Stereotactic Boost and Short-Course Radiotherapy for p16-Associated Oropharynx Cancer (SHORT-OPC): First Planned Interim Safety Analysis from a Randomized Phase II Trial

PURPOSE/OBJECTIVE(S)

There is a need for safe treatment de-intensification in p16+ oropharynx cancer (OPC). The standard of care (SOC) radiotherapy (RT) regimen is cumbersome and associated with high toxicity. Stereotactic radiotherapy (SBRT) and multimodality image guidance is an opportunity to precisely target the gross tumor while safely reducing elective irradiation dose. We aim to assess the safety and efficacy of a short course RT for p16+ OPC, consisting of an SBRT boost to the gross tumor volume (GTV) followed by de-escalated elective irradiation.

MATERIALS/METHODS

In this randomized phase II trial, patients with p16-positive, stage I-II OPSCC with primary tumor <30 cc (8th Ed AJCC) are planned with combined CT, MRI and FDG-PET, and randomized to 1) SBRT boost (14 Gy in 2 fractions) to the GTV followed with de-escalated RT (+/- Cisplatin) to a dose of 40 Gy in 20 fractions, or 2) SOC RT (+/- Cisplatin) to a dose of 70 Gy in 33 fractions to the GTV and 59.4-54Gy (or equivalent) to the intermediate-to-low dose elective region. Patients are stratified by stage (I vs. II) and use of chemotherapy. The primary endpoint of the trial is locoregional control at 2 years, powered for a sample size of 100 patients. A Bayesian adaptive design includes 2 planned safety interim analysis using grade ≥ 3 subacute toxicities >40% as a stopping criterion, and 1 planned futility analysis. Acute adverse events (AE) are defined as those occurring ≤ 60 days from RT, subacute AE between 60-180 days after RT, and late AE >180 days from RT. This is the first planned toxicity analysis.

RESULTS

Twenty-one patients were randomly assigned and eligible (11 in SOC and 10 in experimental arm). Median age was 69 years (range 49-84); 29% and 71% had stage T1 and T2, while 10%, 85% and 1 patient had N0, N1 and N2 disease, respectively. RT alone and chemoradiation was administered in 67% and 33% of patients, respectively. At a median follow-up of 11 months (range 1.7-17.6), there was 1 local recurrence at the primary tumor site in the SOC arm (at 10 month) and no recurrence in the experimental arm. All enrolled patients remain alive at the time of analysis. There was a 54.5% rate of grade 3 acute AE in the SOC arm and 30.0% rate of grade 3 acute AE in the experimental arm. More specifically, 1, 5 (45%), 2 (18%), and 2 (18%) versus 0, 1, 1 and 1 patient developed acute grade 3 dysphagia, mucositis, pain and dermatitis in the SOC and experimental arm, respectively. There was no acute grade 4 or 5 toxicity. There was no grade ≥ 3 subacute toxicity or late toxicity in both arms.

CONCLUSION

This primary safety analysis showed that SBRT boost followed by a short course of de-escalated elective irradiation in p16+ OPC has limited early toxicity and meets criteria for study continuation.

Exploring patient experiences with a telehealth approach for the PRO-ACTIVE trial intervention in head and neck cancer patients

INTRODUCTION

Following the COVID-19 directive to cease non-essential services, a rapid shift was made in the delivery of Speech Language Pathology (SLP) dysphagia management in the 3-arm, randomized PRO-ACTIVE trial. To inform future programs, this study explored patients' experiences with telehealth when the planned in-person SLP intervention was moved to a telehealth modality.

METHODS

A theory-guided qualitative descriptive approach was used. Willing participants who had received at least one telehealth swallowing therapy session participated in a one-time semi-structured interview. Interview transcripts were subjected to a standard qualitative content/theme analysis. Researchers reviewed all transcripts and used a multi-step analysis process to build a coding framework through consensus discussion. Summaries and key messages were generated for each code.

RESULTS

Eleven participants recounted their telehealth experiences and reported feeling satisfied, comfortable and confident with the session(s). They identified that previous experience with teleconferencing, access to optimal technical equipment, clinician skill, and caregiver assistance facilitated their telehealth participation. Participants highlighted that telehealth was beneficial as it reduced commuting time, COVID-19 exposure and fatigue from travel; and also allowed caregiver participation particularly during COVID. In comparing their in-person SLP sessions to telehealth sessions, limitations were also identified, including: lack of previous experience with and/or poor access to technology, and less opportunity for personalization. Participants indicated that use of phone alone was less preferred than an audio/video platform.

DISCUSSION

Patients reported that overall, telehealth sessions did not compromise their learning experience when compared to in-person sessions. Patients benefited from use of telehealth in several ways despite some limitations of the use of technology. Patient feedback about telehealth provides an important perspective that may be critical to inform best practices for care delivery.

Symptom profile of head and neck patients initiating care in a survivorship clinic

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Background: After treatment, and at a time point of low risk of relapse, cancer patients at our institution transition to Survivorship Clinics (SC) that focus on wellness, late effects management, and psychosocial functioning in additional to cancer screening. We describe the self-reported symptoms of Head and Neck (HNC) survivors at the time of transition to SC, and the level to which these symptoms interfered with their function. Methods: Survivors reporting to their first in person SC appointment were assessed using the MD Anderson Symptom Inventory Head and Neck (MDASI–HN). This validated patient-reported outcome (PRO) instrument consists of 28 questions grouped into three subscales (core symptoms, disease specific symptoms, and interference items). Symptom severity is measured using a 0 to 10 scale (0 = not present, 10 = as bad as can be imagined). Descriptive statistics were used to characterize the sample. Percent of patients reporting moderate to severe symptoms (> = 4) are also noted. Results: This sub-analysis consisted of 377 patients seen for their initial transition visit to the survivorship clinic. Patients were mostly male (83%) and Caucasian (89%), with an average age of 63.8 years, and on average 41.5 months from diagnosis. Most common cancers were oropharynx (49%), oral cavity (33.7%), and larynx/hypopharynx (12.5%), nasopharynx (4.5%). Average symptom reports are presented in table. In rank order of prevalence (4% to 31% of patients), the top reported moderate to severe symptoms included dry mouth, swallowing/chewing, mucus, remembering, distress, and shortness of breath associated with moderated to severe interference in general activity in 8% of patients. Conclusions: HNC survivors report multiple persistent symptoms of moderate to high severity in a significant number, most commonly mouth dryness and swallowing and chewing difficulty. PROs can identify patients with high symptom burden, and lead in interventions to support the patients at their SC visit.[Table: see text]

Development and validation of a novel patient-reported outcomes (PRO) measure for symptom burden in patients with cancer and COVID-19 infection

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Background: The symptom burden experienced by patients with cancer who contract the COVID-19 (C19) infection remains to be fully understood. To accurately assess this symptom burden, we developed a valid, reliable patient-reported outcome (PRO) measure of C19 symptoms combined with a known measure of cancer symptom burden. Methods: Within the institutional initiative on COVID-19 and cancer named Data-Driven Determinants for COVID-19 Oncology Discovery Effort (D3CODE), patients with cancer and PCR-positive C19 tests were invited to participate in this longitudinal study after providing consent. Pts completed the EQ-5D-5L and the 13 symptom severity and 6 interference items of the core MD Anderson Symptom Inventory (MDASI) plus 14 COVID-specific symptom items generated from literature and expert review. Items were measured on a 0-10 scale, 0 = none to 10 = worst imaginable symptom or interference. Demographic and disease information was collected. Psychometric procedures determined validity and reliability of the MDASI-COVID. Results: 600 pts enrolled, mean age 56.5y (range 20 to 91y). 59% female, 80% white. 78% solid tumors, 19% heme cancers. 12.5% required hospitalization for C19. Median number of days between positive C19 test and PRO completion was 17 days. Mean overall health rating on EQ-5D-5L was 78.3 (SD 19.6), best being 100. Highest mean (M) severity symptoms on the MDASI-COVID were fatigue (M 3.45, SD 2.17), drowsiness (M 2.50, SD 2.89), sleep disturbance (M 2.44, SD 2.99), malaise (M 2.37, SD 3.05), and distress (M 2.27, SD 2.90). Most severe (≥ 7) symptoms) reported were fatigue (21.3% of pts), change in taste (14.8%), change in smell (14.4%), malaise (14.3%), sleep disturbance (14.3%), and drowsiness (14%). Internal consistency (Cronbach α) of the 27 symptom items was 0.957, of the 6 interference items was 0.937. Mean severity of the 27 symptom items was significantly correlated with overall EQ-5D-5L health rating (correlation = -0.45, P < 0.0005), demonstrating concurrent validity. Mean symptom severity and interference showed known-group validity between patients who required C19 hospitalization (symptom M 2.32, SD 2.09; interference M 3.29, SD 3.02) and those who did not (symptom M 1.69, SD 1.85; interference M 2.20, SD 2.64) (symptom P 0.007; interference P 0.004). Conclusions: We have validated a novel PRO, the MDASI-COVID, to quantify the combined symptom burden in patients with cancer and COVID-19. This measure allows longitudinal evaluation of COVID-19 on cancer symptom burden and provide clinicians with an accurate tool for ongoing symptom assessment and management. Longitudinal analysis on long-term symptoms related to COVID-19 and cancer are ongoing.

Patterns of self-reported symptom distress among survivors of head and neck cancers

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Background: Head and neck cancer (HNC) survivors are known to experience debilitating disease-related symptoms and late effects. Patterns of symptoms among HNC survivors who have transitioned care to survivorship clinics could inform supportive care needs. We sought to assess patterns of self-reported symptoms in HNC survivors and to describe the level to which these symptoms interfered with their function. Methods: Symptoms and their interference were assessed using the MD Anderson Symptom Inventory Head and Neck (MDASI–HN). This validated patient-reported outcome (PRO) instrument consists of 28 questions grouped into 3 subscales; 1) 13 “core” or general symptoms, 2) 9 symptoms specific to HN and 3) 6 daily life interference items. Symptom severity is measured using a 0 to 10 scale, 0 = not present, 10 = as bad as can be imagined. Patients completed the MDASI-HN during a visit to the HNC Survivorship Clinic. Three databases a) MDASI HN, b) institutional, and c) the HNC survivorship provided data. We defined the primary outcome, symptom distress, as the combination of severity and interference rated ≥5 (0-10). Descriptive statistics were used to characterize the sample. Results: The sample included 1390 HNC survivors, majority were male (77%), Caucasian (83%) with a median age of 63 years (range 22- 95 years). The median years since diagnosis was five (range 2-37 years). The top disease sites were oropharynx (37%), oral cavity (35%), and larynx/hypopharynx (15%). The table summarizes the patterns of symptom distress. Conclusions: These results highlight the variation in symptom distress reported by long-term HNC survivors. Understanding the clinical implications of these patterns is important to ensure the well-being of those with head and neck cancers. [Table: see text]

Prospective, longitudinal digital activity monitoring before and after treatment of low-risk oropharyngeal squamous cell carcinoma: A feasibility study

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Background: Given the expected excellent prognosis of low-risk oropharyngeal squamous cell carcinoma (OPSCC), consideration of long-term toxicity and functional outcomes has become increasingly important. Activity monitors (e.g. FITBIT) are imperfect but have been shown to have reasonable validity in healthy adults. Here we aimed to test the feasibility of using medical grade longitudinal digital activity monitoring to better define objective functional outcomes after treatment of low-risk OPSCC. Methods: This prospective, observational parallel cohort study included patients with previously untreated stage I-III (AJCC 7) OPSCC eligible for standard of care single-modality treatment with either Intensity-Modulated Proton Therapy (IMPT) or TransOral Robotic Surgery (TORS). Objective Actigraph accelerometer data (Actigraph, Pensacola, FL) were collected continuously for 1 week at baseline, 3, 6 and 12 months after treatment along with subjective patient-reported outcome (PRO) measures. Results: Forty-four patients (34M, 10F) enrolled with median age 59 years (range: 42-78). Baseline, 3 and 6 month activity data were available for 40 patients (91%): 16 IMPT and 24 TORS. There was a significant decrease in mean percent of day performing moderate to vigorous physical activity (MVPA) (-0.78, 0.021) mean number of steps/minute (-1.1, p = 0.035), and mean kcals/day (-115.9, p < 0.001) from baseline to 3 months after treatment for the overall cohort. A significant decrease in mean kcals/day (-82.2, p = 0.004) persisted for the overall cohort at 6 months with no significant difference between groups. Conclusions: Longitudinal digital activity monitoring is feasible before and after treatment of low-risk OPSCC. This approach may offer objective functional endpoints for future de-escalation trials. Similar short-term decreases in objective activity measurements were observed after IMPT and TORS. Long-term (12 month) activity data and correlations to subjective PRO measures will be available at the time of presentation. Clinical trial information: 02663583 .

Automatic registration of 2D MR cine images for swallowing motion estimation

PURPOSE

To automate the estimation of swallowing motion from 2D MR cine images using deformable registration for future applications of personalized margin reduction in head and neck radiotherapy and outcome assessment of radiation-associated dysphagia.

METHODS

Twenty-one patients with serial 2D FSPGR-MR cine scans of the head and neck conducted through the course of definitive radiotherapy for oropharyngeal cancer. Included patients had at least one cine scan before, during, or after radiotherapy, with a total of 52 cine scans. Contours of 7 swallowing related regions-of-interest (ROIs), including pharyngeal constrictor, epiglottis, base of tongue, geniohyoid, hyoid, soft palate, and larynx, were manually delineated from consecutive frames of the cine scan covering at least one swallowing cycle. We applied a modified thin-plate-spline robust-point-matching algorithm to register the point sets of each ROI automatically over frames. The deformation vector fields from the registration were then used to estimate the motion during swallowing for each ROI. Registration errors were estimated by comparing the deformed contours with the manual contours.

RESULTS

On average 22 frames of each cine scan were contoured. The registration for one cine scan (7 ROIs over 22 frames) on average took roughly 22 minutes. A number of 8018 registrations were successfully batch processed without human interaction after the contours were drawn. The average registration error for all ROIs and all patients was 0.36 mm (range: 0.06 mm- 2.06 mm). Larynx had the average largest motion in superior direction of all structures under consideration (range: 0.0 mm- 58.7 mm). Geniohyoid had the smallest overall motion of all ROIs under consideration and the superior-inferior motion was larger than the anterior-posterior motion for all ROIs.

CONCLUSION

We developed and validated a deformable registration framework to automate the estimation of swallowing motion from 2D MR cine scans.

Checkpoint inhibitors assessment in oropharynx carcinoma (CIAO)

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Background: Oropharyngeal squamous cell carcinoma (OPSCC) is classified by HPV status. Patients with HPV negative OPSCC have worse prognosis when compared to HPV positive. The epidemic of HPV associated OPSCC emphasizes the need to improve outcomes and reduce treatment related toxicities in this patient population. Taken together, there is an unmet need for novel treatment approaches to improve survival and/or quality of life in patients with OPSCC. Checkpoint inhibitors, particularly anti-PD-1/PD-L1, have shown encouraging activity in metastatic head and neck SCC. Targeting both PD-1 and CTLA-4 pathways may have additive or synergistic activity. Durvalumab and tremelimumab are immune checkpoint inhibitors that target, respectively, PD-L1 and CTLA-4. The optimal integration of novel therapeutics into clinical practice requires a thorough understanding of the molecular effects of treatment that is best evaluated by longitudinal tumor sampling. Minimally invasive transoral robotic surgery (TORS) provides opportunities to leverage standard-of-care surgery to interrogate the tumor microenvironment after neoadjuvant treatment. Methods: This is a randomized, window of opportunity trial evaluating durvalumab single agent or combined with tremelimumab in OPSCC patients amenable to curative intent surgery. The primary objective is to quantify differences in CD8+ TILs between pre- and post-treatment surgical specimens in patients treated with durvalumab vs. durvalumab plus tremelimumab. Secondary objectives include assessing the safety and toxicity of durvalumab plus or minus tremelimumab in the preoperative setting; objective response rate by RECIST at 8 weeks; percentage of patients undergoing surgery at 8 weeks; percentage of viable tumor cells in the surgical specimen; and patient-reported outcomes. Pre- and post- treatment tumor and blood based immune biomarkers will be evaluated and correlated with HPV status, outcomes, and toxicity. Eligible patients must be ≥ 18 years old, have surgically resectable stage II-IVA newly diagnosed OPSCC or loco-regional recurrence from an OPSCC primary ≥ 6 months after completion of curative intent treatment, and have a performance status ECOG 0-1. Enrollment is ongoing. Clinical trial information: NCT03144778.

Long-term patient reported outcomes following radiation therapy for oropharyngeal cancer: cross-sectional assessment of a prospective symptom survey in patients ≥65 years old

Background

Given the potential for older patients to experience exaggerated toxicity and symptoms, this study was performed to characterize patient reported outcomes in older patients following definitive radiation therapy (RT) for oropharyngeal cancer (OPC).

Methods

Cancer-free head and neck cancer survivors (>6 months since treatment completion) were eligible for participation in a questionnaire-based study. Participants completed the MD Anderson Symptom Inventory-Head and Neck module (MDASI-HN). Those patients ≥65 years old at treatment for OPC with definitive RT were included. Individual and overall symptom severity and clinical variables were analyzed.

Results

Of the 79 participants analyzed, 82% were male, 95% white, 41% T3/4 disease, 39% RT alone, 27% induction chemotherapy, 52% concurrent, and 18% both, and 96% IMRT. Median age at RT was 71 yrs. (range: 65–85); median time from RT to MDASI-HN was 46 mos. (2/3 > 24 mos.). The top 5 MDASI-HN items rated most severe in terms of mean (±SD) ratings (0–10 scale) were dry mouth (3.48 ± 2.95), taste (2.81 ± 3.29), swallowing (2.59 ± 2.96), mucus in mouth/throat (2.04 ± 2.68), and choking (1.30 ± 2.38) reported at moderate-severe levels (≥5) by 35, 29, 29, 18, and 13%, respectively. Thirty-nine % reported none (0) or no more than mild (1–4) symptoms across all 22 MDASI-HN symptoms items, and 38% had at least one item rated as severe (≥7). Hierarchical cluster analysis resulted in 3 patient groups: 1) ~65% with ranging from none to moderate symptom burden, 2) ~35% with moderate-severe ratings for a subset of classically RT-related symptoms (e.g. dry mouth, mucus, swallowing) and 3) 2 pts. with severe ratings of most items.

Conclusions

The overall long-term symptom burden seen in this older OPC cohort treated with modern standard therapy was largely favorable, yet a higher symptom group (~35%) with a distinct pattern of mostly local and classically RT-related symptoms was identified.

Electronic supplementary material

The online version of this article doi: (10.1186/s13014-017-0878-9) contains supplementary material, which is available to authorized users.

Long-term patient reported outcomes following radiation therapy for oropharyngeal cancer: A symptom assessment study in patients >65 years old

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Background: Given the potential for older patients (pts) to experience exaggerated toxicity and symptoms, this study was performed to characterize pt reported outcomes (PROs) in older pts following definitive radiation therapy (RT) for oropharyngeal cancer (OPC). Methods: Disease-free head and neck cancer survivors ( > 6 mos. since tx) were eligible for participation in a questionnaire-based study. Participants completed the MD Anderson Symptom Inventory-Head and Neck module (MDASI-HN). Those who had been treated for OPC with definitive RT (w/ or w/o systemic therapy) and were > 65 y/o at time of RT were included. Individual and overall symptom severity and clinical variables were analyzed. Results: Of the 79 participants analyzed, 82% were male, 95% white, 41% T3/4 disease, 39% RT alone, 27% induction chemotherapy, 52% concurrent, and 18% both, and 96% IMRT. Median age at the time of RT was 71 yrs. (range: 65-85); median time from end of RT to MDASI-HN completion was 46 mos. (2/3 > 24 mos.). The top 5 MDASI-HN items rated most severe in terms of mean (±SD) ratings (0-10 scale) were dry mouth (3.48±2.95), taste (2.81±3.29), swallowing (2.59±2.96), mucus in mouth/throat (2.04±2.68), and choking (1.30±2.38) reported at moderate to severe levels (≥5) by 35, 29, 29, 18, and 13%, respectively. Thirty-nine % reported none (0) or no more than mild (1-4) symptoms across all 22 MDASI-HN symptoms items, and 38% had at least one item rated as severe (≥7). Hierarchal cluster analysis resulted in 3 patient groups: 1) ~75% with generally no to moderate symptom burden, 2) ~25% with moderate to severe ratings for a subset of classically RT-related symptoms (e.g. dry mouth, mucus, swallow, taste), and 3) only 2 pts with severe ratings of nearly all items. Subgroup comparisons will be presented. Conclusions: The overall long-term symptom burden seen in this older OPC cohort was largely favorable, yet a higher symptom group (~25%) with a distinct pattern of mostly local symptoms was identified. We have implemented the routine use of symptom assessment tools as part of OPC survivorship programs and plan to explore age-dose-modeling of symptoms identified and associated normal structures.

Influence of timing, radiation, and reconstruction on complications and speech outcomes with tracheoesophageal puncture

BACKGROUND

We evaluated the impact of radiation, reconstruction, and timing of tracheoesophageal puncture (TEP) on complications and speech outcomes.

METHODS

Retrospective review identified 145 patients who underwent TEP between 2003 and 2007.

RESULTS

Ninety-nine patients (68%) had primary and 46 (32%) had secondary TEP, with complications occurring in 65% and 61%, respectively (p = .96). Twenty-nine patients (20%) had major complications (18 primary and 11 secondary; p = .42). Ninety-four patients (65%) had pre-TEP radiation, 39 (27%) post-TEP radiation, and 12 (8%) no radiation. With patients grouped by TEP timing and radiation history, there was no difference in complications, fluency, or TEP use. With mean 4.7-year follow-up, 82% primary and 85% secondary used TEP for primary communication (p = .66). Free-flap patients used TEP more commonly for primary communication after secondary versus primary TEP (90% vs 50%; p = .02).

CONCLUSION

Primary and secondary tracheoesophageal speakers experience similar high rates of complications. Extent of pharyngeal reconstruction, rather than radiation, may be more important in selection of TEP timing. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1765-1771, 2016.

Intensity-modulated proton beam therapy (IMPT) versus intensity-modulated photon therapy (IMRT) for patients with oropharynx cancer - A case matched analysis

BACKGROUND

Owing to its physical properties, intensity-modulated proton therapy (IMPT) used for patients with oropharyngeal carcinoma has the ability to reduce the dose to organs at risk compared to intensity-modulated radiotherapy (IMRT) while maintaining adequate tumor coverage. Our aim was to compare the clinical outcomes of these two treatment modalities.

METHODS

We performed a 1:2 matching of IMPT to IMRT patients. Our study cohort consisted of IMPT patients from a prospective quality of life study and consecutive IMRT patients treated at a single institution during the period 2010-2014. Patients were matched on unilateral/bilateral treatment, disease site, human papillomavirus status, T and N status, smoking status, and receipt of concomitant chemotherapy. Survival analyzes were performed using a Cox model and binary toxicity endpoints using a logistic regression analysis.

RESULTS

Fifty IMPT and 100 IMRT patients were included. The median follow-up time was 32months. There were no imbalances in patient/tumor characteristics except for age (mean age 56.8years for IMRT patients and 61.1years for IMPT patients, p-value=0.010). Statistically significant differences were not observed in overall survival (hazard ratio (HR)=0.55; 95% confidence interval (CI): 0.12-2.50, p-value=0.44) or in progression-free survival (HR=1.02; 95% CI: 0.41-2.54; p-value=0.96). The age-adjusted odds ratio (OR) for the presence of a gastrostomy (G)-tube during treatment for IMPT vs IMRT were OR=0.53; 95% CI: 0.24-1.15; p-value=0.11 and OR=0.43; 95% CI: 0.16-1.17; p-value=0.10 at 3months after treatment. When considering the pre-planned composite endpoint of grade 3 weight loss or G-tube presence, the ORs were OR=0.44; 95% CI: 0.19-1.0; p-value=0.05 at 3months after treatment and OR=0.23; 95% CI: 0.07-0.73; p-value=0.01 at 1year after treatment.

CONCLUSION

Our results suggest that IMPT is associated with reduced rates of feeding tube dependency and severe weight loss without jeopardizing outcome. Prospective multicenter randomized trials are needed to validate such findings.

Measuring value in bundled payments for head and neck cancer

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Background: Value, defined as outcomes relative to costs, cannot be improved without rigorous long-term measurement. To assess value within a bundled payment pilot for head and neck cancer, we aim to generate timely, patient-centered outcomes and robust, near-real time financial tracking (Porter and Teisberg, Redefining health care. Creating value-based competition on results; Harvard Business School Press, 2006). Methods: Clinical and quality experts created an outcome measure set for head and neck cancer, using a three-tiered outcomes hierarchy from Michael Porter of Harvard Business School as a framework. Process measures were identified to evaluate compliance with standards of care. Data sources were verified and patient-reported outcomes were collected via a patient portal. A REDCap database was created to aggregate all longitudinal outcomes. The project managers and financial leaders identified key financial metrics to be tracked for enrolled patients. Outcomes and financial data were built into a dashboard to deliver timely, actionable information on value. Patients will be tracked for 2 years post-treatment completion. Results: 22 outcome measures and 6 process measures are being collected for all enrolled patients. Financial indicators, such as cumulative costs and fee-for-service payment vs. bundled payment, are being tracked for each patient. Currently, most outcomes and financial data are extracted manually. Implementation of a new electronic health record (EHR) should alleviate much of this administrative burden (Table). Conclusions: The project demonstrates the feasibility of value measurement for bundled payment. With provider and patient input, the outcome measures direct attention to what is important to patients and is actionable by clinicians. Additionally, near real-time financial tracking offers insights into the financial implications of this alternative payment model for cancer care. With automation via the EHR, this value measurement methodology can be scaled for other disease sites and additional payers. [Table: see text]

Clinical Outcomes and Patterns of Disease Recurrence After Intensity Modulated Proton Therapy for Oropharyngeal Squamous Carcinoma

PURPOSE

A single-institution prospective study was conducted to assess disease control and toxicity of proton therapy for patients with head and neck cancer.

METHODS AND MATERIALS

Disease control, toxicity, functional outcomes, and patterns of failure for the initial cohort of patients with oropharyngeal squamous carcinoma (OPC) treated with intensity modulated proton therapy (IMPT) were prospectively collected in 2 registry studies at a single institution. Locoregional failures were analyzed by using deformable image registration.

RESULTS

Fifty patients with OPC treated from March 3, 2011, to July 2014 formed the cohort. Eighty-four percent were male, 50% had never smoked, 98% had stage III/IV disease, 64% received concurrent therapy, and 35% received induction chemotherapy. Forty-four of 45 tumors (98%) tested for p16 were positive. All patients received IMPT (multifield optimization to n=46; single-field optimization to n=4). No Common Terminology Criteria for Adverse Events grade 4 or 5 toxicities were observed. The most common grade 3 toxicities were acute mucositis in 58% of patients and late dysphagia in 12%. Eleven patients had a gastrostomy (feeding) tube placed during therapy, but none had a feeding tube at last follow-up. At a median follow-up time of 29 months, 5 patients had disease recurrence: local in 1, local and regional in 1, regional in 2, and distant in 1. The 2-year actuarial overall and progression-free survival rates were 94.5% and 88.6%.

CONCLUSIONS

The oncologic, toxicity, and functional outcomes after IMPT for OPC are encouraging and provide the basis for ongoing and future clinical studies.

Favorable patient reported outcomes following IMRT for early carcinomas of the tonsillar fossa: Results from a symptom assessment study

BACKGROUND

A questionnaire-based study was conducted to assess long-term patient reported outcomes (PROs) following definitive IMRT-based treatment for early stage carcinomas of the tonsillar fossa.

METHODS

Participants had received IMRT with or without systemic therapy for squamous carcinoma of the tonsillar fossa (T1-2 and N0-2b) with a minimum follow-up of 2years. Patients completed a validated head and neck cancer-specific PRO instrument, the MD Anderson Symptom Inventory-Head and Neck module (MDASI-HN). Symptoms were compared between treatment groups of interest and overall symptom burden was evaluated.

RESULTS

Of 139 participants analyzed, 51% had received ipsilateral neck IMRT, and 62% single modality IMRT alone (no systemic therapy). There were no differences in mean severity ratings for the top-ranked individual symptoms or symptom interference for those treated with bilateral versus ipsilateral neck IMRT alone. However, 40% of those treated with bilateral versus 25% of those treated with ipsilateral neck RT alone reported moderate-to-severe levels of dry mouth (p=0.03). Fatigue, numbness/tingling, and constipation were rated more severe for those who had received systemic therapy (p<0.05 for each), but absolute differences were small. Overall, 51% had no more than mild symptom ratings across all 22 symptoms assessed.

CONCLUSIONS

The long-term patient reported symptom profile in this cohort of tonsil cancer survivors treated with definitive IMRT-based treatment showed a majority of patients with no more than mild symptoms, low symptom interference, and provides an opportunity for future comparison studies with other treatment approaches.

Left ventricular wall motion analysis using real-time three-dimensional ultrasound

This study tested the ability of real-time 3-D (RT 3-D) echocardiography to detect and delineate regions of abnormal contraction (akinesia or dyskinesia) in a canine model of regional myocardial injury and to develop methods to simplify injury assessments. Closed chest RT 3-D scans were obtained and regional left ventricular (LV) contractile function was assessed in nine animals at baseline and after myocardial cryoinjury with a 1-cm cryoprobe. Evaluation of contractile function was based on radial shortening of LV chamber cross-sections at multiple levels. Radial length changes were analyzed using color-coded circumferential maps of the LV. Seven sets of motion maps demonstrated new areas of poorly contracting myocardium in the cryoinjured region relative to baseline. Two sets of data were excluded due to insufficient LV visualization. Motion maps derived from RT 3-D echo have the ability to detect and localize regions of abnormal LV wall motion.

Weaning children with accommodative esotropia out of spectacles: a pilot study

BACKGROUND/AIM

Many children with accommodative esotropia must continue spectacle use throughout life. This study was undertaken to determine which factors are predictive of successfully weaning children with accommodative esotropia out of spectacles.

METHODS

A retrospective review of 10 children with accommodative esotropia, who were gradually weaned from their hyperopic correction, and three age matched controls was performed. The main outcome measure was resolution or non-resolution of esotropia following weaning and eventual discontinuation of spectacles. Secondary outcome measures were final refractive error and the final esotropic or esophoric angle without correction.

RESULTS

Six patients were successfully weaned from spectacles. At the completion of the weaning period one child was orthophoric and the other five children had well controlled esophorias. The other four patients remained spectacle dependent because of persistent esotropia or decreased vision without spectacles. The baseline and final refractive errors were significantly lower in the children successfully weaned from spectacles (p = 0.014). While the children who were successfully weaned from spectacles were older when initially diagnosed with accommodative esotropia (4.6 v 2.5 years), this difference was not statistically significant (p = 0.09).

CONCLUSION

Some children with accommodative esotropia may be weaned out of spectacles during the grade school years with resolution of their esotropia. It is likely that gradual reduction of the hyperopic correction increases divergence amplitudes, but it is unclear whether this facilitates emmetropisation.

Costs of counterdefenses to host resistance in a parasitoid of Drosophila

The ability of a parasitoid to evolve enhanced counterdefenses against host resistance and its possible costs were studied in a Drosophila-parasitoid system. We reared Asobara tabida (Braconidae, Hymenoptera) exclusively on D. melanogaster to impose artificial selection for improved counterdefenses against cellular encapsulation, the main host defense against parasitism. Controls were reared on D. subobscura, the main host of the population of wasps from which the laboratory culture was derived and a species that never encapsulates parasitoids. We observed improved survival and avoidance of encapsulation in all five selection lines compared to their paired control lines, although there was unexpected variation among pairs. Improved survival was associated with parasitoid eggs becoming embedded in host tissue, where they were protected from circulating haemocytes. There were no differences among lines in average adult size, fat content, egg load, or performance on D. subobscura. However, the duration of the egg stage in selection lines was longer than that of control lines, probably because of reduced nutrient and/or oxygen supply when eggs are embedded in host tissue. We suggest that this delay in hatching reduces the probability of parasitoid survival if another parasitoid egg is laid in the same host (superparasitism or multiparasitism) and hence is a cost of enhanced counterdefenses against host resistance.

Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) has been shown to be an accurate method for identifying diaphragmatic injuries (DIs). The purpose of this investigation was to establish specific indications for the use of VATS after penetrating chest trauma.

METHODS

A retrospective review of all patients undergoing VATS after penetrating chest trauma at a level 1 trauma center over an 8-year period was performed. Logistic regression was used in an attempt to identify independent predictors of DI.

RESULTS

One hundred seventy-one patients underwent VATS assessment of a hemidiaphragm, and 60 patients (35%) were found to have a DI. Five independent risk factors for DI were identified from analyzing the patient records: abnormal chest radiograph, associated intraabdominal injuries, high-velocity mechanism of injury, entrance wound inferior to the nipple line or scapula, and right-sided entrance wound.

CONCLUSIONS

In the largest published series of patients undergoing VATS to exclude a DI, this review identifies five independent predictors of DI after penetrating chest trauma. A diagnostic algorithm incorporating these five factors was designed with the goal of reducing the number of unrecognized DIs after penetrating chest trauma by using VATS for patients at greatest risk for such injuries.

Good visual function in posterior microphthalmos

Posterior microphthalmos is a rare condition in which the anterior segment is normal in size and configuration, but the posterior segment is reduced in size; this results in axial hyperopia and retinal folding. Patients have decreased vision that is caused by posterior segment abnormalities, high refractive error, and amblyopia. We present a case of posterior microphthalmos in which retinal function was relatively intact and visual loss was believed to be primarily caused by refractive error and amblyopia. After treatment, the child's visual acuity and school performance improved. This case emphasizes the need for careful examination, refraction, and follow-up for these children because their visual potential may be reasonably good.

Comparison of benefits on myocardial performance of cellular cardiomyoplasty with skeletal myoblasts and fibroblasts

Cellular cardiomyoplasty (CCM), or introduction of immature cells into terminally injured heart, can mediate repair of chronically injured myocardium. Several different cell types, ranging from embryonic stem cells to autologous skeletal myoblasts, have been successfully propagated within damaged heart and shown to improve myocardial performance. However, it is unclear if the functional advantages associated with CCM depend upon the use of myogenic cells or if similar results can be seen with other cell types. Thus, we compared indices of regional contractile (systolic) and diastolic myocardial performance following transplantation of either autologous skeletal myoblasts (Mb) or dermal fibroblasts (Fb) into chronically injured rabbit heart. In vivo left ventricular (LV) pressure (P) and regional segment length (SL) were determined in 15 rabbits by micromanometry and sonomicrometry 1 week following LV cryoinjury (CRYO) and again 3 weeks after autologous skeletal Mb or dermal Fb transplantation. Quantification of systolic performance was based on the linear regression of regional stroke work and end-diastolic (ED) SL. Regional diastolic properties were assessed using the curvilinear relationships between LVEDP and strain (epsilon) as well as LVEDP and EDSL. At study termination, cellular engraftment was characterized histologically in a blinded fashion. Indices of diastolic performance were improved following CCM with either Mb or Fb. However, only Mb transplantation improved systolic performance; Fb transfer actually resulted in a significant decline in systolic performance. These data suggest that both contractile and noncontractile cells can improve regional material properties or structural integrity of terminally injured heart, as reflected by improvements in diastolic performance. However, only Mb improved systolic performance in the damaged region, supporting the role of myogenic cells in augmenting contraction. Further studies are needed to define the mechanism by which these effects occur and to evaluate the long-term safety and efficacy of CCM with any cell type.

Myogenic cell transplantation improves in vivo regional performance in infarcted rabbit myocardium

BACKGROUND

Although cardiac transplantation is an ideal treatment for end-stage heart disease, inadequate donor availability has stimulated efforts to manage terminally injured myocardium by other innovative methods. Autologous skeletal myoblast transplantation, or cellular cardiomyoplasty, is one method to potentially mediate myocardial repair within chronically injured hearts. However, few investigators have documented the ability of myogenic cells to alter load-insensitive indices of systolic and diastolic performance in vivo. In this study, both systolic and diastolic regional myocardial function were evaluated following left ventricular cryoinjury and compared with function after myogenic cell transplantation.

METHODS

Left ventricular pressure and segment length were determined in 9 rabbits by micromanometry and sonomicrometry 1 week following cryoinjury and 3 weeks after myoblast transplantation. At study termination, the extent of myoblast engraftment was determined by histologic analysis. Systolic performance was based on the linear regression of stroke work and end-diastolic segment length. Diastolic properties were evaluated by the curvilinear relationships between left ventricular pressure and strain, and left ventricular pressure and end-diastolic segment length.

RESULTS

Although mean indices of systolic performance were unchanged after cell transplantation, systolic performance improved in 3 animals. In contrast, myoblast engraftment was associated with significantly improved diastolic properties (strain and dynamic stiffness) in all animals.

CONCLUSIONS

These data quantify temporal changes in regional myocardial performance and suggest that cellular cardiomyoplasty improves diastolic compliance prior to affecting systolic performance. Cellular cardiomyoplasty, a potential therapeutic option for ischemic heart disease, appears to reverse diastolic creep and thus may represent a clinical alternative to transplantation in the near future.

Anterior hyaloid face opacification after pediatric Nd:YAG laser capsulotomy

PURPOSE

The purpose of this study was to examine the clarity of the visual axis after Nd:YAG laser capsulotomy following cataract extraction and primary intraocular lens implantation in a pediatric population.

METHODS

A retrospective review was performed of all cases of cataract extraction and primary intraocular lens implantation over a period of 5 years. A group of children who had been treated by primary surgical posterior capsulotomy and anterior vitrectomy (Group 1) was used as the "gold standard," with whom the children treated with Nd:YAG laser capsulotomy (Group 2) were compared. The groups were studied for the incidence of opacification of the visual axis after the primary procedure.

RESULTS

Data on 78 eyes were reviewed, and 56 eyes met inclusion criteria. Of these, 33 eyes were treated with primary posterior capsulotomy and anterior vitrectomy (Group 1) and 23 eyes were treated with Nd:YAG laser capsulotomy (Group 2). One eye (3%) of Group 1 experienced postoperative visual axis reopacification. Thirteen (57%) of 23 eyes in Group 2 experienced reopacification, requiring retreatment. Four eyes (17%) treated with Nd:YAG laser required a third treatment.

CONCLUSIONS

In our series, 57% of patients treated with Nd:YAG laser capsulotomy experienced reopacification across the anterior hyaloid face. With the removal of the anterior vitreous at the time of cataract extraction, the scaffolding for cell migration is removed and reopacification of the visual axis is rarely seen. For patients in whom slit-lamp capsulotomy is not possible, especially if there is no Nd:YAG laser available for use in the operating room or when loss to follow-up may be an issue, primary posterior capsulotomy and anterior vitrectomy should be strongly considered.

Periocular abscess and cellulitis from Pasteurella multocida in a healthy child

PURPOSE

To examine an unusual cause of periorbital cellulitis, Pasteurella multocida.

METHODS

Case report, review of the literature.

RESULTS

We treated a 13-year-old previously healthy child who developed Pasteurella preseptal cellulitis secondary to a cat bite and cat scratch. After receiving a dose of intravenous antibiotics and starting oral antibiotics, the child had delayed onset of several abscesses around the right eye, with marked pain and erythema. After incision and drainage, he improved.

CONCLUSION

Pasteurella multocida is a rare but potentially serious cause of ocular infection. All cases of potential exposure should be treated promptly and followed until complete resolution of infection.

Cellular cardiomyoplasty improves diastolic properties of injured heart

BACKGROUND

Acute myocardial infarction leads to loss of functional myocytes and structural integrity that often decreases diastolic compliance and increases resting myocardial segment length (diastolic creep). Successfully engrafting autologous skeletal myoblasts could improve compliance and potentially reverse creep. Thus, we transplanted myoblasts into cryoinjured rabbit heart (n = 15, CRYO) and measured regional diastolic properties in the presence (n = 9, +ENG) or absence (n = 6, -ENG) of engraftment.

MATERIALS AND METHODS

Left ventricular (LV) pressures (P) and myocardial segment lengths (SL) were measured in vivo by micromanometry and sonomicrometry after cryoinjury (CRYO) and again 3 weeks following transplantation of myoblasts. Performance was estimated from the relationships between end-diastolic (ED) P and strain (epsilon) or between EDP and EDSL. Compliance was characterized by strain (epsilon(8)) and dynamic stiffness (dP/dL(8)) at 8 mm Hg. Creep was characterized by resting myocardial segment length (EDSL(0)) and static stiffness at 8 mm Hg (m(stat8)).

RESULTS

Successful myoblast engraftment was determined via histologic examination. In nine +ENG animals, diastolic properties improved. Regional strain (epsilon(8)) increased (0.06 +/- 0.02 CRYO vs 0.10 +/- 0.04 +ENG; P = 0.0009) while dynamic stiffness (dP/dL(8)) decreased (43 +/- 23 mm Hg/mm CRYO vs 23 +/- 14 mm Hg/mm +ENG; P = 0.009). Static stiffness (m(stat8)) was unaffected (0.78 +/- 0.2 mm Hg/mm CRYO vs 0.72 +/- 0. 1 mm Hg/mm +ENG; P = 0.08), and creep did not occur (EDSL(0) = 10.3 +/- 2.8 CRYO vs 10.4 +/- 2.3 +ENG; P = 0.74). In the absence of myoblast engraftment (n = 6, -ENG), strain decreased (epsilon(8) = 0. 06 +/- 0.02 CRYO vs 0.05 +/- 0.02 -ENG; P = 0.048), but dynamic stiffness (dP/dL(8)) did not (36 +/- 19 mm Hg/mm CRYO vs 28 +/- 12 mm Hg/mm -ENG; P = 0.20). Furthermore, static stiffness decreased (0. 78 +/- 0.3 mm Hg/mm CRYO vs 0.65 +/- 0.2 mm Hg/mm -ENG; P = 0.05) and creep was obvious (EDSL(0) = 10.8 +/- 3.6 mm CRYO vs 13.0 +/- 4. 4 mm -ENG, P = 0.04).

CONCLUSIONS

Myoblast engraftment may partially overcome the loss of myocytes and structural integrity that often follow chronic myocardial ischemia. Improved compliance and reversal of diastolic creep suggest regeneration of viable muscle within once infarcted myocardium.

Intracardiac transplantation of skeletal myoblasts yields two populations of striated cells in situ

BACKGROUND

Adult heart lacks stem cells and cannot effectively regenerate. In contrast, skeletal muscle is constantly undergoing repair. We proposed to transplant immature skeletal myoblasts into injured myocardium.

METHODS

Approximately 7x10(6) soleus skeletal myoblasts were expanded in vitro from adult New Zealand White rabbits (n = 23) whose posterior left ventricle was cryoinjured to create a transmural lesion. Autologous myoblasts (n = 18) or saline (n = 5) was transplanted into the central cryolesion at the time of injury (n = 6) or 1 week later (n = 12). Hearts were harvested 2 weeks after injection.

RESULTS

Myoblast transfer did not incur further morbidity. After cryolesion, grossly, a 1.6-cm epicardial hemorrhagic lesion could be seen. Histologically, the transmural lesion contained inflammatory cells and active scarring but no viable cardiomyocytes. Electron microscopy demonstrated a predominance of collagen and fibroblasts. Nine hearts contained multinucleated cells within the cryolesion that covered approximately 75% of the central cryolesion in 17% of animals. Immunohistochemical analysis confirmed their skeletal muscle origin. At the periphery of the lesion, isolated clusters of nonskeletal muscle cells could be visualized (n = 12) that resembled immature cardiocytes.

CONCLUSIONS

Autologous skeletal myoblasts can regenerate viable striated tissue within damaged myocardium. Myoblast transfer warrants further investigation as a new method for improving myocardial performance within infarcted myocardium.

Cyclic esotropia after a traumatic sixth nerve palsy in a child

Cyclic esotropia is a rare phenomenon in which esotropia and orthophoria alternate over a period of 48 to 96 hours. The mechanism that underlies the phenomenon is unknown. Cyclic esotropia often occurs after a fusion-disrupting event. We report an unusual case of cycling esotropia with onset after a traumatic sixth nerve palsy. The cyclic phase persisted for 2 years, following a 48-hour alternate-day pattern. After strabismus surgery for the esotropic angle, the deviation disappeared and the patient remained orthotropic, with 1 year of follow-up to date.

A load-independent in vivo model for evaluating therapeutic interventions in injured myocardium

Although cardiomyocyte damage is normally irreversible, gene therapy and somatic cell transfer offer potential for improving function in damaged regions of the heart. However, in ischemic models of injury, variability in depth, size, and location of damage compromises statistical evaluation of in vivo function. We have adapted cryoablation to create a reproducible, posterior, transmural lesion within rabbit myocardium in which small changes in function are measurable in vivo. Before and at 2 and 6 wk postinjury, in vivo left ventricular intracavitary pressure and myocardial segment length were measured. Regional indexes of performance, segmental stroke work (SW), and percent systolic shortening (SS) were significantly decreased (P < 0.001) postcryoinjury as was the slope (Mw) of the linear preload recruitable SW relationship between SW and end-diastolic segment length (P = 0.0001). Decreased SW, SS, and Mw correlated with wall thinning, loss of myocytes, presence of fibroblasts, and transmural scar formation. Reproducible changes in regional myocardial performance in vivo postcryoinjury suggest that this is a reasonable model for evaluating novel therapies for cardiovascular disease.

Regenerating functional myocardium: improved performance after skeletal myoblast transplantation

The adult heart lacks reserve cardiocytes and cannot regenerate. Therefore, a large acute myocardial infarction often develops into congestive heart failure. To attempt to prevent this progression, we transplanted skeletal myoblasts into cryoinfarcted myocardium of the same rabbits (autologous transfer), monitored cardiac function in vivo for two to six weeks and examined serial sections of the hearts by light and electron microscopy. Islands of different sizes comprising elongated, striated cells that retained characteristics of both skeletal and cardiac cells were found in the cryoinfarct. In rabbits in which myoblasts were incorporated, myocardial performance was improved. The ability to regenerate functioning muscle after autologous myoblast transplantation could have a important effect on patients after acute myocardial infarction.

Balloon dilatation for treatment of resistant nasolacrimal duct obstruction

PURPOSE

Our purpose was to report our experience with balloon catheter dilatation for resistant nasolacrimal duct obstruction.

METHODS

Patients enrolled had symptoms of nasolacrimal duct obstruction and (1) had failed previous probing or (2) were more than 2 years old. Balloon dilatation was performed with a LacriCATH lacrimal catheter (Atrion Medical Products, Birmingham, Ala.). A subset of patients had Silastic silicone rubber (Dow Corning, Midland, Mich.) intubation after balloon dilatation. Success was determined by clinical examination a minimum of 6 weeks later.

RESULTS

Twenty-one lacrimal systems of 12 patients were treated (age range 4 months to 7 years). Of the patient subset treated with a LacriCATH lacrimal catheter alone, 9 of 18 systems demonstrated complete resolution of symptoms. Three of the 12 patients underwent balloon dilatation intraoperatively after attempts at Silastic silicone rubber intubation were unsuccessful. In two of these patients, who were younger, Silastic silicone rubber tubes passed easily after balloon treatment; however, in an older patient, age 5 years, intubation still could not be accomplished.

CONCLUSION

Common clinical strategy for treatment of resistant nasolacrimal obstruction includes repeat probing, intubation of the nasolacrimal system with Silastic silicone rubber tubes, or dacryocystorhinostomy. Balloon catheter dilatation is an alternative or adjunct to consider. Factors that may affect the success of treatment include the age of the patient, the complexity of the nasolacrimal anatomy, and use of adjunctive systemic antibiotics and steroids.

Intraoperative measurement of parathyroid hormone in the surgical management of hyperparathyroidism

The operative management of patients with hyperparathyroidism is controversial. Higher rates for persistent hypercalcemia and postoperative hypoparathyroidism are seen in multiple-gland hyperplasia and in bilateral neck exploration. Hyperparathyroid patients undergoing unilateral neck exploration with removal of a single parathyroid adenoma have a rapid clearance of parathyroid hormone (PTH) that declines to undetectable levels within hours after successful parathyroid surgery. We have taken advantage of a sensitive immunoradiometric assay (IRMA) for the secreted biologically active, intact PTH-(1-84) molecule and demonstrated a decline of PTH to less than 40% of baseline values 15 minutes after successful parathyroid adenomectomy in 12 patients. Intraoperative measurement of PTH by modification of this IRMA may complement surgical skill and histopathologic information and has the potential for providing guidance regarding the extent of neck exploration necessary for determining surgical care of hyperparathyroidism.