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Yalamanchali A, Griffith C, Reddy CA, Koyfman SA, Woody NM, Campbell SR, Silver N, Scharpf J, Lorenz RR, Prendes B, Ku JA, Lamarre E, Geiger JL. Evaluating the impact of the degree of extranodal extension on outcomes in locally advanced oral cavity cancer. Head Neck 2024. [PMID: 38660928 DOI: 10.1002/hed.27782] [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: 01/29/2024] [Revised: 04/05/2024] [Accepted: 04/11/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Evaluate whether extranodal extension (ENE) extent impacts outcomes in patients with oral cavity squamous cell carcinoma (OCSCC). METHODS From an institutional database, patients with OCSCC and pathologic ENE who received adjuvant treatment were included. Surgical slides were reviewed to confirm ENE extent. Multivariable Cox regression was used to relate patient/treatment characteristics with disease-free survival (DFS) and overall survival (OS). ENE was analyzed as both a dichotomous and continuous variable. RESULTS A total of 113 patients were identified. Between major (>2 mm) versus minor ENE (≤2 mm), there was no significant difference in DFS (HR 1.18, 95%CI 0.72-1.92, p = 0.51) or OS (HR 1.17, 95%CI 0.70-1.96, p = 0.55). There was no significant association between ENE as a continuous variable and DFS (HR 0.97 per mm, 95%CI 0.87-1.4, p = 0.96) or OS (HR 0.96 per mm, 95%CI 0.83-1.11, p = 0.58). CONCLUSION No significant relationship was seen between ENE extent and DFS or OS in individuals with OCSCC.
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Affiliation(s)
- Anirudh Yalamanchali
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christopher Griffith
- Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Shlomo A Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Neil M Woody
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shauna R Campbell
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Natalie Silver
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joseph Scharpf
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert R Lorenz
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brandon Prendes
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jamie A Ku
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric Lamarre
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jessica L Geiger
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Kanyo EC, Wu SS, Reddy CA, Silver NL, Lamarre ED, Burkey BB, Prendes BL, Scharpf J, Lorenz RR, Kmiecik J, Ku JA. Primary fit tracheoesophageal puncture in primary versus salvage laryngectomy: Short-term and long-term complications and functional outcomes. Head Neck 2024. [PMID: 38655707 DOI: 10.1002/hed.27788] [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: 06/14/2023] [Revised: 02/09/2024] [Accepted: 04/16/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Primary fit tracheoesophageal puncture (TEP) is widely preferred for individuals who have not undergone prior radiation. However, there is no consensus on the relative utility of primary-fit TEP in the setting of salvage laryngectomy. METHODS A retrospective, single-center review was conducted of individuals undergoing laryngectomy with primary fit TEP between 2012 and 2018. Multivariable analysis was conducted to compare short-term and long-term complications, as well as speech and swallowing outcomes, of those who underwent primary versus salvage laryngectomy. RESULTS In this study, 134 patients underwent total laryngectomy with primary fit TEP. Aside from a higher rate of peristomal dehiscence (13.1% vs. 1.4%) found in the salvage group, there was no difference in incidence of all other complications, including pharyngocutaneous fistula formation. The groups had comparable speech and swallow outcomes. CONCLUSION Primary fit TEP is a safe and effective surgical choice for individuals undergoing salvage laryngectomy who desire a voice prosthesis.
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Affiliation(s)
- Emese C Kanyo
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Shannon S Wu
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Eric D Lamarre
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian B Burkey
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Joseph Scharpf
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert R Lorenz
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joann Kmiecik
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jamie A Ku
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
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3
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Schuster J, Sheng IY, Reddy CA, Khorana AA, Nizam A, Gupta S, Gilligan T, Wee CE, Sussman TA, Bonham A, Maroli K, Martin A, Ornstein MC. Risk of Thromboembolism in Patients Receiving Immunotherapy-Based Combinations as Front-Line Therapy for Metastatic Renal Cell Carcinoma. Clin Genitourin Cancer 2024; 22:92-97. [PMID: 37932205 DOI: 10.1016/j.clgc.2023.09.005] [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] [Received: 07/21/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Most patients with treatment-naïve metastatic renal cell carcinoma (mRCC) receive combination-based immunotherapy with either 2 immune-oncology checkpoint inhibitors (IO/IO) or an IO agent in combination with a vascular endothelial growth factor receptor (VEGF-R) tyrosine kinase inhibitor (IO/TKI). The rates of thromboembolism (TE) in these cohorts are not clearly described and can potentially impact decision-making between IO/IO and IO/TKI. METHODS We conducted a retrospective investigation of patients with treatment-naïve mRCC treated with IO-based combinations between January 2015 and April 2021 at the Cleveland Clinic. TE events, including venous and arterial, were identified in each group. Competing risk regression was done to identify factors associated with the development of TE following therapy, with all-cause mortality treated as a competing event. RESULTS Of 180 patients identified, 77 (43%) received IO/TKI and 103 (57%) received IO/IO. Median age was 65 years, 75% were male, and 80% had clear cell histology. Baseline characteristics were similar between the 2 groups. At a median follow-up of 22.0 months, 10.0% of all patients had a TE. The one-year incidence of TE was 8.1% (95% CI: 3.3%-15.8%) with IO/TKI and 9.8% (95% CI: 5.0%-16.5%) with IO/IO and was not significantly different between the 2 groups (HR 0.89, 95% CI: 0.35%-2.28%). Occurrence of TE was associated with decreased overall survival regardless of IO/IO or IO/TKI therapy (HR 2.80, 95% CI: 1.57-5.02). There was no difference in incidence of TE based on patient age, gender, prior history of TE, International Metastatic Renal Cell Carcinoma (IMDC) risk group, or Khorana score. CONCLUSIONS Incidence of TE is similar between IO/IO and IO/TKI regimens in treatment-naïve mRCC and is also associated with decreased overall survival. While risk of TE may not guide decision-making in choice of front-line mRCC therapy, careful attention should be given to the high risk of TE in this population.
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Ganguly S, Lone Z, Muskara A, Imamura J, Hardaway A, Patel M, Berk M, Smile TD, Davicioni E, Stephans KL, Ciezki J, Weight CJ, Gupta S, Reddy CA, Tendulkar RD, Chakraborty AA, Klein EA, Sharifi N, Mian OY. Intratumoral androgen biosynthesis associated with 3β-hydroxysteroid dehydrogenase 1 promotes resistance to radiotherapy in prostate cancer. J Clin Invest 2023; 133:e165718. [PMID: 37966114 PMCID: PMC10645386 DOI: 10.1172/jci165718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 09/19/2023] [Indexed: 11/16/2023] Open
Abstract
Half of all men with advanced prostate cancer (PCa) inherit at least 1 copy of an adrenal-permissive HSD3B1 (1245C) allele, which increases levels of 3β-hydroxysteroid dehydrogenase 1 (3βHSD1) and promotes intracellular androgen biosynthesis. Germline inheritance of the adrenally permissive allele confers worse outcomes in men with advanced PCa. We investigated whether HSD3B1 (1245C) drives resistance to combined androgen deprivation and radiotherapy. Adrenally permissive 3βHSD1 enhanced resistance to radiotherapy in PCa cell lines and xenograft models engineered to mimic the human adrenal/gonadal axis during androgen deprivation. The allele-specific effects on radiosensitivity were dependent on availability of DHEA, the substrate for 3βHSD1. In lines expressing the HSD3B1 (1245C) allele, enhanced expression of DNA damage response (DDR) genes and more rapid DNA double-strand break (DSB) resolution were observed. A correlation between androgen receptor (AR) expression and increased DDR gene expression was confirmed in 680 radical prostatectomy specimens. Treatment with the nonsteroidal antiandrogen enzalutamide reversed the resistant phenotype of HSD3B1 (1245C) PCa in vitro and in vivo. In conclusion, 3βHSD1 promotes prostate cancer resistance to combined androgen deprivation and radiotherapy by upregulating DNA DSB repair. This work supports prospective validation of early combined androgen blockade for high-risk men harboring the HSD3B1 (1245C) allele.
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Affiliation(s)
| | - Zaeem Lone
- Translational Hematology and Oncology Research
| | | | | | | | - Mona Patel
- Department of Cancer Biology, Lerner Research Institute
| | - Mike Berk
- Department of Cancer Biology, Lerner Research Institute
| | - Timothy D Smile
- Department of Radiation Oncology, and Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Kevin L Stephans
- Department of Radiation Oncology, and Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jay Ciezki
- Department of Radiation Oncology, and Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Shilpa Gupta
- Department of Radiation Oncology, and Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Rahul D Tendulkar
- Department of Radiation Oncology, and Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Abhishek A Chakraborty
- Department of Cancer Biology, Lerner Research Institute
- Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric A Klein
- Veracyte Inc., San Francisco, California, USA
- Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nima Sharifi
- Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Desai Sethi Urology Institute and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Ohio, USA
| | - Omar Y Mian
- Translational Hematology and Oncology Research
- Department of Radiation Oncology, and Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Somasundaram E, Anderson PM, Smile TD, Halima A, Broughman JB, Reddy CA, Parsai S, Scott JG, Chan T, Campbell S, Angelov L, Zahler S, Trucco M, Thomas SM, Johnson S, Qi P, Magnelli A, Murphy ES. Neutrophil to lymphocyte ratio (NTLR) predicts local control and overall survival after stereotactic body radiotherapy (SBRT) in metastatic sarcoma. Sci Rep 2023; 13:19256. [PMID: 37935813 PMCID: PMC10630331 DOI: 10.1038/s41598-023-46476-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 11/01/2023] [Indexed: 11/09/2023] Open
Abstract
The neutrophil to lymphocyte ratio (NTLR) and absolute lymphocyte count (ALC) recovery are prognostic across many cancers. We investigated whether NLTR predicts SBRT success or survival in a metastatic sarcoma cohort treated with SBRT from 2014 and 2020 (N = 42). Wilcox Signed Rank Test and Friedman Test compare NTLR changes with local failure vs. local control (N = 138 lesions). Cox analyses identified factors associated with overall survival. If local control was successful, NLTR change was not significant (p = 0.30). However, NLTR significantly changed in patients with local failure (p = 0.027). The multivariable Cox model demonstrated higher NLTR before SBRT was associated with worse overall survival (p = 0.002). The optimal NTLR cut point was 5 (Youden index: 0.418). One-year overall survival in SBRT metastatic sarcoma cohort was 47.6% (CI 34.3%-66.1%). Patients with an NTLR above 5 had a one-year overall survival of 37.7% (21.4%-66.3%); patients with an NTLR below 5 had a significantly improved overall survival of 63% (43.3%-91.6%, p = 0.014). Since NTLR at the time of SBRT was significantly associated with local control success and overall survival in metastatic sarcoma treated with SBRT, future efforts to reduce tumor inhibitory microenvironment factors and improve lymphocyte recovery should be investigated.
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Affiliation(s)
| | - Peter M Anderson
- Department of Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Timothy D Smile
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, R3 9500 Euclid Ave, Cleveland, 44195, OH, USA
| | - Ahmed Halima
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, R3 9500 Euclid Ave, Cleveland, 44195, OH, USA
| | - James B Broughman
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, R3 9500 Euclid Ave, Cleveland, 44195, OH, USA
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, R3 9500 Euclid Ave, Cleveland, 44195, OH, USA
| | - Shireen Parsai
- Department of Radiation Oncology, Ohio Health Riverside Methodist Hospital, Columbus, OH, USA
| | - Jacob G Scott
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, R3 9500 Euclid Ave, Cleveland, 44195, OH, USA
| | - Timothy Chan
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, R3 9500 Euclid Ave, Cleveland, 44195, OH, USA
| | - Shauna Campbell
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, R3 9500 Euclid Ave, Cleveland, 44195, OH, USA
| | - Lilyana Angelov
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Stacey Zahler
- Department of Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Matteo Trucco
- Department of Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Stefanie M Thomas
- Department of Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Shavaughn Johnson
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, R3 9500 Euclid Ave, Cleveland, 44195, OH, USA
| | - Peng Qi
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, R3 9500 Euclid Ave, Cleveland, 44195, OH, USA
| | - Anthony Magnelli
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, R3 9500 Euclid Ave, Cleveland, 44195, OH, USA
| | - Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, R3 9500 Euclid Ave, Cleveland, 44195, OH, USA.
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6
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Wu SS, Woody N, Hesse J, Cook S, Cracolici V, Ku JA, Prendes B, Silver N, Scharpf J, Brauer PR, Reddy CA, Campbell SR, Koyfman SA, Burkey B, Lamarre ED. Margin Assessment Methods in Oral Cavity Squamous Cell Carcinoma and Recurrence: Tumor Bed vs Resection Specimen Sampling. JAMA Otolaryngol Head Neck Surg 2023; 149:1011-1020. [PMID: 37768650 PMCID: PMC10540056 DOI: 10.1001/jamaoto.2023.2982] [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] [Received: 04/24/2023] [Accepted: 08/05/2023] [Indexed: 09/29/2023]
Abstract
Importance Positive margins and margin clearance are risk factors for recurrence in oral cavity squamous cell carcinoma (OCSCC), and these features are used to guide decisions regarding adjuvant radiation treatment. However, the prognostic value of intraoperative tumor bed vs resection specimen sampling is not well defined. Objective To determine the prognostic implications of intraoperative margin assessment methods (tumor bed vs resection specimen sampling) with recurrence among patients who undergo surgical resection for OCSCC. Design, Setting, and Participants This was a retrospective study of patients who had undergone surgical resection of OCSCC between January 1, 2000, and December 31, 2021, at a tertiary-level academic institution. Patients were grouped by margin assessment method (tumor bed [defect] or resection specimen sampling). Of 223 patients with OCSCC, 109 patients had localized tumors (pT1-T2, cN0), 154 had advanced tumors, and 40 were included in both cohorts. Disease recurrence after surgery was estimated by the cumulative incidence method and compared between cohorts using hazard ratios (HRs). Data analyses were performed from January 5, 2023, to April 30, 2023. Main Outcome and Measures Recurrence-free survival (RFS). Results The study population comprised 223 patients (mean [SD] age, 62.7 [12.0] years; 88 (39.5%) female and 200 [90.0%] White individuals) of whom 158 (70.9%) had defect-driven and 65 (29.1%) had specimen-driven margin sampling. Among the 109 patients with localized cancer, intraoperative positive margins were found in 5 of 67 (7.5%) vs 8 of 42 (19.0%) for defect- vs specimen-driven sampling, respectively. Final positive margins were 3.0% for defect- (2 of 67) and 2.4% for specimen-driven (1 of 42) margin assessment. Among the 154 patients with advanced cancer, intraoperative positive margins were found in 29 of 114 (25.4%) vs 13 of 40 (32.5%) for defect- and specimen-driven margins, respectively. Final positive margins were higher in the defect-driven group (9 of 114 [7.9%] vs 1 of 40 [2.5%]). When stratified by margin assessment method, the 3-year rates of local recurrence (9.7% vs 5.1%; HR, 1.37; 95% CI, 0.51-3.66), regional recurrence (11.0% vs 10.4%; HR, 0.85; 95% CI, 0.37-1.94), and distant recurrence (6.4% vs 5.0%; HR, 1.10; 95% CI, 0.36-3.35) were not different for defect- vs specimen-driven sampling cohorts, respectively. The 3-year rate of any recurrence was 18.9% in the defect- and 15.2% in the specimen-driven cohort (HR, 0.93; 95% CI, 0.48-1.81). There were no differences in cumulative incidence of disease recurrence when comparing defect- vs specimen-driven cases. Conclusions and Relevance The findings of this retrospective cohort study indicate that margin assessment methods using either defect- or specimen-driven sampling did not demonstrate a clear association with the risk of recurrence after OCSCC resection. Specimen-driven sampling may be associated with reduced surgical margin positivity rates, which often necessitate concurrent chemotherapy with adjuvant radiation therapy.
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Affiliation(s)
- Shannon S. Wu
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Neil Woody
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jennifer Hesse
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Samantha Cook
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Jamie A. Ku
- Department of Otolaryngology, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brandon Prendes
- Department of Otolaryngology, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Natalie Silver
- Department of Otolaryngology, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph Scharpf
- Department of Otolaryngology, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Philip R. Brauer
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Chandana A. Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shauna R. Campbell
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shlomo A. Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian Burkey
- Department of Otolaryngology, Head and Neck Institute, Head and Neck Institute, Cleveland Clinic, Vero Beach, Florida
| | - Eric D. Lamarre
- Department of Otolaryngology, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
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7
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Mayo ZS, Reddy CA, Billena C, Davies EM, Bommireddy A, Davis RW, Murphy ES, Suh JH, Balagamwala EH, Chan TA, Yu JS, Barnett GH, Mohammadi AM, Angelov L, Stevens G, Chao ST. Development of an RPA for Prediction of Radiation Necrosis Following Single Fraction Gamma Knife Radiosurgery for Brain Metastases. Int J Radiat Oncol Biol Phys 2023; 117:e137. [PMID: 37784704 DOI: 10.1016/j.ijrobp.2023.06.943] [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) Radiation necrosis (RN) is a potential complication following treatment of brain metastases with stereotactic radiosurgery (SRS). Several risk factors for RN have been reported, but to our knowledge there are no recursive partitioning analysis (RPA) models to identify patients at highest risk for RN. We therefore sought to develop a predictive tool to identify patients at highest risk for the development of RN following single fraction SRS. MATERIALS/METHODS Patients who underwent single fraction SRS for brain metastases from 2017-2021 were identified from a single institutional IRB-approved database. Patients with concern for RN were discussed in a multi-disciplinary setting and a diagnosis of RN was made based on pathologic or radiographic findings. Cox proportional hazards regression was done to identify factors associated with RN. RPA was performed to categorize patients into distinct risk groups for RN. Variables with p<0.1 on univariate analysis from the Cox regression analysis were included in the RPA. Patients with staged SRS, incomplete treatment records, or < 3 months radiographic follow-up were excluded from the analysis. RESULTS The study population comprised 1,011 lesions from 283 patients with a median follow-up of 9.7 months. The majority of lesions had non-small cell lung cancer (NSCLC) (49%) as the primary site followed by breast (12%) and melanoma (11%). The median prescription dose was 24 Gy (range: 12-24 Gy). RN was diagnosed in 12.2% of lesions, of which 28% (35/123) were symptomatic RN. The median time to RN was 4.9 months. Variables identified for inclusion in the RPA included primary tumor site, use of targeted therapy, tumor location, pre-SRS hemorrhage, post-SRS hemorrhage, prior SRS to other lesions, number of SRS targets, maximum dose, maximum lesion diameter, 70% isodose line, heterogeneity index, conformality index, and gradient index. RPA identified four distinct groups. Group 1 was defined as maximum lesion diameter (MLD) <0.8 cm with primary tumor site other than breast, colorectal (CRC) or NSCLC (n = 174); group 2 was MLD <0.8 cm with breast, CRC, or NSCLC (n = 372). Group 3 was defined as MLD ≥ 0.8 cm without post-SRS hemorrhage (n = 336) and group 4 was MLD ≥0.8 cm with post-SRS hemorrhage (n = 129). Two-year RN free survival for all lesions was 82%, 100% for group 1, 89% for group 2, 76% for group 3, and 58% for group 4. CONCLUSION We created the first RPA predictive model for RN following single fraction SRS and identified a subgroup of patients at highest risk. This RPA can help guide clinicians when educating patients on RN risk for brain metastases.
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Affiliation(s)
- Z S Mayo
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - C A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - C Billena
- Memorial Sloan Kettering Cancer Center, Manhattan, NY
| | | | - A Bommireddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - R W Davis
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - E S Murphy
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - J H Suh
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - E H Balagamwala
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - T A Chan
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - J S Yu
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - G H Barnett
- Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - A M Mohammadi
- Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - L Angelov
- Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - G Stevens
- Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - S T Chao
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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8
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Ballas LK, Reddy CA, Han HR, Makar J, Mian OY, Broughman JR, de Bustamante C, Eggener S, Liauw S, Abramowitz MC, Montoya C, Tendulkar RD. Patterns of Recurrence Following Radiation and ADT for Pathologic Lymph Node Positive Prostate Cancer: A Multi-Institutional Study. Int J Radiat Oncol Biol Phys 2023; 117:e365. [PMID: 37785252 DOI: 10.1016/j.ijrobp.2023.06.2459] [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) Retrospective studies have suggested that post-operative radiation therapy (RT) can reduce the risk of cause-specific mortality in men with pathologic nodal involvement (pN1) after radical prostatectomy (RP). We evaluated prognostic factors and patterns of recurrence in patients who received post-operative RT +/- androgen deprivation therapy (ADT) for pN1 disease in a multicentric cohort of 4 academic centers. MATERIALS/METHODS Data from patients with pN1 prostate cancer after RP who subsequently received RT with short term (< = 6 mo) or long term (>6 mo) ADT were obtained from 4 academic institutions. Patterns of recurrence, biochemical progression free survival (bPFS) and distant metastasis free survival (DMFS) were evaluated. RESULTS A total of 270 patients with a median follow-up of 48 months were included. Gleason grade group (GG) 2 was present in 20 patients (7.5%), GG 3 in 81 (30%), GG4 in 36 (13.5%), GG5 in 130 (49%) patients. 256 (95%) patients had extracapsular extension, 70% had seminal vesicle invasion, 59% had positive surgical margins, and 66% had a detectable post-operative PSA. The number of positive nodes at surgery were 1 in 59%, 2 in 19% and >2 in 22% of patients. Of the 83 patients that had pre-RT imaging, 46 (55%) had a PET scan (PSMA, or fluciclovine); 25 (30%) of those had lymph nodes detected on imaging prior to RT. Median time from RP to RT was 6 mo (IQR 4.5-9.1 mo). 96% received radiation to both the prostate bed (median dose 68.4Gy) and pelvic lymph nodes (median dose 46Gy). ADT was prescribed short-term (20%) or long-term (68%), while 26 (10%) received no ADT, and 7 (3%) had an unknown duration. Biochemical failure (bF) was observed in 29% of men, with 5% having pelvic nodal failure and 11.5% having distant metastases (majority in bones, followed by paraaortic nodes) at last follow up. Of 59 patients who had normal baseline testosterone levels, 37% recovered their testosterone by last follow-up. The 4-year bRFS was 72% for all patients and was 83% for those with a pre-RT PSA of <0.1 ng/mL, 76% for PSA 0.1-<0.5 ng/mL, 60% for PSA 0.5-2 ng/mL, and 35% for PSA >2 ng/mL. On multivariable analysis, maximum pre-RT PSA ≥0.5 (0.5 to 2.0 vs <0.1 HR = 3.19; >2.0 vs <0.1 HR = 9.00), use of LTADT (HR = 0.47), and percent pN1 (HR = 1.03) were significantly associated with bF. Pre-RT PSA >2 (HR = 4.10), use of LT ADT (HR = 0.33) and percent pN1 (HR = 1.03) were also significantly associated with DM. CONCLUSION In pN1 patients, pelvic RT and ADT at low PSA levels is associated with improved oncologic outcomes compared to treatment at higher levels, suggesting that PSA may have prognostic value for pN1 prostate cancer.
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Affiliation(s)
- L K Ballas
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - C A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - H R Han
- Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - J Makar
- California University of Science and Medicine, Colton, CA
| | - O Y Mian
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | | | - C de Bustamante
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, IL
| | - S Eggener
- Department of Surgery, University of Chicago Medical Center, Chicago, IL
| | - S Liauw
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, IL
| | - M C Abramowitz
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - C Montoya
- University of Miami School of Medicine, Miami, FL
| | - R D Tendulkar
- Dept of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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Videtic GM, Reddy CA, Stephans KL. Single-Fraction Lung SBRT Outcomes for Tumors ≥ 3cm. Int J Radiat Oncol Biol Phys 2023; 117:e69. [PMID: 37786025 DOI: 10.1016/j.ijrobp.2023.06.798] [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) Toxicity and local control at 1 year were the primary and secondary endpoints, respectively, of two randomized phase II lung SBRT trials having a single fraction (SF-SBRT) arm. Median tumor size in these trials was 2 cm. We surveyed our institutional database to analyze outcomes for tumors 3 cm or greater. MATERIALS/METHODS A survey from 2003-2022 of 2481 patients (pts) in an IRB-approved prospective registry yielded 61 pts [2.5%] treated with SF-SBRT for tumors > 3cm. SF-SBRT dose was either 34 Gy or 30 Gy in one fraction. Outcomes of interest included rates of local control (LC) as well as treatment-related toxicity graded per CTCAE version 4.0. Gray's test and Log rank test were used to assess significance for disease recurrence and overall survival (OS), respectively. RESULTS For the 61 pts, median follow up interval was 12.2 months (m). Pt characteristics included: female (57.4%); median age 76.8 years (range 56.5-94.3); median KPS 80 (range 50-100); active smokers 11.5%; median body mass-index 25.8 (range 16.4-48.8). Tumor characteristics included: median diameter 3.3 cm (range 3.0-6.6) with tumor size cohorts (% of total) being: 3-3.9 cm (73.8%); 4-4.9 cm (21.3%); 5-6.6 cm (4.9%); median PET SUVmax 9.1 (range 1.7-41.5); 6.6% were oligometastatic and 3.3% oligoprogressive; 93.4% were biopsy-proven with adenocarcinoma being 45.9%; 49.2% abutted the chest wall. SF-SBRT dose was 34 Gy in 80.3% cases and 30 Gy in 19.7%. At analysis, toxicity of any grade/type was seen in 27.5% pts, with no > grade 3 cases; 6.6% of pts had grade 2 chest wall toxicity. Rates (in %) of local, lobar, nodal and distant failure were 1.7, 1.7, 13.1 and 21.3, respectively. There was no significant difference in failure by size cohort. Median OS was 33 m, with 1-year OS at 75%. When analyzed by cohort, OS significantly declined with increasing size (p = 0.0421) CONCLUSION: Local control and toxicity with SF-SBRT for tumors > 3cm is comparable to that seen with smaller tumors treated on randomized trials.
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Affiliation(s)
- G M Videtic
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - C A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - K L Stephans
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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10
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Billena C, Angelov L, Balagamwala EH, Miller JA, Reddy CA, Koro S, Bommireddy A, Emch T, Suh JH, Murphy ES, Xia P, Magnelli A, Chao ST. Phase II Randomized Trial of Single- vs. Two-Fraction Spine Stereotactic Radiosurgery for the Treatment of Vertebral Metastases. Int J Radiat Oncol Biol Phys 2023; 117:e89. [PMID: 37786206 DOI: 10.1016/j.ijrobp.2023.06.845] [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) As systemic therapies improve significantly, more patients with limited metastatic disease are undergoing spine stereotactic radiosurgery (sSRS). High dose (≥24 Gy) single fraction sSRS has been associated with a vertebral compression fracture (VCF) risk of up to 40%. Comparatively, lower dose (16-18 Gy) single fraction sSRS is associated with a fracture risk of 15-20%, with the risk increasing as the dose increases. To mitigate the risk of VCF, while optimizing higher dose delivery, some have advocated utilizing two-fraction sSRS regimen. Therefore, we designed a phase II randomized trial in which we hypothesized that single fraction sSRS is non-inferior to two-fraction sSRS with respect to VCF but offers patients greater convenience. MATERIALS/METHODS Inclusion criteria include age ≥18, Karnofsky performance score ≥70, vertebral metastasis from C3 to L5, maximum of three separate sites of metastases, limited paraspinal extension (<5 cm), and no rapid neurological decline. Patients must also be either Recursive Partitioning Analysis Class 1 (KPS >70 AND controlled systemic disease) or Class 2 (KPS >70, uncontrolled systemic disease OR KPS ≤70, age ≥54, no visceral metastases). Exclusion criteria include multiple primary cancers, primary neoplasm of the spine, prior surgery at the site of sSRS, spinal cord compression, bony retropulsion resulting in neurologic deficit, inability to undergo/contraindication to MRI, or diffuse multi-level metastatic spine disease. Our primary hypothesis is that single fraction sSRS (experimental arm - 16-18 Gy) is non-inferior to two fraction sSRS (standard arm - 24 Gy). Furthermore, we hypothesize that both treatment arms will have similar local control, pain control, quality of life and toxicity profiles. The primary endpoint of this trial is the development or progression of VCF at 6 months. Secondary endpoints include local control, pain control, quality of life and toxicity all of which will be assessed at 12 months. For the sample size calculation, we assumed a VCF risk of 17% in the experimental arm and a 7% risk in the standard arm. Based on these calculations, we aim to enroll 130 patients, 65 in each arm. This trial is currently enrolling patients actively, and approximately 30% of expected enrollment has been completed to date. This trial is registered on clinicaltrials.gov: NCT04218617. RESULTS Pending full accrual. CONCLUSION Pending full accrual.
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Affiliation(s)
- C Billena
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - L Angelov
- Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - E H Balagamwala
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - J A Miller
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - C A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - S Koro
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - A Bommireddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - T Emch
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH
| | - J H Suh
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - E S Murphy
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - P Xia
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - A Magnelli
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - S T Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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11
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McAfee JL, Hoda RS, Hoyle C, McCoy L, Sprague C, Reddy CA, Koyfman SA, Geiger JL, Komforti MK, Griffith CC. ERBB2 Amplification and HER2 Expression in Salivary Duct Carcinoma: Evaluation of Scoring Guidelines and Potential for Expanded Anti-HER2 Therapy. Mod Pathol 2023; 36:100273. [PMID: 37423585 DOI: 10.1016/j.modpat.2023.100273] [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: 03/09/2023] [Revised: 06/09/2023] [Accepted: 06/30/2023] [Indexed: 07/11/2023]
Abstract
Salivary duct carcinoma (SDC) is aggressive with limited therapeutic options. A subset of SDC display human epidermal growth factor receptor 2 (HER2) protein overexpression by immunohistochemistry, and some show ERBB2 gene amplification. Guidelines for HER2 scoring are not firmly established. Recent advances in breast carcinoma have established a role for anti-HER2 therapies in lesions with low HER2 expression lacking ERBB2 amplification. Delineating HER2 staining patterns in SDC is critical for evaluating anti-HER2 treatments. In total, 53 cases of SDC resected at our institution between 2004 and 2020 were identified. Androgen receptor (AR) and HER2 immunohistochemistry and ERBB2 fluorescence in situ hybridization were performed in all cases. AR expression was scored for percentage positive cells and categorized as positive (>10% of cells), low positive (1%-10%), or negative (<1%). HER2 staining levels and patterns were recorded, scored using 2018 ASCO/CAP guidelines, and categorized into HER2-positive (3+ or 2+ with ERBB2 amplification), HER2-low (1+ or 2+ without ERBB2 amplification), HER2-very low (faint staining in <10% of cells), or HER2-absent types. Clinical parameters and vital status were recorded. Median age was 70 years, with a male predominance. ERBB2-amplified tumors (11/53; 20.8%) presented at lower pT stages (pTis/pT1/pT2; P = .005, Fisher exact test) and more frequently had perineural invasion (P = .007, Fisher exact test) compared with ERBB2 nonamplified tumors; no other pathologic features differed significantly by gene amplification status. In addition, 2+ HER2 staining by 2018 ASCO/CAP criteria was most common (26/53; 49%); only 4 cases (8%) were HER2-absent status; 3+ HER2 staining was found in 9 tumors, and all were ERBB2 amplified. Six patients with HER2-expressing tumors received trastuzumab therapy, including 2 with ERBB2-amplified tumors. Overall survival and recurrence-free survival did not differ significantly based on ERBB2 status. This work suggests that 2018 ASCO/CAP guidelines for HER2 evaluation in breast carcinoma could be applied to SDC. Our findings also show broad overexpression of HER2 in SDC raising the possibility that more patients may benefit from anti-HER2-directed therapies.
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Affiliation(s)
- John L McAfee
- Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Raza S Hoda
- Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Carrie Hoyle
- Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lauren McCoy
- Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Cathy Sprague
- Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | | | - Miglena K Komforti
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida
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12
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Miller KM, Sbeih F, Contrera K, Reddy CA, Marquard J, Eng C, Lorenz RR. Reduced Risk of Corporal Tumors in Patients With Head and Neck Paragangliomas With p.Pro81Leu Mutations. Otolaryngol Head Neck Surg 2023; 169:570-576. [PMID: 36939592 DOI: 10.1002/ohn.274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/13/2022] [Accepted: 01/05/2023] [Indexed: 02/10/2023]
Abstract
OBJECTIVE Patients with head and neck paragangliomas who are positive for the SDHD p.Pro81Leu (P81L) mutation are thought to have a distinct phenotype from other SDHx mutations, but few studies have focused on this mutation. The objective of this study was to determine the hazard of developing a second primary, metastatic, or recurrent paraganglioma in SDHx patients with or without P81L. STUDY DESIGN Retrospective chart review of 60 patients with head and neck paragangliomas and genetic testing, followed for a median of 9 years. SETTING Single academic medical center. METHODS Univariable Cox proportional hazards regression evaluated second primary and recurrent paragangliomas in patients with SDHD P81L, SDHx non-P81L, and nonhereditary paraganglioma. RESULTS This series comprised 31 patients without SDHx, 14 with SDHD P81L, and 15 with other SDHx mutations. At a median 9 years of follow-up, corporal (not head and neck) second primary paragangliomas occurred in 31% of patients with SDHx non-P81L mutations, compared with 0% and 4% of patients with SDHD P81L and without SDHx mutations, respectively. Second corporal paragangliomas were more likely in patients with SDHx non-P81L mutations than in those without a mutation (hazard ratio = 5.461, 95% confidence interval: 0.596-50.030, p = .13). CONCLUSION This is the first study to report a lower likelihood of corporal tumors for patients with head and neck paragangliomas with SDH mutations positive for P81L. Larger studies are needed to determine if head and neck paraganglioma patients with P81L qualify for less intensive imaging surveillance to screen for second primary paragangliomas outside the head and neck.
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Affiliation(s)
- Katherine M Miller
- Head and Neck Institute, Cleveland Clinic, Head & Neck Institute, Cleveland, Ohio, USA
| | - Firas Sbeih
- Head and Neck Institute, Cleveland Clinic, Head & Neck Institute, Cleveland, Ohio, USA
| | - Kevin Contrera
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jessica Marquard
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Charis Eng
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Genetics and Genome Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Genetics and Genome Sciences, Germline High Risk Cancer Focus Group, CASE Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Robert R Lorenz
- Head and Neck Institute, Cleveland Clinic, Head & Neck Institute, Cleveland, Ohio, USA
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13
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Somasundaram E, Smile TD, Halima A, Broughman JB, Reddy CA, Parsai S, Scott JG, Chan T, Campbell S, Angelov L, Zahler S, Trucco M, Thomas SM, Johnson S, Qi P, Magnelli A, Anderson PM, Murphy ES. Neutrophil to Lymphocyte Ratio (NTLR) Predicts Local Control Failure and Overall Survival after Stereotactic Body Radiotherapy (SBRT) In Metastatic Sarcoma. Res Sq 2023:rs.3.rs-2570832. [PMID: 37333401 PMCID: PMC10275040 DOI: 10.21203/rs.3.rs-2570832/v1] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
The neutrophil to lymphocyte ratio (NTLR) and absolute lymphocyte count (ALC) recovery are prognostic across many cancers. We investigated whether NLTR predicts SBRT success or survival in a metastatic sarcoma cohort treated with SBRT from 2014 and 2020 (N = 42). Wilcox Signed Rank Test and Friedman Test compare NTLR changes with local failure vs. local control (N = 138 lesions). Cox analyses identified factors associated with overall survival. If local control was successful, NLTR change was not significant (p = 0.30). However, NLTR significantly changed in patients local failure (p = 0.027). The multivariable Cox model demonstrated higher NLTR before SBRT was associated with worse overall survival (p = 0.002). The optimal NTLR cut point was 5 (Youden index: 0.418). One-year overall survival in SBRT metastatic sarcoma cohort was 47.6% (CI 34.3%-66.1%). Patients with an NTLR above 5 had a one-year overall survival of 37.7% (21.4%-66.3%); patients with an NTLR below 5 had a significantly improved overall survival of 63% (43.3%-91.6%, p = 0.014). Since NTLR at the time of SBRT was significantly associated with local control success and overall survival in metastatic sarcoma treated with SBRT, future efforts to reduce tumor inhibitory microenvironment factors and improved lymphocyte recovery should be investigated.
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14
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Wu SS, Hong H, Fritz M, Ku J, Prendes B, Silver N, Genther DJ, Ciolek P, Byrne P, Brauer P, Reddy CA, Woody N, Campbell S, Koyfman SA, Lamarre ED. Rates of osteoradionecrosis in resected oral cavity cancer reconstructed with free tissue transfer in the intensity-modulated radiotherapy era. Head Neck 2023; 45:890-899. [PMID: 36808674 DOI: 10.1002/hed.27310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 01/24/2023] [Accepted: 02/03/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Resected oral cavity carcinoma defects are often reconstructed with osteocutaneous or soft-tissue free flaps, but risk of osteoradionecrosis (ORN) is unknown. METHODS This retrospective study included oral cavity carcinoma treated with free-tissue reconstruction and postoperative IMRT between 2000 and 2019. Risk-regression assessed risk factors for grade ≥2 ORN. RESULTS One hundred fifty-five patients (51% male, 28% current smokers, mean age 62 ± 11 years) were included. Median follow-up was 32.6 months (range, 1.0-190.6). Thirty-eight (25%) patients had fibular free flap for mandibular reconstruction, whereas 117 (76%) had soft-tissue reconstruction. Grade ≥2 ORN occurred in 14 (9.0%) patients, at a median 9.8 months (range, 2.4-61.5) after IMRT. Post-radiation teeth extraction was significantly associated with ORN. One-year and 10-year ORN rates were 5.2% and 10%, respectively. CONCLUSIONS ORN risk was comparable between osteocutaneous and soft-tissue reconstruction for resected oral cavity carcinoma. Osteocutaneous flaps can be safely performed with no excess concern for mandibular ORN.
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Affiliation(s)
- Shannon S Wu
- Cleveland Clinic Lerner, College of Medicine, Cleveland, Ohio, USA
| | - Hanna Hong
- Cleveland Clinic Lerner, College of Medicine, Cleveland, Ohio, USA
| | - Michael Fritz
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
| | - Jamie Ku
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
| | - Brandon Prendes
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
| | - Natalie Silver
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
| | - Dane J Genther
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
| | - Peter Ciolek
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
| | - Patrick Byrne
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
| | - Philip Brauer
- Case Western Reserve, University School of Medicine, Cleveland, Ohio, USA
| | - Chandana A Reddy
- Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Neil Woody
- Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Shauna Campbell
- Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Shlomo A Koyfman
- Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Eric D Lamarre
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
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15
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Wu SS, Lamarre ED, Yalamanchali A, Brauer PR, Hong H, Reddy CA, Yilmaz E, Woody N, Ku JA, Prendes B, Burkey B, Nasr C, Skugor M, Heiden K, Chute DJ, Knauf JA, Campbell SR, Koyfman SA, Geiger JL, Scharpf J. Association of Treatment Strategies and Tumor Characteristics With Overall Survival Among Patients With Anaplastic Thyroid Cancer: A Single-Institution 21-Year Experience. JAMA Otolaryngol Head Neck Surg 2023; 149:300-309. [PMID: 36757708 PMCID: PMC9912167 DOI: 10.1001/jamaoto.2022.5045] [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] [Received: 10/04/2022] [Accepted: 12/15/2022] [Indexed: 02/10/2023]
Abstract
Importance Survival outcomes for anaplastic thyroid cancer (ATC), the most aggressive subtype of thyroid cancers, have remained poor. However, targeted therapies and immunotherapies present new opportunities for treatment of this disease. Evaluations of survival outcomes over time with new multimodal therapies are needed for optimizing treatment plans. Objective To evaluate the association of treatment strategies and tumor characteristics with overall survival (OS) among patients with ATC. Design, Setting, and Participants This retrospective case series study evaluated the survival outcomes stratified by treatment strategies and tumor characteristics among patients with ATC treated at a tertiary level academic institution from January 1, 2000, to December 31, 2021. Demographic, tumor, treatment, and outcome characteristics were analyzed. Kaplan-Meier method and log rank test modeled OS by treatment type and tumor characteristics. Data were analyzed in May 2022. Main Outcomes and Measures Overall survival (OS). Results The study cohort comprised 97 patients with biopsy-proven ATC (median [range] age at diagnosis, 70 [38-93] years; 60 (62%) female and 85 [88%] White individuals; 59 [61%] never smokers). At ATC diagnosis, 18 (19%) patients had stage IVA, 19 (20%) had stage IVB, and 53 (55%) had stage IVC disease. BRAF status was assessed in 38 patients; 18 (47%) had BRAF-V600E variations and 20 (53%), BRAF wild type. Treatment during clinical course included surgery for 44 (45%) patients; chemotherapy, 41 (43%); definitive or adjuvant radiation therapy, 34 (RT; 35%); and targeted therapy, 28 (29%). Median OS for the total cohort was 6.5 (95% CI, 4.3-10.0) months. Inferior OS was found in patients who did not receive surgery (hazard ratio [HR], 2.12; 95% CI, 1.35-3.34; reference, received surgery), chemotherapy (HR, 3.28; 95% CI, 1.99-5.39; reference, received chemotherapy), and definitive or adjuvant RT (HR, 2.47; 95% CI, 1.52-4.02; reference, received definitive/adjuvant RT). On multivariable analysis, age at diagnosis (HR, 1.03; 95% CI, 1.01-1.06), tumor stage IVC (HR, 2.65; 95% CI, 1.35-5.18), and absence of definitive or adjuvant RT (HR, 1.90; 95% CI, 1.01-3.59) were associated with worse OS. Conclusions and Relevance This retrospective single-institution study found that lower tumor stage, younger age, and the ability to receive definitive or adjuvant RT were associated with improved OS in patients with ATC.
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Affiliation(s)
- Shannon S. Wu
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | | | | | - Philip R. Brauer
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Hanna Hong
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Chandana A. Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emrullah Yilmaz
- Department of Hematology & Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Neil Woody
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jamie A. Ku
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Brian Burkey
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christian Nasr
- Department of Internal Medicine, Division of Endocrinology, University of Arizona, Phoenix
| | - Mario Skugor
- Department of Endocrinology, Endocrinology & Metabolism Institute, Cleveland Clinic, Cleveland, Ohio
| | - Katherine Heiden
- Department of Endocrinology, Endocrinology & Metabolism Institute, Cleveland Clinic, Cleveland, Ohio
| | - Deborah J. Chute
- Department of Pathology, Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeffrey A. Knauf
- Center for Immunotherapy and Precision Immuno-Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Shauna R. Campbell
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shlomo A. Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jessica L. Geiger
- Department of Hematology & Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph Scharpf
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
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Videtic GMM, Reddy CA, Woody NM, Stephans KL. Local Control With Single-Fraction Lung Stereotactic Body Radiotherapy is not influenced by Non-Small Cell Lung Cancer Histologic Subtype. Clin Lung Cancer 2022; 23:e428-e434. [PMID: 35750570 DOI: 10.1016/j.cllc.2022.05.014] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/26/2022] [Accepted: 05/28/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION/BACKGROUND For early stage medically inoperable lung cancer treated with fractionated stereotactic body radiotherapy (SBRT), higher local failure is associated with squamous carcinoma (SqC) compared to adenocarcinoma (AC). This study explored whether histology influences single-fraction SBRT local control. MATERIALS AND METHODS We surveyed our prospective data registry from 12/2009 to 12/2019 for SF-SBRT cases with biopsy-proven AC or SqC only. Outcomes of interest included local (LF), nodal (NF), distant (DF) failure rates and overall survival (OS), as well as treatment-related toxicity. RESULTS For the 10-year interval surveyed, 113 patients met study criteria. There was no association between histology and dose received (34 Gy or 30 Gy). Median follow up was 22.9 months. Patient characteristics were balanced between histologic cohorts. Median tumor size was 1.9 cm. Comparing total AC vs. SqC cohorts, 2-year LF rates (%) were 7.3 vs. 9.6, respectively (P = .9805). In %, 2-year LF, NF, DF and OS rates for AC for 30 Gy and 34 Gy, respectively, were 10.8 vs. 6.4; 10.5 vs. 16.2; 15.8 vs. 13.0; 77.9 vs.71.2 (all P = non-significant). In %, 2-year LF, NF, DF, and OS rates for SqC for 30 Gy and 34 Gy, respectively, were 11.8 vs. 8.1; 5.9 vs. 18.0; 23.5 vs. 9.7; 70.6 vs. 77.1 (all P = non-significant). When considering toxicities, there were no grade 4/5 toxicities and no significant differences in any other toxicity rate by histology or dose. CONCLUSION SF-SBRT local control was not associated with histology, unlike fractionated schedules. This novel finding adds to the evolving understanding of this treatment schedule.
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Affiliation(s)
- Gregory M M Videtic
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Neil M Woody
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Kevin L Stephans
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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Sheng IY, Gupta S, Reddy CA, Angelini D, Funchain P, Sussman TA, Sleiman J, Ornstein MC, McCrae K, Khorana AA. Thromboembolism in Patients with Metastatic Urothelial Cancer Treated with Immune Checkpoint Inhibitors. Target Oncol 2022; 17:563-569. [PMID: 35986816 DOI: 10.1007/s11523-022-00905-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Immunotherapy has become one of the mainstays for metastatic urothelial carcinoma treatment. Whether immune checkpoint inhibitor therapy increases thromboembolism (TE) risk is unknown. OBJECTIVE We investigated the incidence of arterial thromboembolism (ATE) and venous thromboembolism (VTE) events and its associated outcomes in patients with metastatic urothelial cancer treated with immune checkpoint inhibitors. METHODS Patients with urothelial cancer treated with immune checkpoint inhibitors at the Cleveland Clinic from 1/1/2015 to 12/31/2019 were identified. The Kaplan-Meier method estimated overall survival and Cox proportional hazards regression evaluated the impact of TE on overall survival. RESULTS Of 279 patients, 72% were men with pure urothelial cancer (62%) who started atezolizumab (40%), nivolumab (3%), or pembrolizumab (57%). At a median follow-up of 5.6 months (range 0.3-51.6), 42 patients developed a TE (VTE n = 37, 13%, ATE n = 5, 2%). The cumulative incidence of TE after immune checkpoint inhibitor therapy was 9.1% (95% confidence interval 6.0-13.0) at 6 months and 13.6% (95% confidence interval 9.6-18.4) at 12 months. Most TE (VTE 62%, ATE 100%) occurred within 6 months of immune checkpoint inhibitor initiation (median doses 5, range 1-59), and the majority (VTE 81%, ATE 100%) resulted in hospitalization (median: 5 days, 4 days, respectively). Thromboembolism (hazard ratio 2.296, p = 0.0004), Bajorin score 1 or 2 (hazard ratio 1.490, p = 0.0315), and Bajorin score 2 (hazard ratio 3.50, p < 0.0001) were associated with worse overall survival. CONCLUSIONS Immune checkpoint inhibitors are associated with a high TE risk. Thromboembolism is associated with worsened survival, among other poor outcomes. Further investigation into the mechanism behind immune checkpoint inhibitor-associated TE is needed.
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Affiliation(s)
- Iris Y Sheng
- Department of Medicine, Beth Israel Lahey Mt. Auburn Hospital, Boston, MA, USA
| | - Shilpa Gupta
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Chandana A Reddy
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Dana Angelini
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Pauline Funchain
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Tamara A Sussman
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Joseph Sleiman
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Moshe C Ornstein
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Keith McCrae
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Alok A Khorana
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA.
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18
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Smile TD, Reddy CA, Matia B, Fleming CW, Domb C, Geiger JL, Joshi NP, Woody NM, Chute DJ, Griffith CC, Adelstein DJ, Koyfman SA. A Reappraisal of Definitive Chemoradiotherapy for Older Adults With Advanced Head and Neck Cancer. Anticancer Res 2022; 42:3845-3852. [PMID: 35896238 DOI: 10.21873/anticanres.15875] [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: 05/17/2022] [Revised: 06/08/2022] [Accepted: 06/15/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Definitive treatment for locally advanced head and neck squamous cell carcinoma (LAHNSCC) is often compromised in older adults due to concerns about potential treatment toxicity intolerance. We reviewed our institutional experience with definitive management of older adults with LAHNSCC. PATIENTS AND METHODS From our Institutional Review Board-approved registry, we identified patients aged >60 years with stage III-IV, M0 LAHNSCC (seventh/earlier editions of the American Joint Committee on Cancer classification) treated with definitive radiotherapy from 1993-2019. Indications for concurrent chemotherapy included T3-4 or N2-3 disease. Multivariable analysis using Fine and Gray regression was performed to identify risk factors associated with recurrence. The cumulative incidence method was used to calculate recurrence rates. RESULTS Overall, 350 patients were identified: 223 aged 60-69, 82 aged 70-74, and 45 aged ≥75 years. Median follow-up was 36.3 months. Two-year recurrence rates were 13.7%, 20.2% and 34.8%, respectively; human papillomavirus-positive disease was present in 190 (85%), 44 (54%), and 25 (56%), respectively; and systemic therapy was given to 194 (87%), 64 (88%), and 23 (56%) patients, respectively. Factors significantly associated with increased risk of recurrence included age ≥75 years, Karnofsky performance status 70-80, clinical N2c-N3, and Charlson score 2-3. CONCLUSION Patients aged ≥75 years received less aggressive therapy and experienced increased recurrence compared to younger patients. Outcomes for those aged 70-74 years were similar to younger patients treated with aggressive therapy, despite their inferior performance status/comorbidity, and such patients should not routinely be excluded from standard-of-care therapy. Further study is needed to optimize therapy for a redefined older adult (age ≥75 years) population.
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Affiliation(s)
- Timothy D Smile
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, U.S.A.;
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Brian Matia
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Christopher W Fleming
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Chaim Domb
- Case Western Reserve University College of Medicine, Cleveland, OH, U.S.A
| | - Jessica L Geiger
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Nikhil P Joshi
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, U.S.A
| | - Neil M Woody
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Deborah J Chute
- Department of Pathology, Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Christopher C Griffith
- Department of Pathology, Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - David J Adelstein
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, U.S.A
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Yalamanchali A, Griffith C, Reddy CA, Koyfman SA, Woody NM, Campbell S, Silver NL, Scharpf J, Lorenz RR, Prendes B, Ku J, Lamarre E, Geiger JL. Evaluating the impact of the degree of extranodal extension on outcomes in locally advanced oral cavity cancer. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e18058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18058 Background: The presence of extranodal extension (ENE) in oral cavity cancer is associated with a higher risk of distant metastasis and worse overall survival (OS). Trials show that patients with locally advanced head and neck cancer and ENE benefit from concurrent chemoradiation over radiation therapy alone.We explored whether degree of ENE impacts survival outcomes in individuals with oral cavity cancer. Methods: From an IRB-approved database of 303 pts with locally advanced oral cavity cancer treated with surgical resection between 2001-2020, patients with pathologic ENE who received adjuvant treatment were included. Patient demographics, tumor staging, treatment information, disease recurrence, and survival were collected. Surgical slides were reviewed to confirm the extent of ENE. All staging was updated to AJCC 8th edition. Cox proportional hazards regression was used to relate patient, tumor, or treatment characteristics with either disease-free survival (DFS, composite of disease recurrence and death) or OS, from the time of radiation therapy completion. ENE was analyzed as both a dichotomous variable (major if > 2 mm, minor if ≤2 mm) and as a continuous variable in the subset of patients for whom exact ENE extent could be confirmed. Results: A total of 113 patients were identified who underwent surgery and adjuvant therapy for advanced oral cavity cancer with ENE, with 35 having major ENE and 78 having minor ENE. Forty-one patients had T1-T2 disease while 72 had T3-T4 disease. Additionally, 24 had N2a disease and 89 had N3b disease. Of these, 78 received concurrent chemoradiation while 35 received radiation therapy alone. Ninety-nine patients had pathologic slides available for review to determine exact ENE extent. Median ENE distance was 1 mm (IQR 1-2, range 0.1-10). With a median follow up time of 22.3 months, there were 48 recurrences and 67 deaths. Median DFS was 21.3 months (95%CI 11.1-33.2) and median OS was 29.9 months (95%CI 20.6-66.6). Between major vs minor ENE, there was no statistically significant difference in DFS (HR 1.18, 95%CI 0.72-1.92, p = 0.51) or OS (HR 1.17, 95%CI 0.70-1.96, p = 0.55). Furthermore, there was no statistically significant association between ENE as a continuous variable and DFS (HR 0.97 per mm, 95%CI 0.87-1.4, p = 0.96) or OS (HR 0.96 per mm, 95%CI 0.83-1.11, p = 0.58). The benefit of concurrent chemotherapy on OS was not seen (HR 0.74, 95%CI 0.44-1.22, p = 0.24), though those patients on average had more advanced nodal disease (85% N3b vs 66%). Conclusions: No significant relationship was seen between extent of ENE and DFS or OS in individuals with locally advanced oral cavity cancer. This analysis was limited by the small number of patients, that most patients had ≤2 mm of ENE, and the presence of confounding risk factors such as nodal stage and receipt of chemotherapy. Overall, the effect of the degree of ENE on outcomes in advanced oral cavity cancer remains unclear.
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Affiliation(s)
| | - Christopher Griffith
- Department of Pathology and Laboratory Medicine, Cleveland Clinic, Cleveland, OH
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20
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Allen-Proctor MK, Rahman M, Reddy CA, Koyfman SA, Chute DJ, Griffith CC. Variability in Depth of Invasion Measurements in Carcinomas of the Oral Cavity and the Effect on Pathologic Tumor Staging. Head Neck Pathol 2022; 16:963-968. [PMID: 35499641 PMCID: PMC9729630 DOI: 10.1007/s12105-022-01439-4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/17/2022] [Accepted: 02/25/2022] [Indexed: 12/16/2022]
Abstract
Depth of invasion (DOI) was added to the staging criteria for carcinoma of the lip and oral cavity in the 8th edition of the American Joint Committee on Cancer Staging Manual (AJCC8). However, there are multiple practical challenges to obtaining an accurate DOI measurement with limited data regarding interobserver variability in DOI measurement. The aim of this study was to investigate interobserver variability in DOI measurement and its effect on tumor stage. We performed an electronic medical record search for excisions of squamous cell carcinoma of the oral cavity between January 1, 2010 and December 25, 2017. All slides containing significant tumor were selected for independent blinded DOI measurement by four head and neck pathologists per AJCC8 guidelines. Pathologic stage was assigned in conjunction with reported tumor greatest dimension. Observers recorded the slide used for measurement and potential issues limiting assessment of DOI. Results were compared for reproducibility in DOI and tumor stage using intraclass correlation coefficient (ICC) analysis. A total of 167 cases of oral squamous cell carcinoma with available slides were included. The ICC score for DOI between observers was 0.91339 (> 0.9 considered excellent). Only 7.2% of cases had uniform DOI amongst observers. Increasing overall tumor size and average DOI correlated with increasing range in DOI amongst observers. Differences in DOI resulted in differences in pathologic tumor staging (pT) for 15% of tumors. Use of different slides for DOI measurements was significantly associated with different pT staging. In contrast, ulceration and exophytic growth did not correlate with higher DOI or pT variability. Despite the excellent ICC score, differences in DOI measurement resulted in variable pT staging for a considerable number of cases. We therefore recommend consensus for DOI in at least some cases in which potential differences in DOI could alter pT stage assignment.
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Affiliation(s)
- Mary K. Allen-Proctor
- Department of Anatomic Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, 9500 Euclid Ave, L2, 44195 Cleveland, Ohio USA
| | - Mobeen Rahman
- Department of Anatomic Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, 9500 Euclid Ave, L2, 44195 Cleveland, Ohio USA
| | - Chandana A. Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio USA
| | - Shlomo A. Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio USA
| | - Deborah J. Chute
- Department of Anatomic Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, 9500 Euclid Ave, L2, 44195 Cleveland, Ohio USA
| | - Christopher C. Griffith
- Department of Anatomic Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, 9500 Euclid Ave, L2, 44195 Cleveland, Ohio USA
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21
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Wu SS, Chen B, Fleming CW, Shah AA, Griffith CC, Domb C, Reddy CA, Campbell SR, Woody NM, Lamarre ED, Lorenz RR, Prendes BL, Scharpf J, Schwartzman L, Geiger JL, Koyfman SA, Ku JA. Nasopharyngeal cancer: Incidence and prognosis of human papillomavirus and Epstein-Barr virus association at a single North American institution. Head Neck 2022; 44:851-861. [PMID: 35040516 DOI: 10.1002/hed.26976] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/21/2021] [Accepted: 01/03/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The prognostication of Epstein-Barr virus (EBV) and human papillomavirus (HPV) status in nasopharyngeal cancer (NPC) is unclear. METHODS This retrospective study analyzed NPC from 2000 to 2019. RESULTS Seventy-eight patients were included: 43 EBV+ , 12 HPV+ , 23 EBV- /HPV- , and 0 EBV+ /HPV+ . All p16+ tumors were also positive for HPV-CISH. Baseline characteristics were not different between groups except age, N-classification, and Karnofsky Performance Scale (KPS) (p < 0.05). For EBV+ , HPV+ , and EBV- /HPV- respectively, 3-year overall survival (OS) was 89.9%, 69.8%, and 52.5% (p = 0.006). EBV- /HPV- status was significantly associated with worse OS but not freedom from progression (FFP) on univariate analysis, and did not remain a significant predictor of OS after adjusting for KPS, age, and group stage. CONCLUSIONS EBV+ NPC tumors were seen in younger, healthier patients than HPV+ and EBV- tumors, and there were no cases of coinfection. The association of viral status with OS was insignificant after adjusting for KPS and age.
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Affiliation(s)
- Shannon S Wu
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Bonnie Chen
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christopher W Fleming
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Akeesha A Shah
- Department of Pathology, Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christopher C Griffith
- Department of Pathology, Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Chaim Domb
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shauna R Campbell
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Neil M Woody
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric D Lamarre
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert R Lorenz
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Joseph Scharpf
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Larissa Schwartzman
- Department of Hematology & Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jessica L Geiger
- Department of Hematology & Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jamie A Ku
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
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22
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Somasundaram E, D Smile T, Halima A, Broughman JB, Reddy CA, Parsai S, Scott JG, Shah C, Chan T, Campbell S, Angelov L, Anderson PM, Zahler S, Trucco M, Thomas SM, Johnson S, Mesko N, Nystrom L, Shepard D, Budd GT, Qi P, Magnelli A, Murphy ES. Association between biologically effective dose and local control after stereotactic body radiotherapy for metastatic sarcoma. J Radiosurg SBRT 2022; 8:265-273. [PMID: 37416333 PMCID: PMC10322177] [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: 08/23/2022] [Accepted: 02/28/2023] [Indexed: 07/08/2023]
Abstract
Introduction Stereotactic body radiation therapy (SBRT) is increasingly utilized for patients with recurrent and metastatic sarcoma. SBRT affords the potential to overcome the relative radioresistance of sarcomas through delivery of a focused high biological effective dose (BED) as an alternative to invasive surgery. We report local control outcomes after metastatic sarcoma SBRT based on radiation dose and histology. Methods From our IRB-approved single-institution registry, all patients treated with SBRT for metastatic sarcoma between 2014 and 2020 were identified. Kaplan-Meier analysis was used to estimate local control and overall survival at 1 and 2 years. A receiver operating characteristic (ROC) curve was generated to determine optimal BED using an α/β ratio of 3. Local control was compared by SBRT dose using the BED cut point and evaluated by histology. Results Forty-two patients with a total of 138 lesions met inclusion criteria. Median imaging follow up was 7.73 months (range 0.5-35.0). Patients were heavily pre-treated with systemic therapy. Median SBRT prescription was 116.70 Gy BED (range 66.70-419.30). Desmoplastic small round cell tumor, Ewing sarcoma, rhabdomyosarcoma, and small round blue cell sarcomas were classified as radiosensitive (n = 63), and all other histologies were classified as radioresistant (n = 75). Local control for all lesions was 66.7% (95% CI, 56.6-78.5) at 1 year and 50.2% (95% CI, 38.2-66.1) at 2 years. Stratifying by histology, 1- and 2-year local control rates were 65.3% and 55.0%, respectively, for radiosensitive, and 68.6% and 44.5%, respectively, for radioresistant histologies (p = 0.49). The ROC cut point for BED was 95 Gy. Local control rates at 1- and 2-years were 75% and 61.6%, respectively, for lesions receiving >95 Gy BED, and 46.2% and 0%, respectively, for lesions receiving <95 Gy BED (p = 0.01). On subgroup analysis, local control by BED > 95 Gy was significant for radiosensitive histologies (p = 0.013), and trended toward significance for radioresistant histologies (p = 0.25). Conclusion There is a significant local control benefit for sarcoma SBRT when a BED > 95 Gy is used. Further investigation into the dose-response relationship is warranted to maximize the therapeutic index.
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Affiliation(s)
| | - Timothy D Smile
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmed Halima
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - James B Broughman
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Shireen Parsai
- Department of Radiation Oncology, Ohio Health Riverside Methodist Hospital, Columbus, OH, USA
| | - Jacob G Scott
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Timothy Chan
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Shauna Campbell
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Lilyana Angelov
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Peter M Anderson
- Department of Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Stacy Zahler
- Department of Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Matteo Trucco
- Department of Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Stefanie M Thomas
- Department of Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Shavaughn Johnson
- Department of Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Nathan Mesko
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Lukas Nystrom
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Dale Shepard
- Department of Hematology and Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - George Thomas Budd
- Department of Hematology and Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Peng Qi
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Anthony Magnelli
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
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23
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Sheng IY, Gupta S, Reddy CA, Angelini D, Funchain P, Sussman TA, Sleiman J, Ornstein MC, McCrae K, Khorana AA. Thromboembolism in Patients with Metastatic Renal Cell Carcinoma Treated with Immunotherapy. Target Oncol 2021; 16:813-821. [PMID: 34741719 DOI: 10.1007/s11523-021-00852-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Metastatic renal cell carcinoma (mRCC) is associated with a high risk of thromboembolism (TE). OBJECTIVE We investigated whether immunotherapy (IO) increases the hypercoagulable state in this high-risk population. PATIENTS AND METHODS Patients with mRCC treated with IO between 1 January 2015 and 31 December 2019 at the Cleveland Clinic were identified. Cumulative incidence analysis calculated TE rates over time and Gray's test determined differences in TE rates among groups. The Kaplan-Meier method estimated survival, while Cox proportional hazard regression evaluated the impact of TE on OS. RESULTS Of 351 patients, 75% were men with clear cell mRCC (81%) and International Metastatic Renal Cell Carcinoma (IMDC) intermediate- to poor-risk disease (77%). Patients received single-agent IO (52%), doublet IO (31%), or IO with non-IO therapy (17%). The median number of IO doses was 8 (range 1-81). At a median follow-up of 12.8 months, 12% of patients (n = 43) had a TE event (venous n = 37 [11%], arterial n = 6 [2%]). The cumulative TE incidence at 6 months was 4.4% (95% confidence interval [CI] 2.6-6.9) and 9.8% (95% CI 6.8-13.4) at 12 months. No factors, including IMDC or Khorana score, were identified to predict TE development. Seventy-two percent of TE resulted in hospitalization (9% TE-related mortality and 21% TE-related dose delay). TE (p < 0.0001), poor IMDC score (p < 0.0001), and Khorana score ≥ 2 (p < 0.0001) were associated with worse OS. CONCLUSIONS Patients with mRCC treated with IO had a high incidence of TE. TE was associated with risk of treatment delay, hospitalization, and mortality, while TE, IMDC poor risk, and Khorana score ≥ 2 were associated with worse survival. Further investigations into IO-associated TE are needed to identify benefit from primary thromboprophylaxis.
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Affiliation(s)
- Iris Y Sheng
- Department of Medicine, Beth Israel Lahey Mt. Auburn Hospital, Boston, MA, USA
| | - Shilpa Gupta
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Chandana A Reddy
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Dana Angelini
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Pauline Funchain
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Tamara A Sussman
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Joseph Sleiman
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Moshe C Ornstein
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Keith McCrae
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Alok A Khorana
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA.
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Videtic GMM, Reddy CA, Woody NM, Stephans KL. Ten-Year Experience in Implementing Single-Fraction Lung SBRT for Medically Inoperable Early-Stage Lung Cancer. Int J Radiat Oncol Biol Phys 2021; 111:436-442. [PMID: 34048817 DOI: 10.1016/j.ijrobp.2021.05.116] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/12/2021] [Accepted: 05/19/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE To review 10 years of using single-fraction lung stereotactic body radiation therapy (SF-SBRT) for medically inoperable peripheral early-stage lung cancer. METHODS AND MATERIALS An institutional review board-approved prospective lung SBRT data registry was surveyed until the end of December 2019 for all patients receiving SF-SBRT with minimum 6-month follow-up. Doses used were either 34 Gy or 30 Gy. Outcomes of interest included rates of local failure and overall survival (OS), as well as treatment-related toxicity graded per Common Terminology Criteria for Adverse Events version 3.0. RESULTS A total of 229 patients met the study criteria. Patient characteristics included female sex (55%); median age, 74.6 years (range, 47-94); and median Karnofsky Performance Status 80 (range, 50-100). Tumor characteristics included median diameter, 1.6 cm (range, 0.7-4.1); median positron emission tomography standardized uptake value maximum 6.1 (range, 0.8-24.3); and 63.6% of patients biopsied. SF-SBRT dose was 34 Gy in 72.1% cases and 30 Gy in 27.9%, with patient and tumor characteristics balanced between cohorts. Overall median follow-up times for 30 Gy and 34 Gy were 36.7 and 17.2 months, respectively (P < .0001). At analysis, 55.9% patients were alive. Two (0.9%) patients developed grade 3 toxicities, and none had grade 4/5 toxicities. Grades 1 to 2 pneumonitis and chest wall toxicity were seen in 7% and 12.7% patients, respectively. Median overall survival was 44.1 months. Rates of 2-year local, nodal, and distant failure were 7.3%, 9.4%, and 12.2%, respectively. There were no significant differences in outcomes by dose. CONCLUSIONS This is the largest institutional series to date reporting on SF-SBRT outcomes for medically inoperable peripheral early-stage lung cancer and the first to report on a decade's experience in implementing this schedule. Outcomes from this analysis are comparable to published results from 2 randomized trials and validate the use of this schedule in routine practice. In the absence of phase 3 trials, this study should encourage increased use of SF-SBRT for inoperable tumors.
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Affiliation(s)
- Gregory M M Videtic
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Neil M Woody
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kevin L Stephans
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
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Brauer PR, Burkey BB, Reddy CA, Lamarre ED. Risk Assessment in Thyroid Lobectomy and Total Thyroidectomy using Over 100 Thousand Cases. Ann Otol Rhinol Laryngol 2021; 130:1351-1359. [PMID: 33834878 DOI: 10.1177/00034894211007219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To assess risk factors and non-thyroid specific postoperative complications for thyroid lobectomy compared to total thyroidectomy. METHODS A retrospective, cross-sectional study of adults undergoing a lobectomy or total thyroidectomy using the National Surgical Quality Improvement Program database between 2005 and 2017. Patients not treated by otolaryngologists or general surgeons and with unknown demographic variables were excluded. RESULTS A total of 106 915 patients were analyzed, 64 763 total thyroidectomies and 42 152 lobectomies. Multivariable analysis demonstrated that total thyroidectomy patients were half as likely to return to the operating room (OR = 0.491 (95%CI 0.445-0.542), P < .001). Within this cohort, patients at greater risk for reoperation had a history of hypertension (OR = 1.225 (95%CI 1.090-1.376), P < .001), a malignant pathology (OR = 1.921 (95%CI 1.734-2.128), P < .001), and smoked (OR = 1.237 (95%CI 1.087-1.407), P = .001). Conversely, diabetes and body mass index did not impact the rate of reoperation when assessing total thyroidectomy and lobectomy. The most frequent non-thyroid specific complications in total thyroidectomy were unplanned intubation (0.5%), urinary tract infection (0.3%), and superficial surgical site infection (0.3%). In thyroid lobectomy, the most common complications were superficial surgical site infection (0.3%) and urinary tract infection (0.2%). CONCLUSIONS Our multi-institutional study indicates specific risk factors for returning to the operating room that may warrant closer follow up after surgery for total thyroidectomy or thyroid lobectomy. We also identified the most common post-operative complications. During pre-operative planning, these findings should be considered by thyroid surgeons to help mitigate risk to patients.
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Affiliation(s)
- Philip R Brauer
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Head and Neck Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Brian B Burkey
- Head and Neck Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Chandana A Reddy
- Taussig Cancer Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Eric D Lamarre
- Head and Neck Institute, The Cleveland Clinic, Cleveland, OH, USA
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Roopkumar J, Poudel SK, Gervaso L, Reddy CA, Velcheti V, Pennell NA, McCrae KR, Khorana AA. Risk of thromboembolism in patients with ALK- and EGFR-mutant lung cancer: A cohort study. J Thromb Haemost 2021; 19:822-829. [PMID: 33314597 DOI: 10.1111/jth.15215] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Thromboembolism (TE) is common in patients with non-small cell lung cancer (NSCLC) and is associated with worse outcomes. Recent advances in the understanding of NSCLC have led to the identification of molecular subtypes such as anaplastic lymphocyte kinase (ALK) and epidermal growth factor receptor (EGFR) mutations. The association of these subtypes with risk of TE has not been fully explored. METHODS We conducted a retrospective cohort study of consecutive NSCLC patients seen at the Cleveland Clinic from July 2002 through July 2017 for whom molecular classification and follow-up were available. TE events included deep vein thrombosis (DVT), pulmonary embolism (PE), visceral vein thrombosis (VVT), and arterial events. TE-free survival and overall survival rates for each of the molecular subtypes (wild-type, ALK-mutant, and EGFR-mutant) were estimated by the Kaplan-Meier method. Cox proportional hazard regression analysis was used to identify factors associated with the endpoints TE and overall survival. TE was analyzed as a conditional, time-dependent covariate to assess its impact with respect to overall survival. RESULTS The study population consisted of 461 patients. Approximately half were females (n = 263, 57%) and 58% (n = 270) were older than 65 years. TE occurred in 98 of 461 patients (21.3%) during a median follow-up of 33.1 months. The highest cumulative rates of TE were observed in patients with ALK-mutant NSCLC (N = 20/46, 43.5%) followed by patients with EGFR-mutant cancers (N = 35/165, 21.2%) and wild-type cancers (N = 43/250, 17.2%) P < .05. Cumulative incidence of TE at 6 months of follow-up was 15.7% (95% confidence interval [CI]: 5.0%-26.4%) for ALK-mutant cancers, 8.8% (95% CI: 4.4%-13.2%) for EGFR-mutant cancers, and 9.2% (95% CI: 5.4%-12.9%) for wild-type cancers. Patients who experienced TE had worse overall survival (all patients: hazard ratio = 2.8 95% CI 2.1-3.6, P < .001). CONCLUSIONS Patients with ALK-mutant advanced lung adenocarcinoma have the highest rate of TE. TE is associated with worse survival across molecular subtypes. These findings should be taken into consideration in decision-making regarding thromboprophylaxis.
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Affiliation(s)
- Joanna Roopkumar
- Department of Cancer Research, Mayo Clinic, Jacksonville, FL, USA
| | - Shyam K Poudel
- Department of Internal Medicine, Western Reserve Health Education, Warren, OH, USA
| | - Lorenzo Gervaso
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, Milan, Italy
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Vamsidhar Velcheti
- Department of Thoracic Medical Oncology, New York University, New York, NY, USA
| | - Nathan A Pennell
- Department of Hematology & Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Keith R McCrae
- Department of Hematology & Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alok A Khorana
- Department of Hematology & Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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Liu HYH, Tam L, Woody NM, Caudell J, Reddy CA, Ghanem A, Schymick M, Joshi N, Geiger J, Lamarre E, Burkey B, Adelstein D, Dunlap N, Siddiqui F, Koyfman S, Porceddu SV. Failure rate in the untreated contralateral node negative neck of small lateralized oral cavity cancers: A multi-institutional collaborative study. Oral Oncol 2021; 115:105190. [PMID: 33581503 DOI: 10.1016/j.oraloncology.2021.105190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The importance of treating the bilateral neck in lateralized small oral cavity squamous cell carcinoma (OCC) is unclear. We sought to define the incidence and predictors of contralateral neck failure (CLF) in patients who underwent unilateral treatment. MATERIALS AND METHODS We performed a multi-institutional retrospective study of patients with pathologic T1-T2 (AJCC 7th edition) OCC with clinically node negative contralateral neck who underwent unilateral treatment with primary surgical resection ± adjuvant radiotherapy between 2005 and 2015. Incidence of CLF was estimated using the cumulative incidence method. Clinicopathological factors were analyzed by univariate (UVA) and multivariate analysis (MVA) for possible association with CLF. Kaplan-Meier analysis was used to estimate overall survival (OS). RESULTS 176 patients were evaluated with a median of 65.9 months of follow-up. Predominant pathologic T-stage was T1 (68%), 8.5% of patients were N1, 2.8% were N2b. Adjuvant radiotherapy was delivered to 17% of patients. 5-year incidence of CLF was 4.3% (95% CI 1.2-7.4%). Depth of invasion (DOI) > 10 mm and positive ipsilateral neck node were significant predictors for CLF on UVA. DOI > 10 mm remained significant on MVA (HR = 6.7, 95% CI 1.4-32.3, p = 0.02). The 2- and 5-year OS was 90.6% (95% CI 86.2-95.0%) and 80.6% (95% CI 74.5-86.8%), respectively. CONCLUSION Observation of the clinically node negative contralateral neck in small lateralized OCC can be a suitable management approach in well selected patients, however caution should be applied when DOI upstages small but deeply invasive tumors to T3 on 8th edition AJCC staging.
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Affiliation(s)
- Howard Yu-Hao Liu
- Department of Cancer Services, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, St. Lucia, Australia.
| | - Laura Tam
- Department of Cancer Services, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Queensland, Australia
| | - Neil M Woody
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Jimmy Caudell
- Department of Radiation Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, United States
| | - Chandana A Reddy
- Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Ahmed Ghanem
- Department of Radiation Oncology, Henry Ford Cancer Institute, 2799 W. Grand Boulevard, Detroit, MI 48202, United States
| | - Matthew Schymick
- Department of Radiation Oncology, Henry Ford Cancer Institute, 2799 W. Grand Boulevard, Detroit, MI 48202, United States
| | - Nikhil Joshi
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Jessica Geiger
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Eric Lamarre
- Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Brian Burkey
- Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - David Adelstein
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Neal Dunlap
- Department of Radiation Oncology, University of Louisville, James Graham Brown Cancer Center, 529 S. Jackson Street, 4th Floor, Louisville, KY 40202, United States
| | - Farzan Siddiqui
- Department of Radiation Oncology, Henry Ford Cancer Institute, 2799 W. Grand Boulevard, Detroit, MI 48202, United States
| | - Shlomo Koyfman
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Sandro Virgilio Porceddu
- Department of Cancer Services, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, St. Lucia, Australia
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Smile TD, Reddy CA, Qiao-Guan G, Winter WI, Stephans KL, Woody NM, Balagamwala EH, Amarnath SR, Magnelli A, AlHilli MM, Michener CM, Mahdi H, DeBernardo RL, Rose PG, Cherian SS. Stereotactic body radiotherapy for the treatment of oligometastatic gynecological malignancy in the abdomen and pelvis: A single-institution experience. J Radiosurg SBRT 2021; 7:189-197. [PMID: 33898082 PMCID: PMC8055243] [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] [Grants] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/02/2020] [Indexed: 06/12/2023]
Abstract
PURPOSE/OBJECTIVES Metastasis-directed therapy with stereotactic body radiotherapy (SBRT) in the setting of oligometastatic disease is a rapidly evolving paradigm given ongoing improvements in systemic therapies and diagnostic modalities. However, SBRT to targets in the abdomen and pelvis is historically associated with concerns about toxicity. The purpose of this study was to evaluate the safety and efficacy of SBRT to the abdomen and pelvis for women with oligometastases from primary gynecological tumors. MATERIALS/METHODS From our IRB-approved registry, all patients who were treated with SBRT between 2014 and 2020 were identified. Oligometastatic disease was defined as 1 to 5 discrete foci of clinical metastasis radiographically diagnosed by positron emission tomography (PET) and/or computerized tomography (CT) imaging. The primary endpoint was local control at 12 months. Local and distant control rates were estimated using the Kaplan-Meier method. Time intervals for development of local progression and distant progression were calculated based on follow up visits with re-staging imaging. Acute and late toxicity outcomes were determined based on Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. RESULTS We identified 34 women with 43 treated lesions. Median age was 68 years (range 32-82), and median follow up time was 12 months (range 0.2-54.0). Most common primary tumor sites were ovarian (n=12), uterine (n=11), and cervical (n=7). Median number of previous lines of systemic therapy agents at time of SBRT was 2 (range 0-10). Overall, SBRT was delivered to 1 focus of oligometastasis in 29 cases, 2 foci in 2 cases, 3 foci in 2 cases, and 4 foci in 1 case. All patients were treated comprehensively with SBRT to all sites of oligometastasis. Median prescription dose was 24 Gy (range 18-54 Gy) in 3 fractions (range 3-6) to a median prescription isodose line of 83.5% (range 52-95). Local control by lesion at 12 and 24 months was 92.5% for both time points. Local failure was observed in three treated sites among two patients, two of which were at 11 months in one patient, and the other at 30 months. Systemic control rate was 60.2% at 12 months. Overall survival at 12 and 24 months was 85% and 70.2%, respectively. Acute grade 2 toxicities included nausea (n=3), and there were no grade > 3 acute toxicities. Late grade 1 toxicities included diarrhea (n=1) and fatigue (n=1), and there were no grade > 2 toxicities. CONCLUSION SBRT to oligometastatic gynecologic malignancies in the abdomen and pelvis is feasible with encouraging preliminary safety and local control outcomes. This approach is associated with excellent local control and low rates of toxicity during our follow-up interval. Further investigations into technique, dose-escalation and utilization are warranted.
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Affiliation(s)
- Timothy D Smile
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - George Qiao-Guan
- College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - W Ian Winter
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kevin L Stephans
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Neil M Woody
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ehsan H Balagamwala
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sudha R Amarnath
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Chad M Michener
- Gynecological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Haider Mahdi
- Gynecological Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Peter G Rose
- Gynecological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sheen S Cherian
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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Brauer PR, Reddy CA, Ku JA, Prendes BL, Lamarre ED. Does neck dissection affect post-operative outcomes in parotidectomy? A national study. Am J Otolaryngol 2020; 41:102593. [PMID: 32521296 DOI: 10.1016/j.amjoto.2020.102593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 05/25/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To characterize post-operative complications in parotidectomy with neck dissection. METHODS Patients age ≥ 18 receiving a parotidectomy or parotidectomy with neck dissection between 2005 and 2017 were eligible for inclusion. Patients with unknown demographic variables were excluded. Univariate and multivariable logistic regression analyses were performed. RESULTS A total of 13,609 parotidectomy patients were analyzed, 11,243 (82.6%) without neck dissection and 2366 (17.4%) with neck dissection. Both length of surgery (mean minutes ± standard deviation [SD] = 335.9 ± 189.2 vs. 152.9 ± 99.0, p < 0.001) and length of hospital stay (mean days ± SD = 3.90 ± 4.76 vs. 1.04 ± 2.14, p < 0.001) were greater with dissection. 13.9% of parotidectomies with neck dissection and 3.5% without dissection (p < 0.001) had at least one complication, which remained significant after multivariable adjustment (Odds Ratio[OR] = 1.565 (95%CI = 1.279-1.914), p < 0.001). The increase in post-operative complications was predominately driven by an increased transfusion rate (7.4% vs. 0.5%, p < 0.001). Multivariable analysis also demonstrated no significant difference in rates of returning to the operating room (OR = 1.122 (95%CI 0.843-1.493), p > 0.05) or rates of readmission (OR = 1.007 (95%CI 0.740-1.369), p > 0.05). Parotidectomy with neck dissection was more likely to be inpatient (OR = 4.411 (95%CI 3.887-5.004), p < 0.001) and to be ASA class 3 (OR = 1.367 (95%CI 1.194-1.564), p < 0.001). CONCLUSIONS Nationwide data demonstrates that parotidectomy with neck dissection is associated with increased rates of post-operative complications; however, neck dissection did not significantly impact readmission or reoperation rates. These findings indicate that neck dissection is a relatively safe addition to parotidectomy and provide novel evidence in the management of parotid malignancies.
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Brauer PR, Reddy CA, Burkey BB, Lamarre ED. A National Comparison of Postoperative Outcomes in Completion Thyroidectomy and Total Thyroidectomy. Otolaryngol Head Neck Surg 2020; 164:566-573. [PMID: 32838642 DOI: 10.1177/0194599820951165] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To characterize and assess the non-thyroid-specific postoperative complications of completion thyroidectomy as compared with total thyroidectomy. STUDY DESIGN Retrospective analysis: 2005 to 2017. SETTING National Surgical Quality Improvement Program database. SUBJECTS AND METHODS Patients aged >18 years receiving a completion or total thyroidectomy were eligible for inclusion. Patients not treated by otolaryngologists or general surgeons and with unknown demographic variables were excluded. RESULTS A total of 70,638 patients were analyzed, representing 64,763 total thyroidectomies and 5875 completion thyroidectomies. The 30-day mortality rate was 0.1% for both procedures (P > .05). Overall, 1.7% and 1.4% of patients undergoing total and completion thyroidectomies experienced at least 1 complication (P > .05), while 1.2% and 0.9% had a postoperative medical complication (P = .0186), respectively. On multivariable analysis, patients undergoing total thyroidectomies were significantly more likely to return to the operating room (odds ratio [OR], 1.36; 95% CI, 1.04-1.80; P = .027) and to be readmitted (OR, 1.45; 95% CI, 1.16-1.81; P = .001). Adjusted analysis also demonstrated that patients undergoing total thyroidectomies were more likely to be inpatients (OR, 1.17; 95% CI, 1.11-1.24; P < .001), be treated by nonotolaryngologists (OR, 1.36; 95% CI, 1.29-1.45; P < .001), and smoke (OR, 1.22; 95% CI, 1.13-1.33; P < .001). CONCLUSION National data suggest that total and completion thyroidectomies are relatively safe procedures but that completion thyroidectomies are associated with lower rates of postoperative complications. These findings may play a role in determining treatment plans for patients and optimizing risk reduction.
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Affiliation(s)
- Philip R Brauer
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.,Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Chandana A Reddy
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian B Burkey
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric D Lamarre
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Contrera KJ, Hair BB, Prendes B, Reddy CA, Zimmer DI, Burkey BB, Tassone P. Clinical Versus Pathologic Laryngeal Cancer Staging and the Impact of Stage Change on Outcomes. Laryngoscope 2020; 131:559-565. [PMID: 32692866 DOI: 10.1002/lary.28924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/02/2020] [Accepted: 06/18/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVES/HYPOTHESIS Evaluate the impact and accuracy of clinical laryngeal cancer staging. STUDY DESIGN Retrospective cohort study. METHODS Two hundred sixty-five consecutive patients with laryngeal squamous cell carcinoma who underwent total laryngectomy from 2001 to 2017 were studied. Clinical versus pathologic tumor (T) and nodal (N) categories were compared. Logistic regression and Cox proportional hazards analyzed the association of stage change with perioperative factors and outcomes. RESULTS Forty-seven patients (17.7%, accuracy = 0.969 ± 0.010 [standard error]) changed between T1-2 and T3-4. Sixty-four patients (24.1%, accuracy = 0.866 ± 0.020) had inaccurate N category. Salvage patients were less likely to have stage change (downstage: odds ratio [OR] = 0.20, 95% confidence interval [CI]: 0.08-0.50, P < .001; upstage: OR = 0.41, 95% CI: 0.23-0.74, P = .003), but more likely to have inaccurate nodal category (39.8% vs. 11.7%, P < .001). Patients with stage change tended to have greater odds of positive/close margins (upstage: OR = 1.78, 95% CI: 0.91-3.5, P = .092) and chemotherapy (downstage: OR = 2.21, 95% CI: 0.80-6.14, P = .128; upstage: OR = 1.87, 95% CI: 0.85-4.11, P = .119). Stage change was associated with recurrence (P = .047) with downstaged patients less likely to recur (hazard ratio = 0.26, 95% CI: 0.08-0.82, P = .021). Stage change was not associated with positron emission tomography scan, subsite, time to surgery, or mortality. CONCLUSIONS A third of laryngeal cancer patients were downstaged or upstaged after laryngectomy with 18% and 24% of clinical T and N categories inaccurate, respectively. Stage change was less common for salvage patients and associated with risk of recurrence. LEVEL OF EVIDENCE 3 Laryngoscope, 131:559-565, 2021.
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Affiliation(s)
- Kevin J Contrera
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Bryan B Hair
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Brandon Prendes
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Chandana A Reddy
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - David I Zimmer
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Brian B Burkey
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Patrick Tassone
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri, Columbia, Missouri, U.S.A
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Sittenfeld SMC, Juloori A, Reddy CA, Stephans KL, Videtic GMM. Salvage Stereotactic Body Radiation Therapy for Isolated Local Recurrence After Primary Surgical Resection of Non-small-cell Lung Cancer. Clin Lung Cancer 2020; 22:e360-e365. [PMID: 32624412 DOI: 10.1016/j.cllc.2020.05.025] [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: 04/09/2020] [Revised: 05/20/2020] [Accepted: 05/23/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION We sought to evaluate the safety and efficacy of stereotactic body radiation therapy (SBRT) as salvage treatment for local recurrence after prior surgical resection for non-small-cell lung cancer (NSCLC). MATERIALS AND METHODS We surveyed our prospective lung SBRT registry for patients who received salvage SBRT (sSBRT) for local recurrence after previous resection of a primary NSCLC. Following sSBRT, local control, distant metastases, overall survival, and treatment-related toxicity were evaluated. RESULTS From 2004 to 2017, 48 patients met inclusion criteria. At initial surgery, 44 (83%) patients had stage I to II disease, and surgical approaches were 47.9% wedge resection, 4.2% segmentectomy, 43.8% lobectomy, and 4.2% bilobectomy. The median time to local recurrence after surgery was 26.4 months, and 36 (75%) recurrences were biopsy-proven. Surgical salvage was not possible owing to un-resectability or underlying comorbidities in 45 (93.8%) patients. Most (68.8%) patients received 50 Gy in 5 fractions. The median follow-up after sSBRT was 22.6 months (range, 3.8-108.8 months). Eight (16.7%) patients experienced local or lobar failure, and 9 (19.1%) patients had nodal failure at a median of 12.5 months (range, 2-66.1 months). Nineteen (39.6%) patients failed distantly at a median of 11.4 months. The median overall survival after sSBRT was 29.3 months. A total of 72.9% of patients experienced no toxicity after sSBRT. Three (6.3%) patients developed grade III toxicity (cough, atelectasis, or soft tissue necrosis) following sSBRT. CONCLUSIONS Similar to SBRT for primary early stage NSCLC, sSBRT for local relapse following surgical resection of NSCLC offers high rates of local control with limited toxicity. Distant failure remains the primary pattern of failure.
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Affiliation(s)
- Sarah M C Sittenfeld
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Aditya Juloori
- Department of Cellular and Radiation Oncology, The University of Chicago, Chicago, IL
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Kevin L Stephans
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Gregory M M Videtic
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
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Sheng IYF, Gupta S, Reddy CA, Angelini DE, Funchain P, Sussman TA, Sleiman J, Gilligan TD, Ornstein MC, Khorana AA. Thromboembolism (TE) in patients (pts) with bladder cancer treated with checkpoint inhibitors (CPIs). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.5042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5042 Background: Most pts with bladder cancer will be treated with immunotherapy. There is concern for increased TE risk with CPIs in this already high risk population. We present the first analysis of the incidence and outcomes of venous (VTE) and arterial (ATE) thromboembolism in pts with bladder cancer treated with CPIs. Methods: Consecutive pts with bladder cancer treated with CPIs at the Cleveland Clinic from 1/2015 to 12/2019 were identified and TE events noted. Overall survival (OS) was estimated using Kaplan-Meier method and the impact of VTE on OS was evaluated using Cox proportional hazards regression. Results: Of 274 pts, 72% were men (median age 73.3 years, 89% white), 82% had pure UC, 92% had lower tract disease, and 67% had a Bajorin score ≥1 (median KPS 90, 61% visceral metastases), 59% had prior systemic therapy (median 1, range 0-4) and 36% had prior TE (14% ATE, 19% VTE, 0.4% both). At CPI initiation, 24% were on antiplatelet therapy, and 15% on therapeutic anticoagulation. CPI (median doses 5, range 8.5-59) included: 40% atezolizumab, 3% nivolumab, 57% pembrolizumab. VTE occurred in 14% (n = 37), including 8% DVT, 4% PE, 2% both. DVT locations were 56% lower limb, 26% upper limb, 15% visceral vein, 4% visceral+upper limb. 2% (n = 5) had ATE (1% CVA, 0.4% visceral, 0.4% left subclavian). 92% of VTE and all ATE occurred within 6 months of CPI initiation. The incidence of TE was 10.9% (95%CI 6.6%—15.1%) at 6 months and 19.8% (95%CI 13.3%-26.4%) at 12 months. 82% of VTE (mean 6 days) and all ATE (mean 5 days) resulted in hospitalization. Multivariate analysis showed TE (HR 2.296, 95%CI 1.451-3.632, p = 0.0004), Bajorin score 1 (HR 1.490, 95%CI 1.036-2.142, p = 0.0315), and Bajorin score 2 (HR 3.50, 95%CI 2.14-5.74, p < 0.0001) were independently associated with worse OS. Conclusions: CPIs in bladder cancer pts are associated with a high TE risk, especially within six months of initiation. TE is associated with worsened survival. Further investigation into the risk factors for CPI-associated TE is needed to identify if benefits exist from thromboprophylaxis.
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Parikh RH, Fleming CW, Reddy CA, Koyfman SA, Joshi N, Woody NM, Burkey BB, Scharpf J, Lorenz RR, Prendes B, Ku J, Lamarre E, Schwartzman L, Adelstein DJ, Geiger JL. Single-institute outcomes of palliative chemotherapy in metastatic head and neck squamous cell carcinoma (HNSCC). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e18513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18513 Background: Distantly metastatic HNSCC carries a poor prognosis with limited palliative systemic treatment options and a paucity of literature examining factors impacting outcomes of such therapy. We sought to evaluate characteristics conferring more favorable responses to frontline palliative systemic therapy after distant failure (DF). Methods: From an IRB-approved database, we identified 332 pts with metastatic HNSCC treated from 1999 to 2019. Pts with locoregional HNSCC who developed DF and subsequently were treated with palliative systemic therapy were included. Pts were categorized by disease factors, and outcomes were analyzed for progression-free survival (PFS) and overall survival (OS) with Kaplan-Meier curves and log-rank p-values. Results: A total of 85 pts were identified with median age 59.5 years (37-89); 82.4% male, 90.6% Caucasian, 52.9% with > 10 pack-years tobacco use history. Oropharynx primary was the most common site (36.5%) followed by oral cavity (23.5%). All 31 oropharynx cancer pts were HPV-related. Sixty-six pts initially received definitive chemoradiotherapy, with 43 receiving concurrent radiosensitizing cisplatin. Median time to DF was 15 months (m). Thirty pts (35.3%) had concurrent locoregional failure with DF. 62.4% had only one metastatic organ site, with lung-only metastasis in 43.5%. Carboplatin/paclitaxel was the most commonly used frontline palliative chemotherapy (50.6%); 22.4% received frontline nivolumab or pembrolizumab, and 9.4% were treated with frontline platinum/5-FU/cetuximab (9.4%). 63.5% of pts achieved a best response of stable disease or better with frontline therapy. At two years after initial DF, 6 pts (7%) were disease-free. Sixteen pts were alive at last follow-up. After DF, median PFS was 6.5 m and median OS was 10.6 m. On univariate analysis, HPV-related disease was associated with increased PFS (9.5 vs 5.1 m, p < 0.0001) and increased OS (21.1 vs 7.7 m, p < 0.0001). Pts with one metastatic organ site had better OS (11.0 vs 6.2 m, p = 0.047). There was a trend of increased OS with lung-only metastasis (14.4 vs 7.7 m, p = 0.0776), and absence of concurrent locoregional failure (10.8 vs 8.3 m, p = 0.1153). Conclusions: Our results demonstrate that HPV-related metastatic HNSCC is associated with a statistically significant increased PFS and OS. Additionally, there was a trend of increased OS with lower locoregional and distant metastatic burden at DF though statistical significance was not achieved.
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Kotecha R, Tom MC, Naik M, Angelov L, Benzel EC, Reddy CA, Prayson RA, Kalfas I, Schlenk R, Krishnaney A, Steinmetz MP, Bingaman W, Suh JH, Chao ST. Analyzing the role of adjuvant or salvage radiotherapy for spinal myxopapillary ependymomas. J Neurosurg Spine 2020; 33:392-397. [PMID: 32357340 DOI: 10.3171/2020.2.spine191534] [Citation(s) in RCA: 2] [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: 12/21/2019] [Accepted: 02/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to describe the long-term recurrence patterns, prognostic factors, and effect of adjuvant or salvage radiotherapy (RT) on treatment outcomes for patients with spinal myxopapillary ependymoma (MPE). METHODS The authors reviewed a tertiary institution IRB-approved database and collected data regarding patient, tumor, and treatment characteristics for all patients treated consecutively from 1974 to 2015 for histologically confirmed spinal MPE. Key outcomes included relapse-free survival (RFS), postrecurrence RFS, failure patterns, and influence of timing of RT on recurrence patterns. Cox proportional hazards regression and Kaplan-Meier analyses were utilized. RESULTS Of the 59 patients included in the study, the median age at initial surgery was 34 years (range 12-74 years), 30 patients (51%) were female, and the most common presenting symptom was pain (n = 52, 88%). Extent of resection at diagnosis was gross-total resection (GTR) in 39 patients (66%), subtotal resection (STR) in 15 (25%), and unknown in 5 patients (9%). After surgery, 10 patients (17%) underwent adjuvant RT (5/39 GTR [13%] and 5/15 STR [33%] patients). Median follow-up was 6.2 years (range 0.1-35.3 years). Overall, 20 patients (34%) experienced recurrence (local, n = 15; distant, n = 5). The median RFS was 11.2 years (95% CI 77 to not reached), and the 5- and 10-year RFS rates were 72.3% (95% CI 59.4-86.3) and 54.0% (95% CI, 36.4-71.6), respectively.STR was associated with a higher risk of recurrence (HR 6.45, 95% CI 2.15-19.23, p < 0.001) than GTR, and the median RFS after GTR was 17.2 years versus 5.5 years after STR. Adjuvant RT was not associated with improved RFS, regardless of whether it was delivered after GTR or STR. Of the 20 patients with recurrence, 12 (60%) underwent salvage treatment with surgery alone (GTR, n = 6), 4 (20%) with RT alone, and 4 (20%) with surgery and RT. Compared to salvage surgery alone, salvage RT, with or without surgery, was associated with a significantly longer postrecurrence RFS (median 9.5 years vs 1.6 years; log-rank, p = 0.006). CONCLUSIONS At initial diagnosis of spinal MPE, GTR is key to long-term RFS, with no benefit to immediate adjuvant RT observed in this series. RT at the time of recurrence, however, is associated with a significantly longer time to second disease recurrence. Surveillance imaging of the entire neuraxis remains crucial, as distant failure is not uncommon in this patient population.
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Affiliation(s)
- Rupesh Kotecha
- 1Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami
- 2Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Martin C Tom
- 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic; and Departments of
| | - Mihir Naik
- 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic; and Departments of
| | | | | | - Chandana A Reddy
- 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic; and Departments of
| | | | | | | | | | | | | | - John H Suh
- 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic; and Departments of
| | - Samuel T Chao
- 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic; and Departments of
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Hearn JWD, Sweeney CJ, Almassi N, Reichard CA, Reddy CA, Li H, Hobbs B, Jarrard DF, Chen YH, Dreicer R, Garcia JA, Carducci MA, DiPaola RS, Sharifi N. HSD3B1 Genotype and Clinical Outcomes in Metastatic Castration-Sensitive Prostate Cancer. JAMA Oncol 2020; 6:e196496. [PMID: 32053149 DOI: 10.1001/jamaoncol.2019.6496] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance The adrenal-restrictive HSD3B1(1245A) allele limits extragonadal dihydrotestosterone synthesis, whereas the adrenal-permissive HSD3B1(1245C) allele augments extragonadal dihydrotestosterone synthesis. Retrospective studies have suggested an association between the adrenal-permissive allele, the frequency of which is highest in white men, and early development of castration-resistant prostate cancer (CRPC). Objective To examine the association between the adrenal-permissive HSD3B1(1245C) allele and early development of CRPC using prospective data. Design, Setting, and Participants The E3805 Chemohormonal Therapy vs Androgen Ablation Randomized Trial for Extensive Disease in Prostate Cancer (CHAARTED) was a large, multicenter, phase 3 trial of castration with or without docetaxel treatment in men with newly diagnosed metastatic prostate cancer. From July 28, 2006, through December 31, 2012, 790 patients underwent randomization, of whom 527 had available DNA samples. In this study, the HSD3B1 germline genotype was retrospectively determined in 475 white men treated in E3805 CHAARTED, and clinical outcomes were analyzed by genotype. Data analysis was performed from July 28, 2006, to October 17, 2018. Interventions Men were randomized to castration plus docetaxel, 75 mg/m2, every 3 weeks for 6 cycles or castration alone. Main Outcomes and Measures Two-year freedom from CRPC and 5-year overall survival, with results stratified by disease volume. Patients were combined across study arms according to genotype to assess the overall outcome associated with genotype. Secondary analyses by treatment arm evaluated whether the docetaxel outcome varied with genotype. Results Of 475 white men with DNA samples, 270 patients (56.8%) inherited the adrenal-permissive genotype (≥1 HSD3B1[1245C] allele). Mean (SD) age was 63 (8.7) years. Freedom from CRPC at 2 years was diminished in men with low-volume disease with the adrenal-permissive vs adrenal-restrictive genotype: 51.0% (95% CI, 40.9%-61.2%) vs 70.5% (95% CI, 60.0%-80.9%) (P = .01). Overall survival at 5 years was also worse in men with low-volume disease with the adrenal-permissive genotype: 57.5% (95% CI, 47.4%-67.7%) vs 70.8% (95% CI, 60.3%-81.3%) (P = .03). Hazard ratios were 1.89 (95% CI, 1.13-3.14; P = .02) for CRPC and 1.74 (95% CI, 1.01-3.00; P = .045) for death. There was no association between genotype and outcomes in men with high-volume disease. There was no interaction between genotype and benefit from docetaxel. Conclusions and Relevance Inheritance of the adrenal-permissive HSD3B1 genotype is associated with earlier castration resistance and shorter overall survival in men with low-volume metastatic prostate cancer and may help identify men more likely to benefit from escalated androgen receptor axis inhibition beyond gonadal testosterone suppression.
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Affiliation(s)
- Jason W D Hearn
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Christopher J Sweeney
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nima Almassi
- GU Malignancies Research Center, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.,Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chad A Reichard
- GU Malignancies Research Center, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.,University of Texas MD Anderson Cancer Center, Houston
| | - Chandana A Reddy
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio.,Cancer Biostatistics Section, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hong Li
- Cancer Biostatistics Section, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian Hobbs
- Cancer Biostatistics Section, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - David F Jarrard
- Department of Medical Oncology, University of Wisconsin Hospital and Clinics, Madison
| | - Yu-Hui Chen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Jorge A Garcia
- Taussig Cancer Institute, Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Carducci
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University, Baltimore, Maryland
| | - Robert S DiPaola
- Department of Medical Oncology, University of Kentucky, Lexington
| | - Nima Sharifi
- GU Malignancies Research Center, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.,Taussig Cancer Institute, Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
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Abstract
OBJECTIVE To characterize the recurrence of head and neck paragangliomas and the factors associated with disease progression after treatment. STUDY DESIGN Retrospective cohort study. SETTING Tertiary care center. SUBJECTS AND METHODS In total, 173 adults with 189 paragangliomas (41.3% carotid body, 29.1% glomus jugulare, 19.0% glomus tympanicum, and 10.6% glomus vagale) treated between 1990 and 2010 were evaluated to determine the incidence and risk of recurrence using Cox proportional hazards. RESULTS The mean (SD) follow-up duration was 8.6 (9.1) years. The incidence was 2.92 recurrences per 100 person-years. The rate of recurrence was 8.2% (95% confidence interval [CI], 3.7-12.7) after 4 years and 17.1% (95% CI, 10.2-24.0) after 10 years. Glomus jugulare tumors were more likely to recur (hazard ratio [HR], 3.69; 95% CI, 1.70-8.01; P < .001) while carotid body tumors were less likely (HR, 0.44; 95% CI, 0.21-0.97; P = .041). Radiation had a lower risk of recurrence or progression compared to surgical excision (HR, 0.30; 95% CI, 0.10-.94; P = .040). Recurrence was associated with right-sided paragangliomas (HR, 3.60; 95% CI, 1.63-7.75; P = .001). The median time to recurrence was 18.4 years. Six (3.2%) patients developed metastasis, which was more common with local recurrence (9.5% vs 1.4%, P = .015). CONCLUSIONS Recurrence is more common with glomus jugulare tumors and less common with carotid body tumors. Radiation may have a lower risk of recurrence or progression than surgery for some paraganglioma types. Metastasis is rare but more likely with recurrent disease. Surveillance neck imaging is recommended every several years for decades after treatment.
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Affiliation(s)
| | - Valeda Yong
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Chandana A Reddy
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sara W Liu
- Head & Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert R Lorenz
- Head & Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Sun L, Chin RI, Gastman B, Thorstad W, Yom SS, Reddy CA, Nussenbaum B, Wang SJ, Knackstedt T, Vidimos AT, Koyfman SA, Manyam BV. Association of Disease Recurrence With Survival Outcomes in Patients With Cutaneous Squamous Cell Carcinoma of the Head and Neck Treated With Multimodality Therapy. JAMA Dermatol 2020; 155:442-447. [PMID: 30810715 DOI: 10.1001/jamadermatol.2018.5453] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance It has previously been demonstrated that immunosuppressed patients with cutaneous squamous cell cancer of the head and neck (cSCC-HN) treated with surgery and postoperative radiotherapy have significantly inferior disease-related outcomes compared with immunocompetent patients, but data on outcomes after disease recurrence are limited. Objectives To report survival outcomes in patients with cSCC-HN after disease recurrence after surgery and postoperative radiotherapy and to investigate the association of immune status with disease-related outcomes. Design, Setting, and Participants A multi-institutional study of 205 patients treated at the Cleveland Clinic, Washington University in St Louis, and the University of California, San Francisco, in which patients who underwent surgical resection and postoperative radiotherapy for primary or recurrent stage I to IV (nonmetastatic) cSCC-HN between January 1, 1995, and December 31, 2014, were identified. Patients with any disease recurrence, defined as local, regional, and/or distant failure, were included. Patients were categorized as immunosuppressed if they received a diagnosis of chronic hematologic malignant neoplasm or HIV or AIDS, or were treated with immunosuppressive therapy for organ transplantation 6 months or more before diagnosis. Statistical analysis was conducted from January 1, 1995, to December 31, 2015. Main Outcomes and Measures Overall survival calculated using the Kaplan-Meier method and compared using the log-rank test. Results Of the 205 patients in the original cohort, 72 patients (63 men and 9 women; median age, 71 years [range, 43-91 years]) developed disease recurrence after surgery and postoperative radiotherapy. Forty patients (55.6%) were immunosuppressed, and 32 patients (44.4%) were immunocompetent. Locoregional recurrence was the most common first pattern of failure for both groups (31 immunosuppressed patients [77.5%]; 21 immunocompetent patients [65.6%]). After any recurrence, 1-year overall survival was 43.2% (95% CI, 30.9%-55.4%), and median survival was 8.4 months. For patients for whom information on salvage treatment was available (n = 45), those not amenable to surgical salvage had significantly poorer median cumulative incidence of survival compared with those who were amenable to surgical salvage (4.7 months; 95% CI, 3.7-7.0 months vs 26.1 months; 95% CI, 6.6 months to not reached; P = .01), regardless of their immune status. Conclusions and Relevance Results of this study suggest that patients with cSCC-HN who experience disease recurrence after definitive treatment with surgery and postoperative radiotherapy have poor survival, irrespective of immune status. Survival rates are low for patients with recurrent disease that is not amenable to surgical salvage. The low rate of successful salvage underscores the importance of intensifying upfront treatment to prevent recurrence.
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Affiliation(s)
- Lillian Sun
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Re-I Chin
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| | - Brian Gastman
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Wade Thorstad
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| | - Sue S Yom
- Department of Radiation Oncology, University of California, San Francisco
| | - Chandana A Reddy
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Brian Nussenbaum
- Department of Otolaryngology, Washington University in St Louis, St Louis, Missouri
| | - Steven J Wang
- Department of Otolaryngology, University of Arizona, Tucson
| | | | | | - Shlomo A Koyfman
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Bindu V Manyam
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
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Canavan JF, Harr BA, Bodmann JW, Reddy CA, Ferrini JR, Ives DI, Chute DJ, Fleming CW, Woody NM, Geiger JL, Joshi NP, Koyfman SA, Adelstein DJ. Impact of routine surveillance imaging on detecting recurrence in human papillomavirus associated oropharyngeal cancer. Oral Oncol 2020; 103:104585. [PMID: 32044714 DOI: 10.1016/j.oraloncology.2020.104585] [Citation(s) in RCA: 5] [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: 10/15/2019] [Revised: 01/16/2020] [Accepted: 01/27/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study examines the utility of surveillance imaging in detecting locoregional failures (LRF), distant failures (DF) and second primary tumors (SPT) in patients with human papillomavirus (HPV) associated oropharyngeal cancer (OPC) after definitive chemoradiotherapy (CRT). METHODS AND MATERIALS An institutional database identified 225 patients with biopsy proven, non- metastatic HPV+ OPC treated with definitive CRT between 2004 and 2015, whose initial post-treatment imaging was negative for disease recurrence (DR). Two groups were defined: patients with <2 scans/year Group 1 and patients with ≥2 scans/year Group 2. The Mann-Whitney test or Chi-square was used to determine differences in baseline characteristics between groups. Fine & Gray regression was used to detect an association between imaging frequency, DR and diagnosis of SPT. RESULTS Median follow up was 40.8 months. 30% of patients had ≥T3 disease and 90% had ≥ N2 disease (AJCC 7th edition). Twenty one failures (9.3%) were observed, 7 LRF and 15 DF. Six LRF occurred within 24 months and 14 DF occurred within 36 months of treatment completion. Regression analysis showed Group 2 had increased risk of DR compared to Group1 (HR 10.3; p = 0.002) albeit with more advanced disease at baseline. Five SPT were found (2 lung, 2 esophagus, and 1 oropharynx) between 4.5 and 159 months post-CRT. CONCLUSION Surveillance imaging seems most useful in the first 2-3 years post treatment, and is particularly important in detecting DF. Surveillance scans for SPT has a low yield, but should be considered for those meeting lung cancer screening guidelines.
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Affiliation(s)
- Joycelin F Canavan
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, United States.
| | - Bridgett A Harr
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, United States
| | - Joanna W Bodmann
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, United States
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, United States
| | - Jodi R Ferrini
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, United States
| | - Denise I Ives
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, United States
| | - Deborah J Chute
- Department of Pathology, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, United States
| | - Christopher W Fleming
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, United States
| | - Neil M Woody
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, United States
| | - Jessica L Geiger
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, United States
| | - Nikhil P Joshi
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, United States
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, United States
| | - David J Adelstein
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, United States
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Xiao R, Pham Y, Ward MC, Houston N, Reddy CA, Joshi NP, Greskovich JF, Woody NM, Chute DJ, Lamarre ED, Prendes BL, Lorenz RR, Scharpf J, Burkey BB, Geiger JL, Adelstein DJ, Koyfman SA. Impact of active smoking on outcomes in HPV+ oropharyngeal cancer. Head Neck 2019; 42:269-280. [DOI: 10.1002/hed.26001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 08/13/2019] [Accepted: 10/18/2019] [Indexed: 11/08/2022] Open
Affiliation(s)
- Roy Xiao
- Department of OtolaryngologyHarvard Medical School Boston Massachusetts
- Department of OtolaryngologyMassachusetts Eye and Ear Boston Massachusetts
| | - Yvonne Pham
- Department of Radiation OncologyResearch Medical Center, Therapeutic Radiologists, Inc. Kansas City Missouri
| | | | - Narcissa Houston
- Department of Radiation OncologyTaussig Cancer Institute, Cleveland Clinic Cleveland Ohio
| | - Chandana A. Reddy
- Department of Radiation OncologyTaussig Cancer Institute, Cleveland Clinic Cleveland Ohio
| | - Nikhil P. Joshi
- Department of Radiation OncologyTaussig Cancer Institute, Cleveland Clinic Cleveland Ohio
| | - John F. Greskovich
- Department of Radiation OncologyTaussig Cancer Institute, Cleveland Clinic Florida Weston Florida
| | - Neil M. Woody
- Department of Radiation OncologyTaussig Cancer Institute, Cleveland Clinic Cleveland Ohio
| | - Deborah J. Chute
- Department of Anatomic Pathology, Pathology & Laboratory MedicineCleveland Clinic Cleveland Ohio
| | - Eric D. Lamarre
- Department of OtolaryngologyHead and Neck Institute, Cleveland Clinic Cleveland Ohio
| | - Brandon L. Prendes
- Department of OtolaryngologyHead and Neck Institute, Cleveland Clinic Cleveland Ohio
| | - Robert R. Lorenz
- Department of OtolaryngologyHead and Neck Institute, Cleveland Clinic Cleveland Ohio
| | - Joseph Scharpf
- Department of OtolaryngologyHead and Neck Institute, Cleveland Clinic Cleveland Ohio
| | - Brian B. Burkey
- Department of OtolaryngologyHead and Neck Institute, Cleveland Clinic Cleveland Ohio
| | - Jessica L. Geiger
- Department of Hematology and Medical OncologyTaussig Cancer Institute, Cleveland Clinic Cleveland Ohio
| | - David J. Adelstein
- Department of Hematology and Medical OncologyTaussig Cancer Institute, Cleveland Clinic Cleveland Ohio
| | - Shlomo A. Koyfman
- Department of Radiation OncologyTaussig Cancer Institute, Cleveland Clinic Cleveland Ohio
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Onukwugha E, Jayasekera J, Gardner J, Malik S, Mullins CD, Hussain A, Ciezki JP, Reddy CA, Seal B, Valderrama A, Kwok Y. An Approach to Identify Delivery of Palliative Radiation Therapy Using Health Care Claims Data: A Proof-of-Concept Application of a Visual Analytics Tool. JCO Clin Cancer Inform 2019; 2:1-12. [PMID: 30652549 DOI: 10.1200/cci.17.00075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There is limited information on the use of data visualization tools for health services research applications. We provide a proof-of-concept application that focuses on claims-based measures of palliative radiation therapy. We investigate whether a guided, data-driven investigation contributes information for subsequent statistical analysis and algorithm development. METHODS This retrospective cohort study used linked registry and claims data on men who were diagnosed with stage IV M0 or stage IV M1b prostate cancer between 2005 and 2009, with associated claims from 2005 through 2010, and receiving radiation therapy. Preprocessing of data was accomplished by using EventFlow software to investigate longitudinal patterns in claims for radiation therapy in the 13 months after cancer diagnosis. Guided by results from EventFlow, we developed descriptive statistics to investigate the length of radiation therapy, use of bone metastasis coding, and mortality between M1b and M0 patients. RESULTS A total of 1,151 patients met the inclusion criteria. Taking advantage of the novel aggregation capability of EventFlow, we observed differences in the length of radiation therapy and the use of bone metastasis coding between men with (M1b) and without (M0) a diagnosis of bone metastasis. Seventy-nine percent of M1b patients received radiation for a duration ≤ 4 weeks, which suggested palliative radiation (to the bone). Seventy-six percent of M0 patients received radiation for ≥ 6 weeks, which suggested radiation to the prostate. Mortality was higher among those who received a shorter duration of radiation therapy compared with those who received a longer duration of therapy. CONCLUSION Use of EventFlow, followed by statistical analysis of the linked registry and claims data, identified useful components of a claims-based measure of radiation to the bone.
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Affiliation(s)
- Eberechukwu Onukwugha
- Eberechukwu Onukwugha, Jinani Jayasekera, James Gardner, C. Daniel Mullins, Arif Hussain, and Young Kwok, University of Maryland; Arif Hussain, Veterans Affairs Medical Center, Baltimore; Sana Malik, University of Maryland, College Park, MD; Jay P. Ciezki and Chandana A. Reddy, Cleveland Clinic Foundation, Cleveland, OH; and Brian Seal and Adriana Valderrama, Bayer HealthCare Pharmaceuticals, Pine Brook, NJ
| | - Jinani Jayasekera
- Eberechukwu Onukwugha, Jinani Jayasekera, James Gardner, C. Daniel Mullins, Arif Hussain, and Young Kwok, University of Maryland; Arif Hussain, Veterans Affairs Medical Center, Baltimore; Sana Malik, University of Maryland, College Park, MD; Jay P. Ciezki and Chandana A. Reddy, Cleveland Clinic Foundation, Cleveland, OH; and Brian Seal and Adriana Valderrama, Bayer HealthCare Pharmaceuticals, Pine Brook, NJ
| | - James Gardner
- Eberechukwu Onukwugha, Jinani Jayasekera, James Gardner, C. Daniel Mullins, Arif Hussain, and Young Kwok, University of Maryland; Arif Hussain, Veterans Affairs Medical Center, Baltimore; Sana Malik, University of Maryland, College Park, MD; Jay P. Ciezki and Chandana A. Reddy, Cleveland Clinic Foundation, Cleveland, OH; and Brian Seal and Adriana Valderrama, Bayer HealthCare Pharmaceuticals, Pine Brook, NJ
| | - Sana Malik
- Eberechukwu Onukwugha, Jinani Jayasekera, James Gardner, C. Daniel Mullins, Arif Hussain, and Young Kwok, University of Maryland; Arif Hussain, Veterans Affairs Medical Center, Baltimore; Sana Malik, University of Maryland, College Park, MD; Jay P. Ciezki and Chandana A. Reddy, Cleveland Clinic Foundation, Cleveland, OH; and Brian Seal and Adriana Valderrama, Bayer HealthCare Pharmaceuticals, Pine Brook, NJ
| | - C Daniel Mullins
- Eberechukwu Onukwugha, Jinani Jayasekera, James Gardner, C. Daniel Mullins, Arif Hussain, and Young Kwok, University of Maryland; Arif Hussain, Veterans Affairs Medical Center, Baltimore; Sana Malik, University of Maryland, College Park, MD; Jay P. Ciezki and Chandana A. Reddy, Cleveland Clinic Foundation, Cleveland, OH; and Brian Seal and Adriana Valderrama, Bayer HealthCare Pharmaceuticals, Pine Brook, NJ
| | - Arif Hussain
- Eberechukwu Onukwugha, Jinani Jayasekera, James Gardner, C. Daniel Mullins, Arif Hussain, and Young Kwok, University of Maryland; Arif Hussain, Veterans Affairs Medical Center, Baltimore; Sana Malik, University of Maryland, College Park, MD; Jay P. Ciezki and Chandana A. Reddy, Cleveland Clinic Foundation, Cleveland, OH; and Brian Seal and Adriana Valderrama, Bayer HealthCare Pharmaceuticals, Pine Brook, NJ
| | - Jay P Ciezki
- Eberechukwu Onukwugha, Jinani Jayasekera, James Gardner, C. Daniel Mullins, Arif Hussain, and Young Kwok, University of Maryland; Arif Hussain, Veterans Affairs Medical Center, Baltimore; Sana Malik, University of Maryland, College Park, MD; Jay P. Ciezki and Chandana A. Reddy, Cleveland Clinic Foundation, Cleveland, OH; and Brian Seal and Adriana Valderrama, Bayer HealthCare Pharmaceuticals, Pine Brook, NJ
| | - Chandana A Reddy
- Eberechukwu Onukwugha, Jinani Jayasekera, James Gardner, C. Daniel Mullins, Arif Hussain, and Young Kwok, University of Maryland; Arif Hussain, Veterans Affairs Medical Center, Baltimore; Sana Malik, University of Maryland, College Park, MD; Jay P. Ciezki and Chandana A. Reddy, Cleveland Clinic Foundation, Cleveland, OH; and Brian Seal and Adriana Valderrama, Bayer HealthCare Pharmaceuticals, Pine Brook, NJ
| | - Brian Seal
- Eberechukwu Onukwugha, Jinani Jayasekera, James Gardner, C. Daniel Mullins, Arif Hussain, and Young Kwok, University of Maryland; Arif Hussain, Veterans Affairs Medical Center, Baltimore; Sana Malik, University of Maryland, College Park, MD; Jay P. Ciezki and Chandana A. Reddy, Cleveland Clinic Foundation, Cleveland, OH; and Brian Seal and Adriana Valderrama, Bayer HealthCare Pharmaceuticals, Pine Brook, NJ
| | - Adriana Valderrama
- Eberechukwu Onukwugha, Jinani Jayasekera, James Gardner, C. Daniel Mullins, Arif Hussain, and Young Kwok, University of Maryland; Arif Hussain, Veterans Affairs Medical Center, Baltimore; Sana Malik, University of Maryland, College Park, MD; Jay P. Ciezki and Chandana A. Reddy, Cleveland Clinic Foundation, Cleveland, OH; and Brian Seal and Adriana Valderrama, Bayer HealthCare Pharmaceuticals, Pine Brook, NJ
| | - Young Kwok
- Eberechukwu Onukwugha, Jinani Jayasekera, James Gardner, C. Daniel Mullins, Arif Hussain, and Young Kwok, University of Maryland; Arif Hussain, Veterans Affairs Medical Center, Baltimore; Sana Malik, University of Maryland, College Park, MD; Jay P. Ciezki and Chandana A. Reddy, Cleveland Clinic Foundation, Cleveland, OH; and Brian Seal and Adriana Valderrama, Bayer HealthCare Pharmaceuticals, Pine Brook, NJ
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Manyam BV, Shah C, Woody NM, Reddy CA, Weller MA, Juloori A, Naik M, Valente S, Grobmyer S, Durand P, Djohan R, Tendulkar RD. Long-term complications and reconstruction failures in previously radiated breast cancer patients receiving salvage mastectomy with autologous reconstruction or tissue expander/implant-based reconstruction. Breast J 2019; 25:1071-1078. [PMID: 31264293 DOI: 10.1111/tbj.13428] [Citation(s) in RCA: 13] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/26/2018] [Accepted: 12/17/2018] [Indexed: 11/30/2022]
Abstract
Salvage mastectomy (SM) is the standard of care for patients with local recurrence (LR) after breast conservation therapy (BCT), often with immediate reconstruction. Complications of reconstruction are a concern for these patients, and long-term data are limited. We sought to compare rates of complications requiring re-operation (CRR) and reconstruction failure (RF) between autologous reconstruction (AR) and tissue expander/implant reconstruction (TE/I). Patients with locally recurrent breast cancer after BCT, treated with SM and immediate AR or TE/I between 2000 and 2008, were identified. CRR was defined as unplanned return to operating room for wound infection, dehiscence, necrosis (including flap, skin, or fat), hematoma, or hernia (for AR) and extrusion, leak, or capsular contracture (for TE/I). RF was defined as conversion to another reconstruction technique or to flat chest wall. This study included 103 patients with 107 reconstructions. Median follow-up was 6.6 years. CRR and RF were significantly higher with TE/I (n = 34) compared to AR (n = 73) at 5 years (50.9% vs 25.5%; P = 0.02) and (42.1% vs 5.8%; P < 0.001). On univariate analysis (UVA), TE/I (HR = 2.14; P = 0.02) and diabetes (HR = 5.10; P = 0.007) were significant predictors for CRR. On UVA, TE/I (HR = 7.30; P < 0.001) and older age at reconstruction (HR = 1.03; P = 0.003) were significant predictors for RF. In this population of previously irradiated patients, TE/I was associated with significantly higher CRR and RF. Complications continue to occur up to 10 years after TE/I. AR should be considered in appropriately selected patients, though TE/I may remain a reasonable option in patients without high-risk factors for surgical complications.
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Affiliation(s)
- Bindu V Manyam
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio
| | - Chirag Shah
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio
| | - Neil M Woody
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio
| | - Chandana A Reddy
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio
| | - Michael A Weller
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio
| | - Aditya Juloori
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio
| | - Mihir Naik
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio
| | | | | | - Paul Durand
- Department of Plastic Surgery, Dermatology and Plastic Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Risal Djohan
- Department of Plastic Surgery, Dermatology and Plastic Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Rahul D Tendulkar
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio
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Contrera KJ, Yong V, Reddy CA, Berber E, Lorenz RR. Second primary tumors in patients with a head and neck paraganglioma. Head Neck 2019; 41:3356-3361. [DOI: 10.1002/hed.25849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/11/2019] [Accepted: 06/14/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
| | - Valeda Yong
- School of MedicineCase Western Reserve University Cleveland Ohio
| | | | - Eren Berber
- Department of Endocrine Surgery, Cleveland ClinicEndocrinology and Metabolism Institute Cleveland Ohio
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Abstract
e17521 Background: Human papillomavirus-mediated (HPV+) oropharyngeal cancer is now defined as a clinically distinct entity from HPV-unrelated (HPV-) disease in the 8th edition AJCC staging system, which more accurately informs prognosis for HPV+ patients. Treatment decisions are currently made according to the AJCC 7th ed staging. HPV+ patients are associated with favorable outcome. This study aims to analyze the national pattern of practice for HPV+ disease. Methods: Patients with oropharyngeal squamous cell carcinoma (OPSCC) diagnosed from 2010-2012 were identified from the National Cancer Database (NCDB). Patients were staged using the AJCC 7th system. Chemotherapy, radiotherapy and surgery were counted as treatment modalities. Fisher’s exact test and chi-squared test were used to assess treatment patterns over time. Overall survival (OS) was compared with Cox proportional hazards model. Results: 5,928 HPV+ OPSCC patients were identified. Single modality (surgery or radiation) was the most common treatment choice, used in 53.6% of stage I and 48.8% of stage II patients. For stage I, the use of dual modality therapy (70.8% received surgery with radiation) decreased from 36% in 2010 to 19% in 2012 (p = 0.05), though no significant difference in OS was seen between dual modality and single modality. Dual modality with chemoradiation was the main approach for stage III (58.6%) and stage IVA (67.5%) disease. Use of trimodality decreased from 2010 to 2012 in both stage III (p = 0.03) and stage IVA (p < 0.01). Conclusions: Using a national cohort of HPV+ patients from the NCDB, we showed that single modality was the most common for stages I/II and dual modality was the mainstay for stages III/IVA. Usage of aggressive approaches (dual modality for stages I/II and trimodality for stages III/IVA) decreased over time. Prospective studies would be needed to determine the optimized therapeutic choice for HPV+ patients given favorable outcome.
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Hearn JW, Sweeney C, Almassi N, Reichard CA, Reddy CA, Hobbs B, Jarrard DF, Chen YH, Dreicer R, Garcia JA, Carducci MA, DiPaola RS, Sharifi N. HSD3B1 and overall survival (OS) in men with low-volume (LV) metastatic prostate cancer (PCa) treated with androgen deprivation therapy (ADT) or chemohormonal therapy in the CHAARTED Randomized trial. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.5020] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5020 Background: The HSD3B1(1245A > C) variant allele, whose frequency varies by race, encodes a missense sequence that stabilizes the rate-limiting enzyme responsible for extragonadal androgen synthesis, thus enhancing intratumoral dihydrotestosterone (DHT) synthesis. Multiple retrospective studies have found that men inheriting the HSD3B1(1245C) variant allele exhibit early resistance to ADT. We sought to validate these findings with prospective data from the Chemohormonal Therapy versus Androgen Ablation Randomized Trial for Extensive Disease in Prostate Cancer (CHAARTED). Methods: Men with newly metastatic PCa were randomized to receive either ADT plus docetaxel at a dose of 75 mg/m2 every 3 weeks for 6 cycles (arm A) or ADT alone (arm B). We determined germline HSD3B1 genotype in the subset of men with LV disease ( < 4 bone metastases, no visceral metastases). We analyzed freedom from castration-resistant prostate cancer (CRPC) and OS according to HSD3B1 genotype using Cox and Kaplan-Meier methods. Results: 197 patients with LV disease had blood samples available and were genotyped, including 97 in arm A and 100 in arm B. Docetaxel did not improve OS of LV men. Of the 197 men, 47% were homozygous wild-type (WT), 43% were heterozygous, and 10% were homozygous variant. When all 197 men were analyzed as one goup, the median time to CRPC was 39.7 mos. in homozygous WT men vs. 25.0 mos. in men with one or more copies of the variant allele (HR 1.27, 95% CI 0.89 to 1.82; p = 0.187). Although OS data are still maturing, at 52 months OS was 83% (95% CI 75% to 91%) in homozygous WT men vs. 64% (95% CI 55% to 74%) in men with one or more variant alleles. There was a suggestion that docetaxel delayed development of CRPC among men with at least 1 variant allele (20.3 vs. 40.7 mos.; HR 0.66, 95% CI 0.40 to 1.04; p = 0.08). Benefit for men with high-volume disease was not evident. Conclusions: Inheritance of the HSD3B1(1245C) allele that augments DHT synthesis may be associated with lower OS in men treated with ADT with or without docetaxel for LV newly metastatic PCa. Additional study is warranted in patients with LV disease. Clinical trial information: NCT00309985.
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Affiliation(s)
| | - Christopher Sweeney
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Nima Almassi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Brian Hobbs
- Taussig Cancer Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | | | - Yu-Hui Chen
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Eziokwu AS, Koyfman SA, Reddy CA, Matia B, Woody NM, Joshi NP, Burkey BB, Scharpf J, Lamarre E, Prendes B, Lorenz R, Ku J, Adelstein DJ, Geiger JL. Incidence of severe late toxicities of head and neck squamous cell cancer (HNSCC) treatment in the era of intensity modulated radiotherapy (IMRT). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.e17570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e17570 Background: IMRT for HNSCC limits exposure to critical nearby structures thereby reducing toxicities. Real world data on toxicities after long term follow-up post IMRT for HNSCC are lacking. This study assessed the incidence of late toxicities in patients with HNSCC within 5 years post-treatment with definitive IMRT (d-IMRT). Methods: This is a retrospective, IRB approved, single-institution review of patients (pts) with stage I-IVB HNSCC treated with d-IMRT +/- chemotherapy between 2009 and 2013. The primary outcomes were incidence of severe late toxicities (dysphagia requiring esophageal stricture dilation, physician-reported grade 2 or worse neck fibrosis and xerostomia) occurring 3 months or more after completion of IMRT; feeding tube (FT) dependence within 1st year of IMRT completion, and FT dependence beyond 1st year post IMRT. Toxicities were deemed acute if they occurred during IMRT and up to 90 days post IMRT. Results: 274 pts, median age 59 years (38 – 82.9), were identified. 67.6% were HPV positive, 10.5% HPV negative and HPV status was unknown in 21.9%. Site of disease was oropharynx in 70%, larynx in 25% and hypopharynx in 4%. 206 pts (75.2%) received d-IMRT alone, 37 (13.5%) had definitive concurrent chemoradiation – mostly with cisplatin (58%), and 31 (11.3%) received adjuvant IMRT. Of the 243 pts treated with d-IMRT +/- chemotherapy, 80 (32.9%) required FT during RT due to grade 2 or worse acute dysphagia. Excluding 11 pts with disease recurrence or new HNSCC diagnosis, FT dependence at any time from 3 months to one year post IMRT occurred in 22 of 232 pts (9.48%), while FT dependence beyond 1st year post IMRT occurred in 8 pts (3.4%). 11 pts (4.7%) required stricture dilation for late dysphagia. Late grade 2 or worse fibrosis and xerostomia occurred in 7 (3.0%) and 89 (38.4%) pts, respectively. Conclusions: Our study suggests that except for xerostomia, severe late toxicities after definitive IMRT for HNSCC is likely uncommon. Prospective studies with late IMRT toxicities and their impact on quality of life (QoL) as endpoints are warranted.
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Tom MC, Varra V, Leyrer CM, Park DY, Chao ST, Yu JS, Suh JH, Reddy CA, Balagamwala EH, Broughman JR, Kotagal KA, Vogelbaum MA, Barnett GH, Ahluwalia MS, Peereboom DM, Prayson RA, Stevens GHJ, Murphy ES. Risk Factors for Progression Among Low-Grade Gliomas After Gross Total Resection and Initial Observation in the Molecular Era. Int J Radiat Oncol Biol Phys 2019; 104:1099-1105. [PMID: 31022510 DOI: 10.1016/j.ijrobp.2019.04.010] [Citation(s) in RCA: 6] [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: 01/22/2019] [Revised: 03/16/2019] [Accepted: 04/14/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE To identify risk factors for progression-free survival (PFS) in the molecular era among patients with low-grade glioma (LGG) who undergo gross total resection (GTR) followed by initial observation. METHODS AND MATERIALS We reviewed patients with World Health Organization grade 2 LGG treated at a single institution. We included only those who underwent magnetic resonance imaging (MRI)-confirmed GTR followed by initial observation. Molecular classification was obtained at either the time of diagnosis or pathology review. Cox proportional hazards regression, the Kaplan-Meier method, and the log-rank test were used. P values <.05 were considered statistically significant. RESULTS We included 144 patients who underwent MRI-confirmed GTR between 1994 and 2014 followed by initial observation. Median age was 29 years (interquartile range [IQR], 18-41), median tumor size was 2.7 cm (IQR, 1.8-4.0), and median follow-up was 81 months (IQR, 36-132). Molecular classification was 13% IDH-mutant 1p19q-codeleted; 21% IDH-mutant 1p19q-intact; 39% IDH1-R132H-wildtype; and 28% undetermined. For the entire cohort, 5- and 10-year PFS and overall survival were 71% and 53%, and 98% and 90%, respectively. On multivariate analysis, factors associated with worse PFS included increasing age at diagnosis (hazard ratio [HR], 1.05; 95% CI, 1.00-1.09; P = .03), increasing preoperative tumor size (HR, 1.07; 95% CI, 1.04-1.10; P < .0001), and IDH-mutant 1p19q-intact classification (HR, 3.18; 95% CI, 1.15-8.74, P = .025). Median PFS for patients with IDH-mutant 1p19q-codeleted, IDH-mutant 1p19q-intact, and IDH1-R132H-wildtype tumors were 113 months, 56 months, and not reached, respectively. Molecular classification was significantly associated with PFS (P < .0001) but not overall survival (P = .20). CONCLUSIONS Among patients with LGG who undergo MRI-confirmed GTR and initial observation in the molecular era, increasing age, increasing tumor size, and IDH-mutant 1p19q-intact classification are associated with worse PFS. Because tumor progression is associated with adverse health-related quality of life, these factors may aid clinicians and patients in the shared decision-making process regarding goals of surgery and timing of postoperative therapy. Further study is required to elucidate why IDH-mutant 1p19q-intact LGGs are at higher risk for early progression.
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Affiliation(s)
- Martin C Tom
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vamsi Varra
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - C Marc Leyrer
- Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Deborah Y Park
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Jennifer S Yu
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ehsan H Balagamwala
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - James R Broughman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Gene H Barnett
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manmeet S Ahluwalia
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - David M Peereboom
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richard A Prayson
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Glen H J Stevens
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.
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Mian OY, Abu-Gheida I, Kotecha R, Weller MA, Reddy CA, Kupelian P, Ornstein MC, Gilligan TD, Garcia JA, Rini BI, Stephenson AJ, Klein EA, Shah C, Ciezki JP, Stephans KL, Tendulkar RD. Moderately hypofractionated radiotherapy for localized prostate cancer: Long-term outcomes for 854 consecutive patients treated over 10 years (70 Gy in 2.5 Gy/fraction). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
78 Background: Moderately hypofractionated radiotherapy has been increasingly adopted in the management of localized prostate cancer (PCa). We report 10-year outcomes for patients treated with intensity modulation radiation therapy (IMRT) for localized PCa with 70 Gy in 28 fractions at 2.5 Gy/fraction. Methods: This retrospective study included 854 consecutive patients with localized PCa treated with image-guided moderately hypofractionated IMRT at a single institution between 1998 and 2012. Patients with a single intermediate-risk factor were considered to have favorable intermediate-risk (FIR) disease; multiple intermediate-risk factors were considered unfavorable (UIR). Biochemical relapse free survival (bRFS), clinical relapse free survival (cRFS), overall survival (OS) and PCa specific mortality (PCSM) were analyzed used Kaplan-Meier analysis. Grade ≥3 genitourinary (GU) and gastrointestinal (GI) toxicities were recorded (CTCAE v4.03). Results: The median follow-up was 11.3 years (Max. 19 years). For patients with low-risk (LR, 31%), FIR (28%), UIR (12.5%), and high-risk (HR, 28.5%) disease the 10 year bRFS rates were 88%, 78%, 71% and 42%, respectively (p < 0.0001). The number of patients receiving no ADT, 1-6 months, or > 6 months of ADT were 39%, 50%, and 11%, respectively, reflecting practice patterns during this treatment period. The 10-year cRFS were 95%, 91%, 85% and 72% for patients with LR, FIR, UIR, and HR, respectively (p < 0.0001). The 10-year actuarial OS rate was 69% (95% CI 66-73%) and the 10-year PCSM was 6.8% (95% CI 5.1-8.6%) overall. For patients with LR, FIR, UIR and HR disease, the 10 year PCSM rates were 2%, 5%, 5% and 15%. 10-year cumulative incidence of grade ≥3 GU and GI toxicity was 2% and 1%, respectively. Multivariate analysis identified associations between clinical variables (ADT use, PSA nadir < 0.5ng/ml, and ISUP Grade Group) and bRFS, cRFS, and PCSM. Conclusions: Moderately hypofractionated IMRT with daily image guidance for localized PCa demonstrates favorable 10-year oncologic outcomes with a low incidence of toxicity for patients across all risk groups.
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Affiliation(s)
- Omar Y. Mian
- Cleveland Clinic, Dept. of Radiation Oncology, Dept. of Translational Hematology Oncology Research, Cleveland, OH
| | | | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | | | - Chandana A. Reddy
- Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland, OH
| | - Patrick Kupelian
- University of California Los Angeles Health Syst, Los Angeles, CA
| | | | | | | | - Brian I. Rini
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
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Jiang NY, King CR, Katz AJ, Collins SP, Aghdam N, Suy S, Stephans KL, Reddy CA, Kaplan ID, Appelbaum L, Dang A, Yuan Y, Nickols NG, Steinberg ML, Kupelian P, Kishan AU. Multi-institutional analysis of high-risk prostate cancer patients treated with stereotactic body radiotherapy. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
51 Background: Stereotactic Body Radiotherapy (SBRT) delivers ablative doses of radiation (RT) over a course of five treatments and has been increasingly used as a definitive RT option for low- and intermediate-risk prostate cancer (PCa). Ongoing prospective trials are evaluating the efficacy of SBRT for high-risk PCa, but clinical outcomes reports are limited. Methods: Patients treated for high-risk PCa between 2006-2017 at any of five institutions were included. SBRT doses ranged from 35-40 Gy in 5 fractions per institutional standards, with one institution using an integrated boost approach. The Phoenix definition was used to define biochemical failure (BCR). Physician-reported genitourinary (GU) and gastrointestinal (GI) toxicity outcomes were scored using the Radiation Therapy Oncology Group or Common Terminology Criteria for Adverse Events systems. Results: In total, 182 patients were included in this study with a median follow-up time of 38.4 months (mos). The median age was 72. Most patients (72%) had Gleason 8-10 disease. Sixty-eight percent of patients received androgen deprivation therapy (ADT) for a median of 9 mos (interquartile range 6-9 mos). The rate of distant metastases was 3.8%. There were no acute Grade 3 (G3) or higher GU or GI toxicities. Three patients (1.6%) experienced a late G3 GU toxicity and one patient (0.5%) experienced a late G3 GI toxicity. The incidence of BCR was significantly higher in patients who did not receive ADT (30% vs. 15%, p = 0.02 by Chi-square). Conclusions: In this multi-institutional study, SBRT demonstrated an acceptable safety profile for the treatment of high-risk PCa. Longer term follow-up is necessary to evaluate the oncologic efficacy of this approach, but given the potentially higher incidence of BCR without ADT, ADT likely has an important oncologic role even with SBRT regimens.
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Affiliation(s)
- Naomi Y Jiang
- University of California Los Angeles, Los Angeles, CA
| | | | | | | | - Nima Aghdam
- Georgetown University Hospital, Washington, DC
| | - Simeng Suy
- Georgetown University Hospital, Washington, DC
| | | | | | | | | | - Audrey Dang
- University of California Los Angeles, Los Angeles, CA
| | - Ye Yuan
- UCLA School of Medicine, Los Angeles, CA
| | | | | | - Patrick Kupelian
- University of California Los Angeles Health Syst, Los Angeles, CA
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Ciezki JP, Reddy CA, Mian OY, Tendulkar RD, Ulchaker J, Angermeier K, Campbell S, Stephenson AJ, Stovsky M, Klein EA. The effect of the timing of biochemical failure after external beam radiotherapy or low-dose-rate brachytherapy for definitive prostate cancer treatment. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
28 Background: To assess the effect of the timing of biochemical failure (bF) after definitive radiotherapy with external beam (EBRT) or low dose-rate brachytherapy (LDR) on clinical failure (cF) and prostate cancer-specific mortality (PCSM). Methods: From 1996 to 2009, 4478 patients were treated and by 2010, 456 patients were noted to have a bF. They were categorized as early (< 5 years post-therapy) or late (≥ 5 years post-therapy) failures. Factors thought to influence cF and PCSM were scored. Cox regression was used to assess the timing of bF on cF and Fine and Gray regression was used to assess the timing of bF on PCSM. Results: There were 330 (72.4 %) patients categorized as early and 126 (27.6 %) as late failures. The median PSA follow-up post-radiotherapy for the early bF group is 82 months vs. 155 months for the late bF group, and the median PSA follow-up post-bF is 54 months for the early bF group vs. 69 months for the late bF group. The early failures were more likely to be high-risk (p = 0.0080), have a higher Gleason score (p = 0.0008), and use ADT (p = 0.0325). The five-year rate of cF post early bF is 61% vs 43% post late bF (p <0.0001). The five-year rate of PCSM post early bF is 27% vs 9% post late bF (p <0.0001). The multivariable analyses assessing the cF and PCSM are shown in Table. Conclusions: Early bF is associated with higher rates of cF and PCSM. Patients treated with LDR have a lower risk of PCSM. [Table: see text]
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Affiliation(s)
| | - Chandana A. Reddy
- Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland, OH
| | - Omar Y. Mian
- Cleveland Clinic, Dept. of Radiation Oncology, Dept. of Translational Hematology Oncology Research, Cleveland, OH
| | | | | | | | | | | | - Mark Stovsky
- Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland, OH
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