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De Vis JB, Cmelak AJ, Osmundson EC. Chemoimmunotherapy for Untreated Lung Cancer Brain Metastases: Systemic Before Local Therapy? J Clin Oncol 2024; 42:858-859. [PMID: 38079590 DOI: 10.1200/jco.23.02151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/05/2023] [Accepted: 10/16/2023] [Indexed: 02/29/2024] Open
Affiliation(s)
- Jill B De Vis
- Jill B. De Vis, MD, PhD; Anthony J. Cmelak, MD; and Evan C. Osmundson, MD, PhD, Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Anthony J Cmelak
- Jill B. De Vis, MD, PhD; Anthony J. Cmelak, MD; and Evan C. Osmundson, MD, PhD, Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Evan C Osmundson
- Jill B. De Vis, MD, PhD; Anthony J. Cmelak, MD; and Evan C. Osmundson, MD, PhD, Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
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Darrow KR, McComas KN, Rajkumar AW, Dove A, Kluwe C, Murphy B, Gilbert J, Sinard R, Netterville J, Lockney NA, Cmelak AJ. Definitive Chemoradiation with Concurrent Carboplatin and Paclitaxel for HPV-Mediated Oropharyngeal Cancer (p16+ OPSCC): Survival and Local Control. Int J Radiat Oncol Biol Phys 2023; 117:e577. [PMID: 37785754 DOI: 10.1016/j.ijrobp.2023.06.1913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Standard therapy for locally advanced p16+ OPSCC with cisplatin and bilateral nodal RT results in substantial acute and late toxicities. De-intensification strategies are under active investigation, including the de-escalation of RT dose and field size and use of less toxic RT sensitizing agents. We present our single-institution experience with definitive chemoRT using weekly carboplatin and paclitaxel and modified RT. MATERIALS/METHODS A retrospective review of 139 consecutive patients with non-metastatic p16+ OPSCC treated with definitive chemoRT from 2013 to 2019 was performed. IMRT dose ranged from 60 to 70 Gy (median 69.96 Gy) to gross disease and 44 to 59.4 Gy (median 54.45 Gy) to elective nodal sites. Modified RT included dose reduction from 70 Gy EQD2 to 60-67.8 Gy EQD2 (2.0-2.2 Gy/fraction) and/or field modified contralateral neck. All patients received concurrent weekly paclitaxel (30 mg/m2) and carboplatin (AUC 1); 34 (24.5%) received induction chemotherapy. Patients were classified as low or intermediate risk based on HPV status, smoking history, and nodal staging per RTOG 0129 risk stratification. OS, local and regional RFS, and DSS were estimated using Kaplan-Meier method. RESULTS Median FU was 40.5 months. Of 139 pts, 96 were low and 43 were intermediate risk. Median age 61 yrs (range, 40-81 yrs). 125 pts were male and 14 were female. TNM staging: 29 pts (20.9%) were T1 (22 N1, 7 N2), 68 (48.9%) T2 (4 N0, 52 N1, 12 N2), 27 (19.4%) T3 (5 N0, 15 N1, 7 N2), and 15 (10.8%) T4 (2 N0, 2 N1, 10 N2, 1 N3). Median smoking history of 22.5 pack-yrs (range, 0.25-150 pack-yrs); 59 never smoked. LR recurrence was noted in 6/96 (6.3%) low risk and 7/43 (16.3%) intermediate risk pts. DM developed in 11/96 (11.5%) low risk and 8/43 (18.6%) intermediate risk pts. Synchronous LR recurrence and DM were noted in 1/96 (1%) low risk and 2/43 (4.7%) intermediate risk pts. The 3-year LRC was 93.6% (95% CI, 86.3-97.1) in the low-risk and 77.8% (95% CI, 61.4-87.8) in the intermediate-risk group. The 3-year OS was 95.4% (95% CI, 88.3-98.3) in the low-risk and 77.6% (95% CI, 61.3 to 87.7) in the intermediate-risk group. The 3-year DSS was 96.6% (95% CI, 89.7-98.9) in the low-risk and 86.8% (95% CI, 71.0-94.3) in the intermediate-risk group. CONCLUSION Definitive chemoRT for p16+ OPSCC with concurrent carboplatin and paclitaxel and a modified RT regimen designed to minimize acute and late effects of therapy demonstrated comparable outcomes to standard cisplatin-based chemoRT, such as report on RTOG 0129, with a high rate of LRC at 3 years. Our analysis suggests a role for a less intensive regimen using paclitaxel and carboplatin as a less toxic, effective alternative to cisplatin in the curative management of p16+ OPSCC, particularly in low-risk patients. Strategies for combating distant metastases are needed. Toxicity analysis planned to be presented separately.
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Affiliation(s)
- K R Darrow
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - K N McComas
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - A W Rajkumar
- Mayo Clinic Department of Radiation Oncology, Rochester, MN
| | - A Dove
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | | | - B Murphy
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - J Gilbert
- Vanderbilt University Medical Center, Nashville, TN
| | - R Sinard
- Vanderbilt University Medical Center, Nashville, TN
| | | | - N A Lockney
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - A J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
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McComas KN, Darrow KR, Rajkumar AW, Dove A, Kluwe C, Netterville J, Murphy B, Cmelak AJ. Tailoring Radiation to the Contralateral Neck for Midline HPV-Mediated Oropharyngeal Squamous Cell Carcinoma (p16+ OPSCC). Int J Radiat Oncol Biol Phys 2023; 117:e605-e606. [PMID: 37785825 DOI: 10.1016/j.ijrobp.2023.06.1974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) De-intensification strategies for locally advanced p16+ OPSCC are under active investigation, including omission of contralateral neck radiation (RT) for well-lateralized T1-2N0-2a. This study evaluates the outcomes of omitting contralateral neck nodal levels for p16+ OPSCC that are not well-lateralized. MATERIALS/METHODS A retrospective review was done of 134 consecutive patients with non-metastatic p16+ OPSCC that were not well-lateralized (< 1 cm from midline or ≥ 1 cm extension to soft palate or base of tongue) who were treated with definitive chemoradiation from 2013 to 2019. IMRT to an EQD2 6364-6735 cGy (200-220 cGy per fraction) was used to treat the primary tumor and ipsilateral or bilateral neck, with tailored nodal level coverage and dose, and with concurrent paclitaxel and carboplatin. Contralateral neck RT was tailored in 121 patients: omitted in 11, limited to level II in 9, and limited to level II and III in 101 (contralateral lower neck omitted); the remaining 13 had bilateral level II-IV neck RT. Local and regional recurrences were evaluated. RESULTS Median follow up was 45.34 months. Local and/or regional recurrence was noted in 9/134 (6.7%). 3 (2%) recurred in the contralateral neck in unirradiated tissue (out-of-field). All three were salvaged. The remaining 6 recurrences (4%) were in-field; one was at the primary site and 5 were nodal (all ipsilateral). 4 of the 5 regional recurrences were in a location that was treated to EQD2 7000 cGy (all had PET avid nodal disease upfront that was included in the high dose level); the other region of recurrence was treated to an EQD2 6353 cGy (the only recurrence in a never smoker). 4 of the 5 neck recurrences underwent neck dissection; one further underwent adjuvant RT to 5940 cGy in 33 fractions and remains disease-free. 2 of those who underwent salvage neck dissection alone subsequently developed distant metastases. The majority of first recurrences were distant, 19.4% (26/134). 3-year progression free survival (PFS) was 74.41% (95% CI, 65.63-81.26). Taken together, regional recurrence rate in the contralateral, unirradiated neck was 2.5% (3/121) and ultimate locoregional control was 99% (132/134). CONCLUSION Our tailored approach demonstrates a contralateral neck local control of 97.5% (118/121) regardless of tumor lateralization; those who recurred in unirradiated cervical lymph nodes were successfully salvaged. Limiting this analysis is moderate sample size and retrospective nature, but it raises important alternative de-escalation strategies (RT volume reduction) for p16+ OPSCC aside from dose reduction, which is under active investigation in phase II/III trials. Improved systemic therapies are needed to combat distant metastases. Prospective randomized clinical trials are needed for further evaluation of nodal omission for definitive chemoradiation of non-well-lateralized p16+ OPSCC.
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Affiliation(s)
- K N McComas
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - K R Darrow
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - A W Rajkumar
- Mayo Clinic Department of Radiation Oncology, Rochester, MN
| | - A Dove
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | | | | | - B Murphy
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - A J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
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Deng J, Murphy BA, Niermann KJ, Sinard RJ, Cmelak AJ, Rohde SL, Ridner SH, Dietrich MS. Validity Testing of the Head and Neck Lymphedema and Fibrosis Symptom Inventory. Lymphat Res Biol 2022; 20:629-639. [PMID: 35483066 PMCID: PMC9810345 DOI: 10.1089/lrb.2021.0041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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] [Indexed: 01/13/2023] Open
Abstract
Background: Lack of reliable and valid tools significantly impacts early identification and timely treatment of lymphedema and fibrosis (LEF) in the head and neck cancer population. To address this need, we developed and reported a patient-reported outcome measure (Head and Neck Lymphedema and Fibrosis Symptom Inventory [HN-LEF SI]). This article reports the construct validity (convergent and divergent validity) testing of the tool. Materials and Methods: A prospective, longitudinal, instrument validation study was conducted in patients with a newly diagnosed oral cavity or oropharyngeal cancer. Participants completed the HN-LEF SI and six carefully selected self-report measures at pretreatment, end-of-treatment, and every 3 months up to 12 months after treatment. Spearman correlations were used. Results: A total of 117 patients completed the study. Patterns of correlations of the HN-LEF SI scores with the established self-report measure scores were consistent with expected convergent and divergent validity. Conclusion: Evidence from this work supports the construct validity of the HN-LEF SI.
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Affiliation(s)
- Jie Deng
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | - Sarah L. Rohde
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Sheila H. Ridner
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Mary S. Dietrich
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Khattab MH, Sherry AD, Devan SP, Luo G, Chaballout BH, Jean-Baptiste S, Xu J, Bick S, Petrie WM, Cmelak AJ. Noninvasive Capsulotomy for Refractory Depression by Frameless Stereotactic Radiosurgery. Int J Radiat Oncol Biol Phys 2022; 113:960-966. [PMID: 35595157 DOI: 10.1016/j.ijrobp.2022.04.042] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/16/2022] [Accepted: 04/28/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Effective treatment options for refractory depression are needed. Recent advancements permit both precise ablative radiation and functional neurologic connectome analysis using standard MRI. We combined these innovations to perform stereotactic radiosurgical capsulotomy for the treatment of medically refractory major depressive disorder and study connectome response using a novel tractography-based approach. METHODS AND MATERIALS Patients with medically refractory depression were enrolled on a prospective pilot single-arm observational trial from 2020 to 2021 at a single academic tertiary referral center. Bilateral ablation of the anterior limb of the internal capsule was accomplished by mask-based linear accelerator stereotactic radiosurgery. Beck's Depression Inventory measured efficacy. Montreal Cognitive Assessment evaluated cognition. RESULTS Three patients were enrolled. Depression burden was improved by 88% at 12 month follow-up and by 55% at 18 month follow-up for patient 1 and 2, respectively. Patient 1 discontinued ketamine therapy, and patient 2 discontinued electroconvulsive therapy. Patient 3 reported global improvement in symptoms and function at 3 months. All 3 patients had reduction or resolution of suicidal ideation. No patient experienced cognitive decline or neurologic toxicity, and MoCA score, as well as subjective patient-reported evaluations of concentration and attention, were superior after treatment. Tractography confirmed intended disruption of the cortico-striatal-thalamo-cortical loop with structural reorganization in the connectome. Connectome change was consistent between patients. Observed increases in caudate and putamen connectivity and decreases in thalamic connectivity may explain improved concentration, attention, and depression. The diversity and magnitude of connectome change may correlate with degree of clinical response. CONCLUSIONS In three patients with refractory depression, radiosurgical capsulotomy significantly reduced the burden of depression. Functional connectome reorganization offers neurobiological evidence to support further investigations of the role of radiosurgery in depression.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN; Minneapolis Radiation Oncology, Edina, MN.
| | - Alexander D Sherry
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN; Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sean P Devan
- Department of Radiology and Radiological Sciences, Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Basil H Chaballout
- University of South Carolina School of Medicine Greenville, Greenville, SC
| | - Samuel Jean-Baptiste
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Junzhong Xu
- Department of Radiology and Radiological Sciences, Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN
| | - Sarah Bick
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - William M Petrie
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
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Luo G, Cameron BD, Wang L, Yu H, Neimat JS, Hedera P, Phibbs F, Bradley EB, Cmelak AJ, Kirschner AN. Targeting for stereotactic radiosurgical thalamotomy based on tremor treatment response. J Neurosurg 2022; 136:1387-1394. [PMID: 34715657 DOI: 10.3171/2021.7.jns21160] [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: 01/20/2021] [Accepted: 07/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) treats severe, medically refractory essential tremor and tremor-dominant Parkinson disease. However, the optimal target for SRS treatment within the thalamic ventral intermediate nucleus (VIM) is not clearly defined. This work evaluates the precision of the physician-selected VIM target, and determines the optimal SRS target within the VIM by correlation between early responders and nonresponders. METHODS Early responders and nonresponders were assessed retrospectively by Elements Basal Ganglia Atlas autocontouring of the VIM on the pre-SRS-treatment 1-mm slice thickness T1-weighted MRI and correlating the center of the post-SRS-treatment lesion. Using pre- and posttreatment diffusion tensor imaging, the fiber tracking package in the Elements software generated tremor-related tracts from autosegmented motor cortex, thalamus, red nucleus, and dentate nucleus. Autocontouring of the VIM was successful for all patients. RESULTS Among 23 patients, physician-directed SRS targets had a medial-lateral target range from +2.5 mm to -2.0 mm from the VIM center. Relative to the VIM center, the SRS isocenter target was 0.7-0.9 mm lateral for 6 early responders and 0.9-1.1 mm medial for 4 nonresponders (p = 0.019), and without differences in the other dimensions: 0.2 mm posterior and 0.6 mm superior. Dose-volume histogram analyses for the VIM had no significant differences between responders and nonresponders between 20 Gy and 140 Gy, mean or maximum dose, and dose to small volumes. Tractography data was obtained for 4 patients. CONCLUSIONS For tremor control in early responders, the Elements Basal Ganglia Atlas autocontour for the VIM provides the optimal SRS target location that is 0.7-0.9 mm lateral to the VIM center.
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Affiliation(s)
| | | | | | - Hong Yu
- 3Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joseph S Neimat
- 4Department of Neurological Surgery, University of Louisville, Kentucky; and
| | - Peter Hedera
- 5Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Fenna Phibbs
- 5Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elise B Bradley
- 5Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
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Caudell JJ, Gillison ML, Maghami E, Spencer S, Pfister DG, Adkins D, Birkeland AC, Brizel DM, Busse PM, Cmelak AJ, Colevas AD, Eisele DW, Galloway T, Geiger JL, Haddad RI, Hicks WL, Hitchcock YJ, Jimeno A, Leizman D, Mell LK, Mittal BB, Pinto HA, Rocco JW, Rodriguez CP, Savvides PS, Schwartz D, Shah JP, Sher D, St John M, Weber RS, Weinstein G, Worden F, Yang Bruce J, Yom SS, Zhen W, Burns JL, Darlow SD. NCCN Guidelines® Insights: Head and Neck Cancers, Version 1.2022. J Natl Compr Canc Netw 2022; 20:224-234. [PMID: 35276673 DOI: 10.6004/jnccn.2022.0016] [Citation(s) in RCA: 153] [Impact Index Per Article: 76.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The NCCN Guidelines for Head and Neck Cancers address tumors arising in the oral cavity (including mucosal lip), pharynx, larynx, and paranasal sinuses. Occult primary cancer, salivary gland cancer, and mucosal melanoma (MM) are also addressed. The specific site of disease, stage, and pathologic findings guide treatment (eg, the appropriate surgical procedure, radiation targets, dose and fractionation of radiation, indications for systemic therapy). The NCCN Head and Neck Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel's most recent recommendations regarding management of HPV-positive oropharynx cancer and ongoing research in this area.
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Affiliation(s)
| | | | | | | | | | - Douglas Adkins
- 6Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | | | | | - David W Eisele
- 12The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | - Jessica L Geiger
- 14Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | - Debra Leizman
- 14Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | - Bharat B Mittal
- 20Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - James W Rocco
- 21The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | - David Schwartz
- 24St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | - David Sher
- 25UT Southwestern Simmons Comprehensive Cancer Center
| | | | | | | | | | | | - Sue S Yom
- 30UCSF Helen Diller Family Comprehensive Cancer Center
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Anderson JL, Khattab MH, Sherry AD, Luo G, Chitale RV, Froehler MT, Fusco MR, Cmelak AJ, Attia A. Improved Cerebral Arteriovenous Malformation Obliteration With 3-Dimensional Rotational Digital Subtraction Angiography for Radiosurgical Planning: A Retrospective Cohort Study. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa321_s066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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9
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Totten DJ, Sherry AD, Manzoor NF, Perkins EL, Cass ND, Khattab MH, Cmelak AJ, Haynes DS, Aulino JM. Diameter-Based Volumetric Models May Inadequately Calculate Jugular Paraganglioma Volume Following Sub-Total Resection. Otol Neurotol 2021; 42:e1339-e1345. [PMID: 34149025 DOI: 10.1097/mao.0000000000003226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND As gross total resection of jugular paragangliomas (JPs) may result in cranial nerve deficits, JPs are increasingly managed with subtotal resection (STR) with postoperative radiological monitoring. However, the validity of commonly used diameter-based models that calculate postoperative volume to determine residual tumor growth is dubious. The purpose of this study was to assess the accuracy of these models compared to manual volumetric slice-by-slice segmentation. METHODS A senior neuroradiologist measured volumes via slice-by-slice segmentation of JPs pre- and postoperatively from patients who underwent STR from 2007 to 2019. Volumes from three linear-based models were calculated. Models with absolute percent error (APE) > 20% were considered unsatisfactory based on a common volumetric definition for residual growth. Bland-Altman plots were used to evaluate reproducibility, and Wilcoxon matched-pairs signed rank test evaluated model bias. RESULTS Twenty-one patients were included. Median postoperative APE exceeded the established 20% threshold for each of the volumetric models as cuboidal, ellipsoidal, and spherical model APE were 63%, 28%, and 27%, respectively. The postoperative cuboidal model had significant systematic bias overestimating volume (p = 0.002) whereas the postoperative ellipsoidal and spherical models lacked systematic bias (p = 0.11 and p = 0.82). CONCLUSION Cuboidal, ellipsoidal, and spherical models do not provide accurate assessments of postoperative JP tumor volume and may result in salvage therapies that are unnecessary or inappropriately withheld due to inaccurate assessment of residual tumor growth. While more time-consuming, slice-by-slice segmentation by an experienced neuroradiologist provides a substantially more accurate and precise measurement of tumor volume that may optimize clinical management.
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Affiliation(s)
| | | | - Nauman F Manzoor
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Elizabeth L Perkins
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Nathan D Cass
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center
| | - David S Haynes
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Joseph M Aulino
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Khattab MH, Cmelak AJ, Sherry AD, Luo G, Wang L, Yu H, Hedera P, Phibbs FT, Lindsell CJ, Neimat J, Kirschner AN. Noninvasive Thalamotomy for Refractory Tremor by Frameless Radiosurgery. Int J Radiat Oncol Biol Phys 2021; 112:121-130. [PMID: 34454047 DOI: 10.1016/j.ijrobp.2021.08.021] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 07/27/2021] [Accepted: 08/12/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We sought to determine whether a more widely accessible, non-invasive frameless approach to radiosurgical thalamotomy would improve objective measures of refractory essential or parkinsonian tremor without added toxicity compared to reports of frame-based radiosurgery. METHODS We conducted a single-arm pilot observational prospective trial of adult patients with essential or parkinsonian tremor from 2013 to 2019 and report results at one-year follow-up. Patients were treated with frameless unilateral radiosurgical ablation of the thalamic ventral intermediate nucleus to a maximum dose of 160 Gy. Treatment response was measured by the Fahn-Tolosa-Marin (FTM) tremor rating scale and the Quality of Life in Essential Tremor or Parkinson's Disease Questionnaire obtained prior to treatment and at 3, 6, 9, and 12 months. RESULTS Thirty-three patients, including 23 with essential tremor and 10 with Parkinson's disease, were enrolled. Overall treatment response rate per FTM was 83% (n=15/18) at 6 months. There was a marked improvement in tremor, with average total FTM reduction of 21% at 3 months (from 46 to 30 points, p=0.003) and 41% at 6 months (from 46 to 24 points, p=0.001). At 6 months, functional decline had regressed by 54% (from 15 to 7 points, p=0.001). Quality of life improved by 57% (p=0.001) at 6 months in patients with essential tremor, and patients with Parkinson's Disease had unchanged quality of life. At one-year follow-up, grade 2 neurologic adverse events were observed in 6% (n=2/33) of patients without any grade ≥ 3 events. CONCLUSION Noninvasive, frameless radiosurgical thalamotomy may be a feasible treatment for patients with refractory tremor and demonstrates short-term safety at one-year follow-up. This pilot study provides promising preliminary descriptions of efficacy, and definitive estimates of long-term safety and benefit require further study with longer follow-up.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN.
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Alexander D Sherry
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Hong Yu
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Peter Hedera
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN; Department of Neurology, University of Louisville School of Medicine, Louisville, KY
| | - Fenna T Phibbs
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
| | | | - Joseph Neimat
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN; Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, KY
| | - Austin N Kirschner
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
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Cmelak AJ, Ferris RL, Chen AM, Seiwert T, Burtness B. Treatment De-intensification for HPV-Positive Oropharynx Cancer: What Is Currently Acceptable? J Clin Oncol 2021; 39:2732-2733. [PMID: 34043410 DOI: 10.1200/jco.21.00594] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Anthony J Cmelak
- Anthony J. Cmelak, MD, Vanderbilt University Medical Center, Nashville, TN; Robert L. Ferris, MD, PhD, UPMC Hillman Cancer Center, Pittsburgh, PA; Allen M. Chen, MD, University of California Irvine, Irvine, CA; Tanguy Seiwert, MD, Johns Hopkins Medical Institutions, Johns Hopkins Medical Center, Baltimore, MD; and Barbara Burtness, MD, Yale School of Medicine, Yale University, New Haven, CT
| | - Robert L Ferris
- Anthony J. Cmelak, MD, Vanderbilt University Medical Center, Nashville, TN; Robert L. Ferris, MD, PhD, UPMC Hillman Cancer Center, Pittsburgh, PA; Allen M. Chen, MD, University of California Irvine, Irvine, CA; Tanguy Seiwert, MD, Johns Hopkins Medical Institutions, Johns Hopkins Medical Center, Baltimore, MD; and Barbara Burtness, MD, Yale School of Medicine, Yale University, New Haven, CT
| | - Allen M Chen
- Anthony J. Cmelak, MD, Vanderbilt University Medical Center, Nashville, TN; Robert L. Ferris, MD, PhD, UPMC Hillman Cancer Center, Pittsburgh, PA; Allen M. Chen, MD, University of California Irvine, Irvine, CA; Tanguy Seiwert, MD, Johns Hopkins Medical Institutions, Johns Hopkins Medical Center, Baltimore, MD; and Barbara Burtness, MD, Yale School of Medicine, Yale University, New Haven, CT
| | - Tanguy Seiwert
- Anthony J. Cmelak, MD, Vanderbilt University Medical Center, Nashville, TN; Robert L. Ferris, MD, PhD, UPMC Hillman Cancer Center, Pittsburgh, PA; Allen M. Chen, MD, University of California Irvine, Irvine, CA; Tanguy Seiwert, MD, Johns Hopkins Medical Institutions, Johns Hopkins Medical Center, Baltimore, MD; and Barbara Burtness, MD, Yale School of Medicine, Yale University, New Haven, CT
| | - Barbara Burtness
- Anthony J. Cmelak, MD, Vanderbilt University Medical Center, Nashville, TN; Robert L. Ferris, MD, PhD, UPMC Hillman Cancer Center, Pittsburgh, PA; Allen M. Chen, MD, University of California Irvine, Irvine, CA; Tanguy Seiwert, MD, Johns Hopkins Medical Institutions, Johns Hopkins Medical Center, Baltimore, MD; and Barbara Burtness, MD, Yale School of Medicine, Yale University, New Haven, CT
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12
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Khattab MH, Sherry AD, Aulino JM, Becker JE, Petrie WM, Cmelak AJ. Chronic Electroconvulsive Therapy May Induce Calvarial Hyperemia and Marrow Replacement. J ECT 2021; 37:e13-e16. [PMID: 33122499 DOI: 10.1097/yct.0000000000000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Electroconvulsive therapy (ECT) is a treatment option for a number of psychiatric disorders, including refractory major depression and obsessive compulsive disorder. There are no known structural sequelae of ECT. Here we present a patient with severe refractory obsessive compulsive disorder and major depression treated over 2 years with ECT every 2 weeks. Planning magnetic resonance imaging intended for a potential procedural intervention for her psychiatric disease incidentally demonstrated a new area of increased enhancement and loss of marrow signal within the right frontal bone. Imaging findings were suggestive of underlying bone marrow or bone changes, although there was no evidence of bone destruction on bone-windowed computed tomography (CT) and there was no uptake on nuclear bone scan. The CT chest/abdomen/pelvis were also reassuring that this did not represent metastatic disease, and findings were unchanged on repeat magnetic resonance imaging 4 months later. Thus, this area corresponded to the site directly underlying the unilateral ECT electrode placement, suggestive of never-before described ECT-induced hyperemia. We report for the first time that frequent, chronic ECT may induce asymptomatic skull bone marrow hyperemia with radiologic findings. This appears to be a direct consequence of electrical current leading to chronic inflammatory and edematous marrow replacement. Electroconvulsive therapy should be added to the neuroradiological differential diagnosis of calvarial enhancement and loss of marrow signal. Psychiatrists should counsel patients on the possibility of this rare radiological finding, which may be confused for other processes.
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Affiliation(s)
- Mohamed H Khattab
- From the Department of Radiation Oncology, Vanderbilt University Medical Center
| | | | | | - Jonathan E Becker
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN
| | - William M Petrie
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN
| | - Anthony J Cmelak
- From the Department of Radiation Oncology, Vanderbilt University Medical Center
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13
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Xu MC, Khattab MH, Luo G, Sherry AD, Morales-Paliza M, Chaballout BH, Anderson JL, Attia A, Cmelak AJ. Effects of cone versus multi-leaf collimation on dosimetry and neurotoxicity in patients with small arteriovenous malformations treated by stereotactic radiosurgery. J Radiosurg SBRT 2021; 7:287-294. [PMID: 34631230 PMCID: PMC8492055] [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] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 02/15/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE/OBJECTIVE Linear accelerator (LINAC) based stereotactic radiosurgery (SRS) for arteriovenous malformations (AVMs) is delivered with cone or multileaf collimators (MLCs), and favorable dosimetry is associated with reduced radionecrosis in normal brain tissue. This study aims to determine whether cones or MLCs has better dosimetric characteristics, to predict differences in toxicity. METHODS All patients treated for AVMs using LINAC SRS from 2003-2017 were examined retrospectively. Demographic data, volumes of normal tissue exposed to 12Gy (V12Gy[cc]) and 4Gy (V4Gy[cc]), maximal dose, and dose gradient were analyzed. Univariate and multivariate analyses were used to evaluate relationships between collimator type, dosimetric parameters, and toxicity. Propensity score matching was used to adjust for AVM size. RESULTS Compared to MLC, cones were independently associated with reduced V12Gy[cc] after propensity score matching (p=0.008) and reduced neurotoxicity (p=0.016). Higher V12Gy[cc] (p=0.0008) and V4Gy[cc] (p=0.002) were associated with increased neurotoxicity. CONCLUSIONS Treating AVMs with cone-based SRS over MLC-based SRS may improve dosimetry and reduce toxicities.
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Affiliation(s)
- Mark C Xu
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Manuel Morales-Paliza
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Basil H. Chaballout
- University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | | | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
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14
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Anderson JL, Khattab MH, Sherry AD, Luo G, Chitale RV, Froehler MT, Fusco MR, Cmelak AJ, Attia A. Improved Cerebral Arteriovenous Malformation Obliteration With 3-Dimensional Rotational Digital Subtraction Angiography for Radiosurgical Planning: A Retrospective Cohort Study. Neurosurgery 2020; 88:122-130. [PMID: 32717053 DOI: 10.1093/neuros/nyaa321] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 09/24/2019] [Accepted: 05/24/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) for cerebral arteriovenous malformations (AVMs) is well-established. Radiographic advantages exist for 3-dimensional rotational digital subtraction angiography (3DRA) over 2-dimensional digital subtraction angiography (2D DSA) in delineating AVM nidus structure for SRS treatment planning. However, currently there is limited to no data directly comparing 2D DSA versus 3DRA in terms of patient outcomes. OBJECTIVE To investigate whether the use of 3DRA over 2D DSA in radiosurgical treatment planning for AVMs associates with improved clinical outcomes. METHODS All AVM patients treated with SRS at our institution between the years 2000 and 2018 were identified. Primary outcomes were obliteration rates and time to obliteration (TTO); secondary outcomes included rates of post-SRS hemorrhage, salvage therapy, and symptomatic radionecrosis. A minimum of 12 mo of follow-up imaging/angiogram post-SRS was required, or alternatively evidence of obliteration on angiogram prior to 12 mo post-SRS. Single predictor and multivariable Cox regression and logistic regression models were constructed to test for association between radiographic, clinical, and treatment factors with outcomes. RESULTS A total of 75 patients were included. Total 17 patients received 3DRA and 58 patients received 2D DSA, with a median follow-up of 3.29 yr. The 3DRA is significantly associated with improved TTO on single predictor (HR 2.87, 1.29-6.12; P = .0109) and multivariable analysis (HR 2.448, 1.076-5.750; P = .0330) and increased odds of achieving obliteration by 3 yr post-SRS on single predictor analysis (OR 6.044, 1.405-26.009; P = .0157). CONCLUSION The 3DRA over 2D DSA in SRS treatment planning for AVMs may result in improved TTO and 3-yr obliteration rates. Further investigation and prospective study are warranted.
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Affiliation(s)
| | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rohan V Chitale
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael T Froehler
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew R Fusco
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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15
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Deng J, Dietrich MS, Niermann KJ, Sinard RJ, Cmelak AJ, Ridner SH, Gilbert J, Murphy BA. Refinement and Validation of the Head and Neck Lymphedema and Fibrosis Symptom Inventory. Int J Radiat Oncol Biol Phys 2020; 109:747-755. [PMID: 33068688 DOI: 10.1016/j.ijrobp.2020.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/22/2020] [Accepted: 10/05/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE Lymphedema and fibrosis (LEF) are common yet overlooked late effects of head and neck cancer and its therapy. Lack of reliable and valid measures of head and neck LEF is a critical barrier to the timely identification and management of head and neck LEF. To fill this gap, we developed and pilot tested a 64-item patient-reported outcome measure ( Lymphedema Symptom Intensity and Distress Survey-Head and Neck, LSIDS-H&N). This article aims to report the process of further validation and refinement of the tool. METHODS AND MATERIALS A prospective, longitudinal study was conducted, and 120 patients with oral cavity and oropharyngeal cancer were recruited. Participants completed the LSIDS-H&N at pretreatment, end of treatment, and every 3 months up to 12 months after treatment. SAS PROC VARCLUS was used to generate preliminary clusters of item responses. Internal consistency of the item responses within each cluster was assessed using Cronbach's alpha. RESULTS A total of 117 patients completed the study. The participants reported that the LSIDS-H&N was easy to understand and captured their symptoms and medical conditions. However, >50% of participants indicated that the survey was burdensome due to length. Thus, we proceeded with item reduction, and the shortened tool (33-item) was named Head and Neck Lymphedema and Fibrosis Symptom Inventory (HN-LEF Symptom Inventory). The subsequent exploration of symptom clusters identified 7 symptom domain clusters (eg, soft tissue and neurologic toxicity), all of which demonstrated good internal consistency. CONCLUSIONS The HN-LEF Symptom Inventory has been carefully developed and refined to allow clinicians and researchers to capture LEF-associated symptom burden and function impairments. Additional rigorous psychometric testing of the tool is ongoing to further validate the strength and internal validity of this tool.
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Affiliation(s)
- Jie Deng
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Mary S Dietrich
- School of Nursing, Vanderbilt University, Nashville, Tennessee; Department of Biostatistics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Kenneth J Niermann
- Vanderbilt-Ingram Cancer Center, Vanderbilt Medical Center, Nashville, Tennessee
| | - Robert J Sinard
- Vanderbilt-Ingram Cancer Center, Vanderbilt Medical Center, Nashville, Tennessee
| | - Anthony J Cmelak
- Vanderbilt-Ingram Cancer Center, Vanderbilt Medical Center, Nashville, Tennessee
| | - Sheila H Ridner
- School of Nursing, Vanderbilt University, Nashville, Tennessee
| | - Jill Gilbert
- Vanderbilt-Ingram Cancer Center, Vanderbilt Medical Center, Nashville, Tennessee
| | - Barbara A Murphy
- Vanderbilt-Ingram Cancer Center, Vanderbilt Medical Center, Nashville, Tennessee
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16
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Pfister DG, Spencer S, Adelstein D, Adkins D, Anzai Y, Brizel DM, Bruce JY, Busse PM, Caudell JJ, Cmelak AJ, Colevas AD, Eisele DW, Fenton M, Foote RL, Galloway T, Gillison ML, Haddad RI, Hicks WL, Hitchcock YJ, Jimeno A, Leizman D, Maghami E, Mell LK, Mittal BB, Pinto HA, Ridge JA, Rocco JW, Rodriguez CP, Shah JP, Weber RS, Weinstein G, Witek M, Worden F, Yom SS, Zhen W, Burns JL, Darlow SD. Head and Neck Cancers, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 18:873-898. [DOI: 10.6004/jnccn.2020.0031] [Citation(s) in RCA: 313] [Impact Index Per Article: 78.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Treatment is complex for patients with head and neck (H&N) cancers with specific site of disease, stage, and pathologic findings guiding treatment decision-making. Treatment planning for H&N cancers involves a multidisciplinary team of experts. This article describes supportive care recommendations in the NCCN Guidelines for Head and Neck Cancers, as well as the rationale supporting a new section on imaging recommendations for patients with H&N cancers. This article also describes updates to treatment recommendations for patients with very advanced H&N cancers and salivary gland tumors, specifically systemic therapy recommendations.
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Affiliation(s)
| | | | - David Adelstein
- 3Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Douglas Adkins
- 4Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Yoshimi Anzai
- 5Huntsman Cancer Institute at the University of Utah
| | | | | | | | | | | | | | - David W. Eisele
- 12The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Moon Fenton
- 13The University of Tennessee Health Science Center
| | | | | | | | | | | | | | | | - Debra Leizman
- 3Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | - Bharat B. Mittal
- 22Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | - James W. Rocco
- 23The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | | | | | - Sue S. Yom
- 27UCSF Helen Diller Family Comprehensive Cancer Center
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17
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Khattab MH, Sherry AD, Manzoor N, Totten DJ, Luo G, Chambless LB, Rivas A, Haynes DS, Cmelak AJ, Attia A. Progressive Vestibular Schwannoma following Subtotal or Near-Total Resection: Dose-Escalated versus Standard-Dose Salvage Stereotactic Radiosurgery. J Neurol Surg B Skull Base 2020; 82:e9-e14. [PMID: 34306912 DOI: 10.1055/s-0040-1712462] [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: 09/11/2019] [Accepted: 03/19/2020] [Indexed: 10/24/2022] Open
Abstract
Objective Local failure of incompletely resected vestibular schwannoma (VS) following salvage stereotactic radiosurgery (SRS) using standard doses of 12 to 13 Gy is common. We hypothesized that dose-escalated SRS, corrected for biologically effective dose, would have superior local control of high-grade VS progressing after subtotal or near-total resection compared with standard-dose SRS. Design Retrospective cohort study. Setting Tertiary academic referral center. Participants Adult patients treated with linear accelerator-based SRS for progressive VS following subtotal or near-total resection. Main Outcome Measures Dose-escalated SRS was defined by a biologically effective dose exceeding a single-fraction 13-Gy regimen. Study outcomes were local control and neurologic sequelae of SRS. Binary logistic regression was used to evaluate predictors of study outcomes. Results A total of 18 patients with progressive disease following subtotal (71%) and near-total (39%) resection of Koos grade IV disease (94%) were enrolled. Of the 18 patients, 7 were treated with dose-escalated SRS and 11 with standard-dose SRS. Over a median follow-up of 32 months after SRS, local control was 100% in the dose-escalated cohort and 91% in the standard-dose cohort ( p = 0.95). Neurologic sequelae occurred in 28% of patients, including 60% of dose-escalated cohort and 40% of the standard-dose cohort ( p = 0.12), although permanent neurologic sequelae were low at 6%. Conclusions Dose-escalated SRS has similar local control of recurrent VS following progression after subtotal or near-total resection and does not appear to have higher neurologic sequalae. Larger studies are needed.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alexander D Sherry
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Nauman Manzoor
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Douglas J Totten
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alejandro Rivas
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - David S Haynes
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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18
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Khattab MH, Sherry AD, Xu MC, Kelly P, Anderson JL, Luo G, Chambless LB, Cmelak AJ, Attia A. Stereotactic Radiosurgery and Hypofractionated Stereotactic Radiotherapy for Nonfunctioning Pituitary Adenoma. J Neurol Surg B Skull Base 2020; 82:e51-e58. [PMID: 34306917 DOI: 10.1055/s-0040-1710518] [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: 10/04/2019] [Accepted: 03/14/2020] [Indexed: 10/24/2022] Open
Abstract
Objectives Hypofractionated stereotactic radiotherapy (HSRT) in two to five fractions may offer patients with large nonfunctioning pituitary adenomas (NFPAs) with chiasm involvement a safe and effective treatment over a single week. However, little has been reported regarding this novel approach. Design We compared the feasibility, outcomes, and toxicity of single-fraction stereotactic radiosurgery and HSRT. Setting This study was conducted at a tertiary academic referral center. Participants After approval by the institutional review board, we performed a retrospective cohort study of patients treated at our institution with stereotactic radiosurgery (SRS) and HSRT for NFPA. Selection for SRS or HSRT was based on clinicopathologic factors including tumor size and cavernous sinus invasion at the discretion of the treating physician. Main Outcome Measures Local control, endocrinopathy, and radiation-associated toxicity were evaluated by binary logistic regression and Cox's proportional hazards regression. Results A total of 45 patients with mean follow-up of 5 years were enrolled including 26 patients treated by HSRT with mean follow-up of 3 years and 19 patients treated by SRS with median follow-up of 6 years. Clinicopathologic characteristics were balanced between cohorts. Local failure at last follow-up was 5% in the SRS cohort and 8% in the HSRT cohort, and rates of post-SRS endocrinopathy were similar between each cohort. Late complications including radionecrosis, visual deficit, and secondary malignancy were minimal in either cohort. Conclusions HSRT is an appropriate treatment strategy for patients with NFPAs, particularly for optic pathway preservation in the setting of large tumors with chiasm involvement. Further studies are needed to optimize fractionated approaches and patient selection.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alexander D Sherry
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Mark C Xu
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Patrick Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Joshua L Anderson
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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19
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Khattab MH, Sherry AD, Whitaker R, Wharton DM, Weaver KD, Chambless LB, Cmelak AJ, Attia A. A Retrospective Cohort Study of Longitudinal Audiologic Assessment in Single and Fractionated Stereotactic Radiosurgery for Vestibular Schwannoma. Neurosurgery 2020; 85:E1078-E1083. [PMID: 31215628 DOI: 10.1093/neuros/nyz219] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 10/09/2018] [Accepted: 03/18/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Fractionated stereotactic radiosurgery (SRS) for vestibular schwannomas (VS) has been theorized to allow for tumor control with higher rates of hearing preservation in selected patients with useful hearing. However, there is a paucity of literature with formal audiologic measures of hearing preservation to support the standard use of fractionated SRS in VS. We hypothesized that fractionation would diminish the amount of hearing damage. OBJECTIVE To evaluate the relationship between audiologic performance and SRS fractionation scheme. METHODS We performed an IRB-approved retrospective review of patients treated with 1, 3, or 5 fraction SRS for VS at our institution from 1998 to 2016. Pre- and post-SRS audiograms with speech awareness threshold (SAT) in treated and contralateral ears were obtained. Contralateral ear measurements were used for hearing normalization to account for presbycusis. RESULTS Fifty-six patients with median audiologic follow-up 2.0 yr (mean 2.66 yr, min-max 0.50-9.45 yr) were included. Patients treated with single fractionation had a significantly worsened SAT (dB) compared to patients treated with 5 fractions (P = .008) and compared to all multifraction patients (P = .009) at 12 to 24 mo follow-up. CONCLUSION This retrospective analysis supports the use of fractionated SRS to preserve hearing in patients with VS. SAT can be used as an objective metric of hearing response to radiosurgery.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Ryan Whitaker
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David M Wharton
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Kyle D Weaver
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lola B Chambless
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
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20
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Khattab MH, Sherry AD, Kim E, Anderson J, Luo G, Yu H, Englot DJ, Chambless LB, Cmelak AJ, Attia A. Body mass index and response to stereotactic radiosurgery in the treatment of refractory trigeminal neuralgia: A retrospective cohort study. J Radiosurg SBRT 2020; 6:253-261. [PMID: 32185084 PMCID: PMC7065898] [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] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 07/11/2019] [Indexed: 06/10/2023]
Abstract
Stereotactic radiosurgery (SRS) is used as a noninvasive treatment option for patients with trigeminal neuralgia (TN), but the effect of obesity on pain relief post SRS, if any, is unknown. The primary goal of our study was to evaluate the association between obesity and response to SRS in patients with TN. We conducted an IRB-approved retrospective review of patients treated with SRS for TN between 2010 and 2017. Barrow Neurologic Institute (BNI) Score was assigned pre-and post-SRS to quantify pain level. Thirty-two patients (65% female) between the ages of 24 and 96 were studied with a median follow-up time of 11 months. Patients with BMI >25 were significantly less likely to have improvement in their symptoms with SRS (p = 0.005). Elevated BMI may be associated with worsened response to SRS in the treatment of TN.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN 37232, USA
| | | | - Ellen Kim
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN 37232, USA
| | - Joshua Anderson
- Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN 37232, USA
| | - Hong Yu
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN 37232, USA
- Vanderbilt University School of Medicine, Nashville, TN 37232, USA
- Department of Biomedical Engineering, School of Engineering, Vanderbilt University, Nashville, TN 37232, USA
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Dario J Englot
- Department of Biomedical Engineering, School of Engineering, Vanderbilt University, Nashville, TN 37232, USA
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Lola B Chambless
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN 37232, USA
- Vanderbilt University School of Medicine, Nashville, TN 37232, USA
- Department of Biomedical Engineering, School of Engineering, Vanderbilt University, Nashville, TN 37232, USA
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN 37232, USA
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN 37232, USA
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Sherry AD, Bingham B, Kim E, Monsour M, Luo G, Attia A, Chambless LB, Cmelak AJ. Secondary malignancy following stereotactic radiosurgery for benign neurologic disease: A cohort study and review of the literature. J Radiosurg SBRT 2020; 6:287-294. [PMID: 32185088 PMCID: PMC7065897] [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] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 12/17/2019] [Indexed: 06/10/2023]
Abstract
Radiation-associated malignancy and malignant transformation are risks associated with stereotactic radiosurgery (SRS); however, incidence is uncertain. The purpose of our study is to present the rate of radiation-associated malignancy and malignant transformation at our institution. After IRB approval, we undertook a retrospective cohort study evaluating patients treated with Gamma Knife® or linac-based SRS between 1990 and 2014 for benign CNS pathology with at least 5 years of clinical follow-up. Risk of transformation was calculated using the Kaplan-Meier method. A total of 273 patients met selection criteria. Median clinical follow-up after SRS was 11 years (range 5-27). Over 3,216 patient-years following SRS, we found zero cases of radiation-associated malignancy and two cases of radiation-associated malignant transformation for a crude rate of 0.73% or case rate of 0.62 per 1,000 patient-years. The Kaplan-Meier risk of malignant transformation at 5, 10, and 15 years was 0.4% (95% CI 0.05% 2.6%). These data support the continued use of SRS for benign intracranial pathology without significant concern for secondary malignancy.
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Affiliation(s)
| | - Brian Bingham
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ellen Kim
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lola B. Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anthony J. Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
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Sherry AD, Khattab MH, Xu MC, Kelly P, Anderson JL, Luo G, Utz AL, Chambless LB, Cmelak AJ, Attia A. Outcomes of stereotactic radiosurgery and hypofractionated stereotactic radiotherapy for refractory Cushing's disease. Pituitary 2019; 22:607-613. [PMID: 31552580 DOI: 10.1007/s11102-019-00992-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Hypofractionated stereotactic radiotherapy (HSRT) for refractory Cushing's disease may offer a condensed treatment schedule for patients with large tumors abutting the optic chiasm unsuitable for stereotactic radiosurgery (SRS). To-date only four patients have been treated by HSRT in the published literature. We investigated the feasibility, toxicity, and efficacy of HSRT compared to SRS. METHODS After approval, we retrospectively evaluated patients treated at our institution for refractory Cushing's disease with SRS or HSRT. Study outcomes included biochemical control, time to biochemical control, local control, and late complications. Binary logistic regression and Cox proportional hazards regression evaluated predictors of outcomes. RESULTS Patients treated with SRS (n = 9) and HSRT (n = 9) were enrolled with median follow-up of 3.4 years. Clinicopathologic details were balanced between the cohorts. Local control was 100% in both cohorts. Time to biochemical control was 6.6. and 9.5 months in the SRS and HSRT cohorts, respectively (p = 0.6258). Two patients in each cohort required salvage bilateral adrenalectomy. Late complications including secondary malignancy, radionecrosis, cranial nerve neuropathy, and optic pathway injury were minimal for either cohort. CONCLUSIONS HSRT is an appropriate treatment approach for refractory Cushing's disease, particularly for patients with large tumors abutting the optic apparatus. Prospective studies are needed to validate these findings and identify factors suggesting optimal fractionation approaches.
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Affiliation(s)
| | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA.
| | - Mark C Xu
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Patrick Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA
| | - Andrea L Utz
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Diabetes, Endocrinology & Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Pituitary Center, Nashville, TN, USA
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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23
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Khattab MH, Sherry AD, Cmelak AJ, Attia A. In Reply: A Retrospective Cohort Study of Longitudinal Audiologic Assessment in Single and Fractionated Stereotactic Radiosurgery for Vestibular Schwannoma. Neurosurgery 2019; 85:E1127-E1129. [PMID: 31529045 DOI: 10.1093/neuros/nyz373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology Vanderbilt University Medical Center Nashville, Tennessee
| | | | - Anthony J Cmelak
- Department of Radiation Oncology Vanderbilt University Medical Center Nashville, Tennessee
| | - Albert Attia
- Department of Radiation Oncology Vanderbilt University Medical Center Nashville, Tennessee.,Department of Neurological Surgery Vanderbilt University Medical Center Nashville, Tennessee
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24
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Colevas AD, Yom SS, Pfister DG, Spencer S, Adelstein D, Adkins D, Brizel DM, Burtness B, Busse PM, Caudell JJ, Cmelak AJ, Eisele DW, Fenton M, Foote RL, Gilbert J, Gillison ML, Haddad RI, Hicks WL, Hitchcock YJ, Jimeno A, Leizman D, Maghami E, Mell LK, Mittal BB, Pinto HA, Ridge JA, Rocco J, Rodriguez CP, Shah JP, Weber RS, Witek M, Worden F, Zhen W, Burns JL, Darlow SD. NCCN Guidelines Insights: Head and Neck Cancers, Version 1.2018. J Natl Compr Canc Netw 2019; 16:479-490. [PMID: 29752322 DOI: 10.6004/jnccn.2018.0026] [Citation(s) in RCA: 371] [Impact Index Per Article: 74.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The NCCN Guidelines for Head and Neck (H&N) Cancers provide treatment recommendations for cancers of the lip, oral cavity, pharynx, larynx, ethmoid and maxillary sinuses, and salivary glands. Recommendations are also provided for occult primary of the H&N, and separate algorithms have been developed by the panel for very advanced H&N cancers. These NCCN Guidelines Insights summarize the panel's discussion and most recent recommendations regarding evaluation and treatment of nasopharyngeal carcinoma.
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Khattab MH, Newman NB, Wharton DM, Sherry AD, Luo G, Manzoor NF, Rivas A, Davis LT, Chambless LB, Attia A, Cmelak AJ. Longitudinal Radiographic Outcomes of Vestibular Schwannoma in Single and Fractionated Stereotactic Radiosurgery: A Retrospective Cohort Study. J Neurol Surg B Skull Base 2019; 81:308-316. [PMID: 32500007 DOI: 10.1055/s-0039-1692642] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 01/14/2019] [Accepted: 03/20/2019] [Indexed: 02/08/2023] Open
Abstract
Management of vestibular schwannoma (VS) includes stereotactic radiosurgery (SRS) in single or fractionated treatments. There is a paucity of literature on the three-dimensional (3D) volumetric kinetics and radiological changes following SRS and no consensus on appropriate post-SRS surveillance imaging timeline. This is a retrospective cohort study with institutional review board approval. A total of 55 patients met study criteria. We collected volumetric kinetic data in VS treated with SRS over time using a target volume contouring software. We also tracked radiographic phenomena such as pseudoprogression and necrosis. A secondary objective was to describe our overall treatment success rate and any failures. For all treatments groups, pseudoprogression most typically occurred within 12 months post-SRS, after which tumor volumes on average normalized and then decreased from pretreatment size at the last follow-up. Only two patients required salvage therapy post-SRS and were considered SRS treatment failures. Both patients were in the five-fraction cohort but with a lower biologically equivalent dose. Our study is first to collect 3D volumetric kinetics of VS following single and fractionated SRS in contrast to extrapolations from single and two-dimensional measurements. Our longitudinal data also show initial increases in volume in the first 12 months post-SRS followed by later declines, setting up interesting questions regarding the utility of early posttreatment surveillance imaging in the asymptomatic patient. Finally, we show low rates of treatment failure (3.6%) and show in our cohort that SRS dose de-escalation posed a risk of treatment failure.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Neil B Newman
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - David M Wharton
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Alexander D Sherry
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Nauman F Manzoor
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alejandro Rivas
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - L Taylor Davis
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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Abstract
Oropharyngeal squamous cell carcinoma (OPSCC) is increasing in incidence in the United States and in many countries worldwide primarily as a result of increasing rates of human papillomavirus (HPV) infection. HPV-positive OPSCC represents a distinct disease entity from head and neck squamous cell carcinoma caused by traditional risk factors such as tobacco and alcohol, with different epidemiology, patterns of failure, and expected outcomes. Because patients with HPV-positive OPSCC have a younger median age and superior prognosis compared with their HPV-negative counterparts, they live longer with the morbidity of treatment, which can be severe. Therefore, efforts are under way to de-escalate therapy in favorable-risk patients while maintaining treatment efficacy. Additional work is being undertaken to discover new therapies that may benefit both HPV-positive and HPV-negative patient subsets. Herein, we will review the available data for the evolving treatment paradigms in OPSCC as well as discuss ongoing clinical trials.
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Affiliation(s)
- Ryan K. Cleary
- Ryan K. Cleary and Anthony J. Cmelak,
Vanderbilt University Medical Center, Nashville, TN
| | - Anthony J. Cmelak
- Ryan K. Cleary and Anthony J. Cmelak,
Vanderbilt University Medical Center, Nashville, TN
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27
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Wang L, Cmelak AJ, Ding GX. A simple technique to improve calculated skin dose accuracy in a commercial treatment planning system. J Appl Clin Med Phys 2018; 19:191-197. [PMID: 29411506 PMCID: PMC5849836 DOI: 10.1002/acm2.12275] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 12/18/2017] [Accepted: 01/02/2018] [Indexed: 11/15/2022] Open
Abstract
Radiation dermatitis during radiotherapy is correlated with skin dose and is a common clinical problem for head and neck and thoracic cancer patients. Therefore, accurate prediction of skin dose during treatment planning is clinically important. The objective of this study is to evaluate the accuracy of skin dose calculated by a commercial treatment planning system (TPS). We evaluated the accuracy of skin dose calculations by the anisotropic analytical algorithm (AAA) implemented in Varian Eclipse (V.11) system. Skin dose is calculated as mean dose to a contoured structure of 0.5 cm thickness from the surface. The EGSnrc Monte Carlo (MC) simulations are utilized for the evaluation. The 6, 10 and 15 MV photon beams investigated are from a Varian TrueBeam linear accelerator. The accuracy of the MC dose calculations was validated by phantom measurements with optically stimulated luminescence detectors. The calculation accuracy of patient skin doses is studied by using CT based radiotherapy treatment plans including 3D conformal, static gantry IMRT, and VMAT treatment techniques. Results show the Varian Eclipse system underestimates skin doses by up to 14% of prescription dose for the patients studied when external body contour starts at the patient's skin. The external body contour is used in a treatment planning system to calculate dose distributions. The calculation accuracy of skin dose with Eclipse can be considerably improved to within 4% of target dose by extending the external body contour by 1 to 2 cm from the patient's skin. Dose delivered to deeper target volumes or organs at risk are not affected. Although Eclipse treatment planning system has its limitations in predicting patient skin dose, this study shows the calculation accuracy can be considerably improved to an acceptable level by extending the external body contour without affecting the dose calculation accuracy to the treatment target and internal organs at risk. This is achieved by moving the calculation entry point away from the skin.
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Affiliation(s)
- Lilie Wang
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTN37232USA
| | - Anthony J. Cmelak
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTN37232USA
| | - George X. Ding
- Department of Radiation OncologyVanderbilt University Medical CenterNashvilleTN37232USA
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28
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Rana N, Pendyala P, Cleary RK, Luo G, Zhao Z, Chambless LB, Cmelak AJ, Attia A, Stavas MJ. Long-term Outcomes after Salvage Stereotactic Radiosurgery (SRS) following In-Field Failure of Initial SRS for Brain Metastases. Front Oncol 2017; 7:279. [PMID: 29218301 PMCID: PMC5703829 DOI: 10.3389/fonc.2017.00279] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [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: 09/12/2017] [Accepted: 11/06/2017] [Indexed: 12/25/2022] Open
Abstract
Purpose The optimal treatment strategy following local recurrence after stereotactic radiosurgery (SRS) remains unclear. While upfront SRS has been extensively studied, few reports focus on outcomes after retreatment. Here, we report the results following a second course of SRS for local recurrence of brain metastases previously treated with SRS. Methods Using institutional database, patients who received salvage SRS (SRS2) following in-field failure of initial SRS (SRS1) for brain metastases were identified. Radionecrosis and local failure were defined radiographically by MRI following SRS2. The primary endpoint was defined as the time from SRS2 to the date of all-cause death or last follow-up [overall survival (OS)]. The secondary endpoints included local failure-free survival (LFFS) and radionecrosis-free survival, defined as the time from SRS2 to the date of local failure or radionecrosis, or last follow-up, respectively. Results Twenty-eight patients with 32 brain metastases were evaluated between years 2004 and 2015. The median interval between SRS1 and SRS2 was 9.7 months. Median OS was 22.0 months. Median LFFS time after SRS2 was 13.6 months. The overall local control rate following SRS2 was 84.4%. The 1- and 2-year local control rates are 88.3% (95% CI, 76.7–100%) and 80.3% (95% CI, 63.5–100%), respectively. The overall rate of radionecrosis following SRS2 was 18.8%. On univariate analysis, higher prescribed isodose line (p = 0.033) and higher gross tumor volume (p = 0.015) at SRS1 were associated with radionecrosis. Although not statistically significant, there was a trend toward lower risk of radionecrosis with interval surgical resection, fractionated SRS, lower total EQD2 (<50 Gy), and lack of concurrent systemic therapy at SRS2. Conclusion In select patients, repeat LINAC-based SRS following recurrence remains a reasonable option leading to long-term survival and local control. Radionecrosis approaches 20% for high risk individuals and parallels historic values.
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Affiliation(s)
- Nitesh Rana
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Praveen Pendyala
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ryan K Cleary
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Mark J Stavas
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, United States
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29
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Adelstein D, Gillison ML, Pfister DG, Spencer S, Adkins D, Brizel DM, Burtness B, Busse PM, Caudell JJ, Cmelak AJ, Colevas AD, Eisele DW, Fenton M, Foote RL, Gilbert J, Haddad RI, Hicks WL, Hitchcock YJ, Jimeno A, Leizman D, Lydiatt WM, Maghami E, Mell LK, Mittal BB, Pinto HA, Ridge JA, Rocco J, Rodriguez CP, Shah JP, Weber RS, Witek M, Worden F, Yom SS, Zhen W, Burns JL, Darlow SD. NCCN Guidelines Insights: Head and Neck Cancers, Version 2.2017. J Natl Compr Canc Netw 2017; 15:761-770. [DOI: 10.6004/jnccn.2017.0101] [Citation(s) in RCA: 216] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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30
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Cleary RK, Meshman J, Dewan M, Du L, Cmelak AJ, Luo G, Morales-Paliza M, Weaver K, Thompson R, Chambless LB, Attia A. Postoperative Fractionated Stereotactic Radiosurgery to the Tumor Bed for Surgically Resected Brain Metastases. Cureus 2017; 9:e1279. [PMID: 28656127 PMCID: PMC5484602 DOI: 10.7759/cureus.1279] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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] [Indexed: 12/11/2022] Open
Abstract
Introduction Stereotactic radiosurgery (SRS) is increasingly used as an alternative to whole brain radiotherapy (WBRT) following surgical resection of brain metastases. We analyzed the outcomes of postoperative frameless fractionated stereotactic radiosurgery (fSRS) cases for surgically resected brain metastases at our institution. Materials and Methods We performed a retrospective review of 85 patients who underwent fSRS to 87 resection beds from 2006 - 2014 with a median follow-up of 6.4 months. Clinically relevant outcomes were assessed with analysis to determine predictors of these outcomes. Results The median target volume was 9.8 cm3 (1.1 - 43.1 cm3). The most frequently used fractionation scheme was 3,000 cGy in five fractions. The rates of local control (LC), distant brain failure (DBF), and overall survival (OS) at one-year were 87%, 52%, and 52%, respectively. Five patients (5.9%) experienced Grade >2 toxicity related to fSRS, including seizures (two), symptomatic radionecrosis (two), and potential treatment-related death (one). A multivariable analysis revealed that tumor volume (p < 0.001) and number of fractions (p < 0.001) were associated with LC, while recursive partitioning analysis (RPA) class (p < .0001), tumor volume (p = .0181), and the number of fractions (p = .0181) were associated with OS. Conclusions Postoperative fSRS for surgically resected brain metastases is well-tolerated and achieves durable LC. Further studies are needed to determine the optimal dose and fractionation for fSRS as well as to compare outcomes with WBRT.
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Affiliation(s)
- Ryan K Cleary
- Department of Radiation Oncology, Vanderbilt University Medical Center
| | - Jessica Meshman
- Department of Radiation Oncology, Vanderbilt University Medical Center
| | - Michael Dewan
- Department of Neurological Surgery, Vanderbilt University Medical Center
| | - Liping Du
- Center for Quantitative Sciences, Vanderbilt University School of Medicine
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center
| | | | - Kyle Weaver
- Department of Neurological Surgery, Vanderbilt University Medical Center
| | - Reid Thompson
- Department of Neurological Surgery, Vanderbilt University Medical Center
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center
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Arneson K, Mondschein J, Stavas M, Cmelak AJ, Attia A, Horn L, Niermann K, Puzanov I, Chakravarthy AB, Xia F. A phase I trial of concurrent sorafenib and stereotactic radiosurgery for patients with brain metastases. J Neurooncol 2017; 133:435-442. [PMID: 28488066 DOI: 10.1007/s11060-017-2455-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 10/20/2016] [Accepted: 04/30/2017] [Indexed: 01/24/2023]
Abstract
We hypothesized that sorafenib (BAY 43-9006), an oral multi-kinase inhibitor, used in combination with SRS will improve overall intracranial control. This Phase I study assesses the safety, tolerability, and maximal tolerated dose of sorafenib administered with SRS to treat 1-4 brain metastases. This was an open label phase I dose escalation study with an expansion cohort. Eligible adults had 1-4 brain metastases from solid malignancies. Sorafenib was begun 5-7 days prior to SRS and continued for 14 days thereafter. Dose escalation of sorafenib was conducted via a "3 + 3" dose escalation design. Dose limiting toxicities (DLT) were determined 1 month after SRS and defined as ≥grade 3 neurologic toxicities. Twenty-three patients were enrolled. There were no DLTs at dose level 1 (400 mg per day) or dose level 2 (400 mg twice per day). An expansion cohort of 17 patients was treated at dose level 2. There were six grade 3 toxicities: hypertension (n = 2), rash (n = 1), lymphopenia (n = 1), hypokalemia (n = 1), fatigue (n = 1) and hand-foot syndrome (n = 1). All of these were attributable to sorafenib and not to the combination with SRS. The median time to CNS progression was 10 months, 1 year CNS progression-free survival was 46%, the median overall survival was 11.6 months and the 1 year overall survival was 46%. The use of sorafenib concurrent with SRS for the treatment of 1-4 brain metastases is safe and well tolerated at 400 mg twice a day. Our recommended phase II dose of concurrent sorafenib with SRS would be 400 mg twice daily.
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Affiliation(s)
- Kyle Arneson
- Department of Radiation Oncology, Vanderbilt University Medical Center, 22nd at Pierce Avenue, B1034, Nashville, TN, 37232-5671, USA
| | - Joshua Mondschein
- Department of Radiation Oncology, Vanderbilt University Medical Center, 22nd at Pierce Avenue, B1034, Nashville, TN, 37232-5671, USA
| | - Mark Stavas
- Department of Radiation Oncology, Vanderbilt University Medical Center, 22nd at Pierce Avenue, B1034, Nashville, TN, 37232-5671, USA
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, 22nd at Pierce Avenue, B1034, Nashville, TN, 37232-5671, USA
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, 22nd at Pierce Avenue, B1034, Nashville, TN, 37232-5671, USA
| | - Leora Horn
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, 777 Preston Research Building, Nashville, TN, 37232-6307, USA
| | - Kenneth Niermann
- Department of Radiation Oncology, Vanderbilt University Medical Center, 22nd at Pierce Avenue, B1034, Nashville, TN, 37232-5671, USA
| | - Igor Puzanov
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, 777 Preston Research Building, Nashville, TN, 37232-6307, USA
| | - A Bapsi Chakravarthy
- Department of Radiation Oncology, Vanderbilt University Medical Center, 22nd at Pierce Avenue, B1034, Nashville, TN, 37232-5671, USA.
| | - Fen Xia
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, 4301 W. Markham, Little Rock, AR, 72205, USA
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Marur S, Cmelak AJ, Burtness B. Purpose of Induction Chemotherapy in E1308 and Importance of Patient-Reported Outcomes in Deintensification Trials. J Clin Oncol 2017; 35:1968-1969. [PMID: 28430529 DOI: 10.1200/jco.2017.72.2918] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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)
- Shanthi Marur
- Shanthi Marur, Johns Hopkins University, Baltimore, MD; Anthony J. Cmelak, Vanderbilt-Ingram Cancer Center, Nashville, TN; and Barbara Burtness, Yale University School of Medicine, New Haven, CT
| | - Anthony J Cmelak
- Shanthi Marur, Johns Hopkins University, Baltimore, MD; Anthony J. Cmelak, Vanderbilt-Ingram Cancer Center, Nashville, TN; and Barbara Burtness, Yale University School of Medicine, New Haven, CT
| | - Barbara Burtness
- Shanthi Marur, Johns Hopkins University, Baltimore, MD; Anthony J. Cmelak, Vanderbilt-Ingram Cancer Center, Nashville, TN; and Barbara Burtness, Yale University School of Medicine, New Haven, CT
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Vlacich G, Stavas MJ, Pendyala P, Chen SC, Shyr Y, Cmelak AJ. A comparative analysis between sequential boost and integrated boost intensity-modulated radiation therapy with concurrent chemotherapy for locally-advanced head and neck cancer. Radiat Oncol 2017; 12:13. [PMID: 28086954 PMCID: PMC5237132 DOI: 10.1186/s13014-016-0756-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 06/29/2016] [Accepted: 12/27/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Planning and delivery of IMRT for locally advanced head and neck cancer (LAHNC) can be performed using sequential boost or simultaneous integrated boost (SIB). Whether these techniques differ in treatment-related outcomes including survival and acute and late toxicities remain largely unexplored. METHODS We performed a single institutional retrospective matched cohort analysis on patients with LAHNC treated with definitive chemoradiotherapy to 69.3 Gy in 33 fractions. Treatment was delivered via sequential boost (n = 68) or SIB (n = 141). Contours, plan evaluation, and toxicity assessment were performed by a single experienced physician. Toxicities were graded weekly during treatment and at 3-month follow up intervals. Recurrence-free survival, disease-free survival, and overall survival were estimated via Kaplan-Meier statistical method. RESULTS At 4 years, the estimated overall survival was 69.3% in the sequential boost cohort and 76.8% in the SIB cohort (p = 0.13). Disease-free survival was 63 and 69% respectively (p = 0.27). There were no significant differences in local, regional or distant recurrence-free survival. There were no significant differences in weight loss (p = 0.291), gastrostomy tube placement (p = 0.494), or duration of gastrostomy tube dependence (p = 0.465). Rates of acute grade 3 or 4 dysphagia (82% vs 55%) and dermatitis (78% vs 58%) were significantly higher in the SIB group (p < 0.001 and p = 0.012 respectively). Moreover, a greater percentage of the SIB cohort did not receive the prescribed dose due to acute toxicity (7% versus 0, p = 0.028). CONCLUSIONS There were no differences in disease related outcomes between the two treatment delivery approaches. A higher rate of grade 3 and 4 radiation dermatitis and dysphagia were observed in the SIB group, however this did not translate into differences in late toxicity. Additional investigation is necessary to further evaluate the acute toxicity differences.
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Affiliation(s)
- Gregory Vlacich
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA. .,Current affiliation: Department of Radiation Oncology, Washington University School of Medicine, 4291 Parkview Place, Campus Box 63110, St. Louis, MO, 63110, USA.
| | - Mark J Stavas
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Praveen Pendyala
- School of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shaeu-Chiann Chen
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yu Shyr
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
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Marur S, Li S, Cmelak AJ, Gillison ML, Zhao WJ, Ferris RL, Westra WH, Gilbert J, Bauman JE, Wagner LI, Trevarthen DR, Balkrishna J, Murphy BA, Agrawal N, Colevas AD, Chung CH, Burtness B. E1308: Phase II Trial of Induction Chemotherapy Followed by Reduced-Dose Radiation and Weekly Cetuximab in Patients With HPV-Associated Resectable Squamous Cell Carcinoma of the Oropharynx- ECOG-ACRIN Cancer Research Group. J Clin Oncol 2016; 35:490-497. [PMID: 28029303 DOI: 10.1200/jco.2016.68.3300] [Citation(s) in RCA: 313] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Purpose Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is treatment-responsive. Definitive chemoradiation results in high cure rates but causes long-term toxicity and may represent overtreatment of some patients. This phase II trial evaluated whether complete clinical response (cCR) to induction chemotherapy (IC) could select patients with HPV-associated OPSCC for reduced radiation dose as a means of sparing late sequelae. Methods Patients with HPV16 and/or p16-positive, stage III-IV OPSCC received three cycles of IC with cisplatin, paclitaxel, and cetuximab. Patients with primary-site cCR to IC received intensity-modulated radiation therapy (IMRT) 54 Gy with weekly cetuximab; those with less than cCR to IC at the primary site or nodes received 69.3 Gy and cetuximab to those regions. The primary end point was 2-year progression-free survival. Results Of the 90 patients enrolled, 80 were evaluable. Their median age was 57 years (range, 35 to 73 years), with the majority having stage T1-3N0-N2b OPSCC and a history of ≤ 10 pack-years of cigarette smoking. Three cycles of IC were delivered to 77 of the 80 patients. Fifty-six patients (70%) achieved a primary-site cCR to IC and 51 patients continued to cetuximab with IMRT 54 Gy. After median follow-up of 35.4 months, 2-year progression-free survival and overall survival rates were 80% and 94%, respectively, for patients with primary-site cCR treated with 54 Gy of radiation (n = 51); 96% and 96%, respectively, for patients with < T4, < N2c, and ≤ 10 pack-year smoking history who were treated with ≤ 54 Gy of radiation (n = 27). At 12 months, significantly fewer patients treated with a radiation dose ≤ 54 Gy had difficulty swallowing solids (40% v 89%; P = .011) or had impaired nutrition (10% v 44%; P = .025). Conclusion For IC responders, reduced-dose IMRT with concurrent cetuximab is worthy of further study in favorable-risk patients with HPV-associated OPSCC. Radiation dose reduction resulted in significantly improved swallowing and nutritional status.
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Affiliation(s)
- Shanthi Marur
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - Shuli Li
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - Anthony J Cmelak
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - Maura L Gillison
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - Weiqiang J Zhao
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - Robert L Ferris
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - William H Westra
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - Jill Gilbert
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - Julie E Bauman
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - Lynne I Wagner
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - David R Trevarthen
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - Jahagirdar Balkrishna
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - Barbara A Murphy
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - Nishant Agrawal
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - A Dimitrios Colevas
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - Christine H Chung
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
| | - Barbara Burtness
- Shanthi Marur and William H. Westra, Johns Hopkins University, Baltimore, MD; Shuli Li, Dana Farber Cancer Institute, Boston, MA; Anthony J. Cmelak, Jill Gilbert, and Barbara A. Murphy, Vanderbilt University, Nashville, TN; Maura L. Gillison and Weiqiang J. Zhao, Ohio State University, Columbus, OH; Robert L. Ferris and Julie E. Bauman, University of Pittsburgh, Pittsburgh, PA; Lynne I. Wagner, Wake Forest School of Medicine, Winston-Salem, NC; David R. Trevarthen, Colorado Cancer Research Program, Denver, CO; Jahagirdar Balkrishna, University of Minnesota, St Paul, MN; Nishant Agrawal, University of Chicago Medicine, Chicago, IL; A. Dimitrios Colevas, Stanford University, Stanford, CA; Christine H. Chung, Moffitt Cancer Center, Tampa, FL; and Barbara Burtness, Yale University, New Haven, CT
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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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Jackson LK, Ridner SH, Deng J, Bartow C, Mannion K, Niermann K, Gilbert J, Dietrich MS, Cmelak AJ, Murphy BA. Internal Lymphedema Correlates with Subjective and Objective Measures of Dysphagia in Head and Neck Cancer Patients. J Palliat Med 2016; 19:949-56. [PMID: 27227341 DOI: 10.1089/jpm.2016.0018] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Tumor/treatment-related internal lymphedema (IL) and/or external lymphedema (EL) are associated with functional deficits and increased symptom burden in head and neck cancer patients (HNCP). Previously, we noted association between EL/IL and patient-reported dysphagia using the Vanderbilt Head and Neck Symptom Survey (VHNSS) version 1.0. OBJECTIVE To determine the relationship between IL/EL and subjective and objective measures of swallowing function. METHODS Eighty-one HNCP completed: (1) VHNSS version 2.0, including 13 swallowing/nutrition-related questions grouped into three clusters: swallow solids (ss), swallow liquids (sl), and nutrition(nt); (2) physical assessment of EL using Foldi scale; (3) endoscopic assessment of IL using Patterson scale (n = 56); and (4) modified barium swallow study rated by dysphagia outcome and severity scale (DOSS) and in conjunction with a swallow evaluation by National Outcomes Measurement System (NOMS). Examinations were performed at varied time points to assess lymphedema spectrum, from baseline (n = 15, 18.1%) to 18 months post-therapy (n = 20, 24.1%). RESULTS VHNSS swallow/nutrition items scores correlated with NOMS/DOSS ratings (p < 0.001). Highest correlation was with NOMS: ss (-0.73); sl (-0.61); nt (-0.56). VHNSS swallow/nutrition scores correlated with maximum grade of swelling for any single structure on Patterson scale: ss (0.43; p = 0.001); sl (0.38; p = 0.004); nt (0.41; p = 0.002). IL of aryepiglottic/pharyngoepiglottic folds, epiglottis, and pyriform sinus were most strongly correlated with VHNSS and NOMS ratings. NOMS/DOSS ratings correlated with EL (> = -0.34; p < 0.01). No meaningful correlations exist between VHNSS swallow/nutrition items and EL (< ± 0.15, p > 0.20). CONCLUSIONS IL correlated with subjective and objective measures of swallow dysfunction. Longitudinal analysis of trajectory and impact of IL/EL on dysphagia is ongoing.
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Affiliation(s)
- Leanne K Jackson
- 1 Department of Medicine, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Sheila H Ridner
- 2 School of Nursing, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Jie Deng
- 2 School of Nursing, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Carmin Bartow
- 3 Dept of Speech Sciences, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Kyle Mannion
- 4 Dept of Surgery, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Ken Niermann
- 5 Department of Radiation Oncology, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Jill Gilbert
- 1 Department of Medicine, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Mary S Dietrich
- 6 Department of Biostatistics, Schools of Medicine and Nursing, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Anthony J Cmelak
- 5 Department of Radiation Oncology, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Barbara A Murphy
- 1 Department of Medicine, Vanderbilt University Medical Center , Nashville, Tennessee
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Schuster D, Sweeney AD, Stavas MJ, Tawfik KY, Attia A, Cmelak AJ, Wanna GB. Initial radiographic tumor control is similar following single or multi-fractionated stereotactic radiosurgery for jugular paragangliomas. Am J Otolaryngol 2016; 37:255-8. [PMID: 27178519 DOI: 10.1016/j.amjoto.2016.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 01/11/2016] [Accepted: 01/16/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate radiographic tumor control and treatment-related toxicity in glomus jugulare tumors treated with stereotactic radiosurgery (SRS). STUDY DESIGN Retrospective chart review. SETTING Tertiary academic referral center. PATIENTS Glomus jugulare tumors treated with SRS between 1998 and 2014 were identified. The data analysis only included patients with at least 18months of post-treatment follow up (FU). INTERVENTION Patients were treated with either single fraction or fractionated SRS. MAIN OUTCOME MEASURE Patient demographics and tumor characteristics were assessed. Radiographic control was determined by comparing pre and post treatment MRI, and was categorized as no change, regression, or progression. RESULTS Eighteen patients were treated with SRS, and 14 met inclusion criteria. Median age at treatment was 55years (range 35-79), and 71.4% of patients were female. 5 patients (35.7%) received single fraction SRS (dose range 15-18Gy), and 9 (64.3%) fractionated therapy (dose 3-7Gy×3-15 fractions). Median tumor volume was 3.78cm(3) (range 1.15-30.6). Median FU was 28.8months (range 18.6-56.1), with a mean of 31.7months. At their last recorded MRI, 7 patients (50%) had tumor stability, 6 (42.9%) had improvement, and 1 (7.1%) had progression. Disease improvement and progression rates in the single fraction group were 40% and 0%, and in the multiple-fraction group, 44.4% and 11.1%, respectively. There was no statistically significant difference in disease improvement (p=0.88) or progression (p=0.48) rates between groups (unpaired t-test). CONCLUSIONS At a median follow up of 28months, both single fraction and fractionated SRS appear to have comparable radiographic tumor control outcomes and toxicity profiles.
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Pfister DG, Spencer S, Brizel DM, Burtness B, Busse PM, Caudell JJ, Cmelak AJ, Colevas AD, Dunphy F, Eisele DW, Foote RL, Gilbert J, Gillison ML, Haddad RI, Haughey BH, Hicks WL, Hitchcock YJ, Jimeno A, Kies MS, Lydiatt WM, Maghami E, McCaffrey T, Mell LK, Mittal BB, Pinto HA, Ridge JA, Rodriguez CP, Samant S, Shah JP, Weber RS, Wolf GT, Worden F, Yom SS, McMillian N, Hughes M. Head and Neck Cancers, Version 1.2015. J Natl Compr Canc Netw 2016; 13:847-55; quiz 856. [PMID: 26150579 DOI: 10.6004/jnccn.2015.0102] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
These NCCN Guidelines Insights focus on recent updates to the 2015 NCCN Guidelines for Head and Neck (H&N) Cancers. These Insights describe the different types of particle therapy that may be used to treat H&N cancers, in contrast to traditional radiation therapy (RT) with photons (x-ray). Research is ongoing regarding the different types of particle therapy, including protons and carbon ions, with the goals of reducing the long-term side effects from RT and improving the therapeutic index. For the 2015 update, the NCCN H&N Cancers Panel agreed to delete recommendations for neutron therapy for salivary gland cancers, because of its limited availability, which has decreased over the past 2 decades; the small number of patients in the United States who currently receive this treatment; and concerns that the toxicity of neutron therapy may offset potential disease control advantages.
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Abstract
Treatment of locally advanced head and neck squamous cell carcinomas requires a multidisciplinary approach to be able to offer patients definitive therapy while aiming to preserve organ function and minimize acute and long-term toxicities. Advances in surgical techniques will be reviewed for both primary sites and the neck and also in the salvage settings. Recent data on concurrent versus sequential chemoradiotherapy in these patients will be reviewed, with emphasis on identification of appropriate patients for sequential chemoradiotherapy. Finally, advances in modern radiotherapy modalities that have resulted in improved dosimetry and quality of life following treatment will be reviewed.
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Affiliation(s)
- Anthony J Cmelak
- From the Vanderbilt-Ingram Cancer Center, Nashville, TN; Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; University of Toronto, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Abstract
Treatment of locally advanced head and neck squamous cell carcinomas requires a multidisciplinary approach to be able to offer patients definitive therapy while aiming to preserve organ function and minimize acute and long-term toxicities. Advances in surgical techniques will be reviewed for both primary sites and the neck and also in the salvage settings. Recent data on concurrent versus sequential chemoradiotherapy in these patients will be reviewed, with emphasis on identification of appropriate patients for sequential chemoradiotherapy. Finally, advances in modern radiotherapy modalities that have resulted in improved dosimetry and quality of life following treatment will be reviewed.
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Affiliation(s)
- Anthony J Cmelak
- From the Vanderbilt-Ingram Cancer Center, Nashville, TN; Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; University of Toronto, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Pfister DG, Spencer S, Brizel DM, Burtness B, Busse PM, Caudell JJ, Cmelak AJ, Colevas AD, Dunphy F, Eisele DW, Gilbert J, Gillison ML, Haddad RI, Haughey BH, Hicks WL, Hitchcock YJ, Jimeno A, Kies MS, Lydiatt WM, Maghami E, Martins R, McCaffrey T, Mell LK, Mittal BB, Pinto HA, Ridge JA, Rodriguez CP, Samant S, Schuller DE, Shah JP, Weber RS, Wolf GT, Worden F, Yom SS, McMillian NR, Hughes M. Head and neck cancers, Version 2.2014. Clinical practice guidelines in oncology. J Natl Compr Canc Netw 2015; 12:1454-87. [PMID: 25313184 DOI: 10.6004/jnccn.2014.0142] [Citation(s) in RCA: 160] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This selection from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Head and Neck Cancers focuses on glottic laryngeal cancer, which is the most common type of laryngeal cancer and has an excellent cure rate. The lymphatic drainage of the glottis is sparse, and early stage primaries rarely spread to regional nodes. Because hoarseness is an early symptom, most glottic laryngeal cancer is early stage at diagnosis. Updates to these guidelines for 2014 include revisions to "Principles of Radiation Therapy" for each site and "Principles of Surgery," and the addition of a new section on "Principles of Dental Evaluation and Management."
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Shenouda G, Zhang Q, Ang KK, Machtay M, Parliament MB, Hershock D, Suntharalingam M, Lin A, Rotman M, Nabid A, Hong S, Shehata S, Cmelak AJ, Sultanem K, Le QT. Long-term results of radiation therapy oncology group 9903: a randomized phase 3 trial to assess the effect of erythropoietin on local-regional control in anemic patients treated with radiation therapy for squamous cell carcinoma of the head and neck. Int J Radiat Oncol Biol Phys 2015; 91:907-15. [PMID: 25670542 DOI: 10.1016/j.ijrobp.2014.12.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [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: 10/01/2014] [Revised: 11/27/2014] [Accepted: 12/08/2014] [Indexed: 12/27/2022]
Abstract
PURPOSE This paper reports long-term results of RTOG 9903, to determine whether the addition of erythropoietin (EPO) would improve the outcomes of radiation therapy (RT) in mildly to moderately anemic patients with head and neck squamous cell carcinoma (HNSCCa). METHODS AND MATERIALS The trial included HNSCCa patients treated with definitive RT. Patients with stage III or IV disease received concomitant chemoradiation therapy or accelerated fractionation. Pretreatment hemoglobin levels were required to be between 9.0 and 13.5 g/dL (12.5 g/dL for females). EPO, 40,000 U, was administered weekly starting 7 to 10 days before RT was initiated in the RT + EPO arm. RESULTS A total of 141 of 148 enrolled patients were evaluable. The baseline median hemoglobin level was 12.1 g/dL. In the RT + EPO arm, the mean hemoglobin level at 4 weeks increased by 1.66 g/dL, whereas it decreased by 0.24 g/dL in the RT arm. With a median follow-up of 7.95 years (range: 1.66-10.08 years) for surviving patients and 3.33 years for all patients (range: 0.03-10.08 years), the 5-year estimate of local-regional failure was 46.2% versus 39.4% (P=.42), local-regional progression-free survival was 31.5% versus 37.6% (P=.20), and overall survival was 36.9% versus 38.2% (P=.54) for the RT + EPO and RT arms, respectively. Late toxicity was not different between the 2 arms. CONCLUSIONS This long-term analysis confirmed that despite the ability of EPO to raise hemoglobin levels in anemic patients with HNSCCa, it did not improve outcomes when added to RT. The possibility of a detrimental effect of EPO could not be ruled out.
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Affiliation(s)
| | - Qiang Zhang
- NRG Oncology Statistics and Data Management Center
| | - K Kian Ang
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Diane Hershock
- University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | | | - Alexander Lin
- University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | - Marvin Rotman
- Brooklyn Minority-based Community Clinical Oncology Program, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Abdenour Nabid
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke (Québec), Québec, Canada
| | | | - Sarwat Shehata
- Northeastern Ontario Regional Cancer Centre, Sudbury, Ontario, Canada
| | | | | | - Quynh-Thu Le
- Stanford University Medical Center, Stanford, California
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Friedman JM, Stavas MJ, Cmelak AJ. Clinical and scientific impact of human papillomavirus on head and neck cancer. World J Clin Oncol 2014; 5:781-91. [PMID: 25302178 PMCID: PMC4129541 DOI: 10.5306/wjco.v5.i4.781] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 04/21/2014] [Accepted: 05/15/2014] [Indexed: 02/06/2023] Open
Abstract
Head and neck cancer (HNC) arises from the skull base to the clavicles and is the fifth most common cancer in the world by incidence. Historically, in the developed world HNC was associated with tobacco use and alcohol consumption, and the combination of the two produced a synergistic increase in risk. However, beginning in 1983, investigators have found a significant and growing proportion of HNC patients with human papillomavirus-positive (HPV) tumors who neither drank nor used tobacco. Since that time, there has been increased interest in the molecular biology of HPV-positive HNC. Multiple studies now show that HPV has shifted the epidemiological landscape and prognosis of head and neck squamous cell carcinoma (HNSCC). These studies provide strong evidence for improved survival outcomes in patients with HPV-positive HNSCC compared to those with HPV-negative HNSCC. In many reports, HPV status is the strongest predictor of locoregional control, disease specific survival and overall survival. In response to these findings, there has been significant interest in the best management of HPV-positive disease. Discussions within major cooperative groups consider new trials designed to maintain the current strong survival outcomes while reducing the long-term treatment-related toxicities. This review will highlight the epidemiological, clinical and molecular discoveries surrounding HPV-related HNSCC over the recent decades and we conclude by suggesting how these findings may guide future treatment approaches.
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Vlacich G, Spratt DE, Diaz R, Phillips JG, Crass J, Li CI, Shyr Y, Cmelak AJ. Dose to the inferior pharyngeal constrictor predicts prolonged gastrostomy tube dependence with concurrent intensity-modulated radiation therapy and chemotherapy for locally-advanced head and neck cancer. Radiother Oncol 2014; 110:435-40. [DOI: 10.1016/j.radonc.2013.12.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 11/13/2013] [Accepted: 12/25/2013] [Indexed: 11/24/2022]
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Pfister DG, Ang KK, Brizel DM, Burtness BA, Busse PM, Caudell JJ, Cmelak AJ, Colevas AD, Dunphy F, Eisele DW, Gilbert J, Gillison ML, Haddad RI, Haughey BH, Hicks WL, Hitchcock YJ, Kies MS, Lydiatt WM, Maghami E, Martins R, McCaffrey T, Mittal BB, Pinto HA, Ridge JA, Samant S, Schuller DE, Shah JP, Spencer S, Weber RS, Wolf GT, Worden F, Yom SS, McMillian NR, Hughes M. Head and neck cancers, version 2.2013. Featured updates to the NCCN guidelines. J Natl Compr Canc Netw 2013; 11:917-23. [PMID: 23946171 DOI: 10.6004/jnccn.2013.0113] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
These NCCN Guidelines Insights focus on nutrition and supportive care for patients with head and neck cancers. This topic was a recent addition to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Head and Neck Cancers. The NCCN Guidelines Insights focus on major updates to the NCCN Guidelines and discuss the new updates in greater detail. The complete version of the NCCN Guidelines for Head and Neck Cancers is available on the NCCN Web site (NCCN.org).
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Affiliation(s)
- David G Pfister
- From 1Memorial Sloan-Kettering Cancer Center; 2The University of Texas MD Anderson Cancer Center; 3Duke Cancer Institute; 4Fox Chase Cancer Center; 5Massachusetts General Hospital Cancer Center; 6Moffitt Cancer Center; 7Vanderbilt-Ingram Cancer Center; 8Stanford Cancer Institute; 9The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; 10The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; 11Dana-Farber/Brigham and Women's Cancer Center; 12Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; 13Roswell Park Cancer Institute; 14Huntsman Cancer Institute at the University of Utah; 15UNMC Eppley Cancer Center at The Nebraska Medical Center; 16City of Hope Comprehensive Cancer Center; 17University of Washington/Seattle Cancer Care Alliance; 18Robert H. Lurie Comprehensive Cancer Center of Northwestern University; 19St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; 20University of Alabama at Birmingham Comprehensive Cancer Center; 21University of Michigan Comprehensive Cancer Center; 22UCSF Helen Diller Family Comprehensive Cancer Center; and 23National Comprehensive Cancer Network
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Deng J, Murphy BA, Dietrich MS, Wells N, Wallston KA, Sinard RJ, Cmelak AJ, Gilbert J, Ridner SH. Impact of secondary lymphedema after head and neck cancer treatment on symptoms, functional status, and quality of life. Head Neck 2012; 35:1026-35. [PMID: 22791550 DOI: 10.1002/hed.23084] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lymphedema may disrupt local function and affect quality of life (QOL) in patients with head and neck cancer. The purpose of this study was to examine the associations among severity of internal and external lymphedema, symptoms, functional status, and QOL in patients with head and neck cancer. METHODS The sample included 103 patients who were ≥ 3 months after head and neck cancer treatment. Variables assessed included severity of internal and external lymphedema, physical/psychological symptoms, functional status, and QOL. RESULTS Severity of internal and external lymphedema was associated with physical symptoms and psychological symptoms. Patients with more severe external lymphedema were more likely to have a decrease in neck left/right rotation. The combined effects of external and internal lymphedema severity were associated with hearing impairment and decreased QOL. CONCLUSIONS Lymphedema severity correlates with symptom burden, functional status, and QOL in patients after head and neck cancer treatment.
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Affiliation(s)
- Jie Deng
- School of Nursing, Vanderbilt University, Nashville, Tennessee 37240, USA.
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Cooper JS, Zhang Q, Pajak TF, Forastiere AA, Jacobs J, Saxman SB, Kish JA, Kim HE, Cmelak AJ, Rotman M, Lustig R, Ensley JF, Thorstad W, Schultz CJ, Yom SS, Ang KK. Long-term follow-up of the RTOG 9501/intergroup phase III trial: postoperative concurrent radiation therapy and chemotherapy in high-risk squamous cell carcinoma of the head and neck. Int J Radiat Oncol Biol Phys 2012; 84:1198-205. [PMID: 22749632 DOI: 10.1016/j.ijrobp.2012.05.008] [Citation(s) in RCA: 320] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Revised: 04/27/2012] [Accepted: 05/03/2012] [Indexed: 11/17/2022]
Abstract
PURPOSE Previous analysis of this Intergroup trial demonstrated that with a median follow-up among surviving patients of 45.9 months, the concurrent postoperative administration of cisplatin and radiation therapy improved local-regional control and disease-free survival of patients who had high-risk resectable head-and-neck carcinomas. With a minimum of 10 years of follow-up potentially now available for all patients, these results are updated here to examine long-term outcomes. METHODS AND MATERIALS A total of 410 analyzable patients who had high-risk resected head-and-neck cancers were prospectively randomized to receive either radiation therapy (RT: 60 Gy in 6 weeks) or identical RT plus cisplatin, 100 mg/m(2)i.v. on days 1, 22, and 43 (RT + CT). RESULTS At 10 years, the local-regional failure rates were 28.8% vs 22.3% (P=.10), disease-free survival was 19.1% vs 20.1% (P=.25), and overall survival was 27.0% vs 29.1% (P=.31) for patients treated by RT vs RT + CT, respectively. In the unplanned subset analysis limited to patients who had microscopically involved resection margins and/or extracapsular spread of disease, local-regional failure occurred in 33.1% vs 21.0% (P=.02), disease-free survival was 12.3% vs 18.4% (P=.05), and overall survival was 19.6% vs 27.1% (P=.07), respectively. CONCLUSION At a median follow-up of 9.4 years for surviving patients, no significant differences in outcome were observed in the analysis of all randomized eligible patients. However, analysis of the subgroup of patients who had either microscopically involved resection margins and/or extracapsular spread of disease showed improved local-regional control and disease-free survival with concurrent administration of chemotherapy. The remaining subgroup of patients who were enrolled only because they had tumor in 2 or more lymph nodes did not benefit from the addition of CT to RT.
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Affiliation(s)
- Jay S Cooper
- Maimonides Cancer Center, New York, New York, USA.
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Cmelak AJ. Current issues in combined modality therapy in locally advanced head and neck cancer. Crit Rev Oncol Hematol 2012; 84:261-73. [PMID: 22595517 DOI: 10.1016/j.critrevonc.2012.04.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 04/05/2012] [Accepted: 04/13/2012] [Indexed: 02/08/2023] Open
Abstract
Curative treatment for patients with locally advanced squamous cell carcinomas of the head and neck (SCCHN) is complex and multidisciplinary. Our understanding of the optimal management of this disease has improved over the years, incorporating refined surgical approaches, better radiotherapy delivery methods, and greater use of systemic therapies. Investigation into shifting epidemiology patterns has uncovered two biologically and clinically distinct diseases: the smoking-related entity and the increasingly common malignancy associated with human papilloma virus (HPV). Prognosis favors the latter, driving newer investigations into dose de-intensification to limit toxicities in patients with HPV-driven disease, and alternatively intensifying treatment to improve tumor control in those with a significant smoking history. In this review, I describe the most recent progress in the multi-modal integration of radiotherapy and chemoradiotherapy, and the role of targeted agents and personalized therapy, and conclude with a discussion of the relevance of these innovations with respect to HPV tumor status.
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Affiliation(s)
- Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt Ingram Cancer Center, Nashville, TN 37232-5671, USA.
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Vlacich G, Diaz R, Thorpe SW, Murphy BA, Kirby W, Sinard RJ, Shakhtour B, Shyr Y, Murphy P, Netterville JL, Yarbrough WG, Cmelak AJ. Intensity-modulated radiation therapy with concurrent carboplatin and paclitaxel for locally advanced head and neck cancer: toxicities and efficacy. Oncologist 2012; 17:673-81. [PMID: 22550060 DOI: 10.1634/theoncologist.2011-0396] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Intensity-modulated radiation therapy (IMRT) and alternative chemotherapy regimens strive to maintain efficacy while minimizing toxicity in locally advanced head and neck cancer (LAHNC) treatment. Our experience with concurrent IMRT and taxane-based chemotherapy is presented. METHODS A retrospective review of 150 consecutive patients with LAHNC treated with IMRT and concurrent taxane-based chemotherapy with curative intent was performed. The IMRT fractionation regimen consisted of 69.3 Gy to gross disease (2.1 Gy/fraction) and 56.1 Gy to prophylactic nodal sites (1.7 Gy/fraction). Weekly paclitaxel (30 mg/m(2)) and carboplatin (area under the concentration-time curve [AUC], 1) were given concurrently to all patients, and 69% received weekly induction with paclitaxel (60 mg/m(2)) and carboplatin (AUC, 2). RESULTS Over 90% of patients received the prescribed radiation dose. Ninety-six percent completed five or more cycles of concurrent chemotherapy, with similar tolerability for induction chemotherapy. A percutaneous endoscopic gastrostomy (PEG) tube was required in 80 patients, with 10 maintaining PEG use >18 months. Acute grade 4 mucositis and dermatitis developed in 2.0% and 4.0% of patients, respectively. No patient experienced nadir sepsis, grade ≥3 late xerostomia, or significant nephropathy or gastrointestinal toxicity. Median follow-up was 30 months. The 3-year locoregional control rate was 83.2% with disease-free survival and overall survival rates of 78.8% and 76.5%, respectively. CONCLUSION Rates of acute and late toxicities were low, with excellent radiation dose delivery and impressive tumor control at 3 years, suggesting that concurrent carboplatin and paclitaxel with IMRT is a reasonable therapeutic option for the curative treatment of LAHNC.
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Affiliation(s)
- Gregory Vlacich
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee 37232-5671, USA
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Pfister DG, Ang KK, Brizel DM, Burtness B, Cmelak AJ, Colevas AD, Dunphy F, Eisele DW, Gilbert J, Gillison ML, Haddad RI, Haughey BH, Hicks WL, Hitchcock YJ, Kies MS, Lydiatt WM, Maghami E, Martins R, McCaffrey T, Mittal BB, Pinto HA, Ridge JA, Samant S, Sanguineti G, Schuller DE, Shah JP, Spencer S, Trotti A, Weber RS, Wolf G, Worden F. Mucosal Melanoma of the Head and Neck. J Natl Compr Canc Netw 2012; 10:320-38. [DOI: 10.6004/jnccn.2012.0033] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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