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Tong JY, Brimanson K, Moyer K, Wolf J, Taylor R, Kallen M, Mesa H, Hatten KM. Margin analysis of radical tonsillectomy specimens following transoral robotic surgery. Oral Oncol 2025; 167:107403. [PMID: 40449162 DOI: 10.1016/j.oraloncology.2025.107403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2025] [Revised: 03/17/2025] [Accepted: 05/26/2025] [Indexed: 06/03/2025]
Abstract
OBJECTIVES Interpretation of margin adequacy in patients with squamous cell carcinoma (SCC) of the palatine tonsil treated with transoral robotic surgery (TORS) remains controversial and variable in practice. We describe margin analysis after radical tonsillectomy, including muscle invasion and surgical disruption. METHODS Patients undergoing TORS radical tonsillectomy between January 2017 to December 2023 were retrospectively reviewed. Pathology reports were reviewed for positive, close (<2 mm), or clear margins. Slides were evaluated for likely iatrogenic disruption of the pharyngeal constrictor, defined as the separation of muscle fibers with cautery artifact and evidence of margin ink seepage, as well as for muscle invasion, stratified as absent, partial (within muscle) or complete (beyond muscle). RESULTS Sixty-six patients with SCC of the palatine tonsil underwent TORS radical tonsillectomy. Fifty-seven (86.4 %) were male. Mean age was 59.7 years. Thirty-one (47.0 %) were pT1, 32 (48.5 %) pT2, and three (4.5 %) pT3. Thirty-six (54.5 %) demonstrated close, 26 (39.4 %) clear, and four (6.1 %) positive margins. All demonstrated muscle disruption. Twenty-seven (40.9 %) demonstrated no muscle invasion, 32 (48.5 %) partial, and seven (10.6 %) complete invasion. Margin status was not significantly associated with muscle invasion. Muscle invasion was associated with T stage (p = 0.049), number of involved lymph nodes (p = 0.043), and adjuvant treatment (p = 0.016). Margin status was significantly associated with PNI (p < 0.001). CONCLUSIONS Surgical muscle disruption was universal during radical tonsillectomy. Muscle invasion (59.1 %) and close margins (54.5 %) also were common. Muscle invasion was associated with T stage, number of involved lymph nodes, and adjuvant treatment, but not margin status, although this requires further study. Clear margins traditionally defined as ≥ 5 mm may not be anatomically feasible for palatine tonsil malignancies.
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Affiliation(s)
- Jane Y Tong
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Maryland, School of Medicine, Baltimore, MD, United States.
| | - Kathryn Brimanson
- Department of Pathology, University of Maryland, School of Medicine, Baltimore, MD, United States
| | - Kelly Moyer
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Maryland, School of Medicine, Baltimore, MD, United States
| | - Jeffrey Wolf
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Maryland, School of Medicine, Baltimore, MD, United States
| | - Rodney Taylor
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Maryland, School of Medicine, Baltimore, MD, United States
| | - Michael Kallen
- Department of Pathology, University of Maryland, School of Medicine, Baltimore, MD, United States
| | - Hector Mesa
- Department of Pathology, University of Maryland, School of Medicine, Baltimore, MD, United States
| | - Kyle M Hatten
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Maryland, School of Medicine, Baltimore, MD, United States
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Hopkins BD, Bates JE. The role of biomarkers in the management of HPV-related oropharyngeal cancer. Curr Opin Oncol 2025; 37:203-208. [PMID: 40026007 DOI: 10.1097/cco.0000000000001126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2025]
Abstract
PURPOSE OF REVIEW Patients with HPV-related oropharyngeal cancer have very good survival outcomes but a high burden of toxicity. This has led to significant efforts to attempt to use a variety of biomarkers to select patients who are candidates for de-escalated treatment. RECENT FINDINGS Initially, the field used HPV status alone as a biomarker to select patients with oropharyngeal cancer for de-escalation, however, the recently presented results of NRG Oncology HN005 showed that this is an insufficient strategy to select patients for potential de-escalation as patients in that study who received 60 Gy rather than the standard 70 Gy of radiation had diminished progression-free survival. This has led to a myriad of other strategies to potentially identify patients who may be able to receive less intense treatment but maintain a high rate of cure. SUMMARY Many biomarker options exist to try and select patients for potential treatment de-escalation. We anxiously await the results of multiple ongoing phase II studies regarding many of these biomarkers and believe that the future of treatment for oropharyngeal cancer will be significantly more personalized.
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Affiliation(s)
- Benjamin D Hopkins
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
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Calcano GA, Rourk KS, Routman DM, O'Byrne JJ, Chintakuntlawar AV, Garcia JJ, Price DL, Tasche KK, Moore EJ, Van Abel KM, Yin LX. The Impact of "Close Margins" in HPV-Associated Oropharyngeal Squamous Cell Carcinoma Treated With TORS. Otolaryngol Head Neck Surg 2025; 172:1291-1299. [PMID: 39764676 DOI: 10.1002/ohn.1127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2024] [Revised: 12/16/2024] [Accepted: 12/21/2024] [Indexed: 03/28/2025]
Abstract
OBJECTIVE Margin distance is a significant prognosticator in oral cavity cancer but its role in HPV-related oropharyngeal squamous cell carcinoma [HPV(+)OPSCC] remains unclear. Here, we investigate the impact of margin distance on locoregional recurrence in HPV(+)OPSCC. STUDY DESIGN This is a retrospective cohort study of surgically treated HPV(+)OPSCC patients. Patients received either standard of care (at least 60 Gy with or without cisplatin) or de-escalated adjuvant therapy (30-36 Gy with concurrent docetaxel). Margin distance was measured in mm from the primary specimen or in combination with separately submitted margins. Kaplan-Meier survival analysis with univariate and multivariable Cox regressions were conducted to determine the impact of margin distance on risk of local and locoregional recurrence. SETTING Setting for this is 3 tertiary centers between January 2010 and February 2024. RESULTS Among 1102 included patients, 33 (3.0%) had positive final margins. 374 patients had adequate margin distance data available. Margin distance was >3 mm in 73.4%, 1 to 3 mm in 24.5%, and <1 mm in 2.2% of patients. Positive final margins, pT4 disease, pN2 disease, and surgery alone as a treatment modality (P < .02 for all) was associated with higher risk of 5-year locoregional recurrence. Margin distance did not significantly impact risk of local or locoregional recurrence even after adjusting for de-escalated adjuvant therapy (P > .05). CONCLUSION Positive final margins after TORS without adjuvant radiotherapy for HPV(+)OPSCC carries a high risk of local recurrence. Margin distance does not appear to significantly impact risk of local or locoregional recurrence, even after de-escalated adjuvant radiotherapy.
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Affiliation(s)
- Gabriela A Calcano
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Katelyn S Rourk
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David M Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jamie J O'Byrne
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Daniel L Price
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kendall K Tasche
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric J Moore
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kathryn M Van Abel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Linda X Yin
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Cortiana V, Nadar S, Gambill J, Mahendru D, Theyver A, Coloma HS, Park CH, Leyfman Y. Understanding and treating HPV-associated oropharyngeal carcinoma: insights from a MedNewsWeek Keynote lecture by Dr Theodoros N. Teknos and literature review. Ther Adv Med Oncol 2025; 17:17588359251322290. [PMID: 40008193 PMCID: PMC11851760 DOI: 10.1177/17588359251322290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2024] [Accepted: 02/05/2025] [Indexed: 02/27/2025] Open
Abstract
Oropharyngeal carcinoma, a type of head and neck cancer (HNC), is an emerging malignancy associated with low survival rates. It typically affects older males and correlates with smoking, drinking, and lower socioeconomic conditions. Traditional treatments such as surgery have often yielded limited outcomes. However, recent insights, particularly those emphasized by Dr Teknos in his Keynote Conference at MedNews Week, have sparked a deeper exploration into alternative and more promising treatment methods. A comprehensive literature review was conducted to explore this subject further. One such approach, demonstrated by the UMCC 9921 trial, involves a comprehensive protocol starting with induction chemotherapy. This initial phase aims to reduce tumor burden and assess response to treatment. Based on the individual outcomes, patients then undergo concurrent chemoradiation or salvage surgery. This strategy has significantly improved survival rates, especially in human papillomavirus (HPV)-positive patients, showcasing the potential of tailored treatments. While these advancements are promising, long-term complications such as dysphagia and osteoradionecrosis remain a cause of concern. The rise of HPV-related head and neck squamous cell carcinoma has further changed how risk factors and treatment outcomes are viewed. HPV-positive cancers have unique characteristics and respond well to modern therapies. Researchers are investigating biomarkers such as circulating HPV DNA and immunoglobulin J polypeptide expression, which could provide valuable insights into disease progression and pave the way for more targeted and effective treatment strategies. In addition, the use of existing medications, such as fenofibrate, to combat HPV infections illustrates the resourcefulness in repurposing specific treatments. Challenges persist, especially in the need for reliable biomarkers for early disease progression detection and monitoring. Deeper insights into viral-host interactions shape promising immunotherapy strategies that could revolutionize treatment approaches. Collaborative efforts between researchers, healthcare providers, and policymakers play a vital role in translating these advancements into substantial clinical benefits, improving outcomes and quality of life for individuals affected by HPV-related diseases. While HPV-associated HNCs present significant challenges, continuous research and innovative treatments offer hope for a brighter future in combating this growing epidemic and improving patient care.
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Affiliation(s)
- Viviana Cortiana
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40126, Italy
| | | | | | | | | | | | | | - Yan Leyfman
- Icahn School of Medicine at Mount Sinai South Nassau, Oceanside, NY, USA
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Huang L, Patel AM, Haleem A, Brant JA, Maxwell R, Brody RM, Carey RM. Missed Adjuvant Therapy in Human Papillomavirus Positive Oropharyngeal Squamous Cell Carcinoma. Laryngoscope 2025; 135:729-740. [PMID: 39377215 PMCID: PMC11725718 DOI: 10.1002/lary.31823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 09/11/2024] [Accepted: 09/16/2024] [Indexed: 10/09/2024]
Abstract
OBJECTIVE Investigate missed adjuvant therapy and associated disparities in overall survival (OS) for human papillomavirus-associated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC). METHODS The 2010-2017 National Cancer Database was queried for patients with surgically resected HPV+ OPSCC. Indications for adjuvant radiotherapy (aRT) included pT3-4 classification, pN2-3 classification, lymphovascular invasion, pathologic extranodal extension (pENE), and/or positive surgical margins (PSM). Indication(s) for adjuvant chemoradiotherapy (aCRT) included pENE and/or PSM. Multivariable logistic and Cox regression models were implemented. RESULTS Of 5297 patients satisfying inclusion criteria, 4288 had indication(s) for aRT; 775 did not receive any adjuvant therapy and were considered as missing aRT. A total of 2234 patients had indication(s) for aCRT. Of these, 1383 (61.9%) received aCRT, 555 (24.8%) patients received aRT alone and were considered as having missed aCRT, and 296 (13.2%) did not receive any adjuvant therapy. Missed aRT and missed aCRT were each associated with age, treatment facility type, pN classification, and surgical margin status (p < 0.015). Among patients with indication(s) for aRT alone, OS of those receiving no adjuvant therapy, aRT alone, and aCRT was 90.0%, 94.8%, and 93.4%, respectively (p = 0.080). Among patients with indication(s) for aCRT, those receiving aRT alone and aCRT had similar OS (89.0% vs. 86.6%, p = 0.357) which was superior to receiving no adjuvant therapy (74.9%, p < 0.001). These patterns in OS persisted on multivariable Cox regression. CONCLUSION Among patients with HPV+ OPSCC and indication(s) for aRT, missed aRT was not associated with worse OS. For patients with indication(s) for aCRT, aRT alone was associated with similar OS as aCRT. LEVEL OF EVIDENCE 3 Laryngoscope, 135:729-740, 2025.
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Affiliation(s)
- Lily Huang
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaU.S.A.
| | - Aman M. Patel
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical SchoolNewarkNew JerseyU.S.A.
| | - Afash Haleem
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical SchoolNewarkNew JerseyU.S.A.
| | - Jason A. Brant
- Department of Otolaryngology–Head and Neck SurgeryUniversity of PennsylvaniaPhiladelphiaPennsylvaniaU.S.A.
- Department of Otolaryngology–Head and Neck SurgeryCorporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPennsylvaniaU.S.A.
| | - Russell Maxwell
- Department of Radiation OncologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaU.S.A.
| | - Robert M. Brody
- Department of Otolaryngology–Head and Neck SurgeryUniversity of PennsylvaniaPhiladelphiaPennsylvaniaU.S.A.
- Department of Otolaryngology–Head and Neck SurgeryCorporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPennsylvaniaU.S.A.
| | - Ryan M. Carey
- Department of Otolaryngology–Head and Neck SurgeryUniversity of PennsylvaniaPhiladelphiaPennsylvaniaU.S.A.
- Department of Otolaryngology–Head and Neck SurgeryCorporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPennsylvaniaU.S.A.
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Elmi M, Dass JH, Dass CR. Current treatments for oropharyngeal squamous cell carcinoma and the move towards molecular therapy. J Pharm Pharmacol 2024; 76:1552-1562. [PMID: 39137149 DOI: 10.1093/jpp/rgae107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 07/25/2024] [Indexed: 08/15/2024]
Abstract
OBJECTIVES In this review, we discuss oropharyngeal squamous cell carcinoma (OPSCC) treatment options with a focus on the molecular mechanisms of OPSCC in head and neck squamous cell carcinoma (HNSCC) and head and neck cancers (HNCs). Treatment can be radical intent (aim for cure) or palliative intent (aim for disease control and symptom management). OPSCC is a prominent subset of HNSCCs in Australia and the Western World. METHOD We looked at the current conventional treatment options with an overview of recent advances and future endeavours. KEY FINDINGS We identified that radiotherapy is the primary management for OPSCC in most countries, including the USA, UK, NZ, and Australia. In contrast, surgery is only considered for superficial OPSCC or neck surgery. If surgery is incomplete, then definitive management still requires radiotherapy. CONCLUSION Molecular therapy is largely at the preclinical stage, with cetuximab, nivolumab, pembrolizumab, Lenvatinib, and bevacizumab being tested clinically currently.
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Affiliation(s)
- Mitra Elmi
- Curtin Medical School, Curtin University, Perth, WA, Australia
- Curtin Health Innovation Research Institute, Perth, WA, Australia
| | - Joshua H Dass
- Curtin Medical School, Curtin University, Perth, WA, Australia
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Crispin R Dass
- Curtin Medical School, Curtin University, Perth, WA, Australia
- Curtin Health Innovation Research Institute, Perth, WA, Australia
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Margalit DN, Anker CJ, Aristophanous M, Awan M, Bajaj GK, Bradfield L, Califano J, Caudell JJ, Chapman CH, Garden AS, Harari PM, Helms A, Lin A, Maghami E, Mehra R, Parker L, Shnayder Y, Spencer S, Swiecicki PL, Tsai JC, Sher DJ. Radiation Therapy for HPV-Positive Oropharyngeal Squamous Cell Carcinoma: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2024; 14:398-425. [PMID: 39078350 DOI: 10.1016/j.prro.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 07/31/2024]
Abstract
PURPOSE Human Papilloma Virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is a distinct disease from other head and neck tumors. This guideline provides evidence-based recommendations on the critical decisions in its curative treatment, including both definitive and postoperative radiation therapy (RT) management. METHODS ASTRO convened a task force to address 5 key questions on the use of RT for management of HPV-associated OPSCC. These questions included indications for definitive and postoperative RT and chemoradiation; dose-fractionation regimens and treatment volumes; preferred RT techniques and normal tissue considerations; and posttreatment management decisions. The task force did not address indications for primary surgery versus RT. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS Concurrent cisplatin is recommended for patients receiving definitive RT with T3-4 disease and/or 1 node >3 cm, or multiple nodes. For similar patients who are ineligible for cisplatin, concurrent cetuximab, carboplatin/5-fluorouracil, or taxane-based systemic therapy are conditionally recommended. In the postoperative setting, RT with concurrent cisplatin (either schedule) is recommended for positive surgical margins or extranodal extension. Postoperative RT alone is recommended for pT3-4 disease, >2 nodes, or a single node >3 cm. Observation is conditionally recommended for pT1-2 disease and a single node ≤3 cm without other risk factors. For patients treated with definitive RT with concurrent systemic therapy, 7000 cGy in 33 to 35 fractions is recommended, and for patients receiving postoperative RT without positive surgical margins and extranodal extension, 5600 to 6000 cGy is recommended. For all patients receiving RT, intensity modulated RT over 3-dimensional techniques with reduction in dose to critical organs at risk (including salivary and swallowing structures) is recommended. Reassessment with positron emission tomography-computed tomography is recommended approximately 3 months after definitive RT/chemoradiation, and neck dissection is recommended for convincing evidence of residual disease; for equivocal positron emission tomography-computed tomography findings, either neck dissection or repeat imaging is recommended. CONCLUSIONS The role and practice of RT continues to evolve for HPV-associated OPSCC, and these guidelines inform best clinical practice based on the available evidence.
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Affiliation(s)
- Danielle N Margalit
- Department of Radiation Oncology, Brigham & Women's/Dana-Farber Cancer Center, Harvard Medical School, Boston, Massachusetts.
| | - Christopher J Anker
- Division of Radiation Oncology, University of Vermont Cancer Center, Burlington, Vermont
| | - Michalis Aristophanous
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Musaddiq Awan
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gopal K Bajaj
- Department of Advanced Radiation Oncology and Proton Therapy, Inova Schar Cancer Institute, Fairfax, Virginia
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Joseph Califano
- Department of Surgery, University of California San Diego Health, San Diego, California
| | - Jimmy J Caudell
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Christina H Chapman
- Department of Radiation Oncology, Baylor College of Medicine, Houston, Texas
| | - Adam S Garden
- Department of Radiation Oncology, University of Texas - MD Anderson Cancer Center, Houston, Texas
| | - Paul M Harari
- Department of Human Oncology, University of Wisconsin, Madison, Wisconsin
| | - Amanda Helms
- American Society for Radiation Oncology, Arlington, Virginia
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ellie Maghami
- Department of Surgery, City of Hope, Duarte, California
| | - Ranee Mehra
- Department of Medical Oncology, University of Maryland Medical School and Greenebaum Comprehensive Cancer Center, Baltimore, Maryland
| | | | - Yelizaveta Shnayder
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Sharon Spencer
- Department of Radiation Oncology, University of Alabama Heersink School of Medicine, Birmingham, Alabama
| | - Paul L Swiecicki
- Department of Medical Oncology, University of Michigan Rogel Cancer Center, Ann Arbor, Michigan
| | | | - David J Sher
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
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8
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Garden AS. Selecting Patients With Oropharyngeal Cancer for Lower Dose Radiation. J Clin Oncol 2024; 42:2835-2836. [PMID: 38788168 DOI: 10.1200/jco.24.00395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/18/2024] [Indexed: 05/26/2024] Open
Affiliation(s)
- Adam S Garden
- Adam S. Garden, MD, University of Texas MD Anderson Cancer Center, Houston, TX
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Lee NY, Sherman EJ, Riaz N. Reply to A.S. Garden. J Clin Oncol 2024; 42:2836-2837. [PMID: 38788165 DOI: 10.1200/jco.24.00561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 05/26/2024] Open
Affiliation(s)
- Nancy Y Lee
- Nancy Y. Lee, MD, FASTRO, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; Eric J. Sherman, MD, Department of Medicine, Head and Neck Cancer Service, Memorial Sloan Kettering Cancer Center, New York, NY; and Nadeem Riaz, MD, MSc, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eric J Sherman
- Nancy Y. Lee, MD, FASTRO, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; Eric J. Sherman, MD, Department of Medicine, Head and Neck Cancer Service, Memorial Sloan Kettering Cancer Center, New York, NY; and Nadeem Riaz, MD, MSc, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nadeem Riaz
- Nancy Y. Lee, MD, FASTRO, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; Eric J. Sherman, MD, Department of Medicine, Head and Neck Cancer Service, Memorial Sloan Kettering Cancer Center, New York, NY; and Nadeem Riaz, MD, MSc, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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10
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Hong SA, Armstrong AT, Snow K, Walker RJ, Massa ST. Association of adjuvant radiation and survival in human papilloma virus-positive oropharynx squamous cell carcinoma with lymphovascular invasion as the sole adverse pathologic feature. Head Neck 2024; 46:1043-1050. [PMID: 38511301 DOI: 10.1002/hed.27740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 02/18/2024] [Accepted: 03/08/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Postoperative radiotherapy radiation therapy (PORT) for early-stage human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) with positive lymphovascular invasion (LVI) has an unclear association with overall survival (OS). METHODS This retrospective cohort study queried the National Cancer Database for surgically treated, T1-2, N0-1 HPV+ OPSCC from 2010 to 2019. Primary exposures were LVI and PORT, and the main outcome was 5-year OS. Odds ratios and hazard ratios (HR) with 95% confidence intervals (CIs) were generated using multivariable models and Cox proportional hazard models, respectively. RESULTS Of 2768 patients, average age was 59.3 years, 2207 (79.7%) were male, and 386 (13.9%) had LVI. Of patients with LVI as their sole adverse pathologic feature, 220 (57.0%) received PORT, which was not associated with 5-year OS (HR, 1.13; CI, 0.65-1.19). CONCLUSIONS Patients with surgically treated, early-stage HPV+ OPSCC and positive LVI as their only pathologic adverse feature may not require PORT.
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Affiliation(s)
- Scott A Hong
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Austin T Armstrong
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Katherine Snow
- Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Ronald J Walker
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Sean T Massa
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
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Melachuri M, Kurukulasuriya C, Rumde P, Patel T, Awad D, Kim S, Ferris R, Sridharan S, Duvvuri U. Treatment package time < 14 weeks improves recurrence free and disease specific survival in HPV positive OPC with high-risk features. Oral Oncol 2024; 151:106703. [PMID: 38422830 DOI: 10.1016/j.oraloncology.2024.106703] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 01/08/2024] [Accepted: 01/20/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Guidelines recommend treatment package time < 85 days and time from surgery to radiation initiation < 6 weeks in head and neck cancer patients. However, HPV positive primaries treated with TORS and adjuvant radiotherapy traditionally demonstrate favorable outcomes. METHODS Single center retrospective chart review of patients diagnosed with HPV positive treatment naïve primary squamous cell carcinoma treated with TORS and postoperative radiation therapy with or without Chemotherapy from 2012 to 2022 with data collection from December 2022-April 2023. Kaplan-Meier survival analysis with log-rank testing assessed the impact of time intervalsbetween diagnosis, TORS, radiation initiation and radiation completion on recurrence free and disease specific survival. Univariate Cox proportional hazards regression analysis was performed to identify factors associated with recurrence free and disease specific survival. Subgroup analysis was done with high risk (positive lymph nodes > 5, >1mm extracapsular extension, positive margins) patients who underwent concurrent Chemotherapy. RESULTS Of 255 patients (225 males [89 %], average age 58 years, 163 [64 %] high-risk, median follow-up 4.3 years), 22 (8.6 %) had recurrence and 14 died due after disease recurrence.Only radiation length of 5-7 weeks prolonged survival in the entire population. In the high-risk cohort, time from TORS to radiation initiation < 6 weeks improvedrecurrence free survival, while total package time < 14 weeks wasassociated with greater recurrence free and disease specific survival.
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Affiliation(s)
- Manasa Melachuri
- University of Pittsburgh Medical Center, Department of Otolaryngology- Head and Neck Surgery, Pittsburgh, PA, USA.
| | - Chareeni Kurukulasuriya
- University of Pittsburgh Medical Center, Department of Otolaryngology- Head and Neck Surgery, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Purva Rumde
- University of Pittsburgh Medical Center, Department of Otolaryngology- Head and Neck Surgery, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Terral Patel
- University of Pittsburgh Medical Center, Department of Otolaryngology- Head and Neck Surgery, Pittsburgh, PA, USA
| | - Daniel Awad
- University of Pittsburgh Medical Center, Department of Otolaryngology- Head and Neck Surgery, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Seungwon Kim
- University of Pittsburgh Medical Center, Department of Otolaryngology- Head and Neck Surgery, Pittsburgh, PA, USA
| | - Robert Ferris
- University of Pittsburgh Medical Center, Department of Otolaryngology- Head and Neck Surgery, Pittsburgh, PA, USA
| | - Shaum Sridharan
- University of Pittsburgh Medical Center, Department of Otolaryngology- Head and Neck Surgery, Pittsburgh, PA, USA
| | - Umamaheswar Duvvuri
- University of Pittsburgh Medical Center, Department of Otolaryngology- Head and Neck Surgery, Pittsburgh, PA, USA; New York University Grossman School of Medicine, Department of Otolaryngology- Head and Neck Surgery, Pittsburgh, PA, USA
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Williamson A, Moen CM, Slim MAM, Warner L, O'Leary B, Paleri V. Transoral robotic surgery without adjuvant therapy: A systematic review and meta-analysis of the association between surgical margins and local recurrence. Oral Oncol 2023; 147:106610. [PMID: 37951118 DOI: 10.1016/j.oraloncology.2023.106610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/09/2023] [Accepted: 10/27/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND Transoral robotic surgery (TORS) is increasingly employed in the management of oropharyngeal cancer without adjuvant treatment. Attaining safe surgical margins is paramount to preventing local recurrence (LR), but the necessary surgical margin dimension remains contentious. METHODS Systematic review and meta-analysis of studies reporting margin status and LR following TORS without adjuvant therapy for primary OPSCC. RESULTS The search identified 269 articles and 11 were selected for inclusion, with 406 patients included in the meta-analysis. Heterogeneity was noted in the definition of "close" margins. Random-effects pooled rate of positive margins was 7 % (95 % CI 0.04-0.12, I2 = 54 %, p = 0.02) and close margins was 7 % (95 % CI 0.02-0.27, I2 = 86 %, p=<0.01). The random-effects overall rate of LR was 6 % (95 % CI 0.04-0.10, I2 = 11 %, p = 0.35), 13 % (95 % CI 0.02-0.620, I2 = 0 %, p = 1.0) after a positive margin, and 3 % (95 % CI 0.03-0.24, I2 = 23 %, p = 0.26) after a close margin. Odds ratio (OR) for LR indicated higher risk of LR for positive compared to close margins (7.5; 95 % CI 1.31-42.91, I2 = 0 %, p = 0.51), and a slightly lower risk of LR between close and negative margins (2.22; 95 % CI 0.67-7.38, I2 = 0 %, p = 0.8). A lack of frozen-section analysis (OR 2.91, p = 0.36) and HPV-negative disease (OR 1.68, p = 0.03) were associated with an elevated risk of LR. CONCLUSIONS TORS as a standalone treatment is associated with low rates of LR; however, the literature is hampered by considerable heterogeneity in margin definitions. Larger multicentre studies are required to determine the precise margin cut-off required for oropharyngeal tumours managed with TORS alone.
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Affiliation(s)
- Andrew Williamson
- International Centre for Recurrent Head and Neck Cancer (IReC), Department of Head and Neck Surgery, The Royal Marsden Hospital, London, UK; Institute for Cancer Research, London, UK.
| | | | | | - Laura Warner
- Department of Head and Neck Surgery, The Freeman Hospital, Newcastle, UK
| | - Ben O'Leary
- International Centre for Recurrent Head and Neck Cancer (IReC), Department of Head and Neck Surgery, The Royal Marsden Hospital, London, UK; Institute for Cancer Research, London, UK
| | - Vinidh Paleri
- International Centre for Recurrent Head and Neck Cancer (IReC), Department of Head and Neck Surgery, The Royal Marsden Hospital, London, UK; Institute for Cancer Research, London, UK.
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13
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Mrosk F, Doll C, Scheer J, Neumann F, Hofmann E, Kreutzer K, Voss J, Rubarth K, Beck M, Heiland M, Koerdt S. Oncologic Outcome in Advanced Oral Squamous Cell Carcinoma After Refusal of Recommended Adjuvant Therapy. JAMA Otolaryngol Head Neck Surg 2023; 149:1027-1033. [PMID: 37824130 PMCID: PMC10570914 DOI: 10.1001/jamaoto.2023.3111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 08/28/2023] [Indexed: 10/13/2023]
Abstract
Importance Clinicians may be confronted with patients refusing recommended adjuvant therapy (AT) after the primary resection of an advanced oral squamous cell carcinoma (OSCC). However, for this tumor entity, data are lacking regarding the oncological outcomes and associated factors after refusal of AT. Objective To evaluate the difference in survival and disease recurrence for patients with and without recommended AT after resection of advanced OSCC. Design, Setting, and Participants In this single-center retrospective matched cohort study, patients with advanced OSCC who refused recommended AT between January 2010 and December 2021 were matched 1:1 according to Union for International Cancer Control tumor staging with patients who completed AT. Exposures Patients with advanced OSCC who refused or completed recommended AT between 2010 and 2021. Main Outcomes and Measures The primary outcome of this study was the comparison of overall survival (OS) and recurrence-free survival (RFS) between the 2 study groups. Results A total of 82 patients (mean [SD] age at time of surgery, 68.0 [11.3] years; 38 [46.3%] female, 44 [53.7%] male) with and without AT (41 per study group) were included in the analysis. Patients refusing AT developed more frequent disease recurrence than patients who completed AT (61.0% vs 26.8%; difference, 34.2%; odds ratio, 4.26; 95% CI, 1.68-10.84). In addition, patients who refused AT presented with lower 2-year OS (72.7% vs 88.6%; difference, 15.9%; 95% CI, 8.6%-40.6%) and much lower 2-year RFS (39.1% vs 74.2%; difference, 35.1%; 95% CI, 0.2%-70.5%). In the patient cohort who rejected AT, a worse OS was associated with female sex (48.6% vs 90.5%; difference, 41.9%; 95% CI, 0.6%-84.4%), pT1-2 category (57.1% vs 92.3%; difference, 35.2%; 95% CI, 3.3%-73.6%), and pN1 or higher category (61.2% vs 82.6%; difference, 21.4%; 95% CI, 14.1%-56.8%). Lower RFS was associated with female sex (37.9% vs 90.9%; difference, 53.0%; 95% CI, 8.0%-97.9%), advanced T category (pT3-4, 35.3% vs 80.0%; difference, 44.7%; 95% CI, 6.4%-95.3%), lymph node yield of 20 or greater (31.4% vs 80.6%; difference, 49.2%; 95% CI, 4.9%-93.4%), and lymph node ratio of less than 4.6% (36.6% vs 84.4%; difference, 47.8%; 95% CI, 1.8%-93.1%). Conclusions and Relevance In this cohort study of patients with advanced OSCC, refusal of AT was associated with worse oncological outcomes. The prevalence of disease recurrence during follow-up was 34% higher in patients who refused AT than in patients who completed AT. The results from this study may assist clinicians in guiding patients who are considering refusal of or withdrawal from AT.
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Affiliation(s)
- Friedrich Mrosk
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Oral and Maxillofacial Surgery, Berlin, Germany
| | - Christian Doll
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Oral and Maxillofacial Surgery, Berlin, Germany
| | - Julia Scheer
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Oral and Maxillofacial Surgery, Berlin, Germany
| | - Felix Neumann
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Oral and Maxillofacial Surgery, Berlin, Germany
| | - Elena Hofmann
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Oral and Maxillofacial Surgery, Berlin, Germany
- Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Kilian Kreutzer
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Oral and Maxillofacial Surgery, Berlin, Germany
| | - Jan Voss
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Oral and Maxillofacial Surgery, Berlin, Germany
- Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Kerstin Rubarth
- Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Berlin, Germany
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Charitéplatz 1, Berlin, Germany
| | - Marcus Beck
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, Berlin, Germany
| | - Max Heiland
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Oral and Maxillofacial Surgery, Berlin, Germany
| | - Steffen Koerdt
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Oral and Maxillofacial Surgery, Berlin, Germany
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14
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Singh R, Song S. Clinical outcomes following observation, post-operative radiation therapy, or post-operative chemoradiation for HPV-associated oropharyngeal squamous cell carcinomas. Oral Oncol 2023; 146:106493. [PMID: 37713768 DOI: 10.1016/j.oraloncology.2023.106493] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/14/2023] [Accepted: 07/02/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Intermediate and high-risk features (IRFs/HRFs) for locoregional recurrence following initial surgery for oropharyngeal SCCs (OP-SCCs) were defined prior to the known association of HPV with OP-SCC. There are limited reports on practice patterns and outcomes associated with post-operative radiation therapy (PORT) or chemoradiation (POCRT) for HPV-associated OP-SCCs. MATERIALS/METHODS The National Cancer Database was queried for patients with HPV-associated OP-SCCs managed initially with surgery with IRFs or HRFs. IRFs were defined as pT3/T4 disease, pN1-3 disease, and lymphovascular space invasion, and HRFs as positive margins and extranodal extension (ENE). Patients were stratified into no adjuvant therapy, PORT, or POCRT arms. Kaplan-Meier analysis was utilized for comparison of overall survival (OS) between treatment arms followed by a Cox multivariate (MVA) proportional-hazards model and propensity score analyses with inverse probability treatment weighting (IPTW). RESULTS We identified 6,301 patients; 51.2% had IRFs only and 48.8% had HRFs. Regarding treatment, 25.5%, 38.2%, and 36.3% of patients received no RT, PORT, and POCRT, respectively. Patients with IRFs who did not receive RT or CRT had inferior 8-year OS (81.1% vs. 87.8%; p < 0.001) that remained significant on IPTW MVA (hazard ratio (HR) = 1.69 (95% CI: 1.27-2.24; p < 0.001). Among patients with HRFs, 8-year OS was not significantly different between patients receiving PORT vs. POCRT (77.3% vs. 79.2%; p = 0.22) that remained insignificant on IPTW MVA (HR = 0.91(0.72-1.17); p = 0.48). CONCLUSION A significant proportion of HPV-associated OP-SCC patients with IRFs or HRFs did not receive PORT, which was associated with inferior OS. We did not demonstrate with statistical power that POCRT vs. PORT was associated with superior OS in patients with HRFs, though prospective studies are warranted.
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Affiliation(s)
- Raj Singh
- Department of Radiation Oncology, The James Cancer Hospital and Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH USA
| | - Shiyu Song
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, VA USA.
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15
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Taniguchi AN, Sutton SR, Nguyen SA, Kejner AE, Albergotti WG. The Lack of Standardized Outcomes for Surgical Salvage of HPV-Positive Recurrent Oropharyngeal Squamous Cell Carcinoma: A Systematic Scoping Review. Cancers (Basel) 2023; 15:2832. [PMID: 37345169 PMCID: PMC10216204 DOI: 10.3390/cancers15102832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/13/2023] [Accepted: 05/17/2023] [Indexed: 06/23/2023] Open
Abstract
Although HPV status is known to provide an improved prognosis in initial treatments of HPV-positive oropharyngeal squamous cell carcinoma (OPSCC), it is unclear how it affects patients who receive salvage surgery (SS), which has historically poor survival rates. The purpose of this study was to evaluate the role of SS for patients with locoregional recurrence (LRR) of HPV-positive OPSCC and its impact survival rates. We conducted a scoping review of literature through October 2022 and included 995 individuals. Survival endpoints, such as overall survival (OS), Kaplan-Meier curves, and median post-recurrence survival, were analyzed in addition to demographics. Of all studies, 18.8% (6/32) reported any survival data for SS patients, with the most prevalent reporting 2- and 5-year OS in two studies. Median post-recurrence survival was not reported for SS. These findings reveal the limited and unpredictable reporting of survival-specific data on SS for HPV-positive OPSCC. With limited survival assessment, it is difficult to assess the potential advantages and disadvantages of this therapy to guide clinical decision-making.
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Affiliation(s)
- April N. Taniguchi
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
- College of Medicine, University of Central Florida, Orlando, FL 32827, USA
| | - Sarah R. Sutton
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
- School of Medicine, University of Nevada, Reno, NV 89557, USA
| | - Shaun A. Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Alexandra E. Kejner
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
| | - William G. Albergotti
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
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16
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Berlin E, Ma DJ, Bakst RL, Quon H, Lin A, Lukens JN. Close Margins After Transoral Robotic Surgery for Human Papillomavirus-Positive Oropharyngeal Carcinoma: A Review of the Literature and Practical Recommendations. Pract Radiat Oncol 2023; 13:251-255. [PMID: 36599392 DOI: 10.1016/j.prro.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 12/12/2022] [Indexed: 01/02/2023]
Abstract
The purpose of this article is to summarize the literature and practical recommendations from experienced centers for close margins after transoral robotic surgery for human papillomavirus-positive oropharyngeal carcinoma.
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Affiliation(s)
- Eva Berlin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania
| | - Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Richard L Bakst
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Harry Quon
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander Lin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania
| | - J Nicholas Lukens
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania.
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17
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Soliman SI, Faraji F, Pang J, Mell LK, Califano JA, Orosco RK. Adjuvant Radiotherapy in Surgically Treated HPV-Positive Oropharyngeal Carcinoma with Adverse Pathological Features. Cancers (Basel) 2022; 14:cancers14184515. [PMID: 36139676 PMCID: PMC9496867 DOI: 10.3390/cancers14184515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/12/2022] [Accepted: 09/16/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose: HPV-positive oropharyngeal carcinoma (HPV-OPC) is increasingly treated with primary surgery. The National Comprehensive Cancer Network (NCCN) recommends adjuvant therapy for surgically treated HPV-OPC displaying adverse pathological features (AF). We evaluated adjuvant radiotherapy patterns and outcomes in surgically treated AF-positive HPV-OPC (AF-HPV-OPC). Methods: The National Cancer Database was interrogated for patients ≥ 18 years with early-stage HPV-OPC from 2010 to 2017 who underwent definitive resection. Patients that had an NCCN-defined AF indication for adjuvant radiotherapy were assessed, including positive surgical margins (PSM), extranodal extension (ENE), lymphovascular invasion, and level 4/5 cervical lymph nodes. Overall survival (OS) was evaluated using Cox proportional hazards models and Kaplan−Meier analysis in whole and propensity score matched (PM) cohorts. Results: Of 15,036 patients meeting inclusion criteria, 55.7% were positive for at least one AF. Presence of any AF was associated with worse OS (hazard ratio (HR) = 1.56, p < 0.001). In isolation, each AF was associated with worse OS. On PM analysis, insurance status, T2 category, Charlson-Deyo comorbidity score, ENE (HR = 1.81, p < 0.001), and PSM (HR = 1.58, p = 0.002) were associated with worse OS. Median 3-year OS was 92.0% among AF-HPV-OPC patients undergoing adjuvant radiotherapy and 84.2% for those who did not receive adjuvant radiotherapy (p < 0.001, n = 1678). The overall rate of patients with AF-HPV-OPC who did not receive adjuvant radiotherapy was 13% and increased from 10% in 2010 to 17% in 2017 (ptrend = 0.007). Conclusions: In patients with AF-HPV-OPC, adjuvant radiotherapy is associated with improved survival. In the era of de-escalation therapy for HPV-OPC, our findings demonstrate the persistent prognostic benefit of post-operative radiotherapy in the setting of commonly identified adverse features. Ongoing clinical trials will better elucidate optimized patient selection for de-escalated therapy.
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Affiliation(s)
- Shady I. Soliman
- School of Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | - Farhoud Faraji
- Department of Otolaryngology-Head & Neck Surgery, University of California San Diego, La Jolla, CA 92037, USA
- Correspondence: (F.F.); (R.K.O.)
| | - John Pang
- Department of Otolaryngology-Head & Neck Surgery, Louisiana State University, Shreveport, LA 71103, USA
| | - Loren K. Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA 92037, USA
- Moores Cancer Center, La Jolla, CA 92037, USA
| | - Joseph A. Califano
- Department of Otolaryngology-Head & Neck Surgery, University of California San Diego, La Jolla, CA 92037, USA
- Moores Cancer Center, La Jolla, CA 92037, USA
| | - Ryan K. Orosco
- Department of Otolaryngology-Head & Neck Surgery, University of California San Diego, La Jolla, CA 92037, USA
- Moores Cancer Center, La Jolla, CA 92037, USA
- Correspondence: (F.F.); (R.K.O.)
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18
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Warner L, O'Hara JT, Lin DJ, Oozeer N, Fox H, Meikle D, Hamilton D, Iqbal MS, Robinson M, Paleri V. Transoral robotic surgery and neck dissection alone for head and neck squamous cell carcinoma: Influence of resection margins on oncological outcomes. Oral Oncol 2022; 130:105909. [PMID: 35636080 DOI: 10.1016/j.oraloncology.2022.105909] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 05/03/2022] [Accepted: 05/08/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES This study reports oncological outcomes of transoral robotic surgery (TORS) and neck dissection (ND) alone for head and neck squamous cell carcinoma (HNSCC) and aims to analyse the influence of resection margins on local recurrence rates. MATERIALS AND METHODS Fifty-one patients treated with curative intent for HNSCC, with TORS and ND alone between 2013 and 2019 at two tertiary centres were included in this observational multi-centre prospective cohort study. Oncological outcomes are reported on 47 patients for whom the aim was to treat with TORS and ND alone; this excluded four patients who were recommended adjuvant radiotherapy based on resective pathology but did not receive treatment. Local control is the primary endpoint; disease specific, progression free and overall survival are secondary outcomes. RESULTS With a median follow up of 43 months, estimated outcomes at 3 years (n = 47) were as follows: local control 92%, progression free survival 80%, disease specific survival 94%, and overall survival 84%. Presence of a positive margin on the main specimen was the only statistically significant predictor of local recurrence on univariate Cox regression analysis. Time dependent receiver operating characteristic curve identified margins of 1.1 mm as a threshold for local control, with area under the curve 0.788 (95% CI 0.616-0.960), indicating a good classifier. CONCLUSION This is the first UK surgery alone series reporting mature oncological outcomes following TORS and ND. Positive margins on the resected specimen are the strongest predictor of local recurrence, with conventional definitions of "close margins" having no impact.
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Affiliation(s)
- Laura Warner
- Department of Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - James T O'Hara
- Department of Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - Daniel J Lin
- Department of Otolaryngology - Head and Neck Surgery, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - Nashreen Oozeer
- Department of Otolaryngology - Head and Neck Surgery, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - Hannah Fox
- Department of Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - David Meikle
- Department of Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - David Hamilton
- Department of Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - Muhammad Shahid Iqbal
- Department of Oncology, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - Max Robinson
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - Vinidh Paleri
- Head and Neck Unit, The Royal Marsden Hospitals NHS Foundation Trust and Institute of Cancer Research, Fulham Road, Chelsea, London SW3 6JJ, UK.
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19
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De Ravin E, Carey RM, Stubbs VC, Jaffe S, Lee JYK, Rajasekaran K, Newman JG. Second Window Indocyanine Green for Oropharyngeal Tumors: A Case Series and Comparison of Near-Infrared Camera Systems. Clin Otolaryngol 2022; 47:589-593. [PMID: 35604054 DOI: 10.1111/coa.13945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 01/24/2022] [Accepted: 05/01/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Emma De Ravin
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ryan M Carey
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Vanessa C Stubbs
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Samantha Jaffe
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jason G Newman
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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20
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Bates JE, Steuer CE. HPV as a Carcinomic Driver in Head and Neck Cancer: a De-escalated Future? Curr Treat Options Oncol 2022; 23:325-332. [PMID: 35244886 DOI: 10.1007/s11864-022-00950-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 01/15/2023]
Abstract
OPINION STATEMENT Patients with HPV-associated oropharyngeal squamous cell carcinoma have improved prognosis relatively to those with tumors not driven by HPV. Both definitive radiotherapy (typically with concurrent chemotherapy) and transoral robotic surgery (with adjuvant therapies based on pathologic risk factors) are both acceptable treatment options for patients. The decision on which treatment is optimal depends on individual patient factors and should be made in a multi-disciplinary setting with input from a radiation oncologist, head and neck surgeon, and medical oncologist. Where appropriate, patients in this setting should be considered for enrollment on clinical studies evaluating de-escalation of treatment intensity given the very favorable outcomes and high toxicity profile associated with conventional therapies. However, caution is needed given negative data for de-escalation in the definitive chemotherapy and radiation setting. It remains unclear what the prognostic significance of HPV status is in patients with squamous cell carcinomas of the head and neck outside of the oropharynx.
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Affiliation(s)
- James E Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 550 Peachtree St NE, Atlanta, GA, 30308, USA.
| | - Conor E Steuer
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Road, Atlanta, GA, 30307, USA
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21
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HPV-associated oropharyngeal cancer: epidemiology, molecular biology and clinical management. Nat Rev Clin Oncol 2022; 19:306-327. [PMID: 35105976 PMCID: PMC8805140 DOI: 10.1038/s41571-022-00603-7] [Citation(s) in RCA: 470] [Impact Index Per Article: 156.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 12/13/2022]
Abstract
Human papillomavirus (HPV)-positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC) has one of the most rapidly increasing incidences of any cancer in high-income countries. The most recent (8th) edition of the UICC/AJCC staging system separates HPV+ OPSCC from its HPV-negative (HPV−) counterpart to account for the improved prognosis seen in the former. Indeed, owing to its improved prognosis and greater prevalence in younger individuals, numerous ongoing trials are examining the potential for treatment de-intensification as a means to improve quality of life while maintaining acceptable survival outcomes. In addition, owing to the distinct biology of HPV+ OPSCCs, targeted therapies and immunotherapies have become an area of particular interest. Importantly, OPSCC is often detected at an advanced stage owing to a lack of symptoms in the early stages; therefore, a need exists to identify and validate possible diagnostic biomarkers to aid in earlier detection. In this Review, we provide a summary of the epidemiology, molecular biology and clinical management of HPV+ OPSCC in an effort to highlight important advances in the field. Ultimately, a need exists for improved understanding of the molecular basis and clinical course of this disease to guide efforts towards early detection and precision care, and to improve patient outcomes. The incidence of human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) is increasing rapidly in most developed countries. In this Review, the authors provide an overview of the epidemiology, molecular biology and treatment of HPV-positive OPSCC, including discussions of the role of treatment de-escalation and emerging novel therapies. The incidence of human papillomavirus-associated oropharyngeal cancer (HPV+ OPSCC) is expected to continue to rise over the coming decades until the benefits of gender-neutral prophylactic HPV vaccination begin to become manifest. The incidence of HPV+ OPSCC appears to be highest in high-income countries, although more epidemiological data are needed from low- and middle-income countries, in which HPV vaccination coverage remains low. The substantially better prognosis of patients with HPV+ OPSCC compared to those with HPV– OPSCC has been recognized in the American Joint Committee on Cancer TNM8 staging guidelines, which recommend stratification by HPV status to improve staging. The molecular biology and genomic features of HPV+ OPSCC are similar to those of other HPV-associated malignancies, with HPV oncogenes (E6 and E7) acting as key drivers of pathogenesis. Treatment de-intensification is being pursued in clinical trials, although identifying the ~15% of patients with HPV+ OPSCC who have recurrent disease, and who therefore require more intensive treatment, remains a key challenge.
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22
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Shinn JR, Carey RM, Mady LJ, Shimunov D, Parhar HS, Cannady SB, Rajasekaran K, Lukens JN, Lin A, Swisher-McClure S, Cohen RB, Bauml JM, Rassekh CH, Newman JG, Chalian AA, Basu D, Weinstein GS, Brody RM. Sex-based differences in outcomes among surgically treated patients with HPV-related oropharyngeal squamous cell carcinoma. Oral Oncol 2021; 123:105570. [PMID: 34742005 DOI: 10.1016/j.oraloncology.2021.105570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Sex differences in surgically treated HPV-associated oropharyngeal squamous cell carcinoma are not defined due to the low number of affected women. We explored the oncologic outcomes of men and women with p16-positive oropharyngeal squamous cell carinoma treated with primary surgery. MATERIALS AND METHODS Retrospective analysis of patients with HPV-related oropharyngeal cancer treated with surgery and pathology guided adjuvant therapy from 2007 to 2017. Primary end point was recurrence-free and overall survival. RESULTS Of 468 men (86.7%) and 72 women (13.3%), women presented more often with clinical N0 nodal disease (25% vs 12.2%). There were no differences in adverse pathologic features or T stage, although women were more likely to present with N0 disease (16.7% vs 10%), less N2 disease (6.9% vs 17.7%, p = 0.03), and more stage I disease (88.9% vs 75%). As a result, women were more likely to undergo surgery alone (30.6% vs 14.1%) while men were more likely to require adjuvant radiation therapy (47.2% vs 36.1%). Four women (5.6%) and 30 men (6.4%, p = 0.8) died during follow-up. Multivariate analysis controlling for age, sex, treatment, and pathologic stage demonstrated no differences in overall survival between men and women. There were no differences in recurrence-free or overall survival between men and women at two and five years. CONCLUSIONS Although women undergoing transoral robotic surgery for HPV+ oropharyngeal squamous cell carcinoma may have less advanced disease, upfront surgery with pathology-guided adjuvant therapy produces similar oncologic results in men and women while accounting for disease burden.
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Affiliation(s)
- Justin R Shinn
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Ryan M Carey
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Leila J Mady
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States
| | - David Shimunov
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Harman S Parhar
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Steven B Cannady
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - John N Lukens
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Samuel Swisher-McClure
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Roger B Cohen
- Division of Hematology and Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Joshua M Bauml
- Division of Hematology and Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Christopher H Rassekh
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Jason G Newman
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Ara A Chalian
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Devraj Basu
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Gregory S Weinstein
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Robert M Brody
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
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23
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Holcomb AJ, Richmon JD. Surgical margins in a single-modality transoral robotic surgery: A conundrum-Reply. Head Neck 2021; 43:3219-3221. [PMID: 34351028 DOI: 10.1002/hed.26831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/26/2021] [Indexed: 11/07/2022] Open
Affiliation(s)
- Andrew J Holcomb
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy D Richmon
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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24
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Prasad A, Carey RM, Brody RM, Bur AM, Cannady SB, Ojerholm E, Newman JG, Ibrahim S, Brant JA, Rajasekaran K. Postoperative Radiation Therapy Refusal in Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma. Laryngoscope 2021; 132:339-348. [PMID: 34254672 DOI: 10.1002/lary.29743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/29/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVES/HYPOTHESIS Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is a distinct clinical entity with good prognosis, unique demographics, and a trend toward treatment deintensification. Patients with this disease may opt out of recommended postoperative radiation therapy (PORT) for a variety of reasons. The aim of this paper was to examine factors that predict patient refusal of recommended PORT in HPV-associated OPSCC, and the association of refusal with overall survival. STUDY DESIGN Retrospective population-based cohort study of patients in the National Cancer Database. METHODS We conducted a retrospective cohort study of patients in the National Cancer Database diagnosed with OPSCC between January 2010 and December 2015. We primarily assessed overall survival and the odds of refusing PORT based on demographic, socioeconomic, and clinical factors. Analysis was conducted using multivariable logistic regression and multivariable Cox proportional hazards model. RESULTS A total of 4229 patients were included in the final analysis, with 156 (3.7%) patients opting out of recommended PORT. On multivariable analysis, patient refusal of PORT was independently associated with a variety of socioeconomic factors such as race, insurance status, comorbidity, treatment at a single facility, and margin status. Lastly, PORT refusal was associated with significantly lower overall survival compared to receipt of recommended PORT (hazard ratio 1.69, confidence interval 1.02-2.82). CONCLUSIONS Patient refusal of recommended PORT in HPV-associated OPSCC is rare and associated with variety of disease and socioeconomic factors. PORT refusal may decrease overall survival in this population. Our findings may help clinicians when counseling patients and identifying those who may be more likely to opt out of recommended adjuvant therapy. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Aman Prasad
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Ryan M Carey
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Robert M Brody
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Andrés M Bur
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas, Kansas City, Kansas, U.S.A
| | - Steven B Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Eric Ojerholm
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.,Department of Radiation Oncology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, U.S.A
| | - Jason G Newman
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Said Ibrahim
- Department of Population Health Sciences, Weill Cornell Medicine, New York City, New York, U.S.A
| | - Jason A Brant
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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25
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Carey RM, Brody RM, Shimunov D, Shinn JR, Mady LJ, Rajasekaran K, Cannady SB, Lin A, Lukens JN, Bauml JM, Cohen RB, Basu D, O'Malley BW, Weinstein GS, Newman JG. Locoregional Recurrence in p16-Positive Oropharyngeal Squamous Cell Carcinoma After TORS. Laryngoscope 2021; 131:E2865-E2873. [PMID: 34076275 DOI: 10.1002/lary.29659] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/07/2021] [Accepted: 05/12/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To analyze the patterns, risk factors, and salvage outcomes for locoregional recurrences (LRR) after treatment with transoral robotic surgery (TORS) for HPV-associated oropharyngeal squamous cell carcinoma (HPV+ OPSCC). STUDY DESIGN Retrospective analysis of HPV+ OPSCC patients completing primary TORS, neck dissection, and NCCN-guideline-compliant adjuvant therapy at a single institution from 2007 to 2017. METHODS Features associated with LRR, detailed patterns of LRR, and outcomes of salvage therapy were analyzed. Disease-free survival (DFS) and overall survival (OS) were calculated for subgroups of patients receiving distinct adjuvant treatments. RESULTS Of 541 patients who completed guideline-indicated therapy, the estimated 5-year LRR rate was 4.5%. There were no identifiable clinical or pathologic features associated with LRR. Compared to patients not receiving adjuvant therapy, those who received indicated adjuvant radiation alone had a lower risk of LRR (HR 0.28, 95% CI [0.09-0.83], P = .023), but there was no difference in DFS (P = .21) and OS (P = .86) between adjuvant therapy groups. The 5-year OS for patients who developed LRR was 67.1% vs. 93.9% for those without LRR (P < .001). Patients who initially received adjuvant chemoradiation and those suffering local, in-field, and/or retropharyngeal node recurrences had decreased disease control after salvage therapy. CONCLUSION LRR rates are low for HPV+ OPSCCs completing TORS and guideline-compliant adjuvant therapy. Patients without indication for adjuvant therapy more often suffer LRR, but these recurrences are generally controllable by salvage therapy. Improved understanding of the patterns of recurrence most amenable to salvage therapy may guide treatment decisions, counseling, and adjuvant therapy de-escalation trials. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Ryan M Carey
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Robert M Brody
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - David Shimunov
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Justin R Shinn
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Leila J Mady
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Steven B Cannady
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Alexander Lin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - John N Lukens
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Joshua M Bauml
- Department of Internal Medicine, Division of Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Roger B Cohen
- Department of Internal Medicine, Division of Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Devraj Basu
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Bert W O'Malley
- University of Maryland Medical Center, Baltimore, Maryland, U.S.A
| | - Gregory S Weinstein
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jason G Newman
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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26
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Jin Z, Hao D, Song Y, Zhuang L, Wang Q, Yu X. Systemic inflammatory response index as an independent risk factor for ischemic stroke in patients with rheumatoid arthritis: a retrospective study based on propensity score matching. Clin Rheumatol 2021; 40:3919-3927. [PMID: 33966169 DOI: 10.1007/s10067-021-05762-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 04/02/2021] [Accepted: 05/03/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To investigate the relationship between systemic inflammatory response index (SIRI) and ischemic stroke (IS) in rheumatoid arthritis (RA) patients. METHODS Fifty-two RA patients with IS, who were admitted to Wujin Hospital Affiliated with Jiangsu University between 2015 and 2019, were selected as the study group, and 236 RA patients without IS were selected as the control group. Propensity score matching (PSM) function of SPSS 26.0 was used to carry out 1:1 propensity score matching for gender, age, blood pressure, blood glucose, blood lipid, and smoking history of patients in the two groups, and the caliper value was set as 0.02 to obtain covariate balanced samples between groups. When performing blood tests, the following are determined: rheumatoid factor (RF), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), mean platelet volume (MPV), calculated SIRI = (neutrophil × monocyte)/lymphocyte, and completed 28-joint disease activity score (DAS28-CRP). The differences in inflammatory markers between the two groups were compared, the independent risk factors were analyzed by logistic regression, and the auxiliary diagnostic value was evaluated by the receiver operating characteristic (ROC) curve. RESULTS A total of 48 pairs of patients were successfully matched. SIRI in the study group was higher than that in the control group (p < 0.05), and the mean platelet volume (MPV) was lower in the study group than in the control group (p < 0.05). SIRI, DAS28-CRP (r = 0.508, p < 0.01), ESR (r = 0.359, p < 0.05), and CRP (r = 0.473, p < 0.01) were positively correlated. Logistic regression analysis showed that SIRI was an independent IS risk factor in RA patients (odds ratio, 1.30; 95% confidence interval, approximately 1.008-1.678). The optimal threshold for SIRI-assisted diagnosis of patients with RA and IS was 1.62, the area under the ROC curve was 0.721 (p < 0.01), sensitivity was 54.17%, and specificity was 83.33%. CONCLUSION SIRI was independently associated with the occurrence of ischemic stroke in patients with RA. Thus, RA patients with elevated SIRI should be closely monitored. Key points • RA patients with IS had fewer traditional risk factors such as hypertension and diabetes, while inflammatory indicators were significantly increased. • The SIRI have drawn attention in recent years as novel non-specific inflammatory markers. However, only a few studies have been conducted to investigate their value in RA. • This study completes the gaps in the research on the relationship between SIRI and the risk of IS occurrence in RA patients.
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Affiliation(s)
- Zihan Jin
- Department of Clinical Laboratory, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou City, Jiangsu Province, China
| | - Dongli Hao
- Department of Neurology, Wujin Hospital Affiliated with Jiangsu University, Changzhou City, Jiangsu Province, China
| | - Yuanjian Song
- School of Basic Medicine, Xuzhou Medical University, Xuzhou City, Jiangsu Province, China
| | - Lin Zhuang
- Department of Surgery, Wujin Hospital Affiliated with Jiangsu University, Changzhou City, Jiangsu Province, China
| | - Qiang Wang
- Department of Surgery, Wujin Hospital Affiliated with Jiangsu University, Changzhou City, Jiangsu Province, China
| | - Xiaolong Yu
- Science and Education Section, Wujin Hospital Affiliated with Jiangsu University, Changzhou City, Jiangsu Province, China. .,Department of Ultrasonics, The Wujin Clinical College of Xuzhou Medical University, Changzhou City, Jiangsu Province, China. .,Jiangsu Key Laboratory of Immunology and Metabolism (Xuzhou Medical University), Xuzhou City, Jiangsu Province, China.
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