=74), 2 in 17% (n=38), 3 in 14.5% (n=32), 4 in 8.2% (n=18), and ⩾5 in 17% (n=37). ECS was recorded in 80% (n=159), and N2c-N3 in 17% (n=38). Adjuvant radiotherapy and chemoradiotherapy was administered in 44% and 34%. Recurrence developed in 22 patients (10%); 4 local, 5 regional, 2 regional and distant, and 11 distant. The 3- and 5-year DSS estimates were 94.6% and 93%. Multivariable logistic regression identified ⩾5 nodes and T3-T4 classification as predictors for recurrence. In multivariable Cox analyses, ⩾5 nodes, T3-T4 classification and margins were prognostic for DSS. ECS, N2c-N3 classification and smoking were not prognostic. CONCLUSIONS Metastatic node number, not ECS or high N-classification is an independent nodal predictor of outcomes in surgically-treated p16+ OPSCC patients. Despite high DSS (~80%), closer surveillance for recurrence is recommended for patients with ⩾5 metastatic nodes.
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Affiliation(s)
- Parul Sinha
- Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Dorina Kallogjeri
- Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, United States; Clinical Outcomes Research, Washington University School of Medicine, St. Louis, MO, United States
| | - Hiram Gay
- Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Wade L Thorstad
- Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - James S Lewis
- Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, United States; Pathology, Washington University School of Medicine, St. Louis, MO, United States
| | - Rebecca Chernock
- Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, United States; Pathology, Washington University School of Medicine, St. Louis, MO, United States
| | - Brian Nussenbaum
- Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Bruce H Haughey
- Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, United States.
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