Longitudinal changes in the carotid arteries of head and neck cancer patients following radiation therapy: Results from a prospective serial imaging biomarker characterization study

INTRODUCTION

We prospectively evaluated morphologic and functional changes in the carotid arteries of patients treated with unilateral neck radiation therapy (RT) for head and neck cancer.

METHODS

Bilateral carotid artery duplex studies were performed at 0, 3, 6, 12, 18 months and 2, 3, 4, and 5 years following RT. Intima media thickness (IMT); global and regional circumferential, as well as radial strain, arterial elasticity, stiffness, and distensibility were calculated.

RESULTS

Thirty-eight patients were included. A significant difference in the IMT from baseline between irradiated and unirradiated carotid arteries was detected at 18 months (median, 0.073 mm vs -0.003 mm; P = 0.014), which increased at 3 and 4 years (0.128 mm vs 0.013 mm, P = 0.016, and 0.177 mm vs 0.023 mm, P = 0.0002, respectively). A significant transient change was noted in global circumferential strain between the irradiated and unirradiated arteries at 6 months (median difference, -0.89, P = 0.023), which did not persist. No significant differences were detected in the other measures of elasticity, stiffness, and distensibility.

CONCLUSIONS

Functional and morphologic changes of the carotid arteries detected by carotid ultrasound, such as changes in global circumferential strain at 6 months and carotid IMT at 18 months, may be useful for the early detection of radiation-induced carotid artery injury, can guide future research aiming to mitigate carotid artery stenosis, and should be considered for clinical surveillance survivorship recommendations after head and neck RT.

Dataset of weekly intra-treatment diffusion weighted imaging in head and neck cancer patients treated with MR-Linac

Radiation therapy (RT) is a crucial treatment for head and neck squamous cell carcinoma (HNSCC); however, it can have adverse effects on patients' long-term function and quality of life. Biomarkers that can predict tumor response to RT are being explored to personalize treatment and improve outcomes. While tissue and blood biomarkers have limitations, imaging biomarkers derived from magnetic resonance imaging (MRI) offer detailed information. The integration of MRI and a linear accelerator in the MR-Linac system allows for MR-guided radiation therapy (MRgRT), offering precise visualization and treatment delivery. This data descriptor offers a valuable repository for weekly intra-treatment diffusion-weighted imaging (DWI) data obtained from head and neck cancer patients. By analyzing the sequential DWI changes and their correlation with treatment response, as well as oncological and survival outcomes, the study provides valuable insights into the clinical implications of DWI in HNSCC.

International Expert-Based Consensus Definition, Staging Criteria, and Minimum Data Elements for Osteoradionecrosis of the Jaw: An Inter-Disciplinary Modified Delphi Study

Purpose

Osteoradionecrosis of the jaw (ORNJ) is a severe iatrogenic disease characterized by bone death after radiation therapy (RT) to the head and neck. With over 9 published definitions and at least 16 diagnostic/staging systems, the true incidence and severity of ORNJ are obscured by lack of a standard for disease definition and severity assessment, leading to inaccurate estimation of incidence, reporting ambiguity, and likely under-diagnosis worldwide. This study aimed to achieve consensus on an explicit definition and phenotype of ORNJ and related precursor states through data standardization to facilitate effective diagnosis, monitoring, and multidisciplinary management of ORNJ.

Methods

The ORAL Consortium comprised 69 international experts, including representatives from medical, surgical, radiation oncology, and oral/dental disciplines. Using a web-based modified Delphi technique, panelists classified descriptive cases using existing staging systems, reviewed systems for feature extraction and specification, and iteratively classified cases based on clinical/imaging feature combinations.

Results

The Consortium ORNJ definition was developed in alignment with SNOMED-CT terminology and recent ISOO-MASCC-ASCO guideline recommendations. Case review using existing ORNJ staging systems showed high rates of inability to classify (up to 76%). Ten consensus statements and nine minimum data elements (MDEs) were outlined for prospective collection and classification of precursor/ORNJ stages.

Conclusion

This study provides an international, consensus-based definition and MDE foundation for standardized ORNJ reporting in cancer survivors treated with RT. Head and neck surgeons, radiation, surgical, medical oncologists, and dental specialists should adopt MDEs to enable scalable health information exchange and analytics. Work is underway to develop both a human- and machine-readable knowledge representation for ORNJ (i.e., ontology) and multidisciplinary resources for dissemination to improve ORNJ reporting in academic and community practice settings.

Longitudinal Changes in the Carotid Arteries of Head and Neck Cancer Patients Following Radiation Therapy: Results from a Prospective Serial Imaging Biomarker Characterization Study

INTRODUCTION

We prospectively evaluated morphologic and functional changes in the carotid arteries of patients treated with unilateral neck radiation therapy (RT) for head and neck cancer.

METHODS

Bilateral carotid artery duplex studies were performed at 0, 3, 6, 12, 18 months and 2, 3, 4, and 5 years following RT. Intima media thickness (IMT); global and regional circumferential, as well as radial strain, arterial elasticity, stiffness, and distensibility were calculated.

RESULTS

Thirty-eight patients were included. A significant difference in the IMT from baseline between irradiated and unirradiated carotid arteries was detected at 18 months (median, 0.073mm vs -0.003mm; P =0.014), which increased at 3 and 4 years (0.128mm vs 0.013mm, P =0.016, and 0.177mm vs 0.023mm, P =0.0002, respectively). A > 0.073mm increase at 18 months was significantly more common in patients who received concurrent chemotherapy (67% vs 25%; P =0.03). A significant transient change was noted in global circumferential strain between the irradiated and unirradiated arteries at 6 months (median difference, -0.89, P =0.023), which did not persist. No significant differences were detected in the other measures of elasticity, stiffness, and distensibility.

CONCLUSIONS

Functional and morphologic changes of the carotid arteries detected by carotid ultrasound, such as changes in global circumferential strain at 6 months and carotid IMT at 18 months, may be useful for the early detection of radiation-induced carotid artery injury, can guide future research aiming to mitigate carotid artery stenosis, and should be considered for clinical surveillance survivorship recommendations after head and neck RT.

Weekly Intra-Treatment Diffusion Weighted Imaging Dataset for Head and Neck Cancer Patients Undergoing MR-linac Treatment

Radiation therapy (RT) is a crucial treatment for head and neck squamous cell carcinoma (HNSCC), however it can have adverse effects on patients' long-term function and quality of life. Biomarkers that can predict tumor response to RT are being explored to personalize treatment and improve outcomes. While tissue and blood biomarkers have limitations, imaging biomarkers derived from magnetic resonance imaging (MRI) offer detailed information. The integration of MRI and a linear accelerator in the MR-Linac system allows for MR-guided radiation therapy (MRgRT), offering precise visualization and treatment delivery. This data descriptor offers a valuable repository for weekly intra-treatment diffusion-weighted imaging (DWI) data obtained from head and neck cancer patients. By analyzing the sequential DWI changes and their correlation with treatment response, as well as oncological and survival outcomes, the study provides valuable insights into the clinical implications of DWI in HNSCC. [Table: see text].

Comparison of Machine-Learning and Deep-Learning Methods for the Prediction of Osteoradionecrosis Resulting From Head and Neck Cancer Radiation Therapy

Purpose

Deep-learning (DL) techniques have been successful in disease-prediction tasks and could improve the prediction of mandible osteoradionecrosis (ORN) resulting from head and neck cancer (HNC) radiation therapy. In this study, we retrospectively compared the performance of DL algorithms and traditional machine-learning (ML) techniques to predict mandible ORN binary outcome in an extensive cohort of patients with HNC.

Methods and Materials

Patients who received HNC radiation therapy at the University of Texas MD Anderson Cancer Center from 2005 to 2015 were identified for the ML (n = 1259) and DL (n = 1236) studies. The subjects were followed for ORN development for at least 12 months, with 173 developing ORN and 1086 having no evidence of ORN. The ML models used dose-volume histogram parameters to predict ORN development. These models included logistic regression, random forest, support vector machine, and a random classifier reference. The DL models were based on ResNet, DenseNet, and autoencoder-based architectures. The DL models used each participant's dose cropped to the mandible. The effect of increasing the amount of available training data on the DL models' prediction performance was evaluated by training the DL models using increasing ratios of the original training data.

Results

The F1 score for the logistic regression model, the best-performing ML model, was 0.3. The best-performing ResNet, DenseNet, and autoencoder-based models had F1 scores of 0.07, 0.14, and 0.23, respectively, whereas the random classifier's F1 score was 0.17. No performance increase was apparent when we increased the amount of training data available for DL model training.

Conclusions

The ML models had superior performance to their DL counterparts. The lack of improvement in DL performance with increased training data suggests that either more data are needed for appropriate DL model construction or that the image features used in DL models are not suitable for this task.

Longitudinal diffusion and volumetric kinetics of head and neck cancer magnetic resonance on a 1.5T MR-Linear accelerator hybrid system: A prospective R-IDEAL Stage 2a imaging biomarker characterization/ pre-qualification study

Objectives

We aim to characterize the serial quantitative apparent diffusion coefficient (ADC) changes of the target disease volume using diffusion-weighted imaging (DWI) acquired weekly during radiation therapy (RT) on a 1.5T MR-Linac and correlate these changes with tumor response and oncologic outcomes for head and neck squamous cell carcinoma (HNSCC) patients as part of a programmatic R-IDEAL biomarker characterization effort.

Methods

Thirty patients with pathologically confirmed HNSCC who received curative-intent RT at the University of Texas MD Anderson Cancer Center, were included in this prospective study. Baseline and weekly Magnetic resonance imaging (MRI) (weeks 1-6) were obtained, and various ADC parameters (mean, 5 th , 10 th , 20 th , 30 th , 40 th , 50 th , 60 th , 70 th , 80 th , 90 th and 95 th percentile) were extracted from the target regions of interest (ROIs). Baseline and weekly ADC parameters were correlated with response during RT, loco-regional control, and the development of recurrence using the Mann-Whitney U test. The Wilcoxon signed-rank test was used to compare the weekly ADC versus baseline values. Weekly volumetric changes (Δvolume) for each ROI were correlated with ΔADC using Spearman's Rho test. Recursive partitioning analysis (RPA) was performed to identify the optimal ΔADC threshold associated with different oncologic outcomes.

Results

There was an overall significant rise in all ADC parameters during different time points of RT compared to baseline values for both gross primary disease volume (GTV-P) and gross nodal disease volumes (GTV-N). The increased ADC values for GTV-P were statistically significant only for primary tumors achieving complete remission (CR) during RT. RPA identified GTV-P ΔADC 5 th percentile >13% at the 3 rd week of RT as the most significant parameter associated with CR for primary tumor during RT (p <0.001). Baseline ADC parameters for GTV-P and GTV-N didn't significantly correlate with response to RT or other oncologic outcomes. There was a significant decrease in residual volume of both GTV-P & GTV-N throughout the course of RT. Additionally, a significant negative correlation between mean ΔADC and Δvolume for GTV-P at the 3 rd and 4 th week of RT was detected (r = -0.39, p = 0.044 & r = -0.45, p = 0.019, respectively).

Conclusion

Assessment of ADC kinetics at regular intervals throughout RT seems to be correlated with RT response. Further studies with larger cohorts and multi-institutional data are needed for validation of ΔADC as a model for prediction of response to RT.

Neutrophil-to-lymphocyte ratio trend: A novel prognostic predictor in patients with nasopharyngeal carcinoma receiving radiotherapy

BACKGROUND

Peripheral neutrophil-lymphocyte ratio (NLR), reflecting immune-inflammation status, shows great potential for tumor progression and outcome. Pre-treatment NLR does not fully reflect the immune-inflammatory response to treatment. This study aimed to introduce the NLR trend as a new indicator and to investigate its prognostic value in patients with nasopharyngeal carcinoma receiving radiotherapy.

METHODS

This retrospective study evaluated patients with nasopharyngeal carcinoma treated with radiotherapy. The NLR trend value was calculated from the fitted line gradient via the NLRs before, during (at least once), and after each patient's first radiotherapy. The Kaplan-Meier curve and log-rank test were used to calculate and compare survival outcomes of different pretreatment NLRs and NLR trends for progression-free survival, locoregional recurrence-free survival (LRFS), and overall survival at 3 and 5 years. Multivariate Cox regression analyses were performed to assess the association between the NLR trend plus 3- and 5-year overall survival.

RESULTS

The study included 528 patients. A lower NLR trend predicted worse progression-free survival, LRFS, plus 3- and 5-year overall survival. Multivariate Cox regression analysis showed that the NLR trend independently predicted 3- and 5-year overall survival. Sub-group analysis showed that the prognosis of patients with a low pretreatment NLR and a high NLR trend were superior to those of other groups.

CONCLUSION

The NLR trend independently predicted the prognosis of patients with nasopharyngeal carcinoma receiving radiotherapy. The NLR trend and the pretreatment NLR combination is more precise than pretreatment NLR in predicting prognosis. A high NLR trend may be evidence of a positive immune response to radiotherapy in patients with nasopharyngeal carcinoma.

Mixed Effect Modeling of Dose and Linear Energy Transfer Correlations With Brain Image Changes After Intensity Modulated Proton Therapy for Skull Base Head and Neck Cancer

Purpose:

Intensity modulated proton therapy (IMPT) could yield high linear energy transfer (LET) in critical structures and increased biological effect. For head and neck cancers at the skull base this could potentially result in radiation-associated brain image change (RAIC). The purpose of the current study was to investigate voxel-wise dose and LET correlations with RAIC after IMPT.

Methods and Materials:

For 15 patients with RAIC after IMPT, contrast enhancement observed on T1-weighted magnetic resonance imaging was contoured and coregistered to the planning computed tomography. Monte Carlo calculated dose and dose-averaged LET (LET_d) distributions were extracted at voxel level and associations with RAIC were modelled using uni- and multivariate mixed effect logistic regression. Model performance was evaluated using the area under the receiver operating characteristic curve and precision-recall curve.

Results:

An overall statistically significant RAIC association with dose and LET_d was found in both the uni- and multivariate analysis. Patient heterogeneity was considerable, with standard deviation of the random effects of 1.81 (1.30–2.72) for dose and 2.68 (1.93–4.93) for LET_d, respectively. Area under the receiver operating characteristic curve was 0.93 and 0.95 for the univariate dose-response model and multivariate model, respectively. Analysis of the LET_d effect demonstrated increased risk of RAIC with increasing LET_d for the majority of patients. Estimated probability of RAIC with LET_d = 1 keV/μm was 4% (95% confidence interval, 0%, 0.44%) and 29% (95% confidence interval, 0.01%, 0.92%) for 60 and 70 Gy, respectively. The TD₁₅ were estimated to be 63.6 and 50.1 Gy with LET_d equal to 2 and 5 keV/μm, respectively.

Conclusions:

Our results suggest that the LET_d effect could be of clinical significance for some patients; LET_d assessment in clinical treatment plans should therefore be taken into consideration.

Outcomes after salvage for HPV-positive recurrent oropharyngeal cancer treated with primary radiation

PURPOSE

HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) carries a favorable prognosis for patients, yet nearly 30% of patients will experience disease relapse. We sought to detail patterns of failure, associated salvage therapy, and outcomes for patients with recurrent HPV-positive OPSCC.

METHODS AND MATERIALS

This is a single institution retrospective study of patients with recurrent HPV-positive OPSCC irradiated from 2002 to 2014. The primary study outcome was overall survival (OS, calculated using the Kaplan-Meier method). Secondary aims included patterns of first failure with descriptive details of salvage therapy. Solitary recurrences were defined as initial presentation of recurrence in a single site (primary, neck or oligometastatic), and multi-site was defined as local and regional and/or multiple sites of distant recurrence. Survival outcomes were compared using the log-rank test.

RESULTS

The cohort consisted of 132 patients. The median follow-up was 59 months for surviving patients. Estimated 2-year and 5-year OS rates were 47% and 32%, respectively. Comparative 2-year and 5-year OS rates were 65% and 46% versus 19% and 9% for the solitary group and multi-site group, respectively (p < .001).

CONCLUSIONS

Patients with recurrent HPV-positive OPSCC experience 5-year survival of approximately 32%. However, patients with a "solitary" recurrence including disease at the primary site, neck or oligometastatic site have more favorable long-term outcomes.

A predictive model of radiation-related fibrosis based on the radiomic features of magnetic resonance imaging and computed tomography

Background

To establish a predictive model for the fibrotic level of neck muscles after radiotherapy by using radiomic features extracted from the magnetic resonance imaging (MRI) before and after radiotherapy and planning computed tomography (CT) in nasopharyngeal carcinoma patients.

Methods

A total of one hundred and eighty-six patients were finally enrolled in this study. According to the specific standard, all patients were divided into three different fibrosis groups. Regions of interests (ROI), including sternocleidomastoids (SCMs), trapezius (T), levator scapulae (LS), and scalenus muscles (S), were delineated manually and used for features extraction on IBEX. XGBoost, a machine learning algorithm, was used for the establishment of the prediction model. First, the patients were divided into training cohort (80%) and testing cohort (20%) randomly. Then the image features of CT or delta changes calculated from pre- and post-radiotherapy MRI images on each cohort constituted training and testing datasets. Then, based on the training dataset, a well-trained prediction model was produced. We used five-fold cross-validation to validate the predictive models. Afterward, the model performance was assessed on the ‘testing’ set and reported in terms of area under the receiver operating characteristic curve (AUC) under five scenarios: (I) only T1 sequence, (II) only T2 sequence, (III) only T1 post-contrast (T1 + C) sequence, (IV) Combination of all MRI sequences, (V) only CT.

Results

Most of the patients enrolled are male (73.1%), mean age was 47 years, receiving concurrent chemo-radiotherapy as the primary treatment (90.9%). By the end of the final follow-up, most of the patients were rated as mild fibrosis (60.8%). We found the prediction model based on the CT image features outperform all MRI features with an AUC of 0.69 and accuracy of 0.65. Contrarily, the model based on features from all MRI sequence showed lower AUC less than 0.5 and lower accuracy less than 0.6.

Conclusions

The prediction model based on CT radiomics features has better performance in the prediction of the grade of post-radiotherapy neck fibrosis. This might help guide radiotherapy treatment planning to achieve a better quality of life.

Stability analysis of CT radiomic features with respect to segmentation variation in oropharyngeal cancer

INTRODUCTION

Accurate segmentation of tumors and quantification of tumor features are important for cancer detection, diagnosis, monitoring, and planning therapeutic intervention. Due to inherent noise components in multi-parametric imaging and inter-observer and intra-observer variations, it is common that various segmentation methods may produce large segmentation errors in tumor volumes and their associated radiomic features. The purpose of this study is to carry out the stability analysis for radiomic features with respect to segmentation variation in oropharyngeal cancer (OPC).

METHODS

In this study, 436 contrast-enhanced computed tomography (CT) axial images were collected from patients with OPC. In order to derive various segmentations of tumor volumes, two additional segmentations were obtained via resizing the original segmented regions of interest (ROIs) based on their geometric information on the boundary. For three ROI image groups, we calculated 109 radiomic features. Then, a logistic regression model was built to investigate the correlation between the radiomic features extracted from GTVp and the response to chemotherapy and radiation in terms of overall survival (OS). Finally, in order to evaluate the stability of each feature with respect to segmentation results, based on the prediction probabilities, we assessed the inter-rater reliability and reproducibility by calculating the intra-class correlation coefficients (ICC) and concordance correlation coefficients (CCC).

RESULTS

Most radiomic features in this study varied a lot when the ROIs were not well segmented. For both the representation agreement and predictive agreement, the ICC and CCC were below 0.5 for all the features. We still found some robust features with relatively high ICC and CCC compared to most features. For example, 25percentile (ICC = 0.38, CCC = 0.37 in representation agreement and ICC = CCC = 0.27 in predictive agreement) is a quantile based feature, which is robust to the extremely high or low values; and Hu_1_std (ICC = 0.31, CCC = 0.31 in representation agreement) is a feature calculated based on the first Hu moment, which is invariant to the transformation of ROIs.

CONCLUSION

In OPC studies, the tumor segmentation variation affects the radiomic features from CT images in terms of both representation and prediction. Some features that are robust to the extreme values or invariant to the transformation of ROIs may be treated as radiomic markers to assist with OPC treatment monitoring and prognostic prediction.

CD8 infiltration is associated with disease control and tobacco exposure in intermediate-risk oropharyngeal cancer

Oropharyngeal squamous cell carcinoma (OPSCC) incidence is increasing at a nearly epidemic rate, largely driven by the human papillomavirus (HPV). Despite the generally favorable clinical outcomes of patients with HPV driven (HPV+) OPSCC, a significant subset of HPV tumors associated with tobacco exposure have diminished treatment response and worse survival. The tumor immune microenvironment (TIME) has been shown to be a critical driver of treatment response and oncologic outcomes in OPSCC generally and HPV+ OPSCC more specifically. However, the impact of tobacco exposure on the TIME in OPSCC patients remains unclear. We analyzed the relationship between TIME, tobacco exposure and clinical outcomes in OPSCC patients (n = 143) with extensive tobacco exposure (median pack-years = 40). P16 overexpression, a surrogate marker of HPV association, was a strong predictor of relapse-free (RFS) and overall survival (OS) (p < 0.001, p < 0.001 respectively) regardless of tobacco exposure and associated strongly with differential infiltration of the tumor by both CD3 and CD8 lymphocytes measured via immunohistochemistry (p < 001, p < 0.001 respectively). CD3 and CD8 infiltration was a strong predictor of RFS and OS and associated strongly with disease stage (AJCC 8th Edition Staging Manual). Tobacco exposure correlated significantly (p < 0.001) with decreased CD8 infiltration in p16+ OPSCC tumors. Our findings demonstrate that the HPV+ OPSCC clinical outcomes are strongly correlated with the TIME, which is potentially modulated by tobacco exposure. Immunomodulatory strategies targeting this disease in smokers must take into consideration the potential modifying effects of tobacco exposure on treatment effectiveness and clinical outcomes.

Imaging for Response Assessment in Radiation Oncology: Current and Emerging Techniques

Imaging in radiation oncology is essential for the evaluation of treatment response in tumors and organs at risk. This influences further treatment decisions and could possibly be used to adapt therapy. This review article focuses on the currently used imaging modalities for response assessment in radiation oncology and gives an overview of new and promising techniques within this field.

A prospective in silico analysis of interdisciplinary and interobserver spatial variability in post-operative target delineation of high-risk oral cavity cancers: Does physician specialty matter?

Background

The aim of this study was to determine the interdisciplinary agreement in identifying the post-operative tumor bed.

Methods

Three radiation oncologists (ROs), four surgeons, and three radiologists segmented post-operative tumor and nodal beds for three patients with oral cavity cancer. Specialty cohort composite contours were created by STAPLE algorithm implementation results for interspecialty comparison. Dice similarity coefficient and Hausdorff distance were utilized to compare spatial differentials between specialties.

Results

There were significant differences between disciplines in target delineation. There was unacceptable variation in Dice similarity coefficient for each observer and discipline when compared to the STAPLE contours. Within surgery and radiology disciplines, there was good consistency in volumes. ROs and radiologists have similar Dice similarity coefficient scores compared to surgeons.

Conclusion

There were significant interdisciplinary differences in perceptions of tissue-at-risk. Better communication and explicit description of at-risk areas between disciplines is required to ensure high-risk areas are adequately targeted.

Dosimetric and Radiobiological Evaluation of Patient Setup Accuracy in Head-and-neck Radiotherapy Using Daily Computed Tomography-on-rails-based Corrections

Introduction:

This study evaluates treatment plans aiming at determining the expected impact of daily patient setup corrections on the delivered dose distribution and plan parameters in head-and-neck radiotherapy.

Materials and Methods:

In this study, 10 head-and-neck cancer patients are evaluated. For the evaluation of daily changes of the patient internal anatomy, image-guided radiation therapy based on computed tomography (CT)-on-rails was used. The daily-acquired CT-on-rails images were deformedly registered to the CT scan that was used during treatment planning. Two approaches were used during data analysis (“cascade” and “one-to-all”). The dosimetric and radiobiological differences of the dose distributions with and without patient setup correction were calculated. The evaluation is performed using dose–volume histograms; the biologically effective uniform dose () and the complication-free tumor control probability (P₊) were also calculated. The dose–response curves of each target and organ at risk (OAR), as well as the corresponding P₊ curves, were calculated.

Results:

The average difference for the “one-to-all” case is 0.6 ± 1.8 Gy and for the “cascade” case is 0.5 ± 1.8 Gy. The value of P₊ was lowest for the cascade case (in 80% of the patients).

Discussion:

Overall, the lowest P_I is observed in the one-to-all cases. Dosimetrically, CT-on-rails data are not worse or better than the planned data.

Conclusions:

The differences between the evaluated “one-to-all” and “cascade” dose distributions were small. Although the differences of those doses against the “planned” dose distributions were small for the majority of the patients, they were large for given patients at risk and OAR.

Symptom burden and dysphagia associated with osteoradionecrosis in long-term oropharynx cancer survivors: A cohort analysis

OBJECTIVE

The purpose is to examine the relationship between mandibular osteoradionecrosis (ORN) and chronic dysphagia in long-term oropharynx cancer (OPC) survivors, and to determine the perceived symptom burden associated with ORN.

MATERIALS AND METHODS

Medical records of 349 OPC patients treated with bilateral IMRT and systemic therapy were reviewed. ORN was graded using a published 4-point classification schema. Patients were considered to have chronic dysphagia if they had aspiration pneumonia, stricture or aspiration detected by fluoroscopy or endoscopy, and/or feeding tube dependence in long-term follow-up ⩾1year following radiotherapy. MD Anderson Symptom Inventory - Head and Neck Module (MDASI-HN) scores were analyzed in a nested cross-sectional survey sample of 118 patients.

RESULTS

34 (9.7%, 95% CI: 6.8-13.3%) patients developed ORN and 45 (12.9%, 95% CI: 9.6-16.9%) patients developed chronic dysphagia. Prevalence of chronic dysphagia was significantly higher in ORN cases (12/34, 35%) compared to those who did not develop ORN (33/315, 11%, p<0.001). ORN grade was also significantly associated with prevalence of dysphagia (p<0.001); the majority of patients with grade 4 ORN requiring major surgery (6 patients, 75%) were found to have chronic dysphagia. Summary MDASI-HN symptom scores did not significantly differ by ORN grade. Significantly higher symptom burden was reported, however, among ORN cases compared to those without ORN for MDASI-HN swallowing (p=0.033), problems with teeth and/or gums (p=0.016) and change in activity (p=0.015) item scores.

CONCLUSIONS

ORN is associated with excess burden of chronic dysphagia and higher symptom severity related to swallowing, dentition and activity limitations.

Improved human observer performance in digital reconstructed radiograph verification in head and neck cancer radiotherapy

PURPOSE

Digitally reconstructed radiographs (DRRs) are routinely used as an a priori reference for setup correction in radiotherapy. The spatial resolution of DRRs may be improved to reduce setup error in fractionated radiotherapy treatment protocols. The influence of finer CT slice thickness reconstruction (STR) and resultant increased resolution DRRs on physician setup accuracy was prospectively evaluated.

METHODS

Four head and neck patient CT-simulation images were acquired and used to create DRR cohorts by varying STRs at 0.5, 1, 2, 2.5, and 3 mm. DRRs were displaced relative to a fixed isocenter using 0-5 mm random shifts in the three cardinal axes. Physician observers reviewed DRRs of varying STRs and displacements and then aligned reference and test DRRs replicating daily KV imaging workflow. A total of 1,064 images were reviewed by four blinded physicians. Observer errors were analyzed using nonparametric statistics (Friedman's test) to determine whether STR cohorts had detectably different displacement profiles. Post hoc bootstrap resampling was applied to evaluate potential generalizability.

RESULTS

The observer-based trial revealed a statistically significant difference between cohort means for observer displacement vector error ([Formula: see text]) and for [Formula: see text]-axis [Formula: see text]. Bootstrap analysis suggests a 15% gain in isocenter translational setup error with reduction of STR from 3 mm to [Formula: see text]2 mm, though interobserver variance was a larger feature than STR-associated measurement variance.

CONCLUSIONS

Higher resolution DRRs generated using finer CT scan STR resulted in improved observer performance at shift detection and could decrease operator-dependent geometric error. Ideally, CT STRs [Formula: see text]2 mm should be utilized for DRR generation in the head and neck.

Prospective randomized double-blind study of atlas-based organ-at-risk autosegmentation-assisted radiation planning in head and neck cancer

BACKGROUND AND PURPOSE

Target volumes and organs-at-risk (OARs) for radiotherapy (RT) planning are manually defined, which is a tedious and inaccurate process. We sought to assess the feasibility, time reduction, and acceptability of an atlas-based autosegmentation (AS) compared to manual segmentation (MS) of OARs.

MATERIALS AND METHODS

A commercial platform generated 16 OARs. Resident physicians were randomly assigned to modify AS OAR (AS+R) or to draw MS OAR followed by attending physician correction. Dice similarity coefficient (DSC) was used to measure overlap between groups compared with attending approved OARs (DSC=1 means perfect overlap). 40 cases were segmented.

RESULTS

Mean ± SD segmentation time in the AS+R group was 19.7 ± 8.0 min, compared to 28.5 ± 8.0 min in the MS cohort, amounting to a 30.9% time reduction (Wilcoxon p<0.01). For each OAR, AS DSC was statistically different from both AS+R and MS ROIs (all Steel-Dwass p<0.01) except the spinal cord and the mandible, suggesting oversight of AS/MS processes is required; AS+R and MS DSCs were non-different. AS compared to attending approved OAR DSCs varied considerably, with a chiasm mean ± SD DSC of 0.37 ± 0.32 and brainstem of 0.97 ± 0.03.

CONCLUSIONS

Autosegmentation provides a time savings in head and neck regions of interest generation. However, attending physician approval remains vital.