Outcomes of mandibular reconstruction using three-dimensional custom-made porous titanium prostheses

BACKGROUND

Our aim was to report the long-term outcomes of mandibular reconstruction using CAD-CAM-designed 3D-printed porous titanium implants in patients not amenable to a free vascularized fibula flap reconstruction.

METHODS

The implants were designed with ProPlan CMF® 2.2 software and manufactured with a Selective Laser Melting (SLM) "layer-by-layer" 3D-printing of pure porous titanium powder beds. Primary endpoints were implant exposure and implant removal calculated using Gray's tests. Secondary endpoints were predictive factors of implant exposure and implant removal, and rates of dental rehabilitation.

RESULTS

Thirty-six patients were operated between 2015 and 2017 and were included in this study. Reconstruction using a porous titanium 3D-printed implant was proposed due to medical contraindication for a fibula free flap (n = 13), due to the failure of a previous fibula free flap reconstruction (n = 7), or due to refusal of a fibula free flap reconstruction by the patient (n = 16). The medical indications for mandibular reconstruction were a primary tumor requiring mandibulectomy in nine patients, mandibular osteoradionecrosis requiring mandibulectomy in nineteen patients, and secondary reconstruction in eight patients. The 2-year rates of implant exposure and implant removal were 69.4% and 52.8%. Reconstruction of the symphysis was a high-risk exposure variable (OR 30; p = 0.0003). Only one patient underwent a successful dental rehabilitation.

CONCLUSION

The use of a porous titanium 3D- implant for mandibular reconstruction in head and neck cancer patients resulted in high rates of implant exposure and of implant removal, notably when symphysis involvement.

Influence of Different Measurement Methods of Arterial Input Function on Quantitative Dynamic Contrast-Enhanced MRI Parameters in Head and Neck Cancer

BACKGROUND

Head and neck cancer (HNC) is the sixth most prevalent cancer worldwide. Dynamic contrast-enhanced MRI (DCE-MRI) helps in diagnosis and prognosis. Quantitative DCE-MRI requires an arterial input function (AIF), which affects the values of pharmacokinetic parameters (PKP).

PURPOSE

To evaluate influence of four individual AIF measurement methods on quantitative DCE-MRI parameters values (K^trans , v_e , k_ep , and v_p ), for HNC and muscle.

STUDY TYPE

Prospective.

POPULATION

A total of 34 HNC patients (23 males, 11 females, age range 24-91) FIELD STRENGTH/SEQUENCE: A 3 T; 3D SPGR gradient echo sequence with partial saturation of inflowing spins.

ASSESSMENT

Four AIF methods were applied: automatic AIF (AIFa) with up to 50 voxels selected from the whole FOV, manual AIF (AIFm) with four voxels selected from the internal carotid artery, both conditions without (Mc-) or with (Mc+) motion correction. Comparison endpoints were peak AIF values, PKP values in tumor and muscle, and tumor/muscle PKP ratios.

STATISTICAL TESTS

Nonparametric Friedman test for multiple comparisons. Nonparametric Wilcoxon test, without and with Benjamini Hochberg correction, for pairwise comparison of AIF peak values and PKP values for tumor, muscle and tumor/muscle ratio, P value ≤ 0.05 was considered statistically significant.

RESULTS

Peak AIF values differed significantly for all AIF methods, with mean AIFmMc+ peaks being up to 66.4% higher than those for AIFaMc+. Almost all PKP values were significantly higher for AIFa in both, tumor and muscle, up to 76% for mean K^trans values. Motion correction effect was smaller. Considering tumor/muscle parameter ratios, most differences were not significant (0.068 ≤ Wilcoxon P value ≤ 0.8).

DATA CONCLUSION

We observed important differences in PKP values when using either AIFa or AIFm, consequently choice of a standardized AIF method is mandatory for DCE-MRI on HNC. From the study findings, AIFm and inflow compensation are recommended. The use of the tumor/muscle PKP ratio should be of interest for multicenter studies.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 1.

Weight and skeletal muscle loss with cabozantinib in metastatic renal cell carcinoma

BACKGROUND

Cabozantinib, a standard of care metastatic renal cell carcinoma (mRCC), may be associated with weight and muscle loss. These effects of new generation VEGFR tyrosine kinase inhibitor on muscle mass loss are poorly described.

METHODS

All cabozantinib-treated mRCC patients from January 2014 to February 2019 in our institution were included. Clinical data including weight were collected during therapy. Computed tomography images were centrally reviewed for response assessment, and axial sections at the third lumbar vertebrae were used to measure the total muscle area. Toxicities and cabozantinib outcomes were evaluated. Co-primary endpoints included skeletal muscle loss and weight loss (WL), longitudinally evaluated during treatment. WL has been classified according to CTCAEv5.0: Grade 1 (loss of 5 to <10% of baseline body weight), Grade 2 (loss of 10% to <20% of baseline body weight), and Grades 3-4 (loss >20% of baseline body weight).

RESULTS

Patients were mostly men (70.3%), median age was 59.2 (range: 22.0-78.0) years, and median baseline body mass index was 25.0 (range: 16.4-49.3) kg/cm² . Prognosis according to International Metastatic RCC Database Consortium score was good, intermediate, and poor for 13 (13.0%), 63 (63.0%), and 24 (24.0%) patients, respectively. Out of a total of 120 patients, 101 patients with a median follow-up of 22.3 months (range: 4.5-62.2) were eligible for analysis; 85 experienced muscle loss and muscle loss >10% increased during cabozantinib exposition, especially after 6 months of treatment. At cabozantinib baseline, 71 patients (70.3%) had sarcopenia, and 16/30 (53.3%) non-sarcopenic patients developed sarcopenia during treatment. Baseline sarcopenia was associated with lower response rates (P = 0.031) and higher grades 3-4 toxicities (P = 0.001). Out of 92 patients included in the WL analysis, 44 (47.8%) and 12 (13.0%) experienced grades 2 and 3 WL, respectively.

CONCLUSIONS

We report a high incidence of grades 3-4 WL, fourth times higher than reported in prior pivotal trials, and half of the patients developed sarcopenia while on cabozantinib treatment. Weight and muscle mass loss with cabozantinib are underreported and may require further investigations and early management.

18F-FDG PET/CT for early response assessment of jaw osteoradionecrosis after the PENTOCLO protocol: A promising imaging modality

INTRODUCTION

The Pentoxifylline, Tocopherol and Clodronate protocol (PENTOCLO) showed promising results for jaw osteoradionecrosis (ORN) management. However, the clinical and radiological improvements are often delayed, leading to unwanted long-term treatment, with potential loss of opportunity for more radical surgical treatments. Our objective was to assess the diagnosis performance of ¹⁸F-FDG PET/CT to early predict ORN response to the PENTOCLO protocol.

MATERIALS AND METHODS

All patients from our center who were treated with the PENTOCLO protocol and with a ¹⁸F-FDG PET/CT performed at diagnosis and three months after the end of antibiotherapy were retrospectively included. The PENTOCLO protocol was always combined with prior appropriate antibiotherapy for six weeks. The healing endpoint was divided into healing, stability or worsening, according to the combination of clinical and radiological assessments at the date of last follow-up. For each patient, the difference between the maximal standardized uptake value (ΔSUVmax) of the ORN lesion at three months and baseline were computed. Diagnostic performance of ¹⁸F-FDG PET/CT was evaluated by sensitivity, specificity and the area under the receiver operating characteristic curve (ROC-AUC) of ΔSUVmax.

RESULTS

24 patients were included with an average follow-up of 29.3 months. The healing, stability and worsening rate were 25%, 62.5% and 12.5% respectively. The AUC for discriminating worsening vs stability or healing was 0.92 (IC95 [0.81-1.00]). A ΔSUVmax greater than or equal to 0 was predictive of a worsening with a sensitivity and specificity of 84 and 66% respectively.

CONCLUSION

¹⁸F-FDG PET/CT imaging could be useful for early prediction of PENTOCLO treatment resistance with appropriate antibiotherapy.

An artificial intelligence model predicts the survival of solid tumour patients from imaging and clinical data

BACKGROUND

The need for developing new biomarkers is increasing with the emergence of many targeted therapies. Artificial Intelligence (AI) algorithms have shown great promise in the medical imaging field to build predictive models. We developed a prognostic model for solid tumour patients using AI on multimodal data.

PATIENTS AND METHODS

Our retrospective study included examinations of patients with seven different cancer types performed between 2003 and 2017 in 17 different hospitals. Radiologists annotated all metastases on baseline computed tomography (CT) and ultrasound (US) images. Imaging features were extracted using AI models and used along with the patients' and treatments' metadata. A Cox regression was fitted to predict prognosis. Performance was assessed on a left-out test set with 1000 bootstraps.

RESULTS

The model was built on 436 patients and tested on 196 patients (mean age 59, IQR: 51-6, 411 men out of 616 patients). On the whole, 1147 US images were annotated with lesions delineation, and 632 thorax-abdomen-pelvis CTs (total of 301,975 slices) were fully annotated with a total of 9516 lesions. The developed model reaches an average concordance index of 0.71 (0.67-0.76, 95% CI). Using the median predicted risk as a threshold value, the model is able to significantly (log-rank test P value < 0.001) isolate high-risk patients from low-risk patients (respective median OS of 11 and 31 months) with a hazard ratio of 3.5 (2.4-5.2, 95% CI).

CONCLUSION

AI was able to extract prognostic features from imaging data, and along with clinical data, allows an accurate stratification of patients' prognoses.

Orofacial intramuscular lymphoma: first presentation

The term lymphoma includes a wide variety of different clinical entities including diffuse large B-cell lymphomas (DLBCL). Skeletal muscle or intramuscular lymphomas represent less than 2% of B-cell Lymphoma, they are quite rare, even more in the orofacial area. We present the case of a painless growing mass of the right cheek mimicking a chronic oral cellulitis in a 34-year-old man. Magnetic resonance imaging (MRI) of the mandible revealed a well-defined 7x3cm mass around the core of the mandible that invades the buccal floor and the subcutaneous planes. A whole-body 18F-FDG PET/CT for the initial diagnosis revealed an intensely isolated hypermetabolic band corresponding to a voluminous tumoral permeation. The diagnosis of a skeletal muscle diffuse large B-cell lymphoma was established after an intraoral biopsy. It was treated with 4 chemotherapy cures and showed complete remission at one year of follow-up. This atypical form of lymphoma should be integrated into the differential diagnosis of soft tissue tumors in the oral cavity.

Abstract 1924: PULS-AI: A multimodal artificial intelligence model to predict survival of solid tumor patients treated with antiangiogenics

The need for developing new biomarkers is increasing with the emergence of many targeted therapies. In this study, we used artificial intelligence (AI) to develop a multimodal model (PULS-AI) predicting the survival of solid tumor patients treated with antiangiogenic treatments.

Our retrospective, multicentric study included 616 patients with 7 different cancer types: renal cell carcinoma, colorectal carcinoma, hepatocellular carcinoma, gastrointestinal carcinoma, melanoma, breast cancer, and sarcoma. A set of 196 patients was left out of the study for validation. Clinical data including patient, treatment, and cancer metadata were collected at baseline for all patients, as well as computed tomography (CT) and ultrasound (US) images. Radiologists annotated all metastases on the CT images and the visible tumor lesion on the US images. AI models were used to extract relevant features from the regions of interest on CT and US images. In addition, handcrafted features related to the tumor burden were extracted from the annotations of all lesions on CT such as the number of lesions and the tumor burden volume per organ (lungs, liver, skull, bone, other). Finally, a Cox regression model was fitted to the set of imaging features and clinical features.

The annotation process led to 1147 annotated US images with lesions delineation and 4564 reviewed CTs, of which 989 were selected and fully annotated with a total of 9516 annotated lesions.The developed model reaches an average concordance index of 0.71 (0.67-0.75, 95% CI). Using a risk threshold of 50%, PULS-AI model is able to significantly isolate (log-rank test P-value &lt; 0.001) high-risk patients from low-risk patients (respective median OS of 12 and 32 months) with a hazard ratio of 3.52 (2.35-5.28, 95% CI).

The results of this study show that AI algorithms are able to extract relevant information from radiology images and to aggregate data from multiple modalities to build powerful prognostic tools. Such tools may provide assistance to oncology clinicians in therapeutic decision-making.

Citation Format: Kathryn Schutte, Fabien Brulport, Sana Harguem-Zayani, Jean-Baptiste Schiratti, Ridouane Ghermi, Paul Jehanno, Alexandre Jaeger, Talal Alamri, Raphael Naccache, Leila Haddag-Miliani, Teresa Orsi, Jean-Philippe Lamarque, Isaline Hoferer, Littisha Lawrance, Baya Benatsou, Imad Bousaid, Mickael Azoulay, Antoine Verdon, François Bidault, Corinne Balleyguier, Victor Aubert, Etienne Bendjebbar, Charles Maussion, Nicolas Loiseau, Benoit Schmauch, Meriem Sefta, Gilles Wainrib, Thomas Clozel, Samy Ammari, Nathalie Lassau. PULS-AI: A multimodal artificial intelligence model to predict survival of solid tumor patients treated with antiangiogenics [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1924.

Can Deep Learning Replace Gadolinium in Neuro-Oncology?: A Reader Study

MATERIALS AND METHODS

This monocentric retrospective study leveraged 200 multiparametric brain MRIs acquired between November 2019 and February 2020 at Gustave Roussy Cancer Campus (Villejuif, France). A total of 145 patients were included: 107 formed the training sample (55 ± 14 years, 58 women) and 38 the separate test sample (62 ± 12 years, 22 women). Patients had glioma, brain metastases, meningioma, or no enhancing lesion. T1, T2-FLAIR, diffusion-weighted imaging, low-dose, and standard-dose postcontrast T1 sequences were acquired. A deep network was trained to process the precontrast and low-dose sequences to predict "virtual" surrogate images for contrast-enhanced T1. Once trained, the deep learning method was evaluated on the test sample. The discrepancies between the predicted virtual images and the standard-dose MRIs were qualitatively and quantitatively evaluated using both automated voxel-wise metrics and a reader study, where 2 radiologists graded image qualities and marked all visible enhancing lesions.

RESULTS

The automated analysis of the test brain MRIs computed a structural similarity index of 87.1% ± 4.8% between the predicted virtual sequences and the reference contrast-enhanced T1 MRIs, a peak signal-to-noise ratio of 31.6 ± 2.0 dB, and an area under the curve of 96.4% ± 3.1%. At Youden's operating point, the voxel-wise sensitivity (SE) and specificity were 96.4% and 94.8%, respectively. The reader study found that virtual images were preferred to standard-dose MRI in terms of image quality (P = 0.008). A total of 91 reference lesions were identified in the 38 test T1 sequences enhanced with full dose of contrast agent. On average across readers, the brain lesion SE of the virtual images was 83% for lesions larger than 10 mm (n = 42), and the associated false detection rate was 0.08 lesion/patient. The corresponding positive predictive value of detected lesions was 92%, and the F1 score was 88%. Lesion detection performance, however, dropped when smaller lesions were included: average SE was 67% for lesions larger than 5 mm (n = 74), and 56% with all lesions included regardless of their size. The false detection rate remained below 0.50 lesion/patient in all cases, and the positive predictive value remained above 73%. The composite F1 score was 63% at worst.

CONCLUSIONS

The proposed deep learning method for virtual contrast-enhanced T1 brain MRI prediction showed very high quantitative performance when evaluated with standard voxel-wise metrics. The reader study demonstrated that, for lesions larger than 10 mm, good detection performance could be maintained despite a 4-fold division in contrast agent usage, unveiling a promising avenue for reducing the gadolinium exposure of returning patients. Small lesions proved, however, difficult to handle for the deep network, showing that full-dose injections remain essential for accurate first-line diagnosis in neuro-oncology.

Three artificial intelligence data challenges based on CT and ultrasound

PURPOSE

The 2020 edition of these Data Challenges was organized by the French Society of Radiology (SFR), from September 28 to September 30, 2020. The goals were to propose innovative artificial intelligence solutions for the current relevant problems in radiology and to build a large database of multimodal medical images of ultrasound and computed tomography (CT) on these subjects from several French radiology centers.

MATERIALS AND METHODS

This year the attempt was to create data challenge objectives in line with the clinical routine of radiologists, with less preprocessing of data and annotation, leaving a large part of the preprocessing task to the participating teams. The objectives were proposed by the different organizations depending on their core areas of expertise. A dedicated platform was used to upload the medical image data, to automatically anonymize the uploaded data.

RESULTS

Three challenges were proposed including classification of benign or malignant breast nodules on ultrasound examinations, detection and contouring of pathological neck lymph nodes from cervical CT examinations and classification of calcium score on coronary calcifications from thoracic CT examinations. A total of 2076 medical examinations were included in the database for the three challenges, in three months, by 18 different centers, of which 12% were excluded. The 39 participants were divided into six multidisciplinary teams among which the coronary calcification score challenge was solved with a concordance index > 95%, and the other two with scores of 67% (breast nodule classification) and 63% (neck lymph node calcifications).

Abstract 2656: Muscle wasting in head and neck carcinomas: Investigations on the underlying transcriptional reprogrammation

Introduction:

Cancer cachexia is a multifactorial syndrome associated with a skeletal muscle atrophy that affects at least 55% of patients bearing Head and Neck Squamous Cell Carcinomas (HNSCCs). To our knowledge, molecular mechanisms of muscle alterations have never been investigated on clinical muscle specimens from HNSCC patients. The aim of this study was to perform transcriptome profiling by bulk RNAseq on muscle fragments from HNSCC patients with and without cachexia and from nude mice bearing human HNSCC xenografts.

Methods:

Our study was made in three parts: 1) In Vitro investigations on human myoblasts co-cultivated with HNSCC cells. 2) In Situ investigations on muscles collected from nude mice xenografted with HNSSCs cells (FADU). 3) Exploration of clinical muscle samples collected from HNSCC patients. RNA sequencing was used to assess gene expression changes and gene function enrichment related to cachexia, in myoblasts co-cultivated with malignant cells as well as skeletal muscle samples collected from mice xenografted with HNSCC cells (FADU) or HNSCC patients.

Results:

In vitro experimentations showed significant impact of malignant cells on myoblast proliferation and differentiation. In nude mice, FADU xenografts resulted in distant loss of muscle mass at various anatomic locations. RNA sequencing of muscle samples from cachectic patients showed significant differences in gene expression compared with control muscles samples from tumor-free donors. Commonly modified pathways included immune and inflammatory response, mitochondrial metabolism and striated muscle differentiation. The most remarkable finding was the up-regulation of the BIRC3 transcript which encodes the anti-apoptotic protein c-IAP2. This alteration was observed both in human cachectic muscles and murine muscle fragments from tumor-bearing mice.

Conclusions:

Although the mechanism of BIRC3 up-regulation in cachectic muscle cells is not well understood, this finding is likely to be important for patient management in a context of promising therapeutic results obtained using Smac mimetics. Because these compounds are inhibitors of the c-IAP protein family, it will be important in the future to monitor their positive or negative effects on muscle alterations in cachectic HNSCC patients.

Citation Format: Héla Hachicha, Iryna Pirozhkova, Aurore Gelin, François Bidault, Valérie Rouffiac, Thibault Dayris, Thierry Ragot, Ingrid Breuskin, Caroline Even, Philippe Gorphe, Pierre Busson. Muscle wasting in head and neck carcinomas: Investigations on the underlying transcriptional reprogrammation [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2656.

Automatic cervical lymphadenopathy segmentation from CT data using deep learning

PURPOSE

The purpose of this study was to develop a fast and automatic algorithm to detect and segment lymphadenopathy from head and neck computed tomography (CT) examination.

MATERIALS AND METHODS

An ensemble of three convolutional neural networks (CNNs) based on a U-Net architecture were trained to segment the lymphadenopathies in a fully supervised framework. The resulting predictions were assessed using the Dice similarity coefficient (DSC) on examinations presenting one or more adenopathies. On examinations without adenopathies, the score was given by the formula M/(M+A) where M was the mean adenopathy volume per patient and A the volume segmented by the algorithm. The networks were trained on 117 annotated CT acquisitions.

RESULTS

The test set included 150 additional CT acquisitions unseen during the training. The performance on the test set yielded a mean score of 0.63.

CONCLUSION

Despite limited available data and partial annotations, our CNN based approach achieved promising results in the task of cervical lymphadenopathy segmentation. It has the potential to bring precise quantification to the clinical workflow and to assist the clinician in the detection task.

Prognostic value and therapeutic implications of nodal involvement in head and neck mucosal melanoma

BACKGROUND

The prognostic significance of nodal involvement is not well established in head and neck mucosal melanoma (HNMM).

METHODS

A retrospective, monocentric study was performed on 96 patients with HNMM treated between 2000 and 2017.

RESULTS

At diagnosis, seventeen patients (17.8%) were cN1, with a higher risk for HNMM arising from the oral cavity (p = 0.01). cN status had no prognostic value in patients with nonmetastatic resectable HNMM. No occult nodal metastasis was observed in the cN0 patients after a nodal dissection (ND). The nodal recurrence rate was similar in the cN1 and the cN0 patients. No isolated nodal recurrences were noted. Among the patients who underwent a ND, no benefit of this procedure was noted.

CONCLUSIONS

cN1 status is not a prognostic factor in patients with resectable HNMM. Elective ND should not be systematically performed in cN0 HNMM.

Outcomes in N3 Head and Neck Squamous Cell Carcinoma and Role of Upfront Neck Dissection

OBJECTIVES

We investigated the prognostic factor of N3 head and neck squamous cell carcinoma (HNSCC), including the role of upfront neck dissection (UFND) before radiotherapy (RT).

METHODS

We retrospectively reviewed the charts of consecutive N3 HNSCC patients treated with curative intent RT.

RESULTS

In the study, 323 N3 HNSCC patients were included. Of those, 125 patients (39%) had UFND. Median follow-up was 3.9 years (0-14.8 years). Overall survival (OS) at 5 years was 31.2%, and progression-free survival (PFS) was 26%. In the multivariate analysis, OS was improved in PS 0, T1-2 tumors, patients receiving concurrent chemotherapy, never or former smokers, and UFND. UFND was strongly associated with increased OS (45.7% vs. 21.2%, P < .001), and PFS (P < .001). Regardless of neck node size, UFND improved survival (P = .001 for ≤ 7 cm and P = .004 for > 7 cm).

CONCLUSION

UFND could improve treatment outcomes in N3 HNSCC, especially for non-oropharyngeal cancer, regardless of neck node size.

LEVEL OF EVIDENCE

2B Laryngoscope, 131:E844-E850, 2021.

Induction chemotherapy followed by radiotherapy for N3 head and neck squamous cell carcinoma

BACKGROUND

The treatment outcomes for N3 HNSCC treated with induction chemotherapy (ICT) followed by definitive radiation were reported to clarify the role of ICT and potential prognostic factors.

METHODS

A retrospective study was conducted on 120 patients with N3 (≥6 cm) HNSCC, who were treated with ICT as initial treatment. Survival outcomes and potential prognostic factors were reported.

RESULTS

The response rate to ICT was 68.3%. There was a statistically significant difference between responders and non-responders in terms of 5-year OS (35.1% vs 13.3%, P < .001) and PFS (29.4% vs 7.4%, P < .001). Good response to ICT (P < .001) and upfront neck dissection (UFND) before radiotherapy (P = .016) were factors predicting for better OS. However, UFND before radiotherapy was not associated with improved outcomes among responders.

CONCLUSIONS

This study suggests that ICT could be one treatment option for N3 HNSCC. Among responders to ICT, UFND before radiotherapy could be avoided.

[Sentinel lymph node biopsy in head and neck oncology]

Sentinel lymph node biopsy (SLNB) has been initially developed for melanoma and breast cancers. Its application in head and neck cancers is recent, probably due to the complexity of the lymphatic drainage, the proximity between the primary tumor and the lymph nodes and the critical anatomical structures (such as the facial nerve). In onco-dermatology, SLNB is validated in head and neck surgery for melanoma with Breslow thickness up to 1mm or ulceration, Merkel carcinoma and high-risk squamous cell carcinoma. Considering the malignancies of the upper aerodigestive tract, the feasibility and oncologic safety of SLNB are now established for T1-T2N0 oral and oropharyngeal squamous cell carcinomas. Thus, it could allow patients with negative sentinel nodes to avoid an unnecessary neck dissection, leading to a decrease of morbidity with an quality of life improvement. For some primary locations (e.g., anterior floor of the mouth) with high proximity between tumor and lymph nodes, it is recommended to remove the tumor before the SLNB so as to improve the detection. New techniques of detection are currently being developed with intra-operative procedures and new tracers (such as tilmanocept), leading to a better accuracy of detection and, probably, new indications.

Anemia and neutrophil-to-lymphocyte ratio in laryngeal cancer treated with induction chemotherapy

OBJECTIVES/HYPOTHESIS

We studied the influence of the neutrophil-to-lymphocyte ratio (NLR) and anemia on the response to induction chemotherapy (IC) and survival outcomes in laryngeal cancer patients treated with a preservation protocol.

STUDY DESIGN

Retrospective single-center case series.

METHODS

We analyzed patients with T3 laryngeal cancer treated with IC using a preservation protocol. The NLR and hemoglobin levels were assessed before treatment and after IC. The response to chemotherapy was assessed using Response Evaluation Criteria in Solid Tumours 1.1 and World Heath Organization standards. The oncological endpoints were overall survival (OS) and disease-free survival (DFS).

RESULTS

Sixty-eight patients were analyzed. The median NLR and hemoglobin levels before and after IC were 2.76 and 14.5 g/dL, and 2.01 and 11.6 g/dL, respectively. The NLR and anemia before treatment were not correlated, and they were not associated with the response to chemotherapy. However, an NLR > 5 and anemia before treatment were both associated with shorter OS and DFS. Notably, they were the only factors found to be significantly associated with survival outcomes.

CONCLUSIONS

In laryngeal cancer, patients treated with a preservation protocol, a high NLR ratio, and anemia before IC were associated with shorter survival, independently of the response to chemotherapy.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:E144-E150, 2020.

Computed tomography evaluation after induction chemotherapy for T3 laryngeal cancer: Does response correlate with vocal cord mobility?

OBJECTIVES

After induction chemotherapy (IC) for laryngeal cancer, Computed Tomography (CT) is used to assess tumor response but lacks rationalized methods for measurement of this response. In T3 laryngeal cancer, remobilization of an initially fixed vocal cord (VC) is a major sign of tumor response. We compared the performances of RECIST1.1, WHO and volumetric methods of evaluating response with laryngeal remobilization to determine if these measurements could objectively assess tumor response.

MATERIAL AND METHODS

This monocentric retrospective cohort study included patients treated with T3 laryngeal cancer with initial VC fixation treated with an organ preservation protocol with IC between 1999 and 2012. Tumors were measured with CT using RECIST1.1, WHO and volumetric methods by two radiologists blinded to VC remobilization (VCR), before and after induction chemotherapy and VC mobility was clinically assessed. Radiologic tumor shrinkage was compared to VCR. AUCs of ROC curves were compared. Inter-reader reliability, sensitivity and specificity of optimal cutoffs were determined.

RESULTS

Seven females and thirty-six males with a mean age of 59 years were included. AUCs were 0.759, [95%CI 0.614; 0.904] for RECIST1.1, 0.763, [95%CI 0.617; 0.909] for WHO and 0.752, [95%CI 0.608; 0.896] for volumetric evaluations with no significant difference among the three techniques. Inter-reader reader reliabilities were good (RECIST1.1) to excellent (WHO and volumetric methods).

CONCLUSION

RECIST1.1, WHO and volumetric measures match with VCR after IC in patient with T3 laryngeal cancer. WHO criteria combine accuracy, reproducibility and practical use; they may be best adapted for response assessment and protocol design.

Vascular anatomy of the free fibula flap including the lateral head of the soleus muscle applied to maxillo-mandibular reconstruction

PURPOSE

Initially described by Baudet in 1982, the fibula flap including the lateral head of the soleus muscle allows a one-stage reconstruction for large maxillo-mandibular defects. The aim of this study was to evaluate the number of muscular branches destined to the soleus muscle and their distance from the origin of the fibular artery, to assess the vascular anatomy of the free fibula flap including the lateral head of the soleus muscle applied to maxillo-mandibular reconstruction.

METHODS

We performed a cadaveric anatomic study on ten lower limbs, and a CT angiography anatomic study on 38 legs. The number of soleus branches originating from the fibular artery, and the distance between the origin of the fibular artery and each of the identified branches were measured.

RESULTS

The number of soleus branches destined to the lateral head of the soleus muscle is variable, with in our study 1-3 branches found. Soleus branches destined to the lateral head of the soleus muscle emerged at a distance ranging between 0 and 2.9 cm (mean value = 1.82 cm) from the origin of the fibular artery in 40% of cases, between 3 and 5.9 cm (mean value = 4.27 cm) from the origin of the fibular artery in 37% of cases, and was at a distance of 6 cm or more (mean value = 6.93 cm) from the origin of the fibular artery in 20% of cases.

CONCLUSIONS

An origin of the soleus vessels in close proximity to the origin of the fibular artery represents the main limitation of this flap, the length of the remaining fibular pedicle making it difficult to achieve secure anastomosis in the cervical area. The vascular distribution of the proximal part of the lateral head of the soleus muscle being segmental, it is possible to lengthen the flap pedicle ligating the most proximal soleus branches originating from the fibular artery.

Laser debulking or tracheotomy in airway management prior to total laryngectomy for T4a laryngeal cancer

PURPOSE

Retrospective studies have shown that tracheotomy prior to total laryngectomy (TL) is associated with decreased survival. We sought to investigate whether this is due to higher local invasiveness associated with obstructive disease or whether it is the result of tracheotomy itself.

METHODS

We reviewed patients with a T4a (AJCC 7th edition) laryngeal squamous-cell carcinoma treated with a primary TL followed by adjuvant radiotherapy between 2001 and 2013. We compared patients who had obstructive lesions with those who had non-obstructive lesions in terms of preoperative data, pathological features, and treatment outcomes. Second, we compared tracheotomized patients with patients who underwent endoscopic laser debulking (ELD).

RESULTS

One hundred patients were reviewed. Thirty-seven of them required an airway intervention prior to a TL (tracheotomy n = 24/ELD n = 13). Patients with obstructive tumors had more frequently subglottic extension (p = 0.0066) and a shorter disease-free survival (DFS) (p = 0.046), due to a higher incidence of additional distant metastases. Tracheotomy was associated with a shorter DFS (p = 0.035) and more frequent perineural invasion (p = 0.0272) as compared to ELD, but not with a higher incidence of stomal recurrence.

CONCLUSIONS

A tracheotomy prior to a total laryngectomy is associated with decreased survival. We recommend laser debulking as the preferred treatment whenever management of an obstructive airway is required prior to a total laryngectomy.

Revisiting vascular contraindications for transoral robotic surgery for oropharyngeal cancer

Objective

We analyzed the outcomes for patients with a retropharyngeal internal carotid artery (ICA) who underwent a transoral robotic surgery (TORS) procedure involving a cervical‐transoral robotic oropharyngectomy course with free flap reconstruction.

Methods

Patients were included in the prospective multicentric trial NCT02517125. These patients were scheduled to undergo surgery for an oropharyngeal localization. By pre‐operative CT scan and MRI it was determined that they had a retropharyngeal internal carotid artery.

Results

Three patients had a retropharyngeal ICA: a patient with a 35 mm synovial sarcoma of the tonsillar fossa, a patient with a T2N2b squamous‐cell carcinoma (SCC) of the glossotonsillar sulcus, and a patient with a T3N0 SCC of the tonsillar fossa in a previously irradiated field. These patients encountered neither preoperative nor postoperative complications.

Conclusions

In our experience, TORS for oropharyngeal cancers appears to be feasible in patients with a retropharyngeal ICA, provided that the procedure has been adapted for complex situations.

Level of evidence

4.

Patterns of responses in metastatic NSCLC during PD-1 or PDL-1 inhibitor therapy: Comparison of RECIST 1.1, irRECIST and iRECIST criteria

BACKGROUND

Immune checkpoint inhibitors are an important tool in the therapeutic strategy against metastatic non-small cell lung cancer (NSCLC); however, radiological evaluation is challenging due to the emergence of atypical patterns of responses. Several evaluation criteria have been proposed, such as the Response Evaluation Criteria in Solid Tumours (RECIST), version 1.1, immune -related RECIST (irRECIST) and iRECIST, but have not been systematically compared in a homogeneous population.

PATIENTS AND METHODS

We conducted a monocentric retrospective analysis of consecutive advanced NSCLC patients treated with an anti-programmed cell death-1 or anti-program death-ligand 1. Response patterns and the discordance between RECIST 1.1, irRECIST and iRECIST guidelines were described, and associations of response patterns and clinical outcome were explored.

RESULTS

Overall, 160 patients treated between February 2013 and October 2016 were included. Atypical responses were observed in 20 patients (13%), including eight pseudoprogressions (PsPDs) (5%) and 12 dissociated responses (8%). Thirteen of the 20 patients demonstrated clinical benefit. Per the RECIST 1.1, 37 patients (23%) showed an objective response or stable disease, and 123 patients (77%) exhibited progression. Eighty progressive patients were assessable for irRECIST and iRECIST: 15 patients were assessed differently; however, only three (3.8%) mismatches with a theoretical impact on the therapeutic decision were identified. Patients with PsPD or dissociated response had higher overall survival than patients with true progression.

CONCLUSION

Atypical responses (PsPD/dissociated response) occurred in 13% of NSCLC patients under immune checkpoint inhibitors. Based on survival analyses, the RECIST 1.1 evaluation underestimated the benefit of immune checkpoint inhibitors in 11% of the progressive patients. Immune-related RECIST and iRECIST identified these unconventional responses, with a 3.8% discrepancy rate.

Diagnostic and prognostic value of 18F-FDG PET, CT, and MRI in perineural spread of head and neck malignancies

OBJECTIVES

We assessed whether quantitative imaging biomarkers derived from fluorodeoxyglucose-positron emission tomography (18F-FDG PET) could be extracted from perineural spread (PNS) in head and neck malignancies (HNM) to improve patient risk stratification.

METHODS

A case-control exploratory study (1:2 ratio) enrolled 81 patients with FDG-avid HNM. The case-group comprised 28 patients with documented PNS (reference: expert consensus), including 14 squamous cell carcinomas (SCC). Imaging biomarkers were extracted from the PNS on 18F-FDG PET, CT-scan, and MRI. The control-group enrolled 53 SCCs. The Cox proportional-hazards regression model explored the association with overall survival by univariate and multivariate analyses.

RESULTS

The rate of PNS detection by 18F-FDG PET was 100% in the case-group. Quantitative imaging biomarkers were not associated with the presence of sensory (p>0.20) or motor (p>0.10) symptoms. In SCC patients (case: 14; control: 53), PNS was associated with a hazard ratio of death of 5.5 (95%CI: 1.4:20.9) by multivariate analysis. Increased cranial nerve SUV_max was significantly associated with poorer overall survival by univariate analysis (p=0.001).

CONCLUSIONS

Our pilot study showed the feasibility of extracting 18F-FDG PET biomarkers from PNS in FDG-avid HNM. Our results encourage the development of new PET/CT- or PET/MRI-guided management strategies in further prospective studies.

KEY POINTS

• 18F-FDG PET/CT detects PNS in FDG-avid HNM. • PNS metabolism is more heterogeneous than healthy tissue. • PNS diagnosis is crucial: most patients were asymptomatic, N0 and M0. • PNS diagnosis is associated with poorer overall survival in SCC. • PET/CT- or PET/MRI-guided management strategies should be evaluated.

Predictive and prognostic value of CT based radiomics signature in locally advanced head and neck cancers patients treated with concurrent chemoradiotherapy or bioradiotherapy and its added value to Human Papillomavirus status

OBJECTIVES

To explore prognostic and predictive value of radiomics in patients with locally advanced head and neck squamous cell carcinomas (LAHNSCC) treated with concurrent chemoradiotherapy (CRT) or bioradiotherapy (BRT).

MATERIALS AND METHODS

Data of 120 patients (CRT vs. BRT matched 2:1) were retrospectively analyzed. A total of 544 radiomics features of the primary tumor were extracted from radiotherapy planning computed tomography scans. Cox proportional hazards models were used to examine the association between survival and radiomics features with false discovery rate correction. The discriminatory performance was evaluated using receiver operating characteristic curve analysis.

RESULTS

Multivariate analysis showed a 24-feature based signature significantly predicted for OS (HR=0.3, P=0.02) and progression-free survival (PFS) (HR=0.3, P=0.01). Combining the radiomics signature with p16 status showed a significant improvement of prognostic performance compared with p16 (AUC=0.78vs. AUC=0.64 at 5years, P=0.01) or radiomics signature (AUC=0.78vs. AUC=0.67, P=0.01) alone. When patients were stratified according to this combination, OS and PFS were significantly different according to the 4 sub-types (p16+ with low/high signature score; p16- with low/high signature score) (P<0.001). Patients with high signature score significantly benefited from CRT (vs. BRT) in terms of OS (P=0.004), while no benefit from CRT in patients with low signature score.

CONCLUSION

Our analysis suggests an added value of radiomics features as prognostic and predictive biomarker in HNSCC treated with CRT/BRT. Moreover, the radiomics signature provided additional information to HPV/p16 status to further stratify patients. External validation of such findings is mandatory given the risk of overfitting.

Surgery for Neck Recurrence of Differentiated Thyroid Cancer: Outcomes and Risk Factors

BACKGROUND

Persistent/recurrent disease in the neck is frequent in patients with differentiated thyroid cancer (DTC).

OBJECTIVE

Assess efficacy, safety, and prognostic factors of first neck reoperation in DTC.

METHODS

Retrospective study of consecutive patients undergoing neck reoperation for recurrent/persistent DTC in a referral cancer center. Response after reoperation was defined according to the 2015 American Thyroid Association guidelines.

FINDINGS

One hundred sixty-one DTC patients were enrolled (64% females, median age 35 years, 96% papillary DTC). Initial stage was pT3 in 43% and pT4 in 10%, pN1 in 74%. Aggressive histology was present in 25% of the patients, in both primary and persistent/recurrent tumor. Four patients had no malignancy in the reoperative specimen, and 1 patient died due to postoperative hematoma and was excluded from further analysis. Following reoperation, 15 patients (10%) had persistent structural disease, 16 (10%) had biochemical incomplete response, 26 (17%) had indeterminate response, and 99 (63%) had complete response (CR), among whom 24 relapsed later. After a median follow-up of 5 years, only 83 patients (53%) had CR without the need for further treatments. The rate of permanent complications was: hypoparathyroidism 2%, laryngeal nerve palsy 0.6%, other 6%. Age ≥45 years, aggressive histology, and lymph node ratio ≥0.6 at initial surgery were independent risk factors for incomplete response after reoperation. Male sex, aggressive histology, and ≥10 metastases at reoperation were independent risk factors of secondary relapse following CR achieved with reoperation.

CONCLUSION

A careful risk-benefit analysis should guide surgical decision, particularly in patients with risk factors for incomplete response.

Antiangiogenic Tyrosine Kinase Inhibitors: Occurrence and Risk Factors of Hemoptysis in Refractory Thyroid Cancer

BACKGROUND

Antiangiogenic tyrosine kinase inhibitors (TKIs) are the mainstay of advanced thyroid cancer (TC) treatment. Concern is rising about TKI-related toxicity.

OBJECTIVE

To determine the incidence and to investigate the risk factors of hemoptysis in TC patients during TKI treatment.

METHODS

We analyzed consecutive TC patients treated with TKI in our center between 2005 and 2013 and performed an independent review of computed tomography scan images for airway invasion assessment. Occurrence of grade 1-2 or grade 3-5 hemoptysis according to Common Terminology Criteria for Adverse Events version 4.03 and risk factors for hemoptysis were investigated.

RESULTS

A total of 140 patients (89 males; median age, 52 y) with medullary (56%), differentiated (33%), and poorly differentiated (11%) TC were enrolled. Thyroidectomy±neck dissection was performed in 123 patients and neck/mediastinum external-beam radiotherapy in 41 (32% with therapeutic purpose and 68% with adjuvant purpose). Patients received from 1 to 4 lines of TKI (median 1). Median follow-up was 24 months. Airway invasion was found in 65 (46%) cases. Hemoptysis occurred in 9 patients: grade 1-2 in 7 cases (5%) and grade 3-5 in 2 (1.4%) cases (fatal in 1). Hemoptysis was associated with presence of airway invasion (P = .04), poorly differentiated pathology (P = .03), history of therapeutic external-beam radiotherapy (P = .003), and thyroidectomy without neck dissection (P = .02).

CONCLUSION

Airway invasion, poorly differentiated pathology, therapeutic external-beam radiotherapy, and thyroidectomy without neck dissection are associated with and increased risk of hemoptysis in TC patients during antiangiogenic TKI treatment. Further research is needed to confirm this data and to sort out interactions between these risk factors. A careful assessment of airway invasion is mandatory before TKI introduction.

Squamous cell carcinoma of the larynx with subglottic extension: is larynx preservation possible?

PURPOSE

Squamous cell carcinoma of larynx with subglottic extension (sSCC) is a rare location described to carry a poor prognosis. The aim of this study was to analyze outcomes and feasibility of larynx preservation in sSCC patients.

PATIENTS AND METHODS

Between 1996 and 2012, 197 patients with sSCC were treated at our institution and included in the analysis. Stage III-IV tumors accounted for 76%. Patients received surgery (62%), radiotherapy (RT) (18%), or induction chemotherapy (CT) (20%) as front-line therapy.

RESULTS

The 5-year actuarial overall survival (OS), locoregional control (LRC), and distant control rate were 59% (95% CI 51-68), 83% (95% CI 77-89), and 88% (95% CI 83-93), respectively, with a median follow-up of 54.4 months. There was no difference in OS and LRC according to front-line treatments or between primary subglottic cancer and glottosupraglottic cancers with subglottic extension. In the multivariate analysis, age > 60 years and positive N stage were the only predictors for OS (HR 2, 95% CI 1.2-3.6; HR1.9, 95% CI 1-3.5, respectively). A lower LRC was observed for T3 patients receiving a larynx preservation protocol as compared with those receiving a front-line surgery (HR 14.1, 95% CI 2.5-136.7; p = 0.02); however, no difference of ultimate LRC was observed according to the first therapy when including T3 patients who underwent salvage laryngectomy (p = 0.6). In patients receiving a larynx preservation protocol, the 5-year larynx-preservation rate was 55% (95% CI 43-68), with 36% in T3 patients. The 5-year larynx preservation rate was 81% (95% CI 65-96) and 35% (95% CI 20-51) for patients who received RT or induction CT as a front-line treatment, respectively.

CONCLUSION

Outcomes of sSCC are comparable with other laryngeal cancers when managed with modern therapeutic options. Larynx-preservation protocols could be a suitable option in T1-T2 (RT or chemo-RT) and selected T3 sSCC patients (induction CT).

Long-term responders to everolimus: A subgroup analysis of the sector study

462

Background: Everolimus is considered as a standard of care for the second line treatment of metastatic renal cell carcinoma (mRCC). Currently no clinical or biological predictive factors are available to help physicians to choose the best second line option between everolimus or TKI. Whether correlation exists between response to first line and response to second line remains debatable. Methods: We performed a subgroup analysis of the SECTOR study, a retrospective survey of patients (pts) receiving everolimus after TKI in 26 french centers to analyse long responders to everolimus. Long-term response to everolimus was defined as progression-free >9 months. Recorded variables included: patients characteristics of first line TKI (duration, response), duration of everolimus, efficacy and toxicity as well as overall survival. Results: 164 patients in 26 french cancer centres were included in the SECTOR study between october 2008 and october 2012. All patients received everolimus as second line treatment. Median age was 64.6 y.o, main histological subtype was clear-cell carcinoma (92.3%). Among the whole study cohort, we identified 30 patients (21%) as long-term responders (ranging from 9 to 33 months). Analysis of this patient population is ongoing and will be presented at the meeting. Correlation between long response and prognostic factors, as well as response to first TKI will be determined. Conclusions: Everolimus achieves long-term response in more than 20% of mRCC treated in second line. Prolonged treatment was relatively well tolerated without any unexpected late toxicity. Further investigations, especially biological studies, are warranted to identify predictive factors which will help physicians to identify long-term responder and choose the best second line option for mRCC patients.

Retrospective evaluation of tyrosine kinase inhibitor (TKI)-everolimus (eve) and/or TKI-eve-TKI sequences in metastatic renal cell carcinoma (mRCC): A French survey—The sector study

509

Background: In the RECORD-1 study, only 22% of the mRCC patients (pts) received eve in pure 2nd line. Thus more data in real world are needed. A retrospective French survey, on a large patient population, was designed to evaluate efficacy for the sequence TKI-eve and/or TKI-eve-TKI in mRCC. Methods: Between 10/08 and 10/12, 164 mRCC pts from 26 french centers, who progressed on initial TKI and received eve as 2nd line were recorded. In these pts, 3rd line TKI was recorded. Primary endpoint was Duration of Treatment (DT) of each sequence. Secondary endpoints were best radiological response for eve evaluated by 2 independent radiologists, tolerability, dose reduction, overall survival from the start of first TKI (OS). Patients characteristics: Amongst 164 pts, 144 pts with follow-up > 4 months since initiation of eve were evaluated, 59/144 pts received TKI-eve-TKI. Before eve initiation: median age was 65 yrs, most pts were male (70.3%), had clear cell histology (92.3%), had received sunitinib as first TKI (94.4%). Main comorbidities were: hypertension (43.8%), diabetes (15.3%), and hypercholesterolemia (19.4%). At the time of eve initiation, MSKCC classification was good (24.4%), intermediate (61.5%) or poor (14.1%). Results: median DT of eve was 4 months and 21% pts were treated >9 months with 2.9% PR and 67.6% SD by central review. Correlation between response to first TKI and eve was observed. Dose reduction of eve for toxicity was 23.2%. The most common toxicities (all grades) were: stomatitis (25.3%), PNI (13%), fatigue (40.7%), hyperglycemia (9.3%), hypercholesterolemia (17.3%) and hypertriglyceridemia (22.8%). Median duration of TKI-eve sequence was 18 months (IC95%: 15-20), and OS was 36 months (IC95%: 27-56). For TKI-eve-TKI sequence (59 pts), sorafenib was mostly used (76.3%) with dose reduction and clinical benefit rate of 26.7% and 42.2% respectively. Median DT and OS were 24 and 41 months (IC95%: 19-29; 25-57) respectively. Conclusions: In real world experience, for mRCC pts receiving TKI-eve sequence, median DT of eve is 4 months with OS of 36 months which compares favorably with RECORD1 and RECORD 3 trials respectively.