Human papillomavirus (HPV) DNA methylation changes in HPV-associated head and neck cancer

Despite the rising incidence, currently, there are no early detection methods for HPV-driven HNC (HPV-HNC). Cervical cancer studies suggest that HPV DNA methylation changes can be used as a biomarker to discriminate cancer patients from HPV-infected individuals. As such, this study was designed to establish a protocol to evaluate DNA methylation changes in HPV late genes and long control region (LCR) in saliva samples of HPV-HNC patients and HPV-positive controls. Higher methylation levels were detected in HPV late genes (L1 and L2) in both tumour and saliva samples of HPV-HNC patients compared with HPV-positive controls. Moreover, methylation patterns between tumours and corresponding saliva samples were observed to have a strong correlation (Passing-Bablok regression analysis; τ = 0.7483, P < 0.0001). Considering the differences between HNC and controls in methylation levels in late genes, and considering primer amplification efficiencies, 13 CpG sites located at L1 and L2 genes were selected for further evaluation. A total of 18 HNC saliva samples and 10 control saliva samples were assessed for the methylation levels in the selected sites. From the CpG sites evaluated statistically significant differences were identified for CpG sites at L2-CpG 6 (P = 0.0004), L1-CpG 3 (P = 0.0144), L1-CpG 2 (P = 0.0395) and L2-CpG 19 (P = 0.0455). Our pilot data indicate that higher levels of DNA methylation in HPV late genes are indicative of HPV-HNC risk, and it is a potential supplementary biomarker for salivary HPV detection-based HPV-HNC screening.

Nutrition outcomes and treatment toxicities in patients with head and neck cancer receiving helical intensity-modulated radiotherapy

BACKGROUND

Helical intensity-modulated radiotherapy (H-IMRT) provides excellent limitation of dose to tissues not requiring treatment, although acute toxicity still occurs. The present study aimed to determine how treatment-related acute toxicities affect nutrition outcomes in patients with head and neck cancer.

METHODS

A prospective observational study was conducted in 194 patients undergoing curative intent H-IMRT with or without other treatment modalities. Weight outcomes (kg) and acute toxicity and dysphagia data were collected during treatment using Common Toxicity Criteria for Adverse Effects (CTCAE), version 4.0.

RESULTS

Significant weight loss (> 10%) was observed in 30% of high nutritional risk patients and 7% of low nutritional risk patients. Nausea, adjusted for baseline dysphagia, in high nutritional risk patients and nausea, dysphagia and pharyngeal mucositis in low nutritional risk patients were significant factors in explaining the percentage loss in baseline weight to treatment completion.

CONCLUSIONS

Significant weight loss remains an issue during treatment, despite improvements in radiotherapy technology and high-level multidisciplinary care.

Standards and quality assurance in interventional oncology: The establishment of the International Accreditation System for Interventional Oncology Services (IASIOS)

Quality assurance is integral to benchmarking and continuous improvement in the clinical care of people affected by cancer. Quality assurance systems are built upon agreed clinical and administrative standards. The Cardiovascular and Interventional Radiology Society of Europe (CIRSE) first developed a set of Standards for Interventional Oncology Services modelled on the Standards of Practice in Radiation Oncology developed in Australia and New Zealand. A subset of these Standards has been used to develop a tiered International Accreditation System in Interventional Oncology (IASIOS). This system covers the entirety of the patient care pathway from referral through to discharge and is clearly aimed at setting the benchmark for safe, quality interventional oncology (IO) services. Such a system has multiple benefits, including increasing the awareness of the availability of IO services and assurance in the quality of the care delivered to patients.

A comparison between mutational profiles in tumour tissue DNA and circulating tumour DNA in head and neck squamous cell carcinoma---A systematic review

BACKGROUND

Head and neck cancer is the seventh most common malignancy globally. Head and neck squamous cell carcinoma (HNSCC) originates from squamous cells and 90% of HNC are HNSCC. The gold standard for diagnosing HNSCC is tissue biopsy. However, given tumour heterogeneity, biopsies may miss important cancer-associated molecular signatures, and more importantly, after the tumour is excised, there is no means of tracking response to treatment in patients. Captured under liquid biopsy, circulating tumour DNA (ctDNA), may identify in vivo molecular genotypes and complements tumour tissue analysis in cancer management. A systematic search was conducted in PubMed, Embase, Scopus and the Cochran Library between 2012 to early 2023 on ctDNA in HNSCC using publications written in English. We summarize 20 studies that compared mutational profiles between tumour tissue DNA (tDNA) and ctDNA, using a cohort of 631 HNSCC patients and 139 controls. Among these studies, the concordance rates varied greatly and the most mutated and the most concordant gene was TP53, followed by PIK3CA, CDKN2A, NOTCH1 and FAT1. Concordant variants were mainly found in Stage IV tumours, and the mutation type is mostly single nucleotide variants (SNV). We conclude that, as a biomarker for HNSCC, ctDNA demonstrates great promise as it recapitulates tumour genotypes, however additional multi-central trials are needed.

Circulating tumour DNA alterations: emerging biomarker in head and neck squamous cell carcinoma

Head and Neck cancers (HNC) are a heterogeneous group of upper aero-digestive tract cancer and account for 931,922 new cases and 467,125 deaths worldwide. About 90% of these cancers are of squamous cell origin (HNSCC). HNSCC is associated with excessive tobacco and alcohol consumption and infection with oncogenic viruses. Genotyping tumour tissue to guide clinical decision-making is becoming common practice in modern oncology, but in the management of patients with HNSCC, cytopathology or histopathology of tumour tissue remains the mainstream for diagnosis and treatment planning. Due to tumour heterogeneity and the lack of access to tumour due to its anatomical location, alternative methods to evaluate tumour activities are urgently needed. Liquid biopsy approaches can overcome issues such as tumour heterogeneity, which is associated with the analysis of small tissue biopsy. In addition, liquid biopsy offers repeat biopsy sampling, even for patients with tumours with access limitations. Liquid biopsy refers to biomarkers found in body fluids, traditionally blood, that can be sampled to provide clinically valuable information on both the patient and their underlying malignancy. To date, the majority of liquid biopsy research has focused on blood-based biomarkers, such as circulating tumour DNA (ctDNA), circulating tumour cells (CTCs), and circulating microRNA. In this review, we will focus on ctDNA as a biomarker in HNSCC because of its robustness, its presence in many body fluids, adaptability to existing clinical laboratory-based technology platforms, and ease of collection and transportation. We will discuss mechanisms of ctDNA release into circulation, technological advances in the analysis of ctDNA, ctDNA as a biomarker in HNSCC management, and some of the challenges associated with translating ctDNA into clinical and future perspectives. ctDNA provides a minimally invasive method for HNSCC prognosis and disease surveillance and will pave the way in the future for personalized medicine, thereby significantly improving outcomes and reducing healthcare costs.

Salivary micro RNAs as biomarkers for oropharyngeal cancer

BACKGROUND

Despite the rising incidence, particularly of the human papillomavirus (HPV)-associated fraction of oropharyngeal cancer (OPC), there are no early detection methods for OPC. Considering the close association between saliva and head and neck cancers, this study was designed to investigate salivary micro RNA (miRNAs) associated with OPC, especially focusing on HPV-positive OPC.

METHODS

Saliva was collected from OPC patients at diagnosis and patients were clinically followed up ≤5 years. Salivary small RNA isolated from HPV-positive OPC patients (N = 6), and HPV-positive (N = 4) and negative controls (N = 6) were analysed by next-generation sequencing to identify dysregulated miRNAs. Discovered miRNAs were validated by quantitative PCR using two different assays in a separate cohort of patients (OPC = 91, controls = 92). The relative expression was calculated considering SNORD-96A as the normalizer. Candidate miRNAs with diagnostic and prognostic potential were evaluated by generalized logistic regression.

RESULTS

A panel consisting of nine miRNAs was identified to have the best diagnostic performance to discriminate HPV-positive OPC from HPV-positive controls (AUC- validation-1 = 94.8%, validation-2 = 98%). Further, a panel consisting of six miRNAs were identified to discriminate OPC from controls regardless of the HPV status (AUC- validation-1 = 77.2%, validation-2 = 86.7%). In addition, the downregulation of hsa-miR-7-5p was significantly associated with poor overall survival of OPC patients (HR = 0.638). A panel consisting of nine miRNAs were identified for the prediction of the overall survival of the OPC patients (log-rank test-p = 0.0008).

CONCLUSION

This study highlights that salivary miRNAs can play an essential role in the detection and prognostication of OPC.

Patient-report symptom severity, health-related quality of life and emotional distress trajectories during and after radiotherapy for HPV-associated oropharyngeal cancer: a XXXX.XXXX secondary analysis

PURPOSE/OBJECTIVES

This secondary analysis of clinical trial XXXX.XXXX, involving patients with human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPVOPSCC), aimed to identify patient-reported outcomes (PRO) trajectories before, during and following chemoradiotherapy.

MATERIALS/METHODS

Head and neck cancer symptom severity (HNSS) and interference (HNSI), generic health-related quality of life (HRQL) and emotional distress were assessed with the MDASI-HN, FACT-G and HADS questionnaires, respectively. Latent class growth mixture modelling (LCGMM) was used to identify distinct underlying trajectories. Baseline and treatment variables were compared between trajectory groups.

RESULTS

The LCGMM identified latent trajectories for all PROs: HNSS, HNSI, HRQL, anxiety and depression. Four HNSS trajectories (HNSS1-4) were identified, distinguished by differences in HNSS at baseline, during the peak of treatment symptoms and during early and intermediate recovery. All trajectories were stable beyond 12m. The reference trajectory (HNSS4, n=74) score was 0.1 (95%CI 0.1-0.2) at baseline, peaking at 4.6 (95%CI 4.2-5.0), with rapid early recovery (1.1, 95%CI 0.8-2.2) and gradual improvement to 12m (0.6, 95%CI 0.5-0.8). Patients in HNSS2 ("high baseline", n=30) reported higher baseline scores (1.4, 95%CI 0.8-2.0) but were otherwise similar to HNSS4. Patients in HNSS3 ("low acute", n=53) reported reduced acute symptoms (2.5, 95%CI 2.2-2.9) with stable scores beyond 9w post chemoradiotherapy (1.1, 95%CI 0.9-1.4). Patients in HNSS1 ("slow recovery", n=25) had slower recovery from an acute peak of 4.9 (95%CI 4.3-5.6) to 0.9 (95%CI 0.6-1.3) at 12m. Age, performance status, education, receipt of cetuximab and baseline anxiety varied between trajectories. The other PRO models demonstrated clinically relevant trajectories, with distinct associations with baseline factors.

CONCLUSION

LCGMM identified distinct PRO trajectories during and after chemoradiotherapy. These and their associations with variations in HPVOPSCC patients' characteristics and treatment factors provide clinically relevant insights into identifying patients who may require increased support before, during or after chemoradiotherapy.

239 PATIENT PERCEPTIONS OF THE EDITH (EMERGENCY DEPARTMENT IN THE HOME) SERVICE

Background

The EDITH service provides an alternative to Emergency Department (ED) attendance for the older adult by providing emergency care in the person home. It is imperative to explore how this service is received by the key stakeholders in order to ensure it is meeting the needs of older adults and to improve and diversify same.

Methods

A patient feedback survey was circulated to patients and family members who received the EDITH service. A postal option and a QR code leading to an online option were utilised. 50 surveys were randomly selected for inclusion. Quantitative data was analysed via paper count method and thematic analysis was completed for the qualitative data.

Results

74% rated the service as “excellent”, 22% “very good” and 4% “good”. Alternative options to the service were identified as “going to ED” 22% , “going to GP” 22%, “waited until they would get better” 4%, “waited until they got worse” 2%, “would do nothing” 6%. 80% rated the combined expertise of a doctor and OT as “extremely important”, 94% rated the home visit aspect as “extremely important” and 90% rated ED avoidance as “extremely important”. Key themes that emerged regarding what the service does well included “personalised care”, “ED avoidance”, “compassion” and “timeliness of service”. Areas for improvement included “improving communication loop to both patients and/or community services! and “ability to directly access the service”. 95% of respondents advised they would or have already recommended the service to others. Of note, a key theme in the comments section was the need for a similar service in other hospitals.

Conclusion

The EDITH service appears to be meeting stake-holders expectations, areas for improvement have been identified and are currently being addressed. It is imperative to obtain the perception of the service user and to tailor interventions accordingly, this feedback is invaluable in order to meet future service needs.

228 LONG TERM OUTCOMES FOR FALLS PATIENTS WHO WERE TREATED BY THE EDITH (EMERGENCY DEPARTMENT IN THE HOME) SERVICE

Background

The EDITH service provides an alternative to an ED attendance for the older adult. Medical treatment and Occupational Therapy (OT) assessment take place within the patient’s home. Patients who experience an explained fall are routinely treated by the EDITH service, these patients receive OT falls prevention and home environment assessment as standard. It is imperative to assess the long-term outcomes for these patients in order to inform future service provision.

Methods

A total of 40 patients, who were referred following an explained fall to the EDITH service and remained at home following assessment, were selected for audit. These patients were seen over a 2-month period in 2021. Data were gathered with regards to ED presentations via healthcare records and mortality rates were captured via RIP.ie

Results

At 3 months, 4 patients had re-presented to ED with a fall and 3 required admission. At 6 months, 6 patients re-presented to ED with a fall with 5 requiring admission. At 9 months, 4 patients re-presented to ED with a fall and 3 required admission. 100% of patients had an OT home environment assessment and received advice regarding falls prevention. The average age of patient was 84 years. At 1 year, the mortality rate for this patient group was 10%.

Conclusion

Patients with explained falls that were treated by the EDITH service appear to have a reasonably low ED re-attendance rate at 3, 6 and 9 months for explained falls. This may be as a result of the tailored falls prevention education/home environment assessment that took place within the patient’s home by the OT. However further audit and a larger population group would be required to suggest a definite correlation between same.

Exosomes at the crossroad between therapeutic targets and therapy resistance in head and neck squamous cell carcinoma

Head and neck squamous cell carcinomas (HNSCCs) are aggressive and clinically challenging tumours that require a multidisciplinary management approach. Despite significant therapy improvements, HNSCC patients have a poor prognosis with a 5-year survival rate of about 65%. As recently recognised key players in cancer, exosomes are extracellular vesicles (EVs) with a diameter of nearly 50-120 nm which transport information from one cell to another. Exosomes are actively involved in various aspects of tumour initiation, development, metastasis, immune regulation, therapy resistance, and therapeutic applications. However, current knowledge of the role of exosomes in the pathophysiological processes of HNSCC is still in its infancy, and additional studies are needed. In this review, we summarise and discuss the relevance of exosomes in mediating local immunosuppression and therapy resistance of HNSCC. We also review the most recent studies that have explored the therapeutic potential of exosomes as cancer vaccines, drug carriers or tools to reverse the drug resistance of HNSCC.

Prognostic stratification of HPV-associated oropharyngeal cancer based on CD103+ immune cell abundance in patients treated on TROG 12.01 and De-ESCALaTE randomized trials

BACKGROUND

High CD103+ intratumoral immune cell (ITIC) abundance is associated with better prognosis in unselected patients with human papilloma virus-associated oropharyngeal squamous cell carcinoma (HPV-associated OPSCC) treated with cisplatin and radiotherapy (CIS/RT). Substituting cetuximab (CETUX) for CIS with RT in HPV-associated OPSCC resulted in inferior efficacy. Our aim was to determine whether quantification of CD103 ITIC could be used to identify a population of HPV-associated OPSCC with superior prognosis.

PATIENTS AND METHODS

We pooled data from the TROG 12.01 and De-ESCALaTE randomized trials that compared CETUX/70GyRT with CIS/70GyRT in low-risk HPV-associated OPSCC: American Joint Committee on Cancer 7 stage III (excluding T1-2N1) or stage IV (excluding N2b-c if smoking history >10 pack-years and/or distant metastases), including all patients with available tumor samples. The primary endpoint was failure-free survival (FFS) in patients receiving CETUX/RT comparing CD103+ ITIC high (≥30%) versus low (<30%). High and low CD103 were compared using Cox regression adjusting for age, stage and trial.

RESULTS

Tumor samples were available in 159/182 patients on TROG 12.01 and 145/334 on De-ESCALaTE. CD103+ ITIC abundance was high in 27% of patients. The median follow-up was 3.2 years. The 3-year FFS in patients treated with CETUX/RT was 93% [95% confidence interval (CI) 79% to 98%] in high CD103 and 74% (95% CI 63% to 81%) in low CD103 [adjusted hazard ratio = 0.22 (95% CI 0.12-0.41), P < 0.001]. The 3-year overall survival in patients treated with CETUX/RT was 100% in high CD103 and 86% (95% CI 76% to 92%) in low CD103, P < 0.001. In patients treated with CIS/RT, there was no significant difference in FFS.

CONCLUSIONS

CD103+ ITIC expression separates CETUX/RT-treated low-risk HPV-associated OPSCC into excellent and poor prognosis subgroups. The high CD103 population is a rational target for de-intensification trials.

265 Assessing Management of Rib Fractures in the ICU Patient

Aim

Assess if the General Intensive Care Unit (ICU) are appropriately following trust guidelines on rib fracture management.

Method

Data gathered from patients admitted to the General Intensive Care Unit between March and May 2021 with any diagnosis code involving rib fracture (n = 19). Exclusions: patients not admitted to general ICU, or who died before being extubated.

Of the remaining patients (n  = 14) data gathered on:

Results

All patients were prescribed regular simple analgesia. Most patients were prescribed strong analgesia (n = 10) and lidocaine patches (n = 13). All patients had regular pain assessments. 9 patients were referred for a block/epidural, out of 12 who met criteria for referral. 10 patients were referred for rib fixation, and 4 patients had rib fixation, out of 11 who met criteria for referral. 6 patients developed a LRTI post rib fracture.

Conclusions

The basic management of rib fractures in General ICU is appropriate; 100% of patients had analgesia prescribed and had regular assessments of pain. However, some patients who met criteria for consideration of a block (n = 3) or fixation (n = 1) did not have documentation that they were referred. Rib fractures often do not occur in isolation, and it may be that other injuries served as distractors.

Analysis of human leukocyte antigen associations in human papillomavirus-positive and -negative head and neck cancer: Comparison with cervical cancer

Background

Although the majority of human papillomavirus (HPV) infections are cleared by the immune system, a small percentage of them progress to develop HPV‐driven cancers. Cervical cancer studies highlight that HPV persistence and cancer risk are associated with genetic factors, especially at the human leukocyte antigen (HLA) genes. This study was conducted to investigate such associations in head and neck cancer (HNC).

Methods

In all, 192 patients with HNC and 384 controls were genotyped with the Infinium Global Screening Array (Illumina, Inc). HLA variants were imputed with SNP2HLA, and an association analysis was performed by logistic regression.

Results

HPV‐positive HNCs were significantly associated with single‐nucleotide polymorphisms (SNPs) at DRB1_32660090 (P = 1.728 × 10^–6) and DRB1_32660116 (P = 1.728 × 10^–6) and with the amino acid variant DRB1_11_32660115 (P = 1.728 × 10^–6). None of these associations were observed in the HPV‐negative cohort, and this suggested their specificity to convey risk for HPV‐associated HNCs. In general, associations observed for HPV‐negative HNC were relatively weak, and variants in the HLA‐DPA1 region were the strongest among them (P = 4.531 × 10^–4). Several lead signals reported by previous HNC genome‐wide association studies, including SNPs rs3135001 (P = .012), rs1049055 (P = .012), and rs34518860 (P = .029) and allele HLA‐DQB1*06 (P = .009), were replicated in the current study. However, these associations were limited to the HPV‐positive HNC group. Several cervical cancer–associated HLA variants, including SNPs rs9272143 (P = .002) and rs9271858 (P = .002) and alleles HLA‐B‐1501 (P = .009) and HLA‐B‐15 (P = .015), were also exclusively associated with HPV‐positive HNC.

Conclusions

HPV‐positive HNC risk is associated with distinct HLA variants, and some of them are shared by both cervical cancer and HPV‐positive HNC.

Human papillomavirus (HPV)–positive head and neck cancer (HNC) risk is associated with distinct human leukocyte antigen variants, and some of them are shared by both cervical cancer and HPV‐positive HNC.

Lay Summary

Cervical cancer studies highlight that human papillomavirus (HPV)–driven cancer risk is linked with human leukocyte antigen (HLA) polymorphism.

Hence, the current study was designed to investigate the HLA associations in HPV‐positive and HPV‐negative head and neck cancer (HNC) and compare these associations with cervical cancer.

Several lead signals reported by previous HNC and cervical genome‐wide association studies were replicated in the current study.

However, these associations were limited to the HPV‐positive HNC group, and this suggests that HPV‐positive HNC risk is associated with distinct HLA variants, and some of them are shared by both cervical cancer and HPV‐positive HNC.

Evaluation of a novel pre-treatment model of nutrition care for patients with head and neck cancer receiving chemoradiotherapy

AIMS

Weight loss and malnutrition occur frequently in patients with head and neck cancer and are associated with reduced survival. This pragmatic study aimed to determine the effect of a novel pre-treatment model of nutrition care on nutrition outcomes for patients with head and neck cancer receiving chemoradiotherapy.

METHODS

This health service evaluation consisted of an evaluation of the new model of care implementation (Phase 1) and an evaluation of patient outcomes (Phase 2) in pre- and post-implementation cohorts (n = 64 and n = 47, respectively). All Phase 2 patients received a prophylactic gastrostomy. The new model of care consisted of dietary counselling and commencement of proactive supplementary enteral nutrition via a prophylactic gastrostomy, in addition to normal oral intake, prior to treatment commencement. Nutrition outcomes were collected at baseline (pre-treatment) and 3 months post-radiotherapy completion.

RESULTS

The new model of care was successfully incorporated into practice with high referral (96.5%) and attendance (91.5%) rates to the counselling session, and high adherence rates to proactive tube feeding (80.9%). Patients in the post-implementation cohort had less weight-loss (1.2%; p = 0.338) and saw less of a decline in nutritional status compared to patients in the pre-implementation cohort (23% vs. 30%, respectively; p = 0.572), deemed clinically important. However, patients still experienced critical weight loss overall (mean 9.9%).

CONCLUSION

Pre-treatment nutrition care was feasible in standard clinical practice and demonstrated clinically relevant outcome improvements for patients. Future high-quality research is warranted to investigate further multidisciplinary strategies to attenuate weight-loss further, inclusive of patient-reported barriers and enablers to nutrition interventions.

106 EDITH (EMERGENCY DEPARTMENT IN THE HOME): AN 18 MONTH AUDIT OF A NOVEL SERVICE

Background

The EDITH team has provided an alternative care pathway for older adults in need of emergency services. The traditional model, which involved the transport of an older adult to an emergency department has been replaced with emergency care that takes place in the persons’ home. The EDITH service provides both medical and Occupational Therapy assessment and intervention in the home environment with onward referrals to appropriate agencies as indicated, thus negating the need for an emergency department presentation.

Methods

Data from electronic patient records and OT logbooks were audited from the period 22/02/20 to 09/08/21. Data was gathered regarding attendances, outcomes and conveyance rates.

Results

Since its’ inception the EDITH service has treated 3,137 patients. Following treatment, 2,909 patients remained at home while 228 patients were transferred to hospital. This gives a conveyance rate of 7.2%. Three hundred and thirty six patients were referred to primary care or day hospital services. The average age of patients is 82 years and the average Manchester Triage category is priority 4. The EDITH service has saved the hospital 7.9 years of bed days (2,909 bed days) as these patients have not presented to the emergency department.

Conclusion

There is a growing body of evidence highlighting the detrimental impact a hospitalisation can have on an older adult (Mudge et al., 2019). There is a clear need for health care services to diversify in order to meet the needs of this ageing population. The EDITH service is leading this change in Irish healthcare by providing specialised emergency care and OT intervention for the older adult in their own homes.

Reference

1. Mudge et al. (2019). Hospital-Associated Complications of Older People: A Proposed Multicomponent Outcome for Acute Care. Journal of the American Geriatrics Society. 67(2).

Salivary High-Risk Human Papillomavirus DNA as a Biomarker for Human Papillomavirus-Driven Head and Neck Cancers

High-risk human papillomavirus (HR-HPV) infection is a major risk factor of head and neck cancers (HNCs). Despite the rising prevalence of HPV-driven HNC (HPV-HNC), biomarkers for detection, prognostication, and disease monitoring are lacking. To evaluate the capacity of salivary HR-HPV DNA as a biomarker of HPV-HNC, the salivary HR-HPV statuses of 491 and 10 patients with primary and recurrent HNC, respectively, were determined at diagnosis, using quantitative real-time PCR, with tumor cyclin-dependent kinase inhibitor 2A (p16) expression determined by IHC analysis. Patients with oropharyngeal cancer (OPC) (n = 215) were followed up for ≤5 years. Survival characteristics were evaluated in terms of event-free and cause-specific survival. Of the primary-HNC cohort, 43.2% were positive for salivary HR-HPV DNA, with most having OPC. Salivary HR-HPV DNA was detected in 81.4% of tumor p16-positive OPC patients at diagnosis. Prognosis in salivary HR-HPV-positive OPC patients was favorable compared with that in salivary HR-HPV-negative patients (event-free survival, hazard ratio = 0.42 [95% CI, 0.21-0.81, P = 0.010]; cause-specific survival, hazard ratio = 0.39 [95% CI, 0.18-0.86, P = 0.019]). In the recurrent-HNC cohort, salivary HR-HPV DNA was detected in 83.3% of those who previously had tumor p16-positive HNC. These findings indicate that this liquid biopsy-based, noninvasive biomarker could be essential in the detection and management of HPV-HNC.

Dosimetric evaluation of a patient-specific 3D-printed oral positioning stent for head-and-neck radiotherapy

As head-and-neck radiotherapy treatments become more complex and sophisticated, and the need to control and stabilise the positioning of intra-oral anatomy becomes more important, leading the increasing use of oral positioning stents during head-and-neck radiotherapy simulation and delivery. As an alternative to the established practice of creating oral positioning stents using wax, this study investigated the use of a 3D printing technique. An Ender 5 3D printer (Creality 3D, Shenzhen, China) was used, with PLA+ "food-safe" polylactic acid filament (3D Fillies, Dandenong South, Australia), to produce a low-density 3D printed duplicate of a conventional wax stent. The physical and dosimetric effects of the two stents were evaluated using radiochromic film in a solid head phantom that was modified to include flexible parts. The Varian Eclipse treatment planning system (Varian Medical Systems, Palo Alto, USA) was used to calculate the dose from two different head-and-neck treatment plans for the phantom with each of the two stents. Examination of the resulting four dose distributions showed that both stents effectively pushed sensitive oral tissues away from the treatment targets, even though most of the phantom was solid. Film measurements confirmed the accuracy of the dose calculations from the treatment planning system, despite the steep density gradients in the treated volume, and demonstrated that the 3D print could be a suitable replacement for the wax stent. This study demonstrated a useful method for dosimetrically testing novel oral positioning stents. We recommend the development of flexible phantoms for future studies.

Randomised trial of radiotherapy with weekly cisplatin or cetuximab in low risk HPV associated oropharyngeal cancer (TROG 12.01) - a Trans-Tasman Radiation Oncology Group study

BACKGROUND

The excellent prognosis of patients with low risk HPV associated oropharyngeal squamous cell carcinoma has led to concerns about overtreatment and excessive toxicity with radiotherapy and cisplatin, leading to interest in de-intensification trials. We investigated whether cetuximab, an EGFR targeting antibody, when combined with radiotherapy would result in a decrease in symptom burden and toxicity with similar efficacy when compared to weekly cisplatin.

METHODS

XXXX, a randomised, multicentre trial involving 15 sites in XXXX enrolled patients with HPV associated oropharyngeal squamous cell carcinoma, AJCC 7^th edition Stage III (excluding T1-2N1) or stage IV (excluding T4 and/or N3 and/or N2b-c if smoking history >10 pack years and/or distant metastases). Patients were randomised (1:1) to receive radiotherapy (70Gy in 35 fractions) with either weekly cisplatin, 7 doses of 40mg/m² or cetuximab, loading dose of 400mg/m² followed by 7 weekly doses of 250 mg/m². The primary outcome was symptom severity assessed by the MD Anderson Symptom Inventory Head and Neck Symptom Severity Scale from baseline to 13 weeks post completion of radiotherapy using the area under the curve (AUC). Trial was registered on ClinicalTrials.gov: XXXX RESULTS: Between 17^th June 2013 and 7^th June 2018, 189 patients were enrolled, with 92 on cisplatin arm and 90 on cetuximab included in the main analysis. There was no difference in the primary endpoint of symptom severity; difference in AUC cetuximab - cisplatin was 0.05 (95%CI: -0.19, 0.30), p= 0.66. The T-score (mean number of ≥ grade 3 acute adverse events) was 4.35 (SD 2.48) in the cisplatin arm and 3.82 (SD 1.8) in the cetuximab arm, p= 0.108. The 3 -year failure-free survival rates were 93% (95% CI: 86-97%) in the cisplatin arm and 80% (95% CI: 70-87%) in the cetuximab arm (hazard ratio = 3.0 (95% CI: 1.2-7.7); p=0.015.

CONCLUSIONS

For patients with low risk HPV associated oropharyngeal cancer, radiotherapy and cetuximab had inferior failure-free survival without improvement in symptom burden or toxicity compared to radiotherapy and weekly cisplatin. Radiotherapy and cisplatin remains the standard of care.

A prospective study investigating the efficacy and toxicity of definitive ChemoRadiation and ImmunOtherapy (CRIO) in locally and/or regionally advanced unresectable cutaneous squamous cell carcinoma

BACKGROUND

Patients with unresectable advanced cutaneous squamous cell carcinoma (cSCC) are generally treated with palliative intent. Immune checkpoint blockade has significant activity in the palliative setting in patients with recurrent or metastatic cSCC. This single arm phase 2 prospective study aims to investigate the combination of curative intent chemoradiation and durvalumab (anti-PD-L1 checkpoint inhibitor) for this patient cohort.

METHODS

Patients with unresectable locally and or regionally advanced pathologically confirmed cSCC (stage III-IVa) deemed fit for CRIO by consensus of the Multidisciplinary meeting will be eligible. In the first stage of a two-stage minimax design, we aim to recruit a total of 15 patients. If fewer than 7 patients achieved a complete response in the first stage, we will conclude the treatment is not more effective than standard treatment. The co-primary endpoints of CRIO are the safety of treatment (acute and late toxicities) and the rate of complete response. Secondary endpoints would include overall survival, progression free survival, and locoregional control. Translational research endpoints including biomarkers (CD73, CD39, PD-1, PD-L1) will also be explored utilising multiplex immunohistochemistry on tumour biopsy samples obtained prior to commencing treatment and during treatment (week 2). In addition, the utility of CXCR-4 PET/CT scan will be explored.

DISCUSSION

CRIO is a novel trial evaluating the combination of curative intent chemoradiotherapy with concurrent and adjuvant durvalumab for patients with unresectable stage III-IVa cSCC.

TRIAL REGISTRATION

Trial registered with the Australian New Zealand Clinical Trial Registry (ACTRN12618001573246).

Validation of local p16 testing for determination of human papilloma virus status eligibility on a low risk oropharyngeal cancer trial - A Trans-Tasman Radiation Oncology Group study

OBJECTIVE

Accurate determination of human papilloma virus (HPV) status is critical when identifying patients with oropharyngeal squamous cell carcinoma (OPSCC) who may be candidates for de-escalation trials. In this study we investigated whether local p16 screening, by immunohistochemistry (IHC), has high positive predictive value (PPV) for HPV status in a good prognosis HPV positive OPSCC (HPVOPSCC) population treated on a clinical trial.

METHODS AND MATERIALS

Patients enrolled on the TROG 12.01 randomised trial for good prognosis HPVOPSCC were randomised based on local p16 IHC testing but subsequently had central p16 IHC and HPV RNA in situ hybridisation (HPV RNA ISH) testing. Correlations between the local and central p16 and central HPV RNA ISH were studied. The main outcome was the positive predictive value (PPV) of local pathology laboratory testing of p16.

RESULTS

176/182 patients had samples available for central testing. 172/176 were evaluable for central testing of p16, and all were confirmed to be p16 positive (172/172, 100%, 95% CI = [97.9%, 100%]). Similarly, 100% of those evaluable for HPV RNA ISH (155/155, 100%, 95% CI = [97.6%, 100%]) were confirmed HPV positive, indicating p16 overexpression driven by transcriptionally active HPV and a PPV of 100% for local p16 testing.

CONCLUSIONS

Our results validate the suitability of local pathology laboratory p16 testing alone, in populations with a high attributable fraction of OPSCC due to HPV, to screen and enrol low risk HPVOPSCC patients onto de-intensification trials. This obviates the need for upfront more complex and expensive HPV assays and/or central laboratory testing.

An Occult HPV-Driven Oropharyngeal Squamous Cell Carcinoma Discovered Through a Saliva Test

Oropharyngeal cancer (OPC) caused by human papillomavirus (HPV) is a rising global concern. Early lesions are small and are often located in difficult to access areas (such as the crypts of the tonsils or base of tongue). Unlike cervical cancer, there is no standard or routine screening program for HPV-driven OPC. HPV DNA from OPC tumors may shed directly into saliva, and this can be used as a biomarker for early diagnosis. In this study, we report the first-ever clinically occult OPC in an asymptomatic patient discovered through a saliva test. This case relied upon serial measurements of HPV-16 DNA in saliva, which fell to undetectable levels following low morbidity, curative treatment.

Variation in outcome reporting in randomized controlled trials of interventions for prevention and treatment of fetal growth restriction

OBJECTIVE

Although fetal growth restriction (FGR) is well known to be associated with adverse outcomes for the mother and offspring, effective interventions for the management of FGR are yet to be established. Trials reporting interventions for the prevention and treatment of FGR may be limited by heterogeneity in the underlying pathophysiology. The aim of this study was to conduct a systematic review of outcomes reported in randomized controlled trials (RCTs) assessing interventions for the prevention or treatment of FGR, in order to identify and categorize the variation in outcome reporting.

METHODS

MEDLINE, EMBASE and The Cochrane Library were searched from inception until August 2018 for RCTs investigating therapies for the prevention and treatment of FGR. Studies were assessed systematically and data on outcomes that were reported in the included studies were extracted and categorized. The methodological quality of the included studies was assessed using the Jadad score.

RESULTS

The search identified 2609 citations, of which 153 were selected for full-text review and 72 studies (68 trials) were included in the final analysis. There were 44 trials relating to the prevention of FGR and 24 trials investigating interventions for the treatment of FGR. The mean Jadad score of all studies was 3.07, and only nine of them received a score of 5. We identified 238 outcomes across the included studies. The most commonly reported were birth weight (88.2%), gestational age at birth (72.1%) and small-for-gestational age (67.6%). Few studies reported on any measure of neonatal morbidity (27.9%), while adverse effects of the interventions were reported in only 17.6% of trials.

CONCLUSIONS

There is significant variation in outcome reporting across RCTs of therapies for the prevention and treatment of FGR. The clinical applicability of future research would be enhanced by the development of a core outcome set for use in future trials. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Variation between hospitals in outcomes following cardiac surgery in the UK

INTRODUCTION

We examine the influence of variations in provision of cardiac surgery in the UK at hospital level on patient outcomes and also to assess whether there is an inequality of access and delivery of healthcare. Cardiothoracic surgery has pioneered the reporting of surgeon-specific outcomes, which other specialties have followed. We set out to identify factors other than the individual surgeon, which can affect outcomes and enable other surgical specialties to adopt a similar model.

MATERIALS AND METHODS

A retrospective analysis of prospectively collected data of patient and hospital level factors between 2013 and 2016 from 16 cardiac surgical units in the UK were analysed through the Society for Cardiothoracic Surgery of Great Britain and Ireland and the Royal College of Surgeons Research Collaborative. Patient demographic data, risks factors, postoperative complications and in-hospital mortality, as well as hospital-level factors such as number of beds and operating theatres, were collected. Correlation between outcome measures was assessed using Pearson's correlation coefficient. Associations between hospital-level factors and outcomes were assessed using univariable and multivariable regression models.

RESULTS

Of 50,871 patients (60.5% of UK caseload), 25% were older than 75 years and 29% were female. There was considerable variation between units in patient comorbidities, bed distribution and staffing. All hospitals had dedicated cardiothoracic intensive care beds and consultants. Median survival was 97.9% (range 96.3-98.6%). Postoperative complications included re-sternotomy for bleeding (median 4.8%; range 3.5-6.9%) and mediastinitis (0.4%; 0.1-1.0%), transient ischaemic attack/cerebrovascular accident (1.7%; range 0.3-3.0%), haemofiltration (3.7%; range 0.8-6.8%), intra-aortic balloon pump use (3.3%; range 0.4-7.4%), tracheostomy (1.6%; range 1.3-2.6%) and laparotomy (0.3%; range 0.2-0.6%). There was variation in outcomes between hospitals. Univariable analysis showed a small number of positive associations between hospital-level factors and outcomes but none remained significant in multivariable models.

CONCLUSIONS

Variations among hospital level factors exists in both delivery of, and outcomes, following cardiac surgery in the UK. However, there was no clear association between these factors and patient outcomes. This negative finding could be explained by differences in outcome definition, differences in risk factors between centres that are not captured by standard risk stratification scores or individual surgeon/team performance.

Repeatability of quantitative 18F-FLT uptake measurements in solid tumors: an individual patient data multi-center meta-analysis

INTRODUCTION

3'-deoxy-3'-[18F]fluorothymidine (18F-FLT) positron emission tomography (PET) provides a non-invasive method to assess cellular proliferation and response to antitumor therapy. Quantitative 18F-FLT uptake metrics are being used for evaluation of proliferative response in investigational setting, however multi-center repeatability needs to be established. The aim of this study was to determine the repeatability of 18F-FLT tumor uptake metrics by re-analyzing individual patient data from previously published reports using the same tumor segmentation method and repeatability metrics across cohorts.

METHODS

A systematic search in PubMed, EMBASE.com and the Cochrane Library from inception-October 2016 yielded five 18F-FLT repeatability cohorts in solid tumors. 18F-FLT avid lesions were delineated using a 50% isocontour adapted for local background on test and retest scans. SUVmax, SUVmean, SUVpeak, proliferative volume and total lesion uptake (TLU) were calculated. Repeatability was assessed using the repeatability coefficient (RC = 1.96 × SD of test-retest differences), linear regression analysis, and the intra-class correlation coefficient (ICC). The impact of different lesion selection criteria was also evaluated.

RESULTS

Images from four cohorts containing 30 patients with 52 lesions were obtained and analyzed (ten in breast cancer, nine in head and neck squamous cell carcinoma, and 33 in non-small cell lung cancer patients). A good correlation was found between test-retest data for all 18F-FLT uptake metrics (R2 ≥ 0.93; ICC ≥ 0.96). Best repeatability was found for SUVpeak (RC: 23.1%), without significant differences in RC between different SUV metrics. Repeatability of proliferative volume (RC: 36.0%) and TLU (RC: 36.4%) was worse than SUV. Lesion selection methods based on SUVmax ≥ 4.0 improved the repeatability of volumetric metrics (RC: 26-28%), but did not affect the repeatability of SUV metrics.

CONCLUSIONS

In multi-center studies, differences ≥ 25% in 18F-FLT SUV metrics likely represent a true change in tumor uptake. Larger differences are required for FLT metrics comprising volume estimates when no lesion selection criteria are applied.

Home-based telehealth service for swallowing and nutrition management following head and neck cancer treatment

Introduction

Following (chemo)radiotherapy (C/RT) for head and neck cancer (HNC), patients return to hospital for regular outpatient reviews with speech pathology (SP) and nutrition and dietetics (ND) for acute symptom monitoring, nutritional management, and swallowing and communication rehabilitation. The aim of the current study was to determine the feasibility of a home-based telehealth model for delivering SP and ND reviews, to provide patients with more convenient access to these appointments.

Methods

Service outcomes, costs, and consumer satisfaction were examined across 30 matched participants: 15 supported via the standard model of care (SMOC), and 15 via the home-based telehealth model of care (TMOC).

Results

All patients were successfully managed via telehealth. The TMOC was more efficient, with a reduced number ( p < 0.003) and duration ( p < 0.01) of appointments required until discharge. Significant patient cost savings ( p = 0.002) were reported for the TMOC due to decreased travel requirements. While staff costs were reduced, additional telehealth equipment levies resulted in a lower but non-significant overall cost difference to the health service when using the TMOC. High satisfaction was reported by all participants attending the TMOC.

Discussion

The findings support the feasibility of a home-based telehealth model for conducting SP and ND reviews post C/RT for HNC.

Maternity Ultrasound in the Republic of Ireland 2016; A Review

Antenatal ultrasound, comprising of a dating ultrasound in the late first trimester followed by a fetal anomaly scan, is a recognised and necessary component of good antenatal care. We conducted a telephone survey of all 19 obstetric units to ascertain the status of maternity ultrasound provision in Ireland. Fetal anomaly ultrasound is offered universally to all women in 7/19 (37%) units, selectively to some women in 7/19 (37%) units and not offered at all in the remaining 5/19 (26%) units. Overall ? 41,700 (64%) women receive a fetal anomaly ultrasound nationally. Universal first trimester ultrasound, performed in a dedicated ultrasound department by a suitably qualified sonographer, is offered to 47% of women nationally. This study highlights the lack of development in Irish maternity ultrasound services over the last decade. Substantial investment by health care policy makers is urgently needed.

Tube feeding during treatment for head and neck cancer - Adherence and patient reported barriers

OBJECTIVES

The main aim was to investigate the incidence of patient adherence to nutritional tube feeding recommendations in patients with head and neck cancer and to determine patient barriers to meeting tube feeding prescription.

MATERIALS AND METHODS

This was an observational study from a randomised controlled trial in patients with head and neck cancer deemed at high nutritional risk with prophylactic gastrostomy (n=125). Patients were randomised to receive early tube feeding prior to treatment (intervention group) or standard care. All patients in the intervention and standard care groups then commenced clinical tube feeding as required during treatment. Patients maintained a daily record of gastrostomy intake, main nutrition impact symptom necessitating gastrostomy use, and reasons for not meeting nutrition prescription. Adherence was defined as meeting ≥75% of total prescribed intake.

RESULTS

Patients were predominantly male (89%), median age 60, with oropharyngeal tumours (78%), stage IV disease (87%) treated with chemoradiotherapy (87%). Primary reasons for gastrostomy use were poor appetite/dysgeusia (week 2-3) and odynophagia/mucositis (week 4-7). Early tube feeding adherence was 51%. Clinical tube feeding adherence was significantly higher in the intervention group (58% vs 38%, p=0.037). Key barriers to both phases of tube feeding were; nausea, early satiety and treatment factors (related to hospital healthcare processes).

CONCLUSIONS

Early tube feeding can improve patient adherence to clinically indicated tube feeding during treatment. Low adherence overall is a likely explanation for clinically significant weight loss despite intensive nutrition interventions. Optimising symptom management and strategies to overcome other barriers are key to improving adherence.

CLINICAL TRIAL REGISTRATION

This trial has been registered in the Australian New Zealand Clinical Trials registry as ACTRN12612000579897.

Prospective study of definitive chemoradiation in locally or regionally advanced squamous cell carcinoma of the skin

BACKGROUND

The purpose of this study was to present our evaluation of the outcomes of concurrent chemoradiotherapy (CRT) in patients with locally advanced cutaneous squamous cell carcinoma (SCC).

METHODS

This was a prospective phase II study. The primary endpoint was complete response (CR). Patients with locally/regionally advanced cutaneous SCC deemed unsuitable for surgery received definitive radiotherapy (RT; 70 Gy in 35fractions) and concurrent weekly platinum-based chemotherapy (cisplatin 40 mg/m2 or carboplatin area under the curve 2).

RESULTS

Twenty-one patients were enrolled in this study. Eighteen patients had a locally advanced primary or nodal disease in the head and neck region with 66% having stage IV nonmetastatic disease. Of 19 evaluable patients, 10 achieved a CR to definitive CRT with 2 further patients rendered disease-free by salvage surgery for an overall CR of 63%.

CONCLUSION

This is the only prospective series of CRT for cutaneous SCC. A high CR rate was documented in patients with locoregional advanced disease who were unable to undergo surgery. © 2016 Wiley Periodicals, Inc. Head Neck 39: 679-683, 2017.

Abnormal frontostriatal connectivity in adolescent-onset schizophrenia and its relationship to cognitive functioning

BACKGROUND

Adolescent-onset schizophrenia (AOS) is associated with cognitive impairment and poor clinical outcome. Cognitive dysfunction is hypothesised, in part, to reflect functional dysconnectivity between the frontal cortex and the striatum, although structural abnormalities consistent with this hypothesis have not yet been demonstrated in adolescence.

OBJECTIVE

To characterise frontostriatal white matter (WM) tracts in relation to cognition in AOS.

DESIGN

A MRI volumetric and diffusion tensor imaging study.

PARTICIPANTS

Thirty-seven AOS subjects and 24 age and sex-matched healthy subjects.

OUTCOME MEASURES

Using probabilistic tractography, cortical regions with the highest connection probability for each striatal voxel were determined, and correlated with IQ and specific cognitive functions after co-varying for age and sex. Fractional anisotropy (FA) from individual tracts was a secondary measure.

RESULTS

Bayesian Structural Equation modeling of FA from 12 frontostriatal tracts showed processing speed to be an intermediary variable for cognition. AOS patients demonstrated generalised cognitive impairment with specific deficits in verbal learning and memory and in processing speed after correction for IQ. Dorsolateral prefrontal cortex connectivity with the striatum correlated positively with these measures and with IQ. DTI voxel-wise comparisons showed lower connectivity between striatum and the motor and lateral orbitofrontal cortices bilaterally, the left amygdalohippocampal complex, right anterior cingulate cortex, left medial orbitofrontal cortex and right dorsolateral prefrontal cortex.

CONCLUSIONS

Frontostriatal dysconnectivity in large WM tracts that can explain core cognitive deficits are evident during adolescence. Processing speed, which is affected by alterations in WM connectivity, appears an intermediary variable in the cognitive deficits seen in schizophrenia.

Effect of p16 Status on the Quality-of-Life Experience During Chemoradiation for Locally Advanced Oropharyngeal Cancer: A Substudy of Randomized Trial Trans-Tasman Radiation Oncology Group (TROG) 02.02 (HeadSTART)

PURPOSE

Human papillomavirus-associated oropharyngeal cancer (OPC) has a favorable prognosis. Current research de-escalates treatment, aiming to improve quality of life (QOL). Understanding the QOL experience with current standard treatment (chemoradiation therapy) provides context for emerging data. We report the impact of p16 status on QOL for patients with stage III or IV OPC undergoing chemoradiation therapy in an international phase 3 trial (TROG 02.02 [HeadSTART]).

METHODS AND MATERIALS

A subgroup analysis by p16 status was conducted in patients with OPC treated in a phase 3 randomized trial. The study subset with OPC and known p16 status was mainly from Australasia, Western Europe, and North America. Of 861 participants, 200 had OPC, known p16 status, and baseline QOL data; 82 were p16 negative and 118 were p16 positive. Radiation therapy (70 Gy over a period of 7 weeks) was given concurrently with 3 cycles of either cisplatin (100 mg/m²) or cisplatin (75 mg/m²) plus tirapazamine. QOL was measured with the Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N) questionnaire at baseline and 2, 6, 12, 23, and 38 months. Because no significant difference in QOL score was observed between arms, results by p16 status are reported with arms combined.

RESULTS

The p16-positive patients were younger, had a better Eastern Cooperative Oncology Group performance status, and were less often current smokers. Our primary hypothesis that the change in FACT-H&N score from baseline to 6 months would be more favorable in the p16-positive cohort was not met (p16 positive, -6.3; p16 negative, -1.8; P=.14). The mean baseline FACT-H&N score was statistically and clinically significantly better in p16-positive patients (111 vs 102, P<.001); at 2 months, scores declined in both groups but more dramatically for p16-positive patients. By 12 months, p16-positive patients again had superior scores. A higher baseline FACT-H&N score and p16-positive status were independent predictors of overall survival.

CONCLUSIONS

Patients with p16-positive OPC exhibited better baseline QOL but showed a more dramatic QOL drop with concurrent chemoradiation. Given the favorable prognosis of p16-positive OPC, efforts to reduce the QOL burden of treatment are warranted.