Multi-Institutional Clinical Outcomes of Biopsy Gleason Grade Group 5 Prostate Cancers Treated With Contemporary High-Dose Radiation and Long-Term Androgen Deprivation Therapy

AIMS

This multicentric retrospective study reports long-term clinical outcomes of non-metastatic grade group 5 prostate cancers treated with external beam radiotherapy (EBRT) alone with long-term androgen deprivation therapy (ADT).

MATERIALS AND METHODS

Patients treated across 19 institutions were studied. The key endpoints that were evaluated were 5-year biochemical recurrence-free survival (bRFS), metastases-free survival (MFS), overall survival, together with EBRT-related acute and late toxicities. The impact of various prognostic factors on the studied endpoints was analysed using univariate and multivariate analyses.

RESULTS

Among the 462 patients, 88% (405) had Gleason 9 disease and 31% (142) had primary Gleason pattern 5. A prostate-specific membrane antigen positron emission tomography-computed tomography scan was used for staging in 33% (153), 80% (371) were staged as T3/T4 and 30% (142) with pelvic nodal disease. The median ADT duration was 24 months; 66% received hypofractionated EBRT and 71.4% (330) received pelvic nodal irradiation. With a median follow-up of 56 months, the 5-year bRFS, MFS and overall survival were 73.1%, 77.4% and 90.5%, respectively. Primary Gleason pattern 5 was associated with worse bRFS, MFS and overall survival with hazard ratios of 0.51 (95% confidence interval 0.35 to 0.73, P < 0.001), 0.64 (95% confidence interval 0.43 to 0.96, P = 0.031) and 0.52 (95% confidence interval 0.28 to 0.97, P = 0.040), respectively, whereas pelvic nodal disease was associated with worse bRFS (hazard ratio 0.67, 95% confidence interval 0.46 to 0.98, P = 0.039) and MFS (hazard ratio 0.56, 95% confidence interval 0.37 to 0.85, P = 0.006). The acute and late radiation-related toxicities were low overall and pelvic nodal irradiation was associated with higher toxicities.

CONCLUSION

Contemporary EBRT and long-term ADT led to excellent 5-year clinical outcomes and low rates of toxicity in this cohort of non-metastatic grade group 5 prostate cancers. Primary Gleason pattern 5 and pelvic node disease portends inferior clinical outcomes.

Distinct Dysphagia Profiles in Patients With Oral Cancer After Surgery

OBJECTIVES

To determine distinct profiles based on symptom severity in patients undergoing surgery for oral cancer and examine whether these profiles differ by participant characteristics.

SAMPLE & SETTING

300 patients who underwent surgery for oral cancer at two outpatient clinics between June and December 2021.

METHODS & VARIABLES

Symptoms were assessed using the MD Anderson Symptom Inventory-Head and Neck Cancer Module. Sociodemographic and clinical characteristics were collected. Latent profile analysis was performed.

RESULTS

Five distinct dysphagia profiles were identified, which qualitatively differed regarding co-occurrence patterns of dysphagia, mucus-related symptoms, speech disturbances, and psychoneurologic symptoms. Significant differences were reported in interference to function, number of co-occurring symptoms, time since diagnosis and treatment completion, use of symptom management medications, oral cancer stage and site, and treatment completed.

IMPLICATIONS FOR NURSING

Identifying distinct dysphagia profiles can improve patient outcomes and help in planning specific nursing interventions to influence nutritional and functional status in oral cancer survivors. Dysphagia and dry mouth can persist beyond one year post-treatment, so follow-up dysphagia assessments are needed.

Imaging Recommendations for Diagnosis, Staging, and Management of Lung Cancer

Globally and in India, lung cancer is one of the leading malignancies in terms of incidence and mortality. Smoking and environmental pollution are the common risk factors for developing lung cancer. Traditionally, lung cancer is divided into small cell and nonsmall cell types, with nonsmall cell carcinomas including squamous cell carcinoma, adenocarcinoma, and large cell carcinoma.

In this review article, we describe the imaging recommendations and findings in the diagnosis, staging, and management of lung cancer, including the imaging of treatment-related complications.

Framework for Machine Learning of CT and PET Radiomics to Predict Local Failure after Radiotherapy in Locally Advanced Head and Neck Cancers

Context:

Cancer Radiomics is an emerging field in medical imaging and refers to the process of converting routine radiological images that are typically qualitatively interpreted to quantifiable descriptions of the tumor phenotypes and when combined with statistical analytics can improve the accuracy of clinical outcome prediction models. However, to understand the radiomic features and their correlation to molecular changes in the tumor, first, there is a need for the development of robust image analysis methods, software tools and statistical prediction models which is often limited in low- and middle-income countries (LMIC).

Aims:

The aim is to build a framework for machine learning of radiomic features of planning computed tomography (CT) and positron emission tomography (PET) using open source radiomics and data analytics platforms to make it widely accessible to clinical groups. The framework is tested in a small cohort to predict local disease failure following radiation treatment for head-and-neck cancer (HNC). The predictors were also compared with the existing Aerts HNC radiomics signature.

Settings and Design:

Retrospective analysis of patients with locally advanced HNC between 2017 and 2018 and 31 patients with both pre- and post-radiation CT and evaluation PET were selected.

Subjects and Methods:

Tumor volumes were delineated on baseline PET using the semi-automatic adaptive-threshold algorithm and propagated to CT; PyRadiomics features (total of 110 under shape/intensity/texture classes) were extracted. Two feature-selection methods were tested for model stability. Models were built based on least absolute shrinkage and selection operator-logistic and Ridge regression of the top pretreatment radiomic features and compared to Aerts' HNC-signature. Average model performance across all internal validation test folds was summarized by the area under the receiver operator curve (ROC).

Results:

Both feature selection methods selected CT features MCC (GLCM), SumEntropy (GLCM) and Sphericity (Shape) that could predict the binary failure status in the cross-validated group and achieved an AUC >0.7. However, models using Aerts' signature features (Energy, Compactness, GLRLM-GrayLevelNonUniformity and GrayLevelNonUniformity-HLH wavelet) could not achieve a clear separation between outcomes (AUC = 0.51–0.54).

Conclusions:

Radiomics pipeline included open-source workflows which makes it adoptable in LMIC countries. Additional independent validation of data is crucial for the implementation of radiomic models for clinical risk stratification.

F-18 FDG PET-CT for response evaluation in head and neck malignancy: Experience from a tertiary level hospital in south India

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) accounts for 90% of head and neck cancers. There has been no established qualitative system of interpretation for therapy response assessment using PET-CT for HNSCC.

AIM

To assess response evaluation of nodal status in post-treatment PET-CT scans in HNSCC using a 5-point Likert scale (Deauville score [DS]).

METHODS AND RESULTS

Retro-prospective analysis was performed of the nodal status of pre and post-RT PET-CT in patients diagnosed with HNSCC (n = 43) from May 2013 to March 2018. All eligible patients underwent a pre-RT PET-CT scan before the start of RT. Another post-RT PET-CT scan was performed 12 weeks after the completion of RT. The median time from completion of radiotherapy (RT) to post-RT PET-CT was 92 days; 80% of the patients had their post-RT PET-CT scan between 77 and 147 days after therapy. Of 43 patients (M/33, F/10, age range 18 to 80 years (median 54 years) selected for the study, good concordance was noted between DS and clinical response in these patients. The change in SUV from pre-RT PET to post-RT PET was analyzed using a paired t-test. The P-value was found to be statistically significant while comparing pre and post-RT SUVmax levels showing that RT had significantly reduced the SUVmax levels of the nodes in DS 2-3 groups whereas the number of patients was too small to allow a reliable calculation in DS 4-5 groups. It was found that 36/39 patients with DS 1-3 had no nodal recurrence showing a high NPV of 92.3%. Of the four patients with DS 4-5, all had active disease showing PPV of 100%. Applying Fisher's exact test, the P-value was found to be .004.

CONCLUSION

DS seems to satisfy the requirements for a simple qualitative method of interpreting PET scans and for identifying patients requiring neck dissection. Consensus regarding qualitative assessment would facilitate standardization of PET reporting in clinical practice and enable comparative multicentric studies.

Patterns of Recurrence in Locally Advanced Resectable Oesophageal Carcinoma: Retrospective Review from a Tertiary Cancer Centre in South India

PURPOSE

The study aims to analyse patterns of recurrence following neoadjuvant treatment and surgery in carcinoma oesophagus with an intent to postulate optimal nodal radiation.

METHODOLOGY

A retrospective review of patients who presented to our centre within a 5-year period (2014-2018), with recurrence following sequential neoadjuvant treatment and radical surgery, was conducted in this single-institution study. The patterns of recurrence and duration of disease-free survival were analysed.

RESULTS

Twenty-one patients (14 men, 7 women) presented with recurrence, of which 13, 7, and 1 patient(s) had received NACT, NACTRT, or both, respectively. Six patients who did not receive neoadjuvant radiotherapy received adjuvant RT. Among the 10 patients who had nodal recurrence after RT (either neoadjuvant or adjuvant), 6 and 4 patients had in-field and out-of-field nodal recurrences, respectively-the latter were equally distributed within 5 cm and outside 5 cm of the PTV margin.

CONCLUSION

Among the patients who presented with recurrence, more than half had not received neoadjuvant RT (treated in the 'pre-CROSS era' or due to long-segment disease), reasserting the therapeutic superiority of NACTRT. Increased regularity of recurrences in the draining nodal region was not noted in this study, but large-scale, prospective, randomised head-to-head comparative trials to determine optimal nodal irradiation in carcinoma oesophagus are required.

The changing landscape of brachytherapy for cervical cancer: a Canadian practice survey

BACKGROUND

We documented changes in practice from 2009 to 2012 for cervical cancer brachytherapy in Canada.

METHODS

Centres with gynecologic brachytherapy services were sent an e-mail questionnaire querying their 2012 practice. Responses are reported and compared with practice patterns identified in a similar survey for 2009.

RESULTS

The response rate was 77% (24 of 31 centres). Almost all use high-dose-rate brachytherapy (92%); low-dose-rate brachytherapy has been completely phased out. Most continue to move patients from the site of applicator insertion to the radiation treatment simulation suite (75%) or to a diagnostic imaging department (29%), or both. In 2012, the imaging modalities used for dose specification were computed tomography [ct (75%)], magnetic resonance imaging [mri (38%)], plain radiography (21%), and cone-beam ct (8%). The number of institutions using mri guidance has markedly increased during the period of interest (9 vs. 1). Most respondents (58% vs. 14%) prescribed using guidelines from the Groupe Européen de Curiethérapie and the European Society for Therapeutic Radiology and Oncology, but they also used point A as a reference. Commonly used high-dose radiation regimens included 30 Gy in 5 fractions and 24 Gy in 3 fractions.

CONCLUSIONS

In Canada, image-guided brachytherapy for cervical cancer continues to evolve. Although ct-based imaging remains the most commonly used modality, many centres have adopted mri for at least 1 brachytherapy treatment. More centres are using fewer fractions and a slightly lower biologically effective dose, but are still achieving EQD2 (2-Gy equivalent) doses of 80-90 Gy in combination with external-beam radiation therapy.

Squamous cell carcinoma cervix with metastasis to pyloroduodenal region

Metastatic squamous cell carcinoma in the pyloroduodenal region is uncommon. Cases have been reported where carcinoma of the lung has presented with metastasis to the duodenum. We present here the case of a 57-year-old lady who was found to have a metastasis in pyloroduodenal region while on treatment for carcinoma cervix. The patient developed features of intestinal obstruction and endoscopy showed a growth extending from pyloric antrum to first part of duodenum up to the junction of first and second part. A biopsy was taken from the duodenal area and it was reported as metastatic squamous cell carcinoma. This is one of the few reported cases of hematogenous visceral metastasis from carcinoma cervix. Since the disease was found to be advanced and her performance status was poor, she was provided best supportive care.

Results in the management of malignant submandibular tumours and guidelines for elective neck treatment

BACKGROUND

Malignant submandibular gland tumours are rare tumours treated primarily with surgery.

PURPOSE

This retrospective study was done to determine the effectiveness of adjuvant radiation therapy (RT), to document the patterns of failure, and to define the prognostic variables for treatment outcome.

MATERIALS AND METHODS

Between 1960 and 2002, 74 patients diagnosed as having malignant submandibular gland tumours were treated with radical surgery. The surgery included neck dissection in 37 patients and adjuvant RT in 50 patients with high-risk features.

RESULTS

Forty-one (54%) patients experienced disease relapse. The local recurrence rates were 35% in those treated only with surgery and 21% in patients who underwent postoperative RT (p  =  .20). The risk of subclinical nodal metastases in the clinical N0 neck was 21%.

CONCLUSIONS

The American Joint Committee on Cancer stage approached statistical significance for cause-specific survival. Although not statistically significant, RT probably reduced local recurrence. All patients with malignant submandibular tumours except T1 need elective neck treatment.

Evaluation of tomotherapy MVCT image enhancement program for tumor volume delineation

The aims of this study were to investigate the variability between physicians in delineation of head and neck tumors on original tomotherapy megavoltage CT (MVCT) studies and corresponding software enhanced MVCT images, and to establish an optimal approach for evaluation of image improvement. Five physicians contoured the gross tumor volume (GTV) for three head and neck cancer patients on 34 original and enhanced MVCT studies. Variation between original and enhanced MVCT studies was quantified by DICE coefficient and the coefficient of variance. Based on volume of agreement between physicians, higher correlation in terms of average DICE coefficients was observed in GTV delineation for enhanced MVCT for patients 1, 2, and 3 by 15%, 3%, and 7%, respectively, while delineation variance among physicians was reduced using enhanced MVCT for 12 of 17 weekly image studies. Enhanced MVCT provides advantages in reduction of variance among physicians in delineation of the GTV. Agreement on contouring by the same physician on both original and enhanced MVCT was equally high.

PACS numbers: 87.57.N‐, 87.57.np, 87.57.nt

The N3 neck: outcomes following primary chemoradiotherapy

OBJECTIVE

To study the treatment outcomes of N3 neck disease following primary chemoradiotherapy.

DESIGN

Retrospective cohort.

SETTING

Tertiary care centre.

METHODS

A review was conducted of 25 consecutive patients with N3 neck disease treated with primary platinum-based chemoradiotherapy. A neck dissection (ND) was offered in the event of clinical and/or radiologic evidence of residual disease on follow-up.

MAIN OUTCOME MEASURES

Recurrence-free, disease-specific, and overall survival and patterns of failure.

RESULTS

A regional complete response (CR) was noted in 48% of the patients. ND was performed in 36% of the cases. The median duration between the end of radiation and ND was 71 days. The recurrence-free survival rates at 1 and 2 years were 73% and 64%, respectively. The 2-, 3-, and 5-year overall survival rates were 66.7%, 52%, and 31.2%, respectively. Disease-specific survival rates were 69.6%, 63.3%, and 50.6%, respectively. Nine patients developed distant recurrence, with one having concurrent local and regional recurrence as well. Patients in the CR group remained free of regional recurrence. Among the initial partial responders, 54% eventually developed distant metastasis compared to 17% in the CR group.

CONCLUSION

Patients with N3 disease may be managed with chemoradiotherapy, with ND reserved for salvage. Distant metastasis accounts for most recurrences and for the reduction in survival.

Image-guided brachytherapy for cervical cancer: a Canadian Brachytherapy Group survey

PURPOSE

To survey the current use and future plans for image-guided brachytherapy (BT) for cervical cancer by radiation oncologists in Canada.

METHODS AND MATERIALS

Canadian radiation oncologists treating gynecologic malignancies were identified in January 2009. A 29-item questionnaire (English and French) querying the current practice in the use of imaging in BT planning, and plans for transition to three-dimensional (3D) image guidance for BT for cervical cancer (curative intent, intact cervix), was electronically circulated. Questionnaire responses were tabulated and analyzed by respondent and by center.

RESULTS

Response rate was 62% (36 of 58 radiation oncologists), representing 71% (22 of 31) of Canadian radiation oncology centers with a gynecologic BT facility. Most of the centers were using high-dose-rate BT (68%), followed by low-dose-rate BT (23%) and pulsed dose-rate BT (10%). Main imaging used for treatment planning by center was plain X-ray (50%), computerized tomography (CT) (45%), and magnetic resonance imaging (MRI) (5%). For respondents using CT or MRI for planning, point A was the most common dose prescription point (50%), followed by gross tumor volume/clinical target volume as per Groupe Européen de Curiethérapie and the European Society for Therapeutic Radiology and Oncology guidelines (44%). For centers using plain X-rays for planning, 73% planned to transition to a 3D image-based approach, with the majority to adopt CT imaging. Eighty percent of respondents agreed that 3D image-guided BT should become standard of care for treatment of cervical cancer in Canada, and additionally support the development of national guidelines.

CONCLUSIONS

Most of the Canadian radiation oncologists surveyed and Canadian cancer centers are either using 3D imaging and planning or transitioning to a 3D image-based approach within the next year. Point A remained a commonly documented prescription point. Access to MRI was very low. These results may lead to national treatment guidelines.

Primitive neuroectodermal tumor of the jejunum; a case report and literature review

OBJECTIVE AND IMPORTANCE

The aim of this paper is to report an unusual presentation of extranodal follicular dendritic cell tumor of neck with spinal metastasis. Follicular dendritic cells are nonlymphoid immune accessory cells present in the germinal centers of lymphoid follicles and play a crucial role in the induction and maintenance of the humoral immune response. Tumors from these cells are rare and treatment modality poorly defined.

CLINICAL PRESENTATION

A 37-year-old lady presented with recurrent neck swelling which was initially reported as malignant paraganglioma. The primary disease was treated with surgery and radiotherapy. Eleven years later, the patient presented with metastasis to the spinal cord. Subsequent immunohistochemical analysis of the primary site tumor and the metastatic deposits revealed it to be a follicular dendritic cell tumor.

INTERVENTION

The patient was treated with surgery followed by radiotherapy to spine, and one and half year after treatment, the patient is doing well and has regained complete motor functions.

CONCLUSION

Metastasis to spinal cord for follicular dendritic cell tumor is very rare, and to the best of our knowledge, no such case has been previously reported in the scientific literature so far. In the present case, good local control was achieved with initial surgery and radiotherapy but resulted in distant failure after 11 years. This underlines the need for adjuvant systemic therapy, and understanding the biology of the tumor may help in formulating targeted therapy in the future for this rare disorder.