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Molteni G, Bassani S, Arsie AE, Zampieri E, Mannelli G, Orlandi E, Bossi P, De Virgilio A. Role of TORS as De-Escalation Strategy in HPV-Related Oropharyngeal Cancer, What We Need to Know. Healthcare (Basel) 2024; 12:1014. [PMID: 38786424 PMCID: PMC11121063 DOI: 10.3390/healthcare12101014] [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: 03/27/2024] [Revised: 05/04/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) presents unique challenges and opportunities for treatment, particularly regarding de-escalation strategies to reduce treatment morbidity without compromising oncological outcomes. This paper examines the role of Transoral Robotic Surgery (TORS) as a de-escalation strategy in managing HPV-related OPSCC. We conducted a comprehensive literature review from January 2010 to June 2023, focusing on studies exploring TORS outcomes in patients with HPV-positive OPSCC. These findings highlight TORS's potential to reduce the need for adjuvant therapy, thereby minimizing treatment-related side effects while maintaining high rates of oncological control. TORS offers advantages such as precise tumor resection and the ability to obtain accurate pathological staging, which can guide the tailoring of adjuvant treatments. Some clinical trials provide evidence supporting the use of TORS in specific patient populations. The MC1273 trial demonstrated promising outcomes with lower doses of adjuvant radiotherapy (RT) following TORS, showing high locoregional tumor control rates and favorable survival outcomes with minimal side effects. ECOG 3311 evaluated upfront TORS followed by histopathologically directed adjuvant therapy, revealing good oncological and functional outcomes, particularly in intermediate-risk patients. The SIRS trial emphasized the benefits of upfront surgery with neck dissection followed by de-escalated RT in patients with favorable survival and excellent functional outcomes. At the same time, the PATHOS trial examined the impact of risk-adapted adjuvant treatment on functional outcomes and survival. The ongoing ADEPT trial investigates reduced-dose adjuvant RT, and the DART-HPV study aims to compare standard adjuvant chemoradiotherapy (CRT) with a reduced dose of adjuvant RT in HPV-positive OPSCC patients. These trials collectively underscore the potential of TORS in facilitating treatment de-escalation while maintaining favorable oncological and functional outcomes in selected patients with HPV-related OPSCC. The aim of this scoping review is to discuss the challenges of risk stratification, the importance of HPV status determination, and the implications of smoking on treatment outcomes. It also explores the evolving criteria for adjuvant therapy following TORS, focusing on reducing radiation dosage and volume without compromising treatment efficacy. In conclusion, TORS emerges as a viable upfront treatment option for carefully selected patients with HPV-positive OPSCC, offering a pathway toward treatment de-escalation. However, selecting the optimal candidate for TORS-based de-escalation strategies is crucial to fully leverage the benefits of treatment de-intensification.
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Affiliation(s)
- Gabriele Molteni
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Sara Bassani
- Otolaryngology-Head and Neck Surgery Department, University of Verona, 37129 Verona, Italy; (A.E.A.)
| | - Athena Eliana Arsie
- Otolaryngology-Head and Neck Surgery Department, University of Verona, 37129 Verona, Italy; (A.E.A.)
| | - Erica Zampieri
- Otolaryngology-Head and Neck Surgery Department, University of Verona, 37129 Verona, Italy; (A.E.A.)
| | - Giuditta Mannelli
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Firenze, Italy
| | - Ester Orlandi
- Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
- Clinical Department, National Center for Oncological Hadrontherapy (Fondazione CNAO), 27100 Pavia, Italy
| | - Paolo Bossi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Italy;
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
| | - Armando De Virgilio
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
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Lee JJ, Rapoport NA, Pipkorn P, Puram SV, Jackson RS. Airway protection and outcomes after staged versus concurrent bilateral neck dissections with transoral base of tongue cancer resection. Head Neck 2024; 46:1020-1027. [PMID: 38414192 DOI: 10.1002/hed.27696] [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: 04/11/2023] [Revised: 12/30/2023] [Accepted: 02/08/2024] [Indexed: 02/29/2024] Open
Abstract
OBJECTIVES To assess airway, safety, and resource utilization outcomes between transoral base of tongue (BOT) surgery with staged versus concurrent bilateral neck dissections (BND). METHODS A retrospective cohort study of patients with human papilloma virus (HPV)-related BOT cancer who underwent transoral surgery and BND from January 2015 through June 2022 was conducted. Free flap patients were excluded. RESULTS Of 126 patients (46 [37%] staged and 80 [63%] concurrent BND), there were no significant differences in rates of postoperative intubation, tracheostomy, intensive care admission, operative takebacks, gastrostomy, and 30-day readmission. Total operative time (median difference 1.4 [95% CI 0.9-1.8] hours), length of stay (1.0 [1.0-1.0] day), and time between primary surgery and adjuvant therapy initiation (4.0 [0.0-8.0] days) were lower in the concurrent BND cohort. CONCLUSION Concurrent BND alongside transoral BOT resection is safe with similar airway outcomes and lower total operative time, length of stay, and time to adjuvant therapy initiation compared to staged BND.
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Affiliation(s)
- Jake J Lee
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | | | - Patrik Pipkorn
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sidharth V Puram
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Genetics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ryan S Jackson
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Abou Kors T, Hofmann L, Betzler A, Payer K, Bens M, Truong J, von Witzleben A, Thomas J, Kraus JM, Kalaajieh R, Huber D, Ezić J, Benckendorff J, Greve J, Schuler PJ, Ottensmeier CH, Kestler HA, Hoffmann TK, Theodoraki MN, Brunner C, Laban S. INHBA is Enriched in HPV-negative Oropharyngeal Squamous Cell Carcinoma and Promotes Cancer Progression. CANCER RESEARCH COMMUNICATIONS 2024; 4:571-587. [PMID: 38329386 PMCID: PMC10901070 DOI: 10.1158/2767-9764.crc-23-0258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 12/15/2023] [Accepted: 02/06/2024] [Indexed: 02/09/2024]
Abstract
Patients with oropharyngeal squamous cell carcinoma (OPSCC) caused by human papilloma virus (HPV) exhibit a better prognosis than those with HPV-negative OPSCC. This study investigated the distinct molecular pathways that delineate HPV-negative from HPV-positive OPSCC to identify biologically relevant therapeutic targets. Bulk mRNA from 23 HPV-negative and 39 HPV-positive OPSCC tumors (n = 62) was sequenced to uncover the transcriptomic profiles. Differential expression followed by gene set enrichment analysis was performed to outline the top enriched biological process in the HPV-negative compared with HPV-positive entity. INHBA, the highest overexpressed gene in the HPV-negative tumor, was knocked down. Functional assays (migration, proliferation, cell death, stemness) were conducted to confirm the target's oncogenic role. Correlation analyses to reveal its impact on the tumor microenvironment were performed. We revealed that epithelial-to-mesenchymal transition (EMT) is the most enriched process in HPV-negative compared with HPV-positive OPSCC, with INHBA (inhibin beta A subunit) being the top upregulated gene. INHBA knockdown downregulated the expression of EMT transcription factors and attenuated migration, proliferation, stemness, and cell death resistance of OPSCC cells. We uncovered that INHBA associates with a pro-tumor microenvironment by negatively correlating with antitumor CD8+ T and B cells while positively correlating with pro-tumor M1 macrophages. We identified three miRNAs that are putatively involved in repressing INHBA expression. Our results indicate that the upregulation of INHBA is tumor-promoting. We propose INHBA as an attractive therapeutic target for the treatment of INHBA-enriched tumors in patients with HPV-negative OPSCC to ameliorate prognosis. SIGNIFICANCE Patients with HPV-negative OPSCC have a poorer prognosis due to distinct molecular pathways. This study reveals significant transcriptomic differences between HPV-negative and HPV-positive OPSCC, identifying INHBA as a key upregulated gene in HPV-negative OPSCC's oncogenic pathways. INHBA is crucial in promoting EMT, cell proliferation, and an immunosuppressive tumor environment, suggesting its potential as a therapeutic target for HPV-negative OPSCC.
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Affiliation(s)
- Tsima Abou Kors
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Linda Hofmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Annika Betzler
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Kathrina Payer
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Martin Bens
- Fritz Lipmann Institute, Leibniz Institute on Aging, University of Jena, Jena, Germany
| | - Jens Truong
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Adrian von Witzleben
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Jaya Thomas
- Cancer Sciences Unit, University of Southampton, Faculty of Medicine, Southampton, United Kingdom
| | - Johann M Kraus
- Institute for Medical Systems Biology, Ulm University, Ulm, Germany
| | - Randa Kalaajieh
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Diana Huber
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Jasmin Ezić
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | | | - Jens Greve
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Patrick J Schuler
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Christian H Ottensmeier
- Institute of Systems, Molecular and Integrative Biology, Liverpool Head and Neck Center, University of Liverpool, Faculty of Medicine, Liverpool, United Kingdom
| | - Hans A Kestler
- Institute for Medical Systems Biology, Ulm University, Ulm, Germany
| | - Thomas K Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Marie-Nicole Theodoraki
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Cornelia Brunner
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Simon Laban
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
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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 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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Dowthwaite S, Jackson J, Dzienis M, Khoo E, Cronin M, Guazzo E. Management of Recurrent HPV-Positive Oropharyngeal Squamous Cell Carcinoma: a Contemporary Review. Curr Oncol Rep 2023; 25:501-510. [PMID: 36881215 DOI: 10.1007/s11912-023-01386-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE OF REVIEW To review the impact of contemporary treatment strategies on salvage outcomes in patients with recurrent human papilloma virus-positive oropharyngeal squamous cell carcinoma (HPV + OPSCC). RECENT FINDINGS Secondary to HPV, changes in disease biology have impacted primary treatments and subsequent approaches to patients with recurrence. With treatment strategies more inclusive of upfront surgery, the characteristics of patients with recurrence HPV + OPSCC have been further redefined. Less invasive endoscopic surgical approaches such as transoral robotic surgery (TORS), and the continued refinement of conformal radiotherapy techniques, have improved treatment options for patients with recurrent HPV + OPSCC. Systemic treatment options have continued to expand including potentially effective immune-based therapies. Effective surveillance with systemic and oral biomarkers offers hope of earlier detection of recurrence. Management of patients with recurrent OPSCC remains difficult. Modest improvements in salvage treatment have been observed within the HPV + OPSCC cohort largely reflecting disease biology and improved treatment techniques.
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Affiliation(s)
- Sam Dowthwaite
- Gold Coast University Hospital, Department of Otolaryngology/Head and Neck Surgery, Suite 2B, Ground Floor, AHC House, 14 Carrara St Benowa, Benowa, QLD, 4217, Australia.
| | - James Jackson
- Gold Coast University Hospital, Department of Radiation Oncology, Benowa, Australia.,Icon Cancer Centre, Benowa, Australia
| | - Marcin Dzienis
- Gold Coast University Hospital, Department of Medical Oncology, Benowa, Australia
| | - Eric Khoo
- Gold Coast University Hospital, Department of Radiation Oncology, Benowa, Australia.,Icon Cancer Centre, Benowa, Australia
| | - Mathew Cronin
- Gold Coast University Hospital, Department of Otolaryngology/Head and Neck Surgery, Suite 2B, Ground Floor, AHC House, 14 Carrara St Benowa, Benowa, QLD, 4217, Australia
| | - Emily Guazzo
- Gold Coast University Hospital, Department of Otolaryngology/Head and Neck Surgery, Suite 2B, Ground Floor, AHC House, 14 Carrara St Benowa, Benowa, QLD, 4217, Australia
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Olson B, Cahill E, Imanguli M. Feasibility and safety of the da Vinci Xi surgical robot for transoral robotic surgery. J Robot Surg 2022; 17:571-576. [PMID: 35972598 DOI: 10.1007/s11701-022-01449-y] [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: 03/09/2022] [Accepted: 07/21/2022] [Indexed: 11/28/2022]
Abstract
The collective experience supporting the safety and efficacy of transoral robotic surgery continues to grow. The surgical robot da Vinci Xi has been used successfully off-label for head and neck surgery, including transoral robotic surgery. We evaluated operative outcomes and efficacy of the da Vinci Xi surgical robot for transoral surgery and compared our experience with the da Vinci Si and published da Vinci Xi experiences in transoral surgery. Nineteen total cases were retrospectively reviewed, six with the Si and thirteen with the Xi. Our experience with the da Vinci Xi showed similar peri- and postoperative outcomes to our Si experience the available da Vinci Xi literature. We advocate for careful patient selection while also considering the surgical team's experience with TORS. Transoral robotic surgery with the da Vinci Xi has specific advantages, and support is accumulating for its use in TORS. However, this indication remains off-label, and we do not anticipate the manufacturer will seek approval for this indication given the ongoing development and regulatory approvals of da Vinci Single Port for similar indications.
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Affiliation(s)
- Birk Olson
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Ellen Cahill
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Matin Imanguli
- Division of Head and Neck Oncologic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
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Ren ZH, Lei JS, Yang ZM, Zhang S, Yu JJ, Wu HJ. Postoperative radiotherapy may not be necessary for locally advanced head and neck squamous cell carcinoma: a case-match multicentre study. BMC Oral Health 2022; 22:253. [PMID: 35751079 PMCID: PMC9229143 DOI: 10.1186/s12903-022-02288-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background Some head and neck cancer surgeons found that many patients with locally advanced head and neck squamous cell carcinoma (LA-HNSCC) without postoperative radiotherapy (PORT) also have a good prognosis. The purpose of this study was to determine the effect of PORT on survival in patients with LA-HNSCC. Methods A case-match cohort analysis was performed at two institutions on patients with LA-HNSCC. Patients who received surgery alone were case-matched 1: 1 with patients treated by surgery plus PORT based on pT, pN, tumor subsite etc. Results 114 patients were matched into 57 pairs, with a median follow-up period of 40.2 months. No difference in overall survival (OS, HR 0.88; 95% CI 0.50–1.58; P = 0.79) or disease-specific survival (DFS, 0.86; 95% CI 0.50–1.50; P = 0.76) was observed with no PORT. Conclusions PORT isn’t necessary for patients with LA-HNSCC who are treated for the first time as long as the head and neck cancer surgeon adhere to appropriate surgical concepts. The indications of PORT for patients with LA-HNSCC need to be further discussed.
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Affiliation(s)
- Zhen-Hu Ren
- Department of Oral and Maxillofacial Surgery, Second Xiangya Hospital of Central South University, Changsha, Hunan, China.,Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Jiao Tong University School of Medicine; College of Stomatology, Shanghai Jiao Tong University; National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - Jing-Shi Lei
- Department of Oral and Maxillofacial Surgery, Second Xiangya Hospital of Central South University, Changsha, Hunan, China.,Department of Oral Implantology, School and Hospital of Stomatology, Shanghai Engineering Research Center of Tooth Restoration and Regeneration, Tongji University, Shanghai, China
| | - Zhi-Min Yang
- Department of Oral and Maxillofacial Surgery, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Sheng Zhang
- Department of Oral and Maxillofacial Surgery, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jian-Jun Yu
- Department of Head and Neck Surgery, Hunan Cancer Hospital, Changsha, Hunan, China.
| | - Han-Jiang Wu
- Department of Oral and Maxillofacial Surgery, Second Xiangya Hospital of Central South University, Changsha, Hunan, China.
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Petrelli F, Luciani A, Ghidini A, Cherri S, Gamba P, Maddalo M, Bossi P, Zaniboni A. Treatment de-escalation for HPV+ oropharyngeal cancer: A systematic review and meta-analysis. Head Neck 2022; 44:1255-1266. [PMID: 35238114 DOI: 10.1002/hed.27019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 02/13/2022] [Accepted: 02/17/2022] [Indexed: 12/12/2022] Open
Abstract
Human Papillomavirus (HPV) related oropharyngeal carcinoma (OPC) carries a better prognosis compared with HPV-counterparts, thereby pushing the adoption of de-intensification treatment approaches as new strategies to preserve superior oncologic outcomes while minimizing toxicity. We evaluated the effect of treatment de-intensification in terms of overall survival (OS), progression-free survival (PFS), locoregional and distant control (LRC and DM) by selecting prospective or retrospective studies, providing outcome data with reduced intensification versus standard curative treatment in HPV+ OPC patients, with a systematic analysis till September 2020. The primary outcome of interest was OS. Secondary endpoints were PFS, LRC, and DM expressed as HR. A total of 55 studies (from 1393 screened references) were employed for quantitative synthesis for 38 929 patients. Among n = 48 studies with data available, de-intensified treatments reduced OS in HPV+ OPCs (HR = 1.33, 95% CI 1.17-1.52; p < 0.01). In de-escalated treatments, PFS was also decreased (HR = 2.11, 95% CI 1.65-2.69; p < 0.01). Compared with standard treatments, reduced intensity approaches were associated with reduced locoregional and distant disease control (HR = 2.51, 95% CI 1.75-3.59; p < 0.01; and HR = 1.9, 95% CI 1.25-2.9; p < 0.01). Chemoradiation improved survival in a definitive curative setting compared with radiotherapy alone (HR = 1.42, 95% CI 1.16-1.75; p < 0.01). When adjuvant treatments were compared, standard and de-escalation strategies provided similar OS. In conclusion, in patients with HPV+ OPC, de-escalation treatments should not be widely and agnostically adopted in clinical practice, as therein lies a concrete risk of offering a sub-optimal treatment to patients.
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Affiliation(s)
| | | | | | - Sara Cherri
- Oncology Unit, Fondazione Poliambulanza, Brescia, Italy
| | - Paolo Gamba
- Otolaryngology Unit, Fondazione Poliambulanza, Brescia, Italy
| | - Marta Maddalo
- Department of Radiation Oncology, University of Brescia and Spedali Civili, Brescia, Italy
| | - Paolo Bossi
- Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences, Public Health, University of Brescia, Brescia, Italy
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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: 244] [Impact Index Per Article: 122.0] [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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Thakar A, Panda S, Kakkar A, Singh V, Singh CA, Sharma A, Bhasker S, Krishnamurthy P, Sharma SC. A matched pair analysis of oncological outcomes in human papillomavirus-negative oropharyngeal squamous cell carcinoma: Transoral surgery versus radiotherapy or concurrent chemoradiation. Head Neck 2021; 43:2896-2906. [PMID: 34050557 DOI: 10.1002/hed.26771] [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: 12/10/2020] [Revised: 04/19/2021] [Accepted: 05/20/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND With the termination of RTOG 1221, there remains a lacuna regarding the optimal treatment for human papillomavirus (HPV)-negative oropharyngeal squamous cell carcinoma (OPSCC). METHODS Matched pair analysis with propensity score matching (PSM) between Arm I (transoral surgery [TOS] + risk-stratified adjuvant treatment) and Arm II (nonsurgical treatment - radiation/chemoradiation) in HPV(-) OPSCC. RESULTS Unmatched comparison of Arm I (n = 57) and Arm II (n = 89) indicated significantly better overall survival (OS) and disease-free survival (DFS) for Arm I. PSM by matched pairs (n = 48, 24 each arm) indicated 5-year OS at 80% and 72.1%, respectively, for Arm I and II (p > 0.05) and corresponding DFS at 65.3% and 33.4% (p > 0.05). Subgroup analysis did not demonstrate statistical difference in outcomes in stage II and III, but stage IV tumors had significantly better outcomes in Arm I than Arm II (4-year OS: 100% vs. 21%, p = 0.04; DFS: 75% vs. 14.3%, p = 0.04). CONCLUSIONS TOS +/- adjuvant was found to have oncological outcomes at par with nonsurgical modalities in stage I-III OPSCC, whereas a distinct survival advantage was noted in case of stage IV tumors.
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Affiliation(s)
- Alok Thakar
- Department of Otorhinolaryngology - Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Smriti Panda
- Department of Otorhinolaryngology - Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Aanchal Kakkar
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Vishwajeet Singh
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Chirom Amit Singh
- Department of Otorhinolaryngology - Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Sharma
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Suman Bhasker
- Department of Radiotherapy, All India Institute of Medical Sciences, New Delhi, India
| | - Padmavathi Krishnamurthy
- Department of Otorhinolaryngology - Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Suresh C Sharma
- Department of Otorhinolaryngology - Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
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11
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Ryan WR, Xu MJ, Ochoa E, Plonowska-Hirschfeld KA, Zebolsky AL, Ha PK, Bewley AF, Mallen-St Clair J, Joshi AS, Coffey CS, Faraji F, MacDonald BV, Houlton JJ, Gobillot TA, Curry JM, Philips R, Hackman TG, Richmon JD, Holcomb AJ, Coughlin AM, Panwar A, Smith RB, Herberg ME, Fakhry C, Cognetti DM. Oncologic outcomes of human papillomavirus-associated oropharynx carcinoma treated with surgery alone: A 12-institution study of 344 patients. Cancer 2021; 127:3092-3106. [PMID: 33957701 DOI: 10.1002/cncr.33611] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/11/2021] [Accepted: 02/19/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The oncologic outcomes of surgery alone for patients with American Joint Committee on Cancer 7th edition (AJCC 7th) pN2a and pN2b human papillomavirus-associated oropharynx squamous cell carcinoma (HPV+OPSCC) are not clear. METHODS The authors performed a 12-institution retrospective study of 344 consecutive patients with HPV+OPSCC (AJCC 7th pT0-3 N3 M0) treated with surgery alone with 6 months or more of follow-up using univariate and multivariate analyses. RESULTS The 2-year outcomes for the entire cohort were 91% (182 of 200) disease-free survival (DFS), 100% (200 of 200) disease-specific survival (DSS), and 98% (200 of 204) overall survival (OS). The 18 recurrences within 2 years were 88.9% (16 of 18) local and/or regional recurrences and 11.1% (2 of 18) distant metastases. Recurrences were not significantly associated with smoking, pT stage, or pN stage. The 16 patients with locoregional recurrences within 2 years all underwent successful salvage treatments (median follow-up after salvage: 13.1 months), 43.8% (7 of 16) of whom underwent salvage surgery alone for a 2-year overall salvage radiation need of 4.5% (9 of 200). The 2-year outcomes for the 59 evaluable patients among the 109 AJCC 7th pT0-2 N2a-N2b patients with 1 to 3 pathologic lymph nodes (LNs) were as follows: local recurrence, 3.4% (2 of 59); regional recurrence, 8.4% (5 of 59); distant metastases, 0%; DFS, 88.1% (52 of 59); DSS, 100% (59 of 59); OS, 96.7% (59 of 61); and salvage radiation, 5.1% (3 of 59). CONCLUSIONS With careful selection, surgery alone for AJCC 7th pT0-T2N0-N2b HPV+OPSCC with zero to 3 pathologic LNs without perineural invasion, extranodal extension, or positive margins results in high DFS, DSS, OS, and salvage treatment success. Because of the short-term follow-up, these data support further investigation of treatment de-escalation in this population.
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Affiliation(s)
- William R Ryan
- Division of Head and Neck Oncologic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California
| | - Mary J Xu
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California
| | - Edgar Ochoa
- School of Medicine, University of California San Francisco, San Francisco, California
| | | | - Aaron L Zebolsky
- Homer Stryker MD School of Medicine, Western Michigan University, Kalamazoo, Michigan
| | - Patrick K Ha
- Division of Head and Neck Oncologic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California
| | - Arnaud F Bewley
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis Medical Center, Sacramento, California
| | | | - Arjun S Joshi
- Division of Head and Neck Oncologic Surgery, Department of Surgery, George Washington University School of Medicine, Washington, DC
| | - Charles S Coffey
- Division of Otolaryngology/Head and Neck Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Farhoud Faraji
- Division of Otolaryngology/Head and Neck Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Bridget V MacDonald
- School of Medicine, University of California San Diego, La Jolla, California
| | - Jeffrey J Houlton
- Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington
| | - Theodore A Gobillot
- School of Medicine, University of Washington Medical Center, Seattle, Washington
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ramez Philips
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Trevor G Hackman
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts
| | - Andrew J Holcomb
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts.,Head and Neck Surgical Oncology, Nebraska Methodist Health System, Omaha, Nebraska
| | - Andrew M Coughlin
- Head and Neck Surgical Oncology, Nebraska Methodist Health System, Omaha, Nebraska
| | - Aru Panwar
- Head and Neck Surgical Oncology, Nebraska Methodist Health System, Omaha, Nebraska
| | - Russell B Smith
- Section of Head and Neck Surgical Oncology, Baptist MD Anderson Cancer Physicians, Baptist Medical Center, Jacksonville, Florida
| | - Matthew E Herberg
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Carole Fakhry
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - David M Cognetti
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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12
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Chen SY, Sinha P, Last A, Ettyreddy A, Kallogjeri D, Pipkorn P, Rich JT, Zevallos JP, Paniello R, Puram SV, Van Abel K, Moore EJ, Oppelt P, Palka K, Adkins D, Daly M, Gay H, Thorstad WL, Jackson RS. Outcomes of Patients With Single-Node Metastasis of Human Papillomavirus-Related Oropharyngeal Cancer Treated With Transoral Surgery. JAMA Otolaryngol Head Neck Surg 2021; 147:16-22. [PMID: 33151273 DOI: 10.1001/jamaoto.2020.3870] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance Regional lymph node metastasis remains an important prognostic factor in patients with oropharyngeal squamous cell carcinoma (OPSCC). Although survival among patients with regional metastasis in human papillomavirus (HPV)-related OPSCC is more favorable compared with patients who are HPV negative, prognostic variables associated with failure in patients with single-node metastasis are not known. Objective To evaluate recurrence and survival in patients with HPV-related OPSCC with single-lymph node metastasis treated with transoral surgery. Design, Setting, and Participants A retrospective cohort study was conducted of 207 adults with newly diagnosed p16-positive OPSCC and pathology-confirmed single-node disease who underwent surgical resection with or without adjuvant therapy at 2 tertiary academic medical centers from January 1, 2007, to December 31, 2016. Statistical analysis was performed from September 1, 2018, to September 1, 2020. Interventions Surgery alone (n = 59), surgery with adjuvant radiation (n = 75), or surgery with adjuvant chemoradiation (n = 73). Main Outcomes and Measures The primary outcome was regional recurrence. Secondary outcomes included overall survival, any recurrence, and identification of factors associated with regional recurrence and overall survival. Results Among 207 patients, 178 (86%) were men, with a median age of 57 years (range, 35-82 years) at the time of surgery. Median follow-up was 36.2 months (range, 7-127 months). Regional recurrence occurred in 11 patients (5%). Of these, 1 patient (9%) was lost to follow-up after diagnosis, 1 (9%) was treated with palliative chemotherapy, and 9 (82%) were treated with curative intent. Ultimately, 7 patients received successful salvage treatment, and 3 died with disease. Overall, there were 21 patients (10%) with any recurrence, with 4 patients (19%) experiencing local recurrence, 11 (52%) experiencing regional recurrence, and 6 (29%) experiencing distant metastasis. The 5-year overall survival was 95% (95% CI, 89%-98%) for all patients. Older age (odds ratio [OR], 1.2; 95% CI, 1.1-1.2), advanced T stage (OR, 3.5; 95% CI, 0.9-14.0), and positive margins (OR, 10.9; 95% CI, 1.8-67.5) were associated with increased regional recurrence. Extranodal extension (OR, 0.2; 95% CI, 0.04-0.8), lymph node size greater than 3 cm (OR, 0.2; 95% CI, 0.1-0.7), and adjuvant therapy (OR, 0.08; 95% CI, 0.02-0.4) were associated with decreased regional recurrence. Advanced comorbidities (hazard ratio, 6.20; 95% CI, 1.4-27.7), lymphovascular invasion (hazard ratio, 4.7; 95% CI, 1.0-21.2), and regional recurrence (hazard ratio, 16.0; 95% CI, 3.1-82.0) were associated with worse overall survival. Conclusions and Relevance The findings of this cohort study suggest that patients with HPV-related OPSCC and single-node disease undergoing surgical resection with or without adjuvant treatment have excellent survival. Adjuvant therapy appears to improve regional control. Among patients with regional recurrence of OPSCC, there is a high rate of successful salvage treatment.
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Affiliation(s)
- Stephanie Y Chen
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Parul Sinha
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Aisling Last
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Abhinav Ettyreddy
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Dorina Kallogjeri
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri.,Statistics Editor, JAMA Otolaryngology-Head & Neck Surgery
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Jason T Rich
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Jose P Zevallos
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Randal Paniello
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Katheryn Van Abel
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - Eric J Moore
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - Peter Oppelt
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Kevin Palka
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Douglas Adkins
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Mackenzie Daly
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Hiram Gay
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Wade L Thorstad
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
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13
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Ochoa E, Stanford-Moore G, Fakhry C, Ryan WR. Predicting Adverse Histopathology and Need for Postsurgical Adjuvant Therapy for Human Papilloma Virus-Associated Oropharynx Carcinoma. Otolaryngol Head Neck Surg 2021; 165:309-316. [PMID: 33399518 DOI: 10.1177/0194599820982913] [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] [Indexed: 12/14/2022]
Abstract
OBJECTIVE For human papillomavirus-associated oropharynx carcinoma treated with definitive surgery, we aimed to find predictors of adverse histopathology indicating the possible need for adjuvant therapy. STUDY DESIGN Retrospective review. SETTING National Cancer Database. METHODS We analyzed 2347 eligible patients from 2010 to 2015. We evaluated (1) the ability of clinical nodal staging and extranodal extension designation per the AJCC, seventh edition (American Joint Committee on Cancer), to predict histopathology and (2) the likelihoods for adverse postsurgery histopathology by common clinical stages. RESULTS Clinical nodal staging predicted pathologic nodal staging 65% of the time, with 24% (569/2347) being upstaged and 11% (251/2347) being downstaged. In patients with cN+ disease, clinical extranodal extension distinction had the following accuracy for pathologic extranodal extension: positive predictive value, 81% (88/109); negative predictive value, 73.1% (505/691); sensitivity, 32.1% (88/274); and specificity, 96.0% (505/526). Patients with cT1-2, N0-N2c, without clinical extranodal extension had the following proportions of pN2+ without pathologic extranodal extension (indicating consideration for adjuvant radiation): cN0, 11%; cN1, 31%; cN2a, 67% (8% downstaged); cN2b, 66% (6% downstaged); and cN2c, 35% (17% downstaged). From this group, patients had the following proportions of pathologic extranodal extension (indicating consideration for adjuvant chemoradiation): cN0, 6%; cN1, 20%; cN2a, 27%; cN2b, 28%; and cN2c, 48%. CONCLUSION For human papillomavirus-associated oropharynx carcinoma, nodal clinical staging per the American Joint Committee on Cancer, seventh edition, predicts pathologic stage about two-thirds of the time, leading to up- and downstaging. Clinical extranodal extension assessment has low sensitivity and moderate predictive capability. With careful selection, definitive surgery can allow patients to often avoid adjuvant chemotherapy and sometimes avoid adjuvant radiation.
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Affiliation(s)
- Edgar Ochoa
- School of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Gaelen Stanford-Moore
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Carole Fakhry
- Division of Head and Neck Cancer Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - William R Ryan
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
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14
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HPV/p16-positive oropharyngeal cancer treated with transoral robotic surgery: The roles of margins, extra-nodal extension and adjuvant treatment. Am J Otolaryngol 2021; 42:102793. [PMID: 33130532 DOI: 10.1016/j.amjoto.2020.102793] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) treatment outcomes are re-defining management. Traditional margins, the role of extranodal extension (ENE) and adjuvant treatment intensity continue to be debated. This study aimed to determine the impact of margins, ENE and adjuvant therapy on survival following transoral robotic surgery (TORS). METHODS Patients treated with TORS at an academic center were retrospectively identified (2013-2019). Survival outcomes were evaluated using Kaplan-Meier curves. RESULTS 48 patients were included. 40 (83%) were male. Mean age was 61.2 years. 43 (90%) were stage I. 22 (45.8%) had ENE. 31 (65%) had margins >1 mm. 38 (79%) had indications for radiation therapy; 9 (24%) refused. Chemotherapy was recommended in 36 (75%) patients; 24 (67%) refused. Locoregional control was 98%, metastasis-free survival was 96%, and disease-specific survival was 100% at 5-years. Overall survival was 95%. CONCLUSIONS Given the high survival rate seen after TORS, it is likely that margins, ENE and adjuvant treatment may not significantly contribute to outcomes.
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15
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Gal TJ, O'Brien KJ, Chen Q, Huang B. Clinical vs Microscopic Extranodal Extension and Survival in Oropharyngeal Carcinoma in the Human Papillomavirus Era. Otolaryngol Head Neck Surg 2020; 162:693-701. [PMID: 32151208 DOI: 10.1177/0194599820910431] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Extranodal extension (ENE) is known to be associated with poor outcomes in head and neck squamous cell carcinoma. The objective of this study is to examine the impact of extent of ENE on survival in oropharyngeal carcinoma in the human papillomavirus (HPV) era. STUDY DESIGN Retrospective database review. SETTING Review of the National Cancer Database. SUBJECTS AND METHODS The National Cancer Database was used to examine surgically treated head and neck squamous cell carcinoma of the tonsil and base of tongue from 2010 to 2015. Nodes available for pathologic examination were classified as ENE negative (-), ENE clinically (+), or ENE (+) on pathology only. The primary outcome was overall survival. Cox regression modeling was used to examine the effect of ENE on survival while controlling for patient demographics, HPV status, stage, adjuvant radiation, and chemotherapy. RESULTS Of the 66,106 patients identified, 16,845 were treated with surgery ± adjuvant therapy, 8780 of whom were known HPV+. Overall 5-year survival for this group was 86%. Documented ENE was associated with over a 60% decrease in survival for clinical (hazard ratio [HR], 1.63) and pathologic (HR, 1.62) ENE compared to negative ENE, after adjustment for stage, adjuvant radiation ± chemotherapy, HPV, and other variables. No significant differences were found between clinical and pathologic ENE (HR, 1.001). CONCLUSION While both surgically resected clinical and pathologic ENE are associated with decreased survival, no significant differences are observed between the two. The impact of these observations on potential de-escalation therapeutic strategies requires further study.
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Affiliation(s)
- Thomas J Gal
- Department of Otolaryngology, University of Kentucky, Lexington, Kentucky, USA
| | | | - Quan Chen
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky, USA
| | - Bin Huang
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky, USA
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16
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Hardman J, Liu Z, Brady G, Roe J, Kerawala C, Riva F, Clarke P, Kim D, Bhide S, Nutting C, Harrington K, Paleri V. Transoral robotic surgery for recurrent cancers of the upper aerodigestive tract—Systematic review and meta‐analysis. Head Neck 2020; 42:1089-1104. [DOI: 10.1002/hed.26100] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/04/2019] [Accepted: 01/28/2020] [Indexed: 11/09/2022] Open
Affiliation(s)
- John Hardman
- Head and Neck Unit The Royal Marsden NHS Foundation Trust London UK
- Institute of Cancer Research London UK
| | - ZiWei Liu
- Head and Neck Unit The Royal Marsden NHS Foundation Trust London UK
| | - Grainne Brady
- Department of Speech and Language Therapy The Royal Marsden NHS Foundation Trust London UK
| | - Justin Roe
- Department of Speech and Language Therapy The Royal Marsden NHS Foundation Trust London UK
- Department of Surgery and Cancer Imperial College London UK
- Department of Otolaryngology Head and Neck Surgery, Imperial College Healthcare NHS Trust London UK
| | - Cyrus Kerawala
- Head and Neck Unit The Royal Marsden NHS Foundation Trust London UK
| | - Francesco Riva
- Head and Neck Unit The Royal Marsden NHS Foundation Trust London UK
| | - Peter Clarke
- Head and Neck Unit The Royal Marsden NHS Foundation Trust London UK
- Department of Otolaryngology Head and Neck Surgery, Imperial College Healthcare NHS Trust London UK
| | - Dae Kim
- Head and Neck Unit The Royal Marsden NHS Foundation Trust London UK
- Institute of Cancer Research London UK
| | - Shreerang Bhide
- Head and Neck Unit The Royal Marsden NHS Foundation Trust London UK
- Institute of Cancer Research London UK
| | - Christopher Nutting
- Head and Neck Unit The Royal Marsden NHS Foundation Trust London UK
- Institute of Cancer Research London UK
| | - Kevin Harrington
- Head and Neck Unit The Royal Marsden NHS Foundation Trust London UK
- Institute of Cancer Research London UK
| | - Vinidh Paleri
- Head and Neck Unit The Royal Marsden NHS Foundation Trust London UK
- Institute of Cancer Research London UK
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17
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Gal T, Slezak JA, Kejner AE, Chen Q, Huang B. Treatment trends in oropharyngeal carcinoma: Surgical technology meets the epidemic. Oral Oncol 2019; 97:62-68. [DOI: 10.1016/j.oraloncology.2019.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/01/2019] [Accepted: 08/06/2019] [Indexed: 12/28/2022]
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18
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Modesto A, Galissier T, Lusque A, Delord JP, Uro-Coste E, Sarini J, Mouchet F, Lopez R, Laprie A, Graff P, Vergez S, Rives M. Definitive radiochemotherapy or initial surgery for oropharyngeal cancer : To what extent can p16 expression be used in the decision process? Strahlenther Onkol 2019; 195:496-503. [PMID: 30877351 DOI: 10.1007/s00066-019-01451-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 02/27/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The decision between definitive radio(chemo)therapy (RCT) or a surgical strategy, i. e. surgery ± adjuvant radio(chemo)therapy for optimal treatment of oropharyngeal cancer is highly debated. Human papillomavirus(HPV)-related tumours are a distinct entity associated with p16 overexpression. While this represents a major prognostic factor, its predictive significance remains unknown. RESULTS Among 183 consecutive unselected patients treated between 2009 and 2013 with a state-of-the-art surgical procedure ± adjuvant radio(chemo)therapy or definitive RCT including intensity-modulated radiotherapy, 3‑year disease-free survival (DFS) was 74 vs. 57%, respectively (p = 0.007). When focusing on p16+ patients (49%), there was no significant difference in tumour control rate between surgery ± radio(chemo)therapy and the definitive RCT group (3-year DFS 83 vs. 82%, respectively; p = 0.48). However, delayed severe dysphagia was significantly lower in favour of definitive RCT: 35 vs. 4%, respectively; p = 0.0002. CONCLUSION Our results highlight distinct outcomes after definitive RCT or initial surgical treatment according to p16 status, which should thus be considered during the decision process.
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Affiliation(s)
- Anouchka Modesto
- Radiation Oncology Department, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, 1 avenue Irène Joliot-Curie, Cedex 9, 31059, Toulouse, France.
| | - Thibaut Galissier
- Pathology Department, Centre Hospitalo-Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse, 1 avenue Irène Joliot-Curie, Cedex 9, 31059, Toulouse, France
| | - Amélie Lusque
- Biostatistics Department, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, 1 avenue Irène Joliot-Curie, Cedex 9, 31059, Toulouse, France
| | - Jean-Pierre Delord
- Medical Oncology Department, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, 1 avenue Irène Joliot-Curie, Cedex 9, 31059, Toulouse, France
| | - Emmanuelle Uro-Coste
- Pathology Department, Centre Hospitalo-Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse, 1 avenue Irène Joliot-Curie, Cedex 9, 31059, Toulouse, France
| | - Jérôme Sarini
- Head and Neck Surgery Department, Centre Hospitalo-Universitaire de Larrey, Institut Universitaire du Cancer de Toulouse, 1 avenue Irène Joliot-Curie, Cedex 9, 31059, Toulouse, France
| | - Frédéric Mouchet
- Head and Neck Surgery Department, Clinique Ambroise Paré, Toulouse, France
| | - Raphaël Lopez
- Maxillo-facial Surgery Department, CHU Toulouse Purpan, 1 place Baylac, Toulouse, France
| | - Anne Laprie
- Radiation Oncology Department, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, 1 avenue Irène Joliot-Curie, Cedex 9, 31059, Toulouse, France
| | - Pierre Graff
- Radiation Oncology Department, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, 1 avenue Irène Joliot-Curie, Cedex 9, 31059, Toulouse, France
| | - Sébastien Vergez
- Head and Neck Surgery Department, Centre Hospitalo-Universitaire de Larrey, Institut Universitaire du Cancer de Toulouse, 1 avenue Irène Joliot-Curie, Cedex 9, 31059, Toulouse, France
| | - Michel Rives
- Radiation Oncology Department, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, 1 avenue Irène Joliot-Curie, Cedex 9, 31059, Toulouse, France
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Cramer JD, Ferris RL, Kim S, Duvvuri U. Primary surgery for human papillomavirus-associated oropharyngeal cancer: Survival outcomes with or without adjuvant treatment. Oral Oncol 2018; 87:170-176. [PMID: 30527235 DOI: 10.1016/j.oraloncology.2018.10.039] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/26/2018] [Accepted: 10/30/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Human papillomavirus-associated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC) is a unique form of head and neck cancer with improved prognosis. We assessed survival for stage I patients with low- or intermediate-risk pathologic features with surgery alone compared with surgery with adjuvant radiation (RT) or chemoradiation (CRT). MATERIALS AND METHODS We identified patients with stage I HPV+ OPSCC (after restaging with 8th edition staging system) treated with surgery alone, adjuvant RT or CRT in the National Cancer Data Base from 2010 to 2013. We compared survival for low-risk patients (≤1 metastatic lymph nodes with no adverse features) and intermediate-risk patients (2-4 metastatic lymph nodes, microscopic extranodal extension (ENE) or lymphovascular invasion). RESULTS We examined 1677 patients with median follow-up of 43.9 months. In the intermediate-risk group, 4-year overall survival was 94.0% with surgery alone, 91.5% with adjuvant RT and 92.0% with adjuvant CRT (p = 0.72). There were similar rates of overall survival in the low-risk group. In multivariable models accounting for clinicopathologic differences the dose of adjuvant RT was not associated with mortality. On Cox proportional hazard modeling, adjuvant RT (HR 0.94; CI 0.43-2.08) or CRT (HR 0.96; CI 0.45-2.11) did not significantly improved survival compared with surgery alone in the intermediate-risk group (reference). Similar results were seen in the low-risk group. The composite number of pathologic risk features significantly improved risk stratification. CONCLUSION We provide observational evidence that adjuvant RT or CRT does not provide a survival benefit for stage I HPV+ OPSCC with low- or intermediate-risk pathologic features.
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Affiliation(s)
- John D Cramer
- Department of Otolaryngology - Head and Neck Surgery, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI, United States.
| | - Robert L Ferris
- Department of Otolaryngology - Head and Neck Surgery, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Seungwon Kim
- Department of Otolaryngology - Head and Neck Surgery, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Umamaheswar Duvvuri
- Department of Otolaryngology - Head and Neck Surgery, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Sinha P, Haughey BH, Kallogjeri D, Jackson RS. Long‐term analysis of transorally resected p16 + Oropharynx cancer: Outcomes and prognostic factors. Laryngoscope 2018; 129:1141-1149. [DOI: 10.1002/lary.27472] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Parul Sinha
- Department of Otolaryngology–Head and Neck SurgeryWashington University School of Medicine St. Louis Missouri U.S.A
| | - Bruce H. Haughey
- Department of Head and Neck SurgeryFlorida Hospital Celebration Health, Celebration Florida U.S.A
- Department of SurgeryUniversity of Auckland Faculty of Medicine and Health Sciences Auckland New Zealand
| | - Dorina Kallogjeri
- Department of Otolaryngology–Head and Neck SurgeryWashington University School of Medicine St. Louis Missouri U.S.A
| | - Ryan S. Jackson
- Department of Otolaryngology–Head and Neck SurgeryWashington University School of Medicine St. Louis Missouri U.S.A
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21
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Philouze P, Céruse P, Thariat J. [Surgery or radiotherapy for oropharyngeal HPV-positive tumours?]. Cancer Radiother 2018; 22:481-486. [PMID: 30145091 DOI: 10.1016/j.canrad.2018.07.125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 07/03/2018] [Accepted: 07/04/2018] [Indexed: 10/28/2022]
Abstract
Oropharyngeal carcinomas related to the human papilloma virus (HPV; usually HPV16) exhibit biological differences in terms of carcinogenesis and are of relatively better prognosis (in the absence of tobacco consumption) compared to tobacco-related cancers. The therapeutic strategies between these two forms of cancers of the upper aerodigestive tract related to different risk factors are however identical, except therapeutic trial. In the absence of a sufficient level of evidence to define a specific strategy for induced HPV carcinomas, the analysis of the recent literature nonetheless allows us to suggest ways to guide the clinician in his therapeutic choice. Given the relative good prognosis HPV+ oropharyngeal cancers, an important goal is to avoid if possible a multimodal treatment that increases the sequelae and could degrade the quality of life. For the early stages I/II, it may be desirable to propose minimally invasive surgery if radiotherapy is avoidable or an exclusive conformal radiation therapy by intensity modulation in the opposite case. For the advanced stages III/IV, the recommendations are similar to those of cancers not related to HPV. Current trials should provide answers on the relevance of therapeutic deflation (absence of chemotherapy in the event of capsular rupture, dose reduction or irradiation volumes, etc.).
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Affiliation(s)
- P Philouze
- Département de cancérologie cervicofaciale, Groupement hospitalier Nord, hospices civils de Lyon, 103, grande-rue de la Croix-Rousse, 69004 Lyon, France; Université Lyon 1, 69000 Lyon, France
| | - P Céruse
- Département de cancérologie cervicofaciale, Groupement hospitalier Nord, hospices civils de Lyon, 103, grande-rue de la Croix-Rousse, 69004 Lyon, France; Université Lyon 1, 69000 Lyon, France
| | - J Thariat
- Département de radiothérapie/archade, Normandie, centre François-Baclesse, 3, avenue du Général-Harris, 14000 Caen, France; Université UniCaen, 14000 Caen, France
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22
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Transoral surgery (TOS) in oropharyngeal cancer: Different tools, a single mini-invasive philosophy. Surg Oncol 2018; 27:643-649. [PMID: 30449487 DOI: 10.1016/j.suronc.2018.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 07/21/2018] [Accepted: 08/16/2018] [Indexed: 12/13/2022]
Abstract
Surgery with or without adjuvant therapy and radiotherapy with or without chemotherapy have traditionally represented the possible treatment options for oropharyngeal cancer. The adverse effects of non-surgical treatments and recent technical innovations have prompted a new interest in the surgical approach. However, in parallel to the possibility of achieving radical cancer clearance, we should remember the impact that traditional open surgery has on the patient's cosmesis, functionality and quality of life. As a result, transoral surgery is an attractive option for oropharyngeal tumors. The term "transoral surgery" only indicates that the tumor is accessed and resected via the oral cavity, but the surgeon can choose among different resection methods, such as transoral laser microsurgery, transoral robotic surgery, transoral videolaryngoscopic surgery, endoscopic laryngo-pharyngeal surgery, and transoral ultrasound surgery. The aim of this paper is to review the recent literature on the transoral treatment of oropharyngeal cancer, to standardize the terminology of transoral procedures, analyzing the common aspects, main differences and future perspectives of the various forms of transoral surgery.
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Cohen N, Fedewa S, Chen AY. Epidemiology and Demographics of the Head and Neck Cancer Population. Oral Maxillofac Surg Clin North Am 2018; 30:381-395. [PMID: 30078696 DOI: 10.1016/j.coms.2018.06.001] [Citation(s) in RCA: 189] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Head and neck malignancies comprise a heterogeneous group of malignancies that cause significant morbidity to those affected. These malignancies are associated with specific risk factors and exposures, some of which impact prognosis. The most common risk factors for developing head and neck cancers are tobacco and alcohol use. Marijuana and e-cigarettes, occupational exposures, and use of topical substances have also been linked to head and neck cancers. Human papilloma virus has been associated with oropharyngeal cancer. Such measures as oral hygiene, screening, smoking cessation, and vaccination are measures taken to decrease the incidence and morbidity of head and neck cancers.
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Affiliation(s)
- Natasha Cohen
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, 550 Peachtree Street. MOT 1135, Atlanta, GA 30308, USA
| | - Stacey Fedewa
- American Cancer Society, 250 Williams Street. NW, Atlanta, GA 30303, USA
| | - Amy Y Chen
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, 550 Peachtree Street. MOT 1135, Atlanta, GA 30308, USA.
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