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Alexander NA, Schaub SK, Goff PH, Hippe DS, Park SY, Lachance K, Bierma M, Liao JJ, Apisarnthanarax S, Bhatia S, Tseng YD, Nghiem PT, Parvathaneni U. Increased risk of recurrence and disease-specific death following delayed postoperative radiation for Merkel cell carcinoma. J Am Acad Dermatol 2024; 90:261-268. [PMID: 37778663 DOI: 10.1016/j.jaad.2023.07.1047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 06/09/2023] [Accepted: 07/27/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Merkel cell carcinoma (MCC) is often treated with surgery and postoperative radiation therapy (PORT). The optimal time to initiate PORT (Time-to-PORT [ttPORT]) is unknown. PURPOSE We assessed if delays in ttPORT were associated with inferior outcomes. METHODS Competing risk regression was used to evaluate associations between ttPORT and locoregional recurrence (LRR) for patients with stage I/II MCC in a prospective registry and adjust for covariates. Distant metastasis and death were competing risks. RESULTS The cohort included 124 patients with median ttPORT of 41 days (range: 8-125 days). Median follow-up was 55 months. 17 (14%) patients experienced a LRR, 14 (82%) of which arose outside the radiation field. LRR at 5 years was increased for ttPORT >8 weeks vs ≤ 8 weeks, 28.0% vs 9.2%, P = .006. There was an increase in the cumulative incidence of MCC-specific death with increasing ttPORT (HR = 1.14 per 1-week increase, P = .016). LIMITATIONS The relatively low number of LRRs limited the extent of our multivariable analyses. CONCLUSIONS Delay of PORT was associated with increased LRR, usually beyond the radiation field. This is consistent with the tendency of MCC to spread quickly via lymphatics. Initiation of PORT within 8 weeks was associated with improved locoregional control and MCC-specific survival.
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Affiliation(s)
- Nora A Alexander
- Department of Dermatology, University of Washington, Seattle, Washington; Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Stephanie K Schaub
- Department of Radiation Oncology, University of Washington, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington.
| | - Peter H Goff
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Daniel S Hippe
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Song Y Park
- Department of Dermatology, University of Washington, Seattle, Washington
| | - Kristina Lachance
- Department of Dermatology, University of Washington, Seattle, Washington
| | - Marika Bierma
- Department of Dermatology, University of Washington, Seattle, Washington
| | - Jay J Liao
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | | | - Shailender Bhatia
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Paul T Nghiem
- Department of Dermatology, University of Washington, Seattle, Washington
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Bierma MM, Goff PH, Hippe DS, Lachance K, Schaub SK, Wallner K, Tseng YD, Liao JJ, Apisarnthanarax S, Nghiem P, Parvathaneni U. Postoperative Radiation Therapy Is Indicated for "Low-Risk" Pathologic Stage I Merkel Cell Carcinoma of the Head and Neck Region but Not for Other Locations. Adv Radiat Oncol 2024; 9:101364. [PMID: 38189056 PMCID: PMC10767274 DOI: 10.1016/j.adro.2023.101364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 08/17/2023] [Indexed: 01/09/2024] Open
Abstract
Purpose The role of postoperative radiation therapy (PORT) in early stage Merkel cell carcinoma (MCC) is controversial. We analyzed the role of PORT in preventing local recurrences (LR) among patients with low-risk, pathologic stage I MCC based on the location of the primary tumors: head/neck (HN) versus non-HN sites. Methods and Materials One hundred forty-seven patients with MCC were identified that had "low risk" disease (pathologic T1 primary tumor, negative microscopic margins, negative pathologic node status, no immunosuppression or prior systemic therapy). LR was defined as tumor recurrence within 2 cm of the primary surgical bed, and its frequency was estimated with the cumulative incidence method. Results Seventy-nine patients received PORT (30 HN, 49 non-HN) with a median dose of 50 Gy (range, 8-64 Gy) and 68 patients were treated with surgery alone (30 HN, 38 non-HN). Overall, PORT was associated with a decreased risk of LR (5-year rate: 0% vs 9.5%; P = .004) with 6 LRs observed in the surgery alone group. Although the addition of PORT significantly reduced LR rates among patients with HN MCC (0% vs. 21%; P = .034), no LRs were observed in patients with non-HN MCC managed with surgery alone. There was no significant difference in MCC-specific survival comparing HN versus non-HN groups, with or without PORT. Conclusions For low-risk, pathologic stage I MCC of the extremities and trunk, excellent local control rates were achieved with surgery, and PORT is not indicated. However, PORT was associated with a significant reduction in LRs among low-risk MCC of the HN.
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Affiliation(s)
- Marika M. Bierma
- Department of Dermatology, University of Washington, Seattle, Washington
| | - Peter H. Goff
- Department of Dermatology, University of Washington, Seattle, Washington
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Daniel S. Hippe
- Fred Hutchinson Cancer Center, Biostatistics, Seattle, Washington
| | - Kristina Lachance
- Department of Dermatology, University of Washington, Seattle, Washington
| | - Stephanie K. Schaub
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Kent Wallner
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Yolanda D. Tseng
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Jay J. Liao
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | | | - Paul Nghiem
- Department of Dermatology, University of Washington, Seattle, Washington
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Moffitt GB, Sandison GA, Argento DC, Emery R, Wootton LS, Parvathaneni U, Liao JJ, Laramore GE, Stewart RD. Effects of tissue heterogeneity and comparisons of collapsed cone and Monte Carlo fast neutron patient dosimetry using the University of Washington clinical neutron therapy system (CNTS). Phys Med Biol 2023; 68:245011. [PMID: 37983905 DOI: 10.1088/1361-6560/ad0e38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/20/2023] [Indexed: 11/22/2023]
Abstract
Fast neutron therapy is a high linear energy transfer (LET) radiation treatment modality offering advantages over low LET radiations. Multileaf collimator technology reduces normal-tissue dose (toxicity) and makes neutron therapy more comparable to MV x-ray treatments. Published clinical-trial and other experiences with fast neutron therapy are reported. Early comparative studies failed to consider differences in target-dose spatial conformality between x-ray and neutron treatments, which is especially important for organs-at-risk close to tumor targets. Treatments planning systems (TPS) for high-energy neutrons lag behind TPS tools for MV x-rays, creating challenges for comparative studies of clinical outcomes. A previously published Monte Carlo model of the University of Washington (UW) Clinical Neutron Therapy System (CNTS) is refined and integrated with the RayStation TPS as an external dose planning/verification tool. The collapsed cone (CC) dose calculations in the TPS are based on measured dose profiles and output factors in water, with the absolute dose determined using a tissue-equivalent ionization chamber. For comparison, independent (external) Monte Carlo simulation computes dose on a voxel-by-voxel basis using an atlas that maps Hounsfield Unit (HU) numbers to elemental composition and density. Although the CC algorithm in the TPS accurately computes neutron dose to water compared to Monte Carlo calculations, calculated dose to water differs from bone or tissue depending largely on hydrogen content. Therefore, the elemental composition of tissue and bone, rather than the material or electron density, affects fast neutron dose. While the CC algorithm suffices for reproducible patient dosimetry in fast neutron therapy, adopting methods that consider tissue heterogeneity would enhance patient-specific neutron dose accuracy relative to national standards for other types of ionizing radiation. Corrections for tissue composition have a significant impact on absolute dose and the relative biological effectiveness (RBE) of neutron treatments compared to other radiation types (MV x-rays, protons, and carbon ions).
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Affiliation(s)
- Gregory B Moffitt
- University of Washington School of Medicine, Department of Radiation Oncology, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, United States of America
| | - George A Sandison
- University of Washington School of Medicine, Department of Radiation Oncology, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, United States of America
| | - David C Argento
- University of Washington School of Medicine, Department of Radiation Oncology, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, United States of America
| | - Robert Emery
- University of Washington School of Medicine, Department of Radiation Oncology, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, United States of America
| | - Landon S Wootton
- University of Washington School of Medicine, Department of Radiation Oncology, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, United States of America
- Baylor Scott and White, Department of Radiation Oncology, 4516 Monterosa Lane, Round Rock, TX 78665, United States of America
| | - Upendra Parvathaneni
- University of Washington School of Medicine, Department of Radiation Oncology, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, United States of America
| | - Jay J Liao
- University of Washington School of Medicine, Department of Radiation Oncology, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, United States of America
| | - George E Laramore
- University of Washington School of Medicine, Department of Radiation Oncology, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, United States of America
| | - Robert D Stewart
- University of Washington School of Medicine, Department of Radiation Oncology, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, United States of America
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Sandison GA, Lehnert A, Miyaoka RS, Kranz M, Kim M, Emery R, Anderson AC, Sponseller PA, Goff PH, Panjwani N, Laramore GE, Parvathaneni U, Liao JJ, Kim EY, Stewart RD. A Novel Approach to Support Quality Assurance (QA) of Intensity Modulated Neutron Therapy (IMNT). Int J Radiat Oncol Biol Phys 2023; 117:e714. [PMID: 37786087 DOI: 10.1016/j.ijrobp.2023.06.2215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Neutron therapy is a form of high linear energy transfer (LET) radiation treatment shown to be beneficial for the treatment of locally advanced head and neck cancers (HNC) resistant to low LET x-ray and proton therapy treatments. The Clinical Neutron Therapy System (CNTS) at our institution has been in clinical operation for over 35 years, and over 3,400 patients have been treated using 3D conformal neutron radiation therapy. In October of 2022, the clinical commissioning of IMNT was completed and the first-ever patient was treated. A novel patient specific quality assurance (PSQA) program has been developed to support IMNT. We present an analysis of our early experiences and PSQA findings for the first 16+ patients treated with IMNT. MATERIALS/METHODS Our pre-treatment IMNT PSQA program includes (1) ionization chamber measurements, (2) a log-file analysis of treatment delivery, and (3) a γ-analysis of the expected and measured doses (fluences) from a novel positron emission portal imaging system based on 12C(n,2n)11C reactions. Patient setup is confirmed on a daily basis with kV portal imaging. We use a modulation factor (MF), defined as the total number of monitor units (MU)/prescribed dose (cGy) per fraction, to identify and help anticipate IMNT plans that may fail our PSQA program. RESULTS We have found that IMNT treatments for large, irregularly shaped treatment volumes (e.g., chest wall or head and neck cancers that require treatment of nodes in the lower neck) are more likely to fail PSQA when the MF exceeds 3 MU/cGy. For smaller, more spherical treatment volumes (e.g., base of tongue cancers), plans with a MF up to 3.5 MU/cGy pass our PSQA criteria. Re-optimized plans subsequently passed PSQA with insignificant or no change in tumor coverage and organ-at-risk (OAR) dose. Re-optimized plans also reduced the total number of MU and number of segments, which has the added benefit of decreasing the overall treatment time and patient time on the table. About 10% of early IMNT patients have required plan re-optimization. CONCLUSION Our pre-treatment clinical PSQA program and workflow provides useful information to guide IMNT treatment planning and delivery, and helps ensure the safe and accurate delivery of IMNT. Our early experiences suggest IMNT plans with smaller MF values are more likely to pass PSQA than plans with larger values of the MF.
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Affiliation(s)
- G A Sandison
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
| | - A Lehnert
- University of Washington, Seattle, WA
| | - R S Miyaoka
- University of Washington, Department of Radiology, Seattle, WA
| | - M Kranz
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
| | - M Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - R Emery
- University of Washington, Seattle, WA
| | - A C Anderson
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - P A Sponseller
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - P H Goff
- Department of Radiation Oncology, University of Washington / Fred Hutchinson Cancer Center, Seattle, WA
| | | | | | - U Parvathaneni
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - J J Liao
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
| | - E Y Kim
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - R D Stewart
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
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Goff PH, Huynh ET, Lachance K, Harikrishnan N, Cook M, Schaub SK, Tseng YD, Liao JJ, Apisarnthanarax S, Wallner K, Nghiem P, Parvathaneni U. Efficacy of Single-Fraction Postoperative Radiotherapy in Resected, Early-Stage Merkel Cell Carcinoma with High-Risk Features. Int J Radiat Oncol Biol Phys 2023; 117:e298. [PMID: 37785091 DOI: 10.1016/j.ijrobp.2023.06.2310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Merkel cell carcinoma (MCC) is an aggressive skin cancer with a high recurrence risk. Postoperative radiotherapy (PORT) improves the local recurrence rate (LRR) in early-stage MCC with risk factors per NCCN guidelines: primary tumor size > 1cm, head/neck (HN) location, immunosuppression, lymphovascular invasion (LVI), and positive/narrow surgical margins. Conventionally fractionated PORT (C-PORT, ∼50 Gy in 25 fractions) is often recommended for localized MCC with these risk factors; however, some institutions elect observation. Prior studies suggest LRR of ∼20% for stage I/II MCC with high-risk features managed with surgery alone. C-PORT significantly decreases LRR but may cause significant morbidity and financial toxicity. We have previously reported that single fraction (SF)-PORT with 8 Gy achieves high rates of in-field control both in the metastatic and adjuvant settings with minimal morbidity. Here, we present updated long-term outcomes of SF-PORT, offered as an alternative to C-PORT with the hypothesis that it improves LRR relative to observation while minimizing toxicity, for resected stage I/II MCC. MATERIALS/METHODS A retrospective, single-institution analysis was completed for stage I/II MCC patients receiving SF-PORT following surgical management. The primary objective was estimating the LRR, defined as recurrence within 2 cm of the primary tumor. Patients with resected, stage I/II MCC with at least one high-risk feature were offered C-PORT as standard of care or SF-PORT as an alternative. RESULTS Forty-six patients (median age: 74.5; range 50-96 years) received SF-PORT to the primary tumor site at a median 44 days after wide local excision (85%), shave/excisional biopsy (13%), or Mohs (2%). Fifty-four percent of patients had 1 high-risk feature, 35% had 2, and 11% had 3 or more. HN (74%) was the most common primary site, 26% of tumors were > 1cm, 26% were LVI+, and 15% of patients were immunosuppressed (pathological margin status was often not available). There were no local recurrences (LRR = 0%) at a median follow-up time of 2.3 years. In-field locoregional control was 96% (44/46 patients) with 2 in-field, regional recurrences observed in draining nodal basins of HN primary lesions. There were 2 out-of-field regional nodal recurrences (1 patient with IMS; neither received elective nodal SFRT). Of 9 patients who received elective nodal SF-PORT, 8 did not have a successful sentinel lymph node biopsy. No MCC-specific deaths were observed. The most common side effect was in-field, grade 1 erythema (13%); no side effects > grade 1 (CTCAE v5) were noted. CONCLUSION SF-PORT is associated with a very low LRR which has proven durable with long-term follow-up. The LRR for SF-PORT appears lower than historical controls treated with surgery alone for patients with resected, stage I/II MCC with high-risk features.
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Affiliation(s)
- P H Goff
- Department of Radiation Oncology, University of Washington / Fred Hutchinson Cancer Center, Seattle, WA
| | - E T Huynh
- University of Washington, Division of Dermatology, Seattle, WA
| | - K Lachance
- University of Washington, Division of Dermatology, Seattle, WA
| | - N Harikrishnan
- University of Washington, Division of Dermatology, Seattle, WA
| | - M Cook
- University of Washington, Division of Dermatology, Seattle, WA
| | - S K Schaub
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Y D Tseng
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - J J Liao
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
| | - S Apisarnthanarax
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - K Wallner
- University of Washington, Seattle, WA
| | - P Nghiem
- University of Washington, Division of Dermatology, Seattle, WA
| | - U Parvathaneni
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
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6
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Anderson AC, Stewart RD, Sponseller PA, Wairiri LW, Goff PH, Panjwani N, Laramore GE, Parvathaneni U, Emery R, Marchiano EJ, Futran N, Rodriguez CP, Liao JJ. Intensity-Modulated Neutron Therapy (IMNT) for Head and Neck Cancer: Early Toxicity Outcomes. Int J Radiat Oncol Biol Phys 2023; 117:e561-e562. [PMID: 37785722 DOI: 10.1016/j.ijrobp.2023.06.1881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Locally advanced head & neck cancers (HNC) are challenging to treat due to abutment of critical, dose-limiting structures. Fast neutron radiotherapy (NT) is a high linear energy transfer (LET) modality that provides better local control than photons for radioresistant cancers such as salivary gland tumors, but there have been concerns of toxicity with 3D conformal neutron therapy in the past. Recent technological advances have enabled the planning and delivery of IMNT, which improves target conformality and may reduce toxicity compared to 3D conformal NT. We report the first clinical evaluation of early toxicity outcomes of IMNT for HNC. MATERIALS/METHODS Study is a single-institution retrospective review of all HNC patients treated with curative-intent IMNT from 10/2022 to 2/2023, using a hospital-based cyclotron (50.5 MeV 1H+ beam incident on a Be target) equipped with an isocentric gantry and multileaf collimator (MLC). A commercial treatment planning system with custom neutron-specific scattering kernels was used for IMNT planning using 4-6 fields. Patient-specific quality assurance included ionization chamber measurements and a novel 12C(n,2n)11C positron emission portal imaging system. kV portal imaging was used to confirm patient setup prior to each treatment session. All patients were prescribed 18.4 Gy at 1.15 Gy/fraction, delivered 4 days/week, which is equivalent to an x-ray EQD2 of approximately 70 Gy (RBE ∼ 3.8). Clinical observations suggest the RBE for radioresistant HNC may be as large as 8. Patients underwent weekly toxicity assessment, and acute toxicities were graded (G) by CTCAE v5.0. RESULTS Ten patients received IMNT, median age 61 (range 34-78). Primary tumor sites were base of tongue (n = 3), sinonasal (n = 3), parotid (n = 2), submandibular (n = 1), larynx (n = 1). Tumor histologies included adenoid cystic carcinoma (n = 7), other salivary gland carcinomas (n = 2) and mucosal melanoma (n = 1). Most had T4 disease (n = 8) and one had N3b disease. Six had surgical resection with high-risk features, and 6 had gross measurable disease prior to IMNT. None had concurrent systemic therapy. Uninvolved salivary glands were spared in most patients. All patients completed treatment. Median follow up was 22 days (0-48). Acute toxicities (n, G 1, 2, 3) included skin (8, 3, 0), dysgeusia (1, 6, 0), xerostomia (3, 5, 0), mucositis (2, 0, 5), nausea (3, 0, 1). One patient had >10% weight loss and brief admission for supportive care and PEG placement; one patient had prophylactic PEG; both regained oral independence during follow-up. There was no Grade 4+ toxicity. CONCLUSION IMNT improves the therapeutic ratio compared to 3D conformal NT and expands indications for NT in patients with radiorefractory tumors. Acute toxicity compares favorably with photons. Longer clinical and toxicity follow-up is anticipated. A prospective trial is planned to evaluate quality of life measures.
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Affiliation(s)
- A C Anderson
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
| | - R D Stewart
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
| | - P A Sponseller
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
| | - L W Wairiri
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
| | - P H Goff
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
| | - N Panjwani
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
| | - G E Laramore
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
| | - U Parvathaneni
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
| | - R Emery
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
| | - E J Marchiano
- Department of Otolaryngology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - N Futran
- Department of Otolaryngology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - C P Rodriguez
- Division of Oncology, Department of Medicine, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - J J Liao
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
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Gobillot TA, Greer M, Parvathaneni U, Liao JJ, Laramore GE, Goff P, Wallner K, Rodriguez CP, Houlton JJ, Barber BR, Futran ND, Rizvi ZH. Radiation therapy for low- and high-risk perineural invasion in head and neck cutaneous squamous cell carcinoma: Clinical outcomes and patterns of failure. Head Neck 2023; 45:2323-2334. [PMID: 37448346 DOI: 10.1002/hed.27458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/27/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Perineural invasion (PNI) in head and neck squamous cell carcinoma (HNSCC) portends poor prognosis. Extent of treatment of nerve pathways with varying degrees of PNI and patterns of failure following elective neural radiotherapy (RT) remain unclear. METHODS Retrospective review of HNSCC patients with high-risk (clinical/gross, large-nerve, extensive) or low-risk (microscopic/focal) PNI who underwent curative-intent treatment from 2010 to 2021. RESULTS Forty-four patients (mean follow-up 22 months; 59% high-risk, 41% low-risk PNI) were included. Recurrence following definitive treatment occurred in 31% high-risk and 17% low-risk PNI patients. Among high-risk patients, 69% underwent surgery with post-operative RT and 46% underwent elective neural RT. Local control (83% low-risk vs. 75% high-risk), disease-free, and overall survival did not differ between groups. CONCLUSIONS High local control rates were achieved in high-risk PNI patients treated with adjuvant or primary RT, including treatment of both involved and uninvolved, communicating cranial nerves, with few failures in electively treated regions.
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Affiliation(s)
- Theodore A Gobillot
- Department of Otolaryngology - Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Matthew Greer
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Jay J Liao
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - George E Laramore
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Peter Goff
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Kent Wallner
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Cristina P Rodriguez
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jeffrey J Houlton
- Department of Otolaryngology - Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Brittany R Barber
- Department of Otolaryngology - Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Neal D Futran
- Department of Otolaryngology - Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Zain H Rizvi
- Department of Otolaryngology - Head & Neck Surgery, University of Washington, Seattle, Washington, USA
- Puget Sound Health Care System, Department of Veterans Affairs, Seattle, Washington, USA
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8
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Lussier L, Wallner K, Kearney KE, Tiwana J, Kim EY, Parvathaneni U, Lombardi WL, Phillips M, Don C, Kim M. Image-guided intravascular brachytherapy dose escalation. Brachytherapy 2023; 22:518-523. [PMID: 37211487 DOI: 10.1016/j.brachy.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/15/2023] [Accepted: 04/05/2023] [Indexed: 05/23/2023]
Abstract
PURPOSE Coronary stents reduce IVBT radiation dose with a single layer by 10-30%. However, the impact of multiple stent layers and stent expansion remains unexplored. Individualized dose adjustments considering variations in stent layers and expansion could improve radiation delivery effectiveness. METHODS EGSnrc was used to compute the delivered vessel wall dose in various IVBT scenarios. Stent effects were modeled for the stent density of 25%, 50%, and 75% with 1, 2, and 3 layers respectively. Doses were calculated at 1.75 to 5.00 mm away from the source center, normalized to 100% at 2 mm. RESULTS Dose fall-off increased with increasing stent density. With a single layer, the dose at 2 mm from source fell from 100% of prescription to 92%, 83% and 73% at 25%, 50% and 75% density, respectively. The computed dose to points with increasing radial distance from the source decreased progressively with increasing stent layers. With three layers, at 75% stent density, the dose at 2 mm from source center fell to 38%. CONCLUSIONS A schema for image-guided IVBT dose adjustment is described. While it would be an improvement over current standard of care, myriad factors remain to be addressed in a comprehensive effort to optimize IVBT.
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Affiliation(s)
- Luke Lussier
- Department of Physics, St. Mary's University, San Antonio, TX
| | - Kent Wallner
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | | | - Jasleen Tiwana
- Department of Cardiology, University of Washington, Seattle, WA
| | - Edward Y Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | | | | | - Mark Phillips
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Creighton Don
- Department of Cardiology, University of Washington, Seattle, WA
| | - Minsun Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA.
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Pan C, Wu QV, Voutsinas J, Houlton JJ, Barber B, Rizvi ZH, Marchiano E, Futran N, Laramore GE, Liao JJ, Parvathaneni U, Martins RG, Fromm JR, Rodriguez CP. Peripheral lymphocytes and lactate dehydrogenase correlate with response and survival in head and neck cancers treated with immune checkpoint inhibitors. Cancer Med 2023; 12:9384-9391. [PMID: 36806947 PMCID: PMC10166901 DOI: 10.1002/cam4.5697] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/31/2023] [Accepted: 02/03/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Little is known regarding associations between peripheral blood biomarkers (PBBMs) and survival, response, and toxicity in recurrent/metastatic head and neck squamous cell carcinomas (R/M HNSCC) treated with immune checkpoint inhibitors (ICIs). METHODS In this single-institution retrospective cohort study, a dataset of patients with R/M HNSCC treated with ICIs between 08/2012-03/2021 was established, including demographic and clinicopathologic characteristics. Pretreatment PBBMs were collected and evaluated for associations with grade ≥3 adverse events (G ≥ 3AE) by CTCAEv5, objective response (ORR) by RECIST 1.1, overall survival (OS), and progression-free survival (PFS). Multivariable models for each outcome were created using elastic net variable selection. RESULTS Our study included 186 patients, with 51 (27%) demonstrating complete or partial response to immunotherapy. Multivariable models adjusted for ECOG performance status (PS), p16, and smoking demonstrated that pretreatment higher LDH and absolute neutrophils, as well as lower percent lymphocytes correlated with worse OS and PFS. Higher LDH and lower % lymphocytes also correlated with worse ORR. CONCLUSIONS In the largest study to date examining PBBMs in ICI-treated R/M HNSCCs, our variable selection method revealed PBBMs prognostic for survival and response to immunotherapy. These biomarkers warrant further investigation in a prospective study along with validation with CPS biomarker.
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Affiliation(s)
- Cassie Pan
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Qian Vicky Wu
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Jenna Voutsinas
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | | | - Brittany Barber
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Zain H Rizvi
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Emily Marchiano
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Neal Futran
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - George E Laramore
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Jay J Liao
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Renato G Martins
- Division of Hematology, Oncology and Palliative Care, Department of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jonathan R Fromm
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Cristina P Rodriguez
- Division of Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
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Pan C, Wu Q“V, Voutsinas J, Houlton JJ, Barber B, Futran N, Laramore GE, Liao JJ, Parvathaneni U, Martins RG, Fromm JR, Rodriguez CP. Neutrophil to lymphocyte ratio and peripheral blood biomarkers correlate with survival outcomes but not response among head and neck and salivary cancer treated with pembrolizumab and vorinostat. Head Neck 2023; 45:391-397. [PMID: 36412064 PMCID: PMC9812876 DOI: 10.1002/hed.27252] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/14/2022] [Accepted: 11/09/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Associations between peripheral blood biomarkers and oncologic outcomes were explored in recurrent/metastatic (R/M) head and neck squamous cell carcinoma (HN) and salivary gland cancer (SGC) treated with pembrolizumab and vorinostat on a phase II trial (NCT02538510). EXPERIMENTAL DESIGN Twenty-five HN and 25 SGCs were treated with pembrolizumab and vorinostat. Baseline peripheral blood was available in 21 HN and 20 SGCs and evaluated for associations with grade ≥3 adverse events (G ≥ 3AE) by CTCAEv4, objective response rate (ORR), overall survival (OS), and progression-free survival (PFS). RESULTS Higher pretreatment neutrophil-to-lymphocyte ratio (NLR) and neutrophils, as well as lower pretreatment lymphocytes and T helper cells correlated with worse OS and PFS. Higher NLR further predicted increased rates of G ≥ 3AEs. No correlations with ORR were observed. CONCLUSIONS In a prospectively evaluated cohort of HN and SGCs treated with pembrolizumab and vorinostat, we observed novel associations between peripheral blood biomarkers and oncologic outcomes and toxicities.
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Affiliation(s)
- Cassie Pan
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington
| | - Qian “Vicky” Wu
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jenna Voutsinas
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jeffrey J. Houlton
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington
| | - Brittany Barber
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington
| | - Neal Futran
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington
| | - George E. Laramore
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Jay J. Liao
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | | | - Renato G. Martins
- Division of Hematology, Oncology and Palliative Care, Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Jonathan R. Fromm
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Cristina P. Rodriguez
- Division of Oncology, Department of Medicine, University of Washington, Seattle, Washington
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Sengupta B, Oh K, Sponseller P, Zaki P, Eastman B, Dinh TKT, Cardenas CE, Court LE, Parvathaneni U, Ford E. Cobalt compensator-based IMRT device: A treatment planning study of head and neck cases. Phys Med 2023; 106:102526. [PMID: 36621080 PMCID: PMC10468209 DOI: 10.1016/j.ejmp.2023.102526] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 12/28/2022] [Accepted: 01/02/2023] [Indexed: 01/08/2023] Open
Abstract
PURPOSE Our goal is to develop a novel cobalt-compensator-based IMRT device for low- and middle-income countries that is reliable and cost-effective while delivering treatment plans of equal quality to those from linac-MLC devices. The present study examines the quality of treatment plans using this device. METHODS A commercial treatment planning system (TPS; RayStation v.8B) was commissioned for this device using Monte Carlo simulations from the Geant4 toolkit. Patient-specific compensators were created as regions-of-interest. Thirty clinical head & neck cases were planned and compared to clinical plans with a 6MV linac using IMRT. The mock head and neck plan from TG-119 was used for further validation. RESULTS PTV objectives were achieved in all 30 plans with PTV V95% >95 %. OAR sparing was similar to clinical plans. There were 14 cases where OAR dose limits exceeded the recommended QUANTEC limits in the clinical plan in order to achieve target coverage. OAR sparing was better in the cobalt compensator plan in 8 cases and worse in 3 cases, in the latter cases exceeding the clinical plan doses by an average of 8.22 % (0.0 %-13.5 %). Average field-by-field gamma pass-rate were 93.7 % (2 %/2mm). Estimated treatment times using the Co-60 compensator device were 1 min 27 s vs 1 min 2 s for the clinical system. CONCLUSION This system is the first of its kind to allow for IMRT with a Co-60 device. Data here suggests that the delivery meets plan quality criteria while maintaining short treatment times which may offer a sustainable and cost-low option for IMRT on the global scale.
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Affiliation(s)
| | - Kyuhak Oh
- Department of Radiation Oncology, University of Washington, Seattle, USA; M.D. Anderson Cancer Center, Houston, USA
| | | | - Peter Zaki
- Department of Radiation Oncology, University of Washington, Seattle, USA
| | - Boryana Eastman
- Department of Radiation Oncology, University of Washington, Seattle, USA
| | - Tru-Khang T Dinh
- Department of Radiation Oncology, University of Washington, Seattle, USA
| | - Carlos E Cardenas
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Eric Ford
- Department of Radiation Oncology, University of Washington, Seattle, USA.
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Singh N, McClure E, Doolittle-Amieva C, Parvathaneni U, Bhatia S, Moshiri AS. Complete resolution of PD-1 refractory, locoregionally advanced Merkel cell carcinoma with talimogene laherparepvec. JAAD Case Rep 2023. [DOI: 10.1016/j.jdcr.2022.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
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13
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Akaike T, Cahill K, Akaike G, Huynh ET, Hippe DS, Shinohara MM, Liao J, Apisarnthanarax S, Parvathaneni U, Hall E, Bhatia S, Cheng RK, Nghiem P, Tseng YD. Management and Prognosis of Cardiac Metastatic Merkel Cell Carcinoma: A Case-Control Study and Literature Review. Cancers (Basel) 2022; 14:cancers14235914. [PMID: 36497395 PMCID: PMC9741306 DOI: 10.3390/cancers14235914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/18/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022] Open
Abstract
Merkel cell carcinoma (MCC), an aggressive neuroendocrine skin cancer, has a high rate (20%) of distant metastasis. Within a prospective registry of 582 patients with metastatic MCC (mMCC) diagnosed between 2003-2021, we identified 9 (1.5%) patients who developed cardiac metastatic MCC (mMCC). We compared overall survival (OS) between patients with cardiac and non-cardiac metastases in a matched case-control study. Cardiac metastasis was a late event (median 925 days from initial MCC diagnosis). The right heart was predominantly involved (8 of 9; 89%). Among 7 patients treated with immunotherapy, 6 achieved a complete or partial response of the cardiac lesion. Among these 6 responders, 5 received concurrent cardiac radiotherapy (median 20 Gray) with immunotherapy; 4 of 5 did not have local disease progression or recurrence in the treated cardiac lesion. One-year OS was 44%, which was not significantly different from non-cardiac mMCC patients (45%, p = 0.96). Though it occurs relatively late in the disease course, cardiac mMCC responded to immunotherapy and/or radiotherapy and was not associated with worse prognosis compared to mMCC at other anatomic sites. These results are timely as cardiac mMCC may be increasingly encountered in the era of immunotherapy as patients with metastatic MCC live longer.
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Affiliation(s)
- Tomoko Akaike
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
- Correspondence: ; Tel.: +1-206-221-4594
| | - Kelsey Cahill
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Gensuke Akaike
- Department of Radiology, University of Washington, Seattle, WA 98195, USA
- TRA Medical Imaging, Tacoma, WA 98402, USA
| | - Emily T. Huynh
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Daniel S. Hippe
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA
| | - Michi M. Shinohara
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Jay Liao
- Department of Radiation Oncology, University of Washington, Seattle, WA 91895, USA
| | | | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington, Seattle, WA 91895, USA
| | - Evan Hall
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Shailender Bhatia
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Richard K. Cheng
- Division of Cardiology, University of Washington Medical Center, Seattle, WA 98195, USA
| | - Paul Nghiem
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA
| | - Yolanda D. Tseng
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA
- Department of Radiation Oncology, University of Washington, Seattle, WA 91895, USA
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Chang S, Parvathaneni U, Laramore G, Humphreys I, Moe K, Patel A, Ferreira M, Rodriguez C, Cranmer L, Futran N, Barber B, Houlton J, Abuzeid W, Jafari A, Rizvi Z, Cash H, Liao J. Surgical Resection and Intensity Modulated Proton Therapy for Esthesioneuroblastoma. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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15
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Rodriguez C, Fromm J, Liao J, Laramore G, Lo S, Goff P, Santana-Davila R, Martins R, Futran N, Houlton J, Barber B, Parvathaneni U. Dual Immune Checkpoint Blockade and Hypofractionated Radiation in Recurrent/Metastatic Squamous Cell Carcinomas of the Head and Neck Previously Treated with Immune Checkpoint Inhibitors. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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16
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Uy NF, Ng K, Voutsinas JM, Wu V, Futran ND, Houlton J, Barber B, Laramore GE, Parvathaneni U, Liao JJ, Rodriguez CP. Gastrostomy, tracheostomy, opioid, and health care utilization among patients with recurrent/metastatic head and neck cancer receiving immunotherapy. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
296 Background: Immune checkpoint inhibitors (ICI) are approved for recurrent and/or metastatic squamous head and neck cancers (R/M HNSCC). Landmark trials have shown stable or improved patient (pt) reported quality of life outcomes. It is unclear how these translate into gastrostomy (G) and tracheostomy (T) dependence, opioid use, or ER/unplanned hospitalizations (UH) in an unselected population. We sought to explore these in our large single institution cohort. Methods: We reviewed R/M HNSCC pts receiving ICI at a tertiary referral NCI designated cancer center. Outcomes were assessed between the first dose of ICI and 100 days after the last dose of ICI. Overall survival (OS) was estimated via Kaplan-Meier estimation. Differences between groups were assessed via log-rank testing procedure and adjusted for age, tumor characteristics, and smoking status. Results: Between 1/2012 and 12/2019, we treated 152 pts with ICI, mostly male (n = 142, 82%), partnered/married (n = 103, 68%), with median age 64 years (range 23 – 90). The most common primary sites were oropharynx (n = 55, 36%) and oral cavity (n = 33, 22%). 50 (35%) had ≥2 lines of prior systemic therapy and 29 (19%) had an ECOG ≥2. The most common pt races were white (n = 114, 75%), Asian (n = 14, 9%), and Hispanic, any race (n = 6, 4%). 83 (55%) and 23 (15%) had history of smoking and heavy alcohol use respectively. Median duration of ICI therapy was 95 days (range 1-1720). Prior to ICI, 49 (32%) had G, 17 (11%) had T, and 15 (10%) had both. While on ICI, 6 (4%) had G placed, and 1 (1%) had a G removed; 1 (1%) had T placed, and 2 (1%) had T removed. 69 (45%) had ER visits and 57 (38%) had UH; 11 (7%) were directly related to ICI adverse effects. Prior to ICI, 104 (68%) were on opiates; requirements increased in 58 (41%) pts and decreased in 17 (12%) pts. Pre-existing G prior to ICI had worse OS on log-rank testing, but significance was lost when adjusted for variables. Pre-existing T prior to ICI (p = 0.001, HR 3.08, 95% Cl [1.56,6.08]), and pts with increasing opiate requirements on ICI (p value = 0.0007, HR 2.13, 95% Cl [1.38,3.28]) had worse OS. Conclusions: In our cohort, ICI did not change G or T usage. Pre-existing T and increasing opiate use were also associated with worse survival. Our data supports augmentation of palliative care and advanced care planning in the R/M HNSCC population.
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Affiliation(s)
| | - Kevin Ng
- Fred Hutchinson Cancer Center, Seattle, WA
| | | | - Vicky Wu
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Neal D. Futran
- Department of Otolaryngology: Head and Neck Surgery, University of Washington, Seattle, WA
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Wallner K, Kearney KE, Kim M, Tiwana J, Elison D, Kim EY, Parvathaneni U, Lombardi WL, Phillips ML, Don C. Failure patterns after intravascular brachytherapy for in-stent coronary restenosis. Catheter Cardiovasc Interv 2022; 100:759-762. [PMID: 36098336 DOI: 10.1002/ccd.30399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 08/18/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION One strategy to improve the effectiveness of intravascular brachytherapy (IVBT) is to study its failures. Previous investigations described mostly discrete, focal recurrences, typically at the proximal or distal edges of the irradiated segment after plain angioplasty or bare metal stents. We reviewed failure patterns of 30 unselected drug-eluting stent (DES) patients who had follow-up angiograms for recurrence within their IVBT-treated vessel. METHODS Records of 53 unselected IVBT patients treated between 2016 and 2021 were reviewed. Thirty of the 53 patients had at least one subsequent percutaneous intervention (PCI) for in-stent restenosis (ISR) after IVBT. Angiographic findings of those 30 patients with ISR within their previously irradiated vessel are reported here. RESULTS Of the 30 patients, 21 (70%) developed recurrent ISR within the irradiated segment. Six of the 21 patients who failed within the irradiated segment also experienced ISR proximal or distal to the irradiated segment. Only 15 patients (50%) failed exclusively within the irradiated segment. In nine patients (30%), restenosis occurred proximally and/or distally to the irradiated segment, but not inside of the irradiated segment itself. CONCLUSIONS We have shown here that 50% of failures after coronary IVBT for DES ISR occur exclusively within the irradiated segment. An additional 20% of patients had failure within and outside of the irradiated segment. These percentages suggest that a higher radiation dose might improve the long-term patency rates, a conclusion that should be tempered by the lack of universal follow-up.
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Affiliation(s)
- Kent Wallner
- Departments of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Kathleen E Kearney
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Minsun Kim
- Departments of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Jasleen Tiwana
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - David Elison
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Edward Y Kim
- Departments of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Upendra Parvathaneni
- Departments of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - William L Lombardi
- Departments of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Mark L Phillips
- Departments of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Creighton Don
- Division of Cardiology, University of Washington, Seattle, Washington, USA
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Michikawa C, Torres-Saavedra PA, Silver NL, Harari PM, Kies MS, Rosenthal DI, Le QT, Jordan RC, Duose DY, Mallampati S, Trivedi S, Luthra R, Wistuba II, Osman AA, Lichtarge O, Foote RL, Parvathaneni U, Hayes DN, Pickering CR, Myers JN. Evolutionary Action Score of TP53 Analysis in Pathologically High-Risk Human Papillomavirus-Negative Head and Neck Cancer From a Phase 2 Clinical Trial: NRG Oncology Radiation Therapy Oncology Group 0234. Adv Radiat Oncol 2022; 7:100989. [PMID: 36420184 PMCID: PMC9677209 DOI: 10.1016/j.adro.2022.100989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 05/04/2022] [Indexed: 12/15/2022] Open
Abstract
Purpose An evolutionary action scoring algorithm (EAp53) based on phylogenetic sequence variations stratifies patients with head and neck squamous cell carcinoma (HNSCC) bearing TP53 missense mutations as high-risk, associated with poor outcomes, or low-risk, with similar outcomes as TP53 wild-type, and has been validated as a reliable prognostic marker. We performed this study to further validate prior findings demonstrating that EAp53 is a prognostic marker for patients with locally advanced HNSCC and explored its predictive value for treatment outcomes to adjuvant bio-chemoradiotherapy. Methods and Materials Eighty-one resection samples from patients treated surgically for stage III or IV human papillomavirus-negative HNSCC with high-risk pathologic features, who received either radiation therapy + cetuximab + cisplatin (cisplatin) or radiation therapy + cetuximab + docetaxel (docetaxel) as adjuvant treatment in a phase 2 study were subjected to TP53 targeted sequencing and EAp53 scoring to correlate with clinical outcomes. Due to the limited sample size, patients were combined into 2 EAp53 groups: (1) wild-type or low-risk; and (2) high-risk or other. Results At a median follow-up of 9.8 years, there was a significant interaction between EAp53 group and treatment for overall survival (P = .008), disease-free survival (P = .05), and distant metastasis (DM; P = .004). In wild-type or low-risk group, the docetaxel arm showed significantly better overall survival (hazard ratio [HR] 0.11, [0.03-0.36]), disease-free survival (HR 0.24, [0.09-0.61]), and less DM (HR 0.04, [0.01-0.31]) than the cisplatin arm. In high-risk or other group, differences between treatments were not statistically significant. Conclusions The docetaxel arm was associated with better survival than the cisplatin arm for patients with wild-type or low-risk EAp53. These benefits appear to be largely driven by a reduction in DM.
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Affiliation(s)
- Chieko Michikawa
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas,Department of Maxillofacial Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Pedro A. Torres-Saavedra
- NRG Oncology Statistics and Data Management Center, American College of Radiology, Philadelphia, Pennsylvania
| | - Natalie L. Silver
- Cleveland Clinic, Head and Neck Institute/Lerner Research Institute, Cleveland, Ohio
| | - Paul M. Harari
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Merrill S. Kies
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David I. Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Quynh-Thu Le
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, California
| | - Richard C. Jordan
- NRG Oncology Biospecimen Bank and University of California, San Francisco, San Francisco, California
| | | | | | - Sanchit Trivedi
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rajyalakshmi Luthra
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Abdullah A. Osman
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Olivier Lichtarge
- Departments of Molecular and Human Genetics, Pharmacology, and Biochemistry and Molecular Biology, Baylor College of Medicine, Houston, Texas
| | - Robert L. Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Upendra Parvathaneni
- Radiation Oncology Center, University of Washington Medical Center, Seattle, Washington
| | - D. Neil Hayes
- Division of Medical Oncology, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Curtis R. Pickering
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey N. Myers
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas,Corresponding author: Jeffrey N. Myers, MD, PhD
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Falek S, Regmi R, Herault J, Dore M, Vela A, Dutheil P, Moignier C, Marcy PY, Drouet J, Beddok A, Letwin NE, Epstein J, Parvathaneni U, Thariat J. Dental management in head and neck cancers: from intensity-modulated radiotherapy with photons to proton therapy. Support Care Cancer 2022; 30:8377-8389. [PMID: 35513755 DOI: 10.1007/s00520-022-07076-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 04/18/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Despite reduction of xerostomia with intensity-modulated compared to conformal X-ray radiotherapy, radiation-induced dental complications continue to occur. Proton therapy is promising in head and neck cancers to further reduce radiation-induced side-effects, but the optimal dental management has not been defined. MATERIAL AND METHODS Dental management before proton therapy was assessed compared to intensity-modulated radiotherapy based on a bicentric experience, a literature review and illustrative cases. RESULTS Preserved teeth frequently contain metallic dental restorations (amalgams, crowns, implants). Metals blur CT images, introducing errors in tumour and organ contour during radiotherapy planning. Due to their physical interactions with matter, protons are more sensitive than photons to tissue composition. The composition of restorative materials is rarely documented during radiotherapy planning, introducing dose errors. Manual artefact recontouring, metal artefact-reduction CT algorithms, dual or multi-energy CT and appropriate dose calculation algorithms insufficiently compensate for contour and dose errors during proton therapy. Physical uncertainties may be associated with lower tumour control probability and more side-effects after proton therapy. Metal-induced errors should be quantified and removal of metal restorations discussed on a case by case basis between dental care specialists, radiation oncologists and physicists. Metallic amalgams can be replaced with water-equivalent materials and crowns temporarily removed depending on rehabilitation potential, dental condition and cost. Implants might contraindicate proton therapy if they are in the proton beam path. CONCLUSION Metallic restorations may more severely affect proton than photon radiotherapy quality. Personalized dental care prior to proton therapy requires multidisciplinary assessment of metal-induced errors before choice of conservation/removal of dental metals and optimal radiotherapy.
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Affiliation(s)
- Sabah Falek
- Department of Oral and Maxillo-Facial Surgery, Francois Baclesse Center, Caen, France
| | - Rajesh Regmi
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
| | - Joel Herault
- Institut Méditerranéen de Protonthérapie, Antoine Lacassagne Center, Nice, France
| | - Melanie Dore
- Department of Radiation Oncology, Institut de Cancérologie de L'Ouest, Nantes, France
| | - Anthony Vela
- Department of Medical Physics, François Baclesse Center / Proton Therapy Center, Caen, France
| | - Pauline Dutheil
- Department of Medical Physics, François Baclesse Center / Proton Therapy Center, Caen, France
| | - Cyril Moignier
- Department of Medical Physics, François Baclesse Center / Proton Therapy Center, Caen, France
| | - Pierre-Yves Marcy
- Radiodiagnostics and Interventional Radiology, Polyclinique ELSAN, Ollioules, France
| | - Julien Drouet
- Department of Oral and Maxillo-Facial Surgery, Francois Baclesse Center, Caen, France
| | - Arnaud Beddok
- Department of Radiation Oncology, Curie Institute, Paris, France
| | - Noah E Letwin
- Swedish Medical Center General Practice Residency, Seattle, WA and owner Seattle Special Care Dentistry, Seattle, WA, USA
| | - Joel Epstein
- City of Hope Comprehensive Cancer Center, Duarte CA and Cedars-Sinai Medical System, Los Angeles, CA, USA
| | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, USA
| | - Juliette Thariat
- Department of Radiation Oncology, Centre François Baclesse, Caen, France.
- Laboratoire de Physique Corpusculaire, IN2P3/ENISAEN-CNRS, Caen, France.
- Normandie Universite, Caen, France.
- SAS Cyclhad, Hérouville-Saint-Clair, France.
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20
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Chalker C, Voutsinas JM, Wu QV, Santana-Davila R, Hwang V, Baik CS, Lee S, Barber B, Futran ND, Houlton JJ, Laramore GE, Liao JJ, Parvathaneni U, Martins RG, Eaton KD, Rodriguez CP. Performance status (PS) as a predictor of poor response to immune checkpoint inhibitors (ICI) in recurrent/metastatic head and neck cancer (RMHNSCC) patients. Cancer Med 2022; 11:4104-4111. [PMID: 35349227 DOI: 10.1002/cam4.4722] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/17/2022] [Accepted: 03/17/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Anti-PD1 checkpoint inhibitors (ICI) represent an established standard-of-care for patients with recurrent/metastatic head and neck squamous cell carcinoma (RMHNSCC). Landmark studies excluded patients with ECOG performance status (PS) ≥2; the benefit of ICI in this population is therefore unknown. METHODS We retrospectively reviewed RMHNSCC patients who received 1+ dose of ICI at our institution between 2013 and 2019. Demographic and clinical data were obtained; the latter included objective response (ORR), toxicity, and any unplanned hospitalization (UH). Associations were explored using uni- and multivariate analysis. Overall survival (OS) was estimated using a Cox proportional hazards model; ORR, toxicity, and UH were evaluated with logistic regression. RESULTS Of the 152 patients, 29 (19%) had an ECOG PS ≥2. Sixty-six (44%) experienced toxicity; 54 (36%) had a UH. A multivariate model for OS containing PS, smoking status, and HPV status demonstrated a strong association between ECOG ≥2 and shorter OS (p < 0.001; HR = 3.30, CI = 2.01-5.41). An association between OS and former (vs. never) smoking was also seen (p < 0.001; HR = 2.17, CI = 1.41-3.35); current smoking did not reach statistical significance. On univariate analysis, poor PS was associated with inferior ORR (p = 0.03; OR = 0.25, CI = 0.06-0.77) and increased UH (p = 0.04; OR = 2.43, CI = 1.05-5.71). There was no significant association between toxicity and any patient characteristic. CONCLUSIONS We observed inferior OS, ORR, and rates of UH among ICI-treated RMHNSCC patients with ECOG 2/3. Our findings help frame discussion of therapeutic options in this poor-risk population.
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Affiliation(s)
- Cameron Chalker
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jenna M Voutsinas
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Qian Vicky Wu
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Rafael Santana-Davila
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Victoria Hwang
- Department of Obstetrics and Gynecology, John Peter Smith Hospital, Fort Worth, Texas, USA
| | - Christina S Baik
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Sylvia Lee
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Brittany Barber
- Department of Otolaryngology Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Neal D Futran
- Department of Otolaryngology Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Jeffrey J Houlton
- Department of Otolaryngology Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - George E Laramore
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Jay Justin Liao
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Renato G Martins
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Keith D Eaton
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Cristina P Rodriguez
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
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21
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Chalker C, Santana-Davila R, Voutsinas JM, Wu QV, Hwang V, Baik CS, Lee S, Barber B, Futran ND, Houlton JJ, Laramore GE, Liao JJ, Parvathaneni U, Martins RG, Eaton KD, Rodriguez CP. High End-of-Life Health Care Utilization in a Contemporary Cohort of Head and Neck Cancer Patients Treated with Immune Checkpoint Inhibitors. J Palliat Med 2021; 25:614-619. [PMID: 34847733 DOI: 10.1089/jpm.2021.0323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background/Objective: End-of-life health care utilization (EOLHCU) is largely uncharacterized among patients with recurrent/metastatic head and neck squamous cell carcinomas (RMHNSCC), particularly now that immune checkpoint inhibitors (ICI) have been introduced to the treatment landscape. We examined this in a single-institution, retrospective study. Design/Settings: We utilized a database of deceased, ICI-treated RMHNSCC patients to obtain demographic and EOLHCU data, the latter of which included advanced care plan documentation (ACPD) and systemic therapy or emergency room (ER)/hospital/intensive care unit (ICU) admission within 30 days of death (DOD). This was compared with a cohort of deceased thoracic malignancy (TM) patients in an exploratory analysis. Multivariate analysis was performed to examine for association between patient factors (such as age, Eastern Cooperative Oncology Group (ECOG) performance status, or smoking status) and overall survival (OS); associations between the said patient factors and EOLHCU were also evaluated. This study was conducted at an academic, tertiary center in the United States. Results: The RMHNSCC patients (n = 74) were more likely to have ACPD (p < 0.01), an emergency department visit (p < 0.01), and/or hospital admission (p < 0.01) within 30 DOD relative to the TM group. There was no difference in ICU admissions, ICU deaths, or systemic therapy at end of life (EOL). The OS declined in association with ECOG performance status (PS) and smoking. No association was observed between patient factors and any EOLHCU metric. Conclusions: At our center, patients with ICI-treated RMHNSCC have higher rates of both ACPD and EOLHCU, suggesting high symptom burden and representing opportunities for further study into supportive care augmentation.
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Affiliation(s)
- Cameron Chalker
- Department of Medicine and Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Rafael Santana-Davila
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jenna M Voutsinas
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Qian Vicky Wu
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Victoria Hwang
- Department of Obstetrics and Gynecology, John Peter Smith Hospital, Fort Worth, Texas, USA
| | - Christina S Baik
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Sylvia Lee
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Brittany Barber
- Department of Otolaryngology Head and Neck Surgery and University of Washington, Seattle, Washington, USA
| | - Neal D Futran
- Department of Otolaryngology Head and Neck Surgery and University of Washington, Seattle, Washington, USA
| | - Jeffrey J Houlton
- Department of Otolaryngology Head and Neck Surgery and University of Washington, Seattle, Washington, USA
| | - George E Laramore
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Jay Justin Liao
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Renato G Martins
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Keith D Eaton
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Cristina P Rodriguez
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington, USA
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22
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Romine PE, Voutsinas J, Wu V, Tratt M, Liao J, Parvathaneni U, Barber B, Dillon J, Timoshchuk MA, Futran N, Houlton J, Laramore G, Martins R, Eaton KD, Rodriguez C. Timing of postoperative radiation therapy and survival in resected salivary gland cancers: Long-term results from a single institution. Oral Oncol 2021; 123:105626. [PMID: 34801976 DOI: 10.1016/j.oraloncology.2021.105626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/27/2021] [Accepted: 11/09/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Timely administration of postoperative radiation therapy (PORT) impacts oncologic outcomes in resected squamous cell carcinomas of the head and neck. Salivary gland cancers (SGCs) are uncommon, and timing of PORT has not been extensively explored. We aimed to determine if the interval between surgery and PORT impacts outcomes in SGCs. MATERIALS AND METHODS This is a retrospective study of patients with SGCs who underwent curative intent surgical resection followed by adjuvant PORT. Locoregional recurrence free survival (LRFS), disease free survival (DFS), and overall survival (OS) were estimated using the Kaplan Meier method. A multivariate analysis explored the association between demographics, tumor characteristics, and PORT timing with oncologic outcomes using a stepwise Cox proportional hazards model. RESULTS 180 eligible patients were identified. The median time to PORT start was 61 (range 8-121) days. 169 (93.5%) of patients received neutron radiation. With a median follow up of 8.2 years in surviving patients, the 10-year OS and LRFS estimates were 61% and 53%. In a multivariate analysis, nodal involvement, histologic grade, and age at diagnosis were associated with OS, while nodal involvement, tumor size, and age at diagnosis were associated with LRFS and DFS. Time to PORT start or completion was not statistically associated with survival outcomes. CONCLUSION SGC patients who underwent surgery in our tertiary institution received PORT within a median of 61 days after surgery. With long term follow up, PORT timing in this retrospective series was not associated with worse oncologic outcomes, and support timely administration of PORT.
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Affiliation(s)
- Perrin E Romine
- University of Washington, Department of Medicine, Division of Medical Oncology, United States.
| | - Jenna Voutsinas
- Fred Hutchinson Cancer Research Institute, Division of Clinical Biostatistics, United States
| | - Vicky Wu
- Fred Hutchinson Cancer Research Institute, Division of Clinical Biostatistics, United States
| | - Micah Tratt
- University of Washington, Department of Medicine, Division of Medical Oncology, United States
| | - Jay Liao
- University of Washington, Department of Radiation Oncology, United States
| | | | - Brittany Barber
- University of Washington, Department of Otolaryngology, United States
| | - Jasjit Dillon
- University of Washington, Department of Oral and Maxillofacial Surgery, United States
| | - Mari-Alina Timoshchuk
- Louisiana State University, Department of Oral and Maxillofacial Surgery, New Orleans, LA, United States
| | - Neal Futran
- University of Washington, Department of Otolaryngology, United States
| | - Jeffrey Houlton
- University of Washington, Department of Otolaryngology, United States
| | - George Laramore
- University of Washington, Department of Radiation Oncology, United States
| | - Renato Martins
- University of Washington, Department of Medicine, Division of Medical Oncology, United States
| | - Keith D Eaton
- University of Washington, Department of Medicine, Division of Medical Oncology, United States
| | - Cristina Rodriguez
- University of Washington, Department of Medicine, Division of Medical Oncology, United States
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23
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Williams VM, Parvathaneni U, Laramore GE, Aljabab S, Wong TP, Liao JJ. Intensity-Modulated Proton Therapy for Nasopharynx Cancer: 2-year Outcomes from a Single Institution. Int J Part Ther 2021; 8:28-40. [PMID: 34722809 PMCID: PMC8489486 DOI: 10.14338/ijpt-20-00057.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 02/22/2021] [Indexed: 01/07/2023] Open
Abstract
Purpose Advances in radiotherapy have improved tumor control and reduced toxicity in the management of nasopharyngeal carcinoma (NPC). Local failure remains a problem for some patients with advanced primary tumors, and toxicities are significant given the large treatment volume and tumor proximity to critical structures, even with modern photon-based radiotherapy. Proton therapy has unique dosimetric advantages, and recent technological advances now allow delivery of intensity-modulated proton therapy (IMPT), which can potentially improve the therapeutic ratio in NPC. We report our 2-year clinical outcomes with IMPT for NPC. Materials and Methods We retrospectively reviewed treatment records of patients with NPC treated with IMPT at our center. Demographics, dosimetry, tumor response, local regional control (LRC), distant metastasis, overall survival, and acute and late toxicity outcomes were reviewed. Analyses were performed with descriptive statistics and Kaplan-Meier method. Toxicity was graded per Common Terminology Criteria for Adverse Events (version 4.0). Results Twenty-six patients were treated from 2015 to 2020. Median age was 48 years (range, 19–73 years), 62% (n = 16) had T3-T4 disease, 92% (n = 24) were node positive, 92% (n = 24) had stage III-IV disease, and 69% (n = 18) had positive results for Epstein-Barr virus. Dose-painted pencil-beam IMPT was used. Most patients (85%; 22 of 26) were treated with 70 Gy(RBE) in 33 fractions once daily; 4 (15%) underwent hyperfractionated accelerated treatment twice daily. All received concurrent cisplatin chemotherapy; 7 (27%) also received induction chemotherapy. All patients (100%) completed the planned radiotherapy, and no acute or late grade 4 or 5 toxicities were observed. At median follow-up of 25 months (range, 4-60), there were 2 local regional failures (8%) and 3 distant metastases (12%). The Kaplan-Meier 2-year LRC, freedom from distant metastasis, and overall survival were 92%, 87%, and 85% respectively. Conclusion IMPT is feasible in locally advanced NPC with early outcomes demonstrating excellent LRC and favorable toxicity profile. Our data add to the growing body of evidence supporting the clinical use of IMPT for NPC.
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Affiliation(s)
- Vonetta M Williams
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | | | - George E Laramore
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Saif Aljabab
- Department of Radiation Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Tony P Wong
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
| | - Jay J Liao
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
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24
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Viscariello N, Greer MD, Parvathaneni U, Liao JJ, Laramore GE, Stewart RD. Comparisons of 3-Dimensional Conformal and Intensity-Modulated Neutron Therapy for Head and Neck Cancers. Int J Part Ther 2021; 8:51-61. [PMID: 34722811 PMCID: PMC8489487 DOI: 10.14338/ijpt-20-00059.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 03/03/2021] [Indexed: 11/21/2022] Open
Abstract
PURPOSE Neutron therapy is a high linear energy transfer modality that is useful for the treatment of radioresistant head and neck (H&N) cancers. It has been limited to 3-dimensioanal conformal-based fast-neutron therapy (3DCNT), but recent technical advances have enabled the clinical implementation of intensity-modulated neutron therapy (IMNT). This study evaluated the comparative dosimetry of IMNT and 3DCNT plans for the treatment of H&N cancers. MATERIALS AND METHODS Seven H&N IMNT plans were retrospectively created for patients previously treated with 3DCNT at the University of Washington (Seattle). A custom RayStation model with neutron-specific scattering kernels was used for inverse planning. Organ-at-risk (OAR) objectives from the original 3DCNT plan were initially used and were then systematically reduced to investigate the feasibility of improving a therapeutic ratio, defined as the ratio of the mean tumor to OAR dose. The IMNT and 3DCNT plan quality was evaluated using the therapeutic ratio, isodose contours, and dose volume histograms. RESULTS When compared with the 3DCNT plans, IMNT reduces the OAR dose for the equivalent tumor coverage. Moreover, IMNT is most advantageous for OARs in close spatial proximity to the target. For the 7 patients with H&N cancers examined, the therapeutic ratio for IMNT increased by an average of 56% when compared with the 3DCNT. The maximum OAR dose was reduced by an average of 20.5% and 20.7% for the spinal cord and temporal lobe, respectively. The mean dose to the larynx decreased by an average of 80%. CONCLUSION The IMNT significantly decreases the OAR doses compared with 3DCNT and provides comparable tumor coverage. Improvements in the therapeutic ratio with IMNT are especially significant for dose-limiting OARs near tumor targets. Moreover, IMNT provides superior sparing of healthy tissues and creates significant new opportunities to improve the care of patients with H&N cancers treated with neutron therapy.
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Affiliation(s)
- Natalie Viscariello
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Matthew D. Greer
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | | | - Jay J. Liao
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - George E. Laramore
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Robert D. Stewart
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
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25
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Bierma M, Goff P, Hippe D, Lachance K, Schaub S, Tseng Y, Apisarnthanarax S, Liao J, Parvathaneni U, Nghiem P. LB759 Post-operative radiation therapy to prevent local recurrence of low-risk Merkel cell carcinomas of the head and neck versus other sites. J Invest Dermatol 2021. [DOI: 10.1016/j.jid.2021.07.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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26
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Kearney KE, Wallner K, Kim M, Hira RS, Kim EY, Nakamura K, Parvathaneni U, Steinberg ZL, McCabe JM, Lombardi WL, Phillips ML, Don C. Intravascular coronary brachytherapy combined with a drug-coated balloon. Brachytherapy 2021; 20:1276-1281. [PMID: 34226148 DOI: 10.1016/j.brachy.2021.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/30/2021] [Accepted: 04/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Coronary artery disease leads to stenosis of the major cardiac vessels, resulting in ischemia and infarction. Percutaneous intervention (PCI) with balloon angioplasty can re-open stenosed vessels. Drug eluting stents (DES) and intravascular brachytherapy (IVBT) and drug-coated balloons (DCBs) are proven to decrease the likelihood of another restenosis after PCI, but neither is completely effective. Due to the limited long-term effectiveness of IVBT or DCB used separately for salvage PCI, we combined the two in some poor prognosis patients. METHODS Combined IVBT+DCB was intended for a total of 36 patients from 2015-2020. PCI with some combination of ballooning, laser and directional/rotational atherectomy was used to maximally open the stenotic region prior to IVBT+DCB. Beta-radiation brachytherapy for all patients was done with a Novoste Beta-Cath. Lutonix 4.0 x 40 mm paclitaxel-coated balloons (Bard, Murray Hill, NJ) were employed. RESULTS Overall survival at two years was 88%. Nine patients had follow-up angiograms, all for cardiac symptoms. Time from IVBT+DCB to follow-up angiography ranged from 4 to 33 months. The average months PCI-free interval before brachy therapy was 11.1 mos (95% CI 1.03-23.25) versus 23.3 mos after VBT (23.3 95% CI 12.3-32.3). The mean difference was 11.2 mos (95% CI 1.06-21.4, p < 0.031). None of the follow-up angiographic procedures displayed evidence of what could be interpreted as radiation damage. CONCLUSIONS In this uncontrolled series, IVBT plus DCB appeared to lengthen the ISR-free interval relative to what had been achieved prior to the combined intervention. We view these results as mildly encouraging, worthy of further study.
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Affiliation(s)
| | - Kent Wallner
- Radiation Oncology, University of Washington, Seattle, WA.
| | - Minsun Kim
- Radiation Oncology, University of Washington, Seattle, WA
| | - Ravi S Hira
- Departments of Cardiology, University of Washington, Seattle, WA
| | - Edward Y Kim
- Radiation Oncology, University of Washington, Seattle, WA
| | - Kenta Nakamura
- Departments of Cardiology, University of Washington, Seattle, WA
| | | | | | - James M McCabe
- Departments of Cardiology, University of Washington, Seattle, WA
| | | | | | - Creighton Don
- Radiation Oncology, University of Washington, Seattle, WA
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27
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Goff PH, Schaub SK, Cook MM, Nghiem PN, Parvathaneni U. In Regard to Barker. Adv Radiat Oncol 2021; 6:100685. [PMID: 34195497 PMCID: PMC8233461 DOI: 10.1016/j.adro.2021.100685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 02/17/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Peter H Goff
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Stephanie K Schaub
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Maclean M Cook
- Division of Dermatology, University of Washington School of Medicine, Seattle, Washington
| | - Paul N Nghiem
- Division of Dermatology, University of Washington School of Medicine, Seattle, Washington
| | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
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28
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Lin A, Chang JHC, Grover RS, Hoebers FJP, Parvathaneni U, Patel SH, Thariat J, Thomson DJ, Langendijk JA, Frank SJ. PTCOG Head and Neck Subcommittee Consensus Guidelines on Particle Therapy for the Management of Head and Neck Tumors. Int J Part Ther 2021; 8:84-94. [PMID: 34285938 PMCID: PMC8270078 DOI: 10.14338/ijpt-20-00071.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/30/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose Radiation therapy is a standard modality in the treatment for cancers of the head and neck, but is associated with significant short- and long-term side effects. Proton therapy, with its unique physical characteristics, can deliver less dose to normal tissues, resulting in fewer side effects. Proton therapy is currently being used for the treatment of head and neck cancer, with increasing clinical evidence supporting its use. However, barriers to wider adoption include access, cost, and the need for higher-level evidence. Methods The clinical evidence for the use of proton therapy in the treatment of head and neck cancer are reviewed here, including indications, advantages, and challenges. Results The Particle Therapy Cooperative Group Head and Neck Subcommittee task group provides consensus guidelines for the use of proton therapy for head and neck cancer. Conclusion This report can be used as a guide for clinical use, to understand clinical trials, and to inform future research efforts.
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Affiliation(s)
| | | | - Ryan S Grover
- University of California-San Diego, San Diego, CA, USA
| | - Frank J P Hoebers
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | | | - Juliette Thariat
- Radiation Oncology Department, François Baclesse Center/ARCHADE, Normandy University, Caen, France
| | - David J Thomson
- The Christie NHS Foundation Trust, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Johannes A Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Steven J Frank
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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29
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Romine P, Voutsinas JM, Wu V, Tratt M, Liao JJ, Parvathaneni U, Barber B, Dillon J, Timoshchuk MA, Futran ND, Houlton J, Laramore GE, Martins RG, Eaton KD, Rodriguez CP. Timing of postoperative radiation therapy and survival in resected salivary gland cancers: Long-term results from a single institution. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e18052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18052 Background: Timely administration of postoperative radiation therapy (PORT) impacts oncologic outcomes in resected squamous cell carcinomas of the head and neck. Salivary gland cancers (SGCs) are uncommon, and timing of PORT has not been extensively explored. We aimed to determine if the interval between surgery and PORT impacts outcomes in SGCs. Methods: We retrospectively identified patients with SGCs who underwent curative intent surgical resection followed by adjuvant PORT at our tertiary referral center. Demographic, tumor, and treatment data were collected. Patients with non-oncologic resections and/or delay of > 6 months to radiation start were excluded. Locoregional control (LRC), relapse free survival (RFS), and overall survival (OS) were estimated using the Kaplan Meier method. A multivariate analysis explored the association between demographics, tumor characteristics, and PORT timing with oncologic outcomes using a stepwise Cox proportional hazards model. Results: Between 1/1/1997 and 12/31/2017 180 eligible patients were identified. Patient characteristics are described in Table. The median time to PORT start was 61 (range 8-121) days, 169 (93.9%) of patients received neutron beam PORT. With a median follow up of 8.2 years in surviving patients, the 5-year OS and LRC estimates were 73% and 67%, respectively. In a multivariate analysis, only nodal involvement, histologic grade, and age at diagnosis were associated with OS, while nodal involvement, tumor size, and age at time of diagnosis were associated with LCR and RFS. Time to PORT start or completion was not statistically associated with survival outcomes on multivariate analysis. Conclusions: SGC patients who underwent surgery in our tertiary institution received PORT within a median of 61 days after surgery. With long term follow up, PORT timing in this retrospective series was not associated with worse oncologic outcomes, and support timely administration of PORT with 3 months of surgical resection. Further work is necessary to assess generalizability of these results.[Table: see text]
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Affiliation(s)
| | | | - Vicky Wu
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Micah Tratt
- University of Washington/Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | | | | | | | - Neal D. Futran
- Department of Otolaryngology: Head and Neck Surgery, University of Washington, Seattle, WA
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Chalker C, Wu V, Voutsinas JM, Hwang V, Baik CS, Liao JJ, Lee S, Futran ND, Houlton J, Barber B, Parvathaneni U, Laramore GE, Santana-Davila R, Eaton KD, Martins RG, Rodriguez CP. Impact of ECOG performance status on recurrent/metastatic head and neck squamous cell carcinomas treated with anti-PD1 inhibitors. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e18004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18004 Background: Anti-PD1 checkpoint inhibitors (ICI) represent an established standard of care for patients with recurrent/metastatic head & neck squamous cell carcinoma (RMHNSCC). Landmark studies excluded patients with ECOG performance status (PS) ≥ 2; the benefit of ICI in this population is therefore unknown. Methods: We retrospectively reviewed RMHNSCC patients who received at least 1 dose of ICI at our institution. Demographic data and clinical outcomes were obtained; the latter included objective response to ICI (ORR), physician-documented CTCAE grade 2+ toxicity (irAE), and any unplanned hospitalization within 100-days of last ICI dose (UH). Associations between demographic data and clinical outcomes were explored using both uni- and multivariate analysis. Overall survival (OS) was estimated using a Cox proportional hazards model; ORR, irAE, and UH were evaluated with logistic regression. This project was approved by our institutional IRB. Results: We identified 152 RMHNSCC patients who were treated with ICI between 1/2013 and 1/2019. ECOG PS was 0 in 42 (27%), 1 in 75 (50%), 2 in 27 (18%), 3 in 2 (1%), and unknown in 6 (4%) patients. The median age was 61 (range: 25 - 90). 124 (82%) were male, 124 (82%) were white, and 69 (45%) were never-smokers. The most common primary sites were the oropharynx (n = 59, 40%), oral cavity (n = 39, 26%), nasopharynx (n = 11, 7%), and larynx (n = 10, 6%). 54 (36%) were p16+ oropharynx cancers. CPS score was available in 10 (6.6%). Single agent ICI was received by 118 (77%) patients. 66 (44%) had a documented irAE and 54 (36%) had an UH. A multivariate model for OS containing PS, smoking status and HPV status showed a strong association between inferior OS and ECOG 2/3 compared to 0/1 (p < 0.001; HR = 3.30, CI = 2.01-5.41), as well as former (vs. never) smoking status (p < 0.001; HR = 2.17, CI = 1.41-3.35). Current smoking (p = 0.25) did not reach statistical significance. On univariate analysis, poor PS was associated with inferior ORR (p = 0.03; OR = 0.25, CI = 0.06-0.77) and increased UH (p = 0.04; OR = 2.43, CI = 1.05—5.71). There was no significant association between irAE and any patient characteristic. Conclusions: We observed inferior overall survival among ICI-treated RMHNSCC patients with ECOG 2/3 in our single-institution, retrospective series. Our findings help frame discussion of therapeutic options in this poor-risk population. Further study must be done to determine which interventions are of greatest benefit for RMHNSCC patients with declining performance status.
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Affiliation(s)
| | - Vicky Wu
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | | | | | - Sylvia Lee
- University of Washington, Seattle Cancer Care Alliance, Seattle, WA
| | - Neal D. Futran
- Department of Otolaryngology: Head and Neck Surgery, University of Washington, Seattle, WA
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Carsuzaa F, Lapeyre M, Gregoire V, Maingon P, Beddok A, Marcy PY, Salleron J, Coutte A, Racadot S, Pointreau Y, Graff P, Beadle B, Benezery K, Biau J, Calugaru V, Castelli J, Chua M, Di Rito A, Dore M, Ghadjar P, Huguet F, Jardel P, Johansen J, Kimple R, Krengli M, Laskar S, Mcdowell L, Nichols A, Tribius S, Valduvieco I, Hu C, Liem X, Moya-Plana A, D'onofrio I, Parvathaneni U, Takiar V, Orlandi E, Psyrri A, Shenouda G, Sher D, Steuer C, Shan Sun X, Tao Y, Thomson D, Tsai MH, Vulquin N, Gorphe P, Mehanna H, Yom SS, Bourhis J, Thariat J. Recommendations for postoperative radiotherapy in head & neck squamous cell carcinoma in the presence of flaps: A GORTEC internationally-reviewed HNCIG-endorsed consensus. Radiother Oncol 2021; 160:140-147. [PMID: 33984351 DOI: 10.1016/j.radonc.2021.04.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Head and neck reconstructive surgery using a flap is increasingly common. Best practices and outcomes for postoperative radiotherapy (poRT) with flaps have not been specified. We aimed to provide consensus recommendations to assist clinical decision-making highlighting areas of uncertainty in the presence of flaps. MATERIAL AND METHODS Radiation, medical, and surgical oncologists were assembled from GORTEC and internationally with the Head and Neck Cancer International Group (HNCIG). The consensus-building approach covered 59 topics across four domains: (1) identification of postoperative tissue changes on imaging for flap delineation, (2) understanding of tumor relapse risks and target volume definitions, (3) functional radiation-induced deterioration, (4) feasibility of flap avoidance. RESULTS Across the 4 domains, international consensus (median score ≥ 7/9) was achieved only for functional deterioration (73.3%); other consensus rates were 55.6% for poRT avoidance of flap structures, 41.2% for flap definition and 11.1% for tumor spread patterns. Radiation-induced flap fibrosis or atrophy and their functional impact was well recognized while flap necrosis was not, suggesting dose-volume adaptation for the former. Flap avoidance was recommended to minimize bone flap osteoradionecrosis but not soft-tissue toxicity. The need for identification (CT planning, fiducials, accurate operative report) and targeting of the junction area at risk between native tissues and flap was well recognized. Experts variably considered flaps as prone to tumor dissemination or not. Discrepancies in rating of 11 items among international reviewing participants are shown. CONCLUSION International GORTEC and HNCIG-endorsed recommendations were generated for the management of flaps in head and neck radiotherapy. Considerable knowledge gaps hinder further consensus, in particular with respect to tumor spread patterns.
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Affiliation(s)
| | - Michel Lapeyre
- Department of Radiation Oncology, Centre Jean Perrin, Clermont-Ferrand, France
| | - Vincent Gregoire
- Department of Radiation Oncology, Centre Léon Bérard, Lyon, France
| | - Philippe Maingon
- Department of Radiation Oncology, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Arnaud Beddok
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Pierre-Yves Marcy
- Department of Radiology, Clinique du Cap d'Or, La Seyne-sur-mer, France
| | - Julia Salleron
- Department of Biostatistics, Institut de cancérologie de Lorraine, France
| | - Alexandre Coutte
- Department of Radiation Oncology, Amiens Picardie University Medical Center, Amiens, France
| | - Severine Racadot
- Department of Radiation Oncology, Centre Léon Bérard, Lyon, France
| | - Yoann Pointreau
- Department of Radiation Oncology, Centre Jean Bernard, Le Mans, France
| | - Pierre Graff
- Department or Radiation Oncology, Institut C. Regaud, Toulouse, France
| | - Beth Beadle
- Department of Radiation Oncology, Stanford University Medical Center, Stanford University Medical Center, USA
| | - Karen Benezery
- Department of Radiation Oncology, Centre Antoine Lacassagne, Nice, France
| | - Julian Biau
- Department of Radiation Oncology, Centre Jean Perrin, Clermont-Ferrand, France
| | | | - Joel Castelli
- Department of Radiation Oncology, Centre Eugène Marquis, Rennes, France
| | - Melvin Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Duke-NUS Medical School, Singapore
| | - Alessia Di Rito
- Department of Radiation Oncology, OC Radioterapia Ospedale "Mons. A.R. Dimiccoli" di Barletta, Rome, Italy
| | - Melanie Dore
- Department of Radiation Oncology, Institut de cancérologie de l'Ouest, St Herblain, France
| | - Pirus Ghadjar
- Department of Radiation Oncology, Charité, Berlin, Germany
| | - Florence Huguet
- Department of Radiation Oncology, Hospital de Tenon, Paris, France
| | - Pauline Jardel
- Department of Radiation Oncology, CHU de la Milétrie, Poitiers, France
| | - Jorgen Johansen
- Department of Radiation Oncology, Odense University Hospital, Denmark
| | - Randall Kimple
- Department of Medical Oncology, University of Wisconsin-Madison, WI, USA
| | - Marco Krengli
- Department of Translational Medicine University of Piemonte Orientale, Novara, Italy
| | | | - Lachlan Mcdowell
- Department of Radiation Oncology, Peter McCallum Cancer Center, Melbourne, Australia
| | - Anthony Nichols
- Department of Head and Neck surgery, London Health Sciences Center, Ontario, Canada
| | - Silke Tribius
- Department of Radiation Oncology, Hermann-Holthusen-Institute for Radiation Oncology, Asklepios Hospital St. Georg, Hamburg, Germany
| | | | - Chaosu Hu
- Department of Radiation Oncology, Fundan University, Shanghai, China
| | - Xavier Liem
- Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
| | | | - Ida D'onofrio
- Department of Radiation Oncology, Hospital Naples, Italy
| | | | - Vinita Takiar
- Department of Radiation Oncology, University of Cincinaty, USA
| | - Ester Orlandi
- Department of Radiation Oncology, CNAO, Milan, Italy
| | - Amanda Psyrri
- Department of Medical Oncology, Attikon University Hospital, Athens, Greece
| | - George Shenouda
- Department of Radiation Oncology, McGill University Health Centre, Montreal, Canada
| | - David Sher
- Department of Radiation Oncology, UT Southwestern, Dallas, USA
| | - Conor Steuer
- Department of Head and Neck Surgery, Winship Cancer Institute, Atlanta, USA
| | - Xu Shan Sun
- Department of Radiation Oncology, University hospital CHBM, Montbéliard, France
| | - Yungan Tao
- Department of Head and Neck Surgery, Gustave Roussy, Villejuif, France
| | - David Thomson
- Department of Radiation Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Mu-Hung Tsai
- Department of Radiation Oncology, National Cheng Kung University Hospital, Tïnan, Taiwan
| | - Noemie Vulquin
- Department of Radiation Oncology, Centre Georges François Leclerc, Dijon, France
| | - Philippe Gorphe
- Department of Head and Neck Surgery, Gustave Roussy, Villejuif, France
| | - Hisham Mehanna
- Department of Radiation Oncology, Institute for Global Innovation, Birmingham, UK
| | - Sue S Yom
- Department of Radiation Oncology, NRG Oncology Cancer Research Group, USA
| | - Jean Bourhis
- Department of Radiation Oncology, UNIL-CHUV, Lausanne, Switzerland
| | - Juliette Thariat
- Department of Radiation Oncology, Centre François-Baclesse, Laboratoire de physique corpusculaire IN2P3/ENSICAEN - UMR6534. Normandie University, Caen, and GORTEC, France.
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Aljabab S, Lui A, Wong T, Liao J, Laramore G, Parvathaneni U. A Combined Neutron and Proton Regimen for Advanced Salivary Tumors: Early Clinical Experience. Cureus 2021; 13:e14844. [PMID: 34104589 PMCID: PMC8175057 DOI: 10.7759/cureus.14844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background and objective Fast neutron radiotherapy (NRT) is a high linear energy transfer (LET) particle therapy that offers a local control (LC) advantage over low-LET X-rays in the treatment of advanced and unresectable salivary gland malignancies. However, in tumors approximating the base of skull (BOS), target volumes may be underdosed to minimize toxicity to the central nervous system (CNS). In this setting, a proton beam boost to the underdosed part of the tumor may improve LC. We report our early experience with a hybrid neutron-proton approach in patients with BOS involvement. Materials and methods We retrospectively reviewed 29 patients with locally advanced and unresectable salivary gland tumors involving the BOS between 2014-2018. The median age of the patients was 56 years, with the majority of them having adenoid cystic carcinomas (ACC) (79%) with advanced T4a/b disease (86%), pathologic perineural invasion (PNI) (55.2%), and orbital invasion (34.5%). Five patients (17.2%) were cases of re-irradiation. Surgical resection was attempted in 15 patients (51.7%), of which none achieved negative margins. The median neutron dose was 18.4 neutron Gray (nGy) with a sequential proton boost (PB) with a median dose of 25 Gy [relative biological effectiveness (RBE)] (range: 16-45 Gy). Toxicity was graded per the Common Terminology Criteria for Adverse Events (CTCAE) version 4.03. Descriptive statistics and the Kaplan-Meier method were used. Results At a median follow-up of 18.9 months [interquartile range (IQR): 6.1-32.5], the entire cohort's overall survival (OS) was 93.1%, progression-free survival (PFS) was 79.3%, and LC was 89.7%. Among patients who were not re-irradiated (n=24), the most commonly recorded acute grade 3 toxicities were mucositis (50%) and dermatitis (37.5%). There was no documented acute grade 4/5 events. Late grade 3/4 events included trismus (n=1), hearing loss (n=2), visual loss (n=6), and bone necrosis (n=1). There were no reported late grade 5 events in de novo patients. Conclusion In this challenging cohort with a poor prognosis, early outcomes for a hybrid neutron-proton approach were found to be promising. Further studies involving longer follow-ups with a larger cohort of patients are required to validate our findings.
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Affiliation(s)
- Saif Aljabab
- Department of Radiation Oncology, King Saud University, Riyadh, SAU
| | - Andrew Lui
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, USA
| | - Tony Wong
- Department of Medical Physics, Seattle Cancer Care Alliance Proton Therapy Center, Seattle, USA
| | - Jay Liao
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, USA
| | - George Laramore
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, USA
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Park SY, Doolittle-Amieva C, Moshiri Y, Akaike T, Parvathaneni U, Bhatia S, Zaba LC, Nghiem P. How we treat Merkel cell carcinoma: within and beyond current guidelines. Future Oncol 2021; 17:1363-1377. [PMID: 33511866 PMCID: PMC7983043 DOI: 10.2217/fon-2020-1036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Merkel cell carcinoma (MCC) is an aggressive skin cancer associated with a high risk of local recurrence and distant metastasis. Optimal care of this potentially life-threatening cancer is critical but challenging because: physicians are often unfamiliar with its management due to rarity, and MCC management remains controversial, in part because it is rapidly evolving across multiple specialties. While guidelines offer a broad overview of management, they are often not sufficient when making decisions for individual patients. Herein, we present a literature review as well as practical approaches adopted at our institutions for staging, surveillance and therapy of MCC. Each of these areas are discussed in light of how they can be appropriately customized for prevalent but challenging situations. We also provide representative examples of MCC patient scenarios and how they were managed by a multidisciplinary team to identify suitable evidence-based, individualized treatment plans. Merkel cell carcinoma (MCC) is a skin cancer with a high risk of recurrence and distant spread. Optimal care of this cancer is important. However, management is challenging because it is rare and its treatment is continuously evolving across multiple specialties. While treatment guidelines offer a broad overview of management, they are often not detailed enough to provide appropriate patient-specific assistance. Herein, we present a review of recent studies and our suggestions relevant to MCC staging, surveillance and treatment options. Each of these areas are discussed in light of how they can be appropriately customized for challenging situations often encountered by practitioners. We also provide representative examples of MCC patient scenarios and how they were managed by a multidisciplinary team to identify evidence-based, individualized treatment plans.
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Affiliation(s)
- Song Y Park
- Division of Dermatology, University of Washington at South Lake Union, Seattle, WA 98109, USA
| | - Coley Doolittle-Amieva
- Division of Dermatology, University of Washington at South Lake Union, Seattle, WA 98109, USA
| | - Yasman Moshiri
- Division of Dermatology, University of Washington at South Lake Union, Seattle, WA 98109, USA
| | - Tomoko Akaike
- Division of Dermatology, University of Washington at South Lake Union, Seattle, WA 98109, USA
| | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington, Seattle, WA 98109, USA
| | - Shailender Bhatia
- Department of Medicine, University of Washington, Seattle, WA 98109, USA
| | - Lisa C Zaba
- Department of Dermatology, Stanford University, Palo Alto, CA 94304, USA
| | - Paul Nghiem
- Division of Dermatology, University of Washington at South Lake Union, Seattle, WA 98109, USA.,Department of Radiation Oncology, University of Washington, Seattle, WA 98109, USA
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Goff P, Bierma M, Lachance K, Schaub S, Tseng Y, Liao J, Apisarnthanarax S, Nghiem P, Parvathaneni U. Primary Tumor Location As a Potential Risk Factor for Local Recurrence in Resected, Low-risk Merkel Cell Carcinoma: Implications for Postoperative Radiotherapy. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cook MM, Schaub SK, Goff PH, Fu A, Park SY, Hippe DS, Liao JJ, Apisarnthanarax S, Bhatia S, Tseng YD, Nghiem PT, Parvathaneni U. Postoperative, Single-Fraction Radiation Therapy in Merkel Cell Carcinoma of the Head and Neck. Adv Radiat Oncol 2020; 5:1248-1254. [PMID: 32838069 PMCID: PMC7373007 DOI: 10.1016/j.adro.2020.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/12/2020] [Accepted: 07/03/2020] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Conventionally fractionated, postoperative radiation therapy (cPORT; 50 Gy in 25 fractions) is considered for patients with Merkel cell carcinoma (MCC) to improve locoregional control. However, cPORT is associated with acute toxicity, especially in the head and neck (H&N) region, and requires daily treatments over several weeks. We previously reported high rates of durable local control with minimal toxicity using 8-Gy single-fraction radiation therapy (SFRT) in the metastatic setting. We report early results on a cohort of patients with localized H&N MCC who received postoperative SFRT if a cPORT regimen was not feasible. METHODS AND MATERIALS Twelve patients with localized MCC of the H&N (clinical/pathologic stages I-II) and no prior radiation therapy to the region were identified from an institutional review board-approved prospective registry who underwent surgical resection followed by postoperative SFRT. Time to event was calculated starting from the date of resection before SFRT. The cumulative incidence of in-field locoregional recurrences and out-of-field recurrences was estimated with death as a competing risk. RESULTS Twelve patients with H&N MCC were identified with clinical/pathologic stages I-II H&N MCC. Median age at diagnosis was 81 years (range, 58-96 years); 25% had immunosuppression. At a median follow-up of 19 months (range, 8-34), there were no in-field locoregional recurrences. A single out-of-field regional recurrence was observed, which was successfully salvaged. There were no MCC-specific deaths. No radiation-associated toxicities greater than grade 1 (Common Terminology Criteria for Adverse Events v5) were observed. CONCLUSIONS Preliminary data suggest that SFRT could offer a potential alternative to cPORT to treat the primary site for localized H&N MCC, particularly in elderly or frail patients, with promising in-field local control and minimal toxicity. Further data with validation in larger cohorts are needed to confirm the sustained safety and efficacy of postoperative SFRT.
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Affiliation(s)
- Maclean M. Cook
- University of Washington School of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
| | - Stephanie K. Schaub
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Peter H. Goff
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Alex Fu
- University of Washington School of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
| | - Song Y. Park
- University of Washington School of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
| | - Daniel S. Hippe
- Department of Radiology, University of Washington, Seattle, Washington
| | - Jay J. Liao
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | | | - Shailender Bhatia
- Division of Medical Oncology, University of Washington, Seattle, Washington
| | - Yolanda D. Tseng
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Paul T. Nghiem
- University of Washington School of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
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Goff P, Cook M, Schaub S, Park S, Hippe D, Liao J, Apisarnthanarax S, Bhatia S, Nghiem P, Tseng Y, Parvathaneni U. Efficacy and Toxicity of Hypofractionated Adjuvant Radiotherapy in Merkel Cell Carcinoma. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.02.577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Moffitt GB, Wootton LS, Hårdemark B, Sandison GA, Laramore GE, Parvathaneni U, Stewart RD. Scattering kernels for fast neutron therapy treatment planning. Phys Med Biol 2020; 65:165009. [DOI: 10.1088/1361-6560/ab9a85] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Tarabadkar ES, Fu T, Lachance K, Hippe DS, Pulliam T, Thomas H, Li JY, Lewis CW, Doolittle-Amieva C, Byrd DR, Kampp JT, Parvathaneni U, Nghiem P. Narrow excision margins are appropriate for Merkel cell carcinoma when combined with adjuvant radiation: Analysis of 188 cases of localized disease and proposed management algorithm. J Am Acad Dermatol 2020; 84:340-347. [PMID: 32711093 DOI: 10.1016/j.jaad.2020.07.079] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/09/2020] [Accepted: 07/20/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Merkel cell carcinoma (MCC) management typically includes surgery with or without adjuvant radiation therapy (aRT). Major challenges include determining surgical margin size and whether aRT is indicated. OBJECTIVE To assess the association of aRT, surgical margin size, and MCC local recurrence. METHODS Analysis of 188 MCC cases presenting without clinical nodal involvement. RESULTS aRT-treated patients tended to have higher-risk tumors (larger diameter, positive microscopic margins, immunosuppression) yet had fewer local recurrences (LRs) than patients treated with surgery only (1% vs 15%; P = .001). For patients who underwent surgery alone, 7 of 35 (20%) treated with narrow margins (defined as ≤1.0 cm) developed LR, whereas 0 of 13 patients treated with surgical margins greater than 1.0 cm developed LR (P = .049). For aRT-treated patients, local control was excellent regardless of surgical margin size; only 1% experienced recurrence in each group (1 of 70 with narrow margins ≤1 cm and 1 of 70 with margins >1 cm; P = .56). LIMITATIONS This was a retrospective study. CONCLUSIONS Among patients treated with aRT, local control was superb even if significant risk factors were present and margins were narrow. We propose an algorithm for managing primary MCC that integrates risk factors and optimizes local control while minimizing morbidity.
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MESH Headings
- Aged
- Aged, 80 and over
- Carcinoma, Merkel Cell/diagnosis
- Carcinoma, Merkel Cell/mortality
- Carcinoma, Merkel Cell/pathology
- Carcinoma, Merkel Cell/therapy
- Critical Pathways/standards
- Dermatologic Surgical Procedures/methods
- Dermatologic Surgical Procedures/standards
- Dermatologic Surgical Procedures/statistics & numerical data
- Disease-Free Survival
- Female
- Follow-Up Studies
- Humans
- Male
- Margins of Excision
- Middle Aged
- Neoplasm Recurrence, Local/diagnosis
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/pathology
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm Staging
- Practice Guidelines as Topic
- Radiotherapy, Adjuvant/standards
- Radiotherapy, Adjuvant/statistics & numerical data
- Retrospective Studies
- Risk Assessment/methods
- Risk Factors
- Skin Neoplasms/diagnosis
- Skin Neoplasms/mortality
- Skin Neoplasms/pathology
- Skin Neoplasms/therapy
- Time-to-Treatment/standards
- Time-to-Treatment/statistics & numerical data
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Affiliation(s)
- Erica S Tarabadkar
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, Washington; Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Teresa Fu
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, Washington; Palo Alto Medical Foundation, Palo Alto, California
| | - Kristina Lachance
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
| | - Daniel S Hippe
- Department of Radiology, University of Washington, Seattle, Washington
| | - Thomas Pulliam
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
| | - Hannah Thomas
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
| | | | - Christopher W Lewis
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
| | - Coley Doolittle-Amieva
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
| | - David R Byrd
- Department of Surgery, Division of Surgical Oncology, University of Washington, Seattle, Washington
| | - Jeremy T Kampp
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
| | | | - Paul Nghiem
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, Washington.
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Cash H, Harbison RA, Futran N, Parvathaneni U, Laramore GE, Liao J, Cannon R, Rodriguez C, Houlton JJ. Neutron Therapy for High-Grade Salivary Carcinomas in the Adjuvant and Primary Treatment Setting. Laryngoscope 2020; 131:541-547. [PMID: 32603506 DOI: 10.1002/lary.28830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS Our primary objective was to compare differences in survival of patients with high-grade salivary gland carcinomas (SGCs) receiving adjuvant neutron versus photon radiotherapy using a hospital-based national cohort and restricted mean survival time (RMST) analysis. Our secondary objective was to compare survival of similar patients treated with primary neutron versus photon radiation. STUDY DESIGN Multicenter, retrospective population-based study of patients within the National Cancer Database from 2004 to 2014. METHODS One thousand eight hundred forty-four patients were selected on diagnosis of high-grade parotid and submandibular malignancies. One thousand seven hundred seventy-seven patients receiving photon and 67 patients receiving neutron therapy were identified who met inclusion criteria. Patients were then categorized as having primary surgery with adjuvant radiation or primary radiation without prior surgery. Bivariate analysis was performed to assess for differences between groups, and RMST analysis was performed at 1-, 2-, and 5-year timepoints with controlling for available covariate data. RESULTS There was no significant difference in RMST for patients receiving neutrons over photons at 1, 2, and 5 years in the adjuvant setting. Among patients undergoing primary radiotherapy, there was a difference in RMST of 2.29 months at 1 year and 5.05 months at 2 years for neutrons over photons, though this benefit was not observed at 5 years post-therapy. CONCLUSIONS For patients with high grade SGCs undergoing adjuvant photon versus neutron radiotherapy, there was no difference in RMST. There was observed to be a significant difference in RMST at 1 and 2 years among patients undergoing primary neutron therapy of up to 5 months. Given the benefit observed with primary neutron therapy, it should be considered in both the primary and adjuvant treatment setting. LEVEL OF EVIDENCE 4 Laryngoscope, 131:541-547, 2021.
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Affiliation(s)
- Harrison Cash
- Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - R Alex Harbison
- Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - Neal Futran
- Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - George E Laramore
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - Jay Liao
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - Richard Cannon
- Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Cristina Rodriguez
- Department of Medicine, Division of Oncology, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - Jeffrey J Houlton
- Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
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Akaike T, Qazi J, Anderson A, Behnia FS, Shinohara MM, Akaike G, Hippe DS, Thomas H, Takagishi SR, Lachance K, Park SY, Tarabadkar ES, Iyer JG, Blom A, Parvathaneni U, Vesselle H, Nghiem P, Bhatia S. High somatostatin receptor expression and efficacy of somatostatin analogues in patients with metastatic Merkel cell carcinoma. Br J Dermatol 2020; 184:319-327. [PMID: 32320473 DOI: 10.1111/bjd.19150] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Merkel cell carcinoma (MCC) is an aggressive, high-grade, cutaneous neuroendocrine tumour (NET). Agents blocking programmed death 1/programmed death ligand 1 have efficacy in metastatic MCC (mMCC), but half of patients do not derive durable benefit. Somatostatin analogues (SSAs) are commonly used to treat low- and moderate-grade NETs that express somatostatin receptors (SSTRs). OBJECTIVES To assess SSTR expression and the efficacy of SSAs in mMCC, a high-grade NET. Methods In this retrospective study of 40 patients with mMCC, SSTR expression was assessed radiologically by somatostatin receptor scintigraphy (SRS; n = 39) and/or immunohistochemically when feasible (n = 9). Nineteen patients (18 had SRS uptake in MCC tumours) were treated with SSA. Disease control was defined as progression-free survival (PFS) of ≥ 120 days after initiation of SSA. RESULTS Thirty-three of 39 patients (85%) had some degree (low 52%, moderate 23%, high 10%) of SRS uptake. Of 19 patients treated with SSA, seven had a response-evaluable target lesion; three of these seven patients (43%) experienced disease control, with a median PFS of 237 days (range 152-358). Twelve of 19 patients did not have a response-evaluable lesion due to antecedent radiation; five of these 12 (42%) experienced disease control (median PFS of 429 days, range 143-1757). The degree of SSTR expression (determined by SRS and/or immunohistochemistry) did not correlate significantly with the efficacy endpoints. CONCLUSIONS In contrast to other high-grade NETs, mMCC tumours appear frequently to express SSTRs. SSAs can lead to clinically meaningful disease control with minimal side-effects. Targeting of SSTRs using SSA or other novel approaches should be explored further for mMCC.
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Affiliation(s)
- T Akaike
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - J Qazi
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - A Anderson
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - F S Behnia
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - M M Shinohara
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - G Akaike
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - D S Hippe
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - H Thomas
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - S R Takagishi
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - K Lachance
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - S Y Park
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - E S Tarabadkar
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - J G Iyer
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - A Blom
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - U Parvathaneni
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - H Vesselle
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - P Nghiem
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA, USA.,Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - S Bhatia
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
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Chalker C, Santana-Davila R, Voutsinas JM, Wu V, Hwang V, Baik CS, Barber B, Futran ND, Houlton J, Laramore GE, Lee S, Liao JJ, Parvathaneni U, Martins RG, Eaton KD, Rodriguez CP. End-of-life health care utilization (EOLHCU) in patients with recurrent, metastatic head and neck squamous cell carcinoma (RMHNSCC) treated with immune checkpoint inhibitors (IO). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e18516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18516 Background: Demographic and EOLHCU trends are undefined in the growing population of IO-treated RMHNSCC; we sought to study these in a single institution retrospective study. Methods: We identified 228 RMHNSCC pts who received ≥1 IO dose between 01/2013 and 12/2018; of these, 74 were deceased with accessible EOLHCU data such as advanced care plan documentation (ACPD) or evidence of systemic therapy or ER/hospital/ICU admission within 30 days of death (DOD). Demographic, tumor and treatment data were obtained. Overall survival (OS) was estimated using the Kaplan Meier method; multivariable analysis was performed using a Cox proportional hazards model. In an exploratory analysis, EOLHCU was compared to a cohort of 379 deceased thoracic malignancy (TM) pts using a chi-square test. This project was approved by our institutional IRB. Results: Median pt age was 62 (25 – 90). Most were male (56, 75%), white (60, 81%), current/former smokers (46, 62%); 34 (46%) smoked ≥10 pack years. Common primary sites included the oral cavity (28, 37.8%) and oropharynx (24, 32.4%). ECOG PS at IO initiation was 0 in 15 pts (20%,) 1 in 37 (50%), 2 in 20 (27%), 3 in 1 (1%), and unknown in 1 (1%). Of the 42 (57%) treated off-trial, 18 (42%) had an ECOG ≥ 2. 71 (95%) had prior curative intent therapy. 42 (57%) had distant metastases. Compared to TM, IO-treated RMHNSCC pts were more likely to have ACPD (66% vs. 45% p < 0.01), an ED visit (42.3% vs 19.5%, p < 0.01) and/or a hospital admission (42.3% vs 17%, p < 0.01) within 30 DOD. There was no difference in ICU admissions within 30 DOD (9.9% vs. 8.2%, p = 0.81), ICU deaths (7% vs. 4%, p = 0.4), or systemic therapy within 7 (4.2% vs. 2.4%, p = 0.63), 14 (8.5% vs. 6.6%, p = 0.76) or 30 (25% vs 19%, p = 0.31) DOD. Among IO-treated RMHNSCC pts, multivariable analysis revealed inferior OS with worse PS (ECOG 2-3 vs. 0: HR = 7.76, p = 0.00002, 95% CI = 3.07 - 19.64; ECOG 1 vs. 0: HR = 2.97, p = 0.008, CI = 1.33 - 6.62). OS also decreased with smoking status (current/former vs. never: HR 2.18, p = 0.007, CI = 1.24-3.84). No association was observed between ECOG PS, age or smoking status at IO initiation and any EOLHCU metric. Conclusions: At our center, a significant proportion of deceased, IO-treated RMHNSCC pts had an ECOG PS ≥ 2 and an inferior OS compared to ECOG 0/1. Exploratory comparison with a non-RMHNSCC TM cohort suggests high rates of EOLHCU within 30 DOD despite ACPD, representing an opportunity for supportive care augmentation. Whether EOLHCU differs among IO vs non-IO treated RMHNSCC is unknown and merits further study.
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Affiliation(s)
| | | | | | - Vicky Wu
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | | | - Neal D. Futran
- Department of Otolaryngology: Head and Neck Surgery, University of Washington, Seattle, WA
| | | | | | - Sylvia Lee
- University of Washington, Seattle Cancer Care Alliance, Seattle, WA
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Bhatia S, Longino NV, Miller NJ, Kulikauskas R, Iyer JG, Ibrani D, Blom A, Byrd DR, Parvathaneni U, Twitty CG, Campbell JS, Le MH, Gargosky S, Pierce RH, Heller R, Daud AI, Nghiem P. Intratumoral Delivery of Plasmid IL12 Via Electroporation Leads to Regression of Injected and Noninjected Tumors in Merkel Cell Carcinoma. Clin Cancer Res 2020; 26:598-607. [PMID: 31582519 PMCID: PMC9868004 DOI: 10.1158/1078-0432.ccr-19-0972] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 07/30/2019] [Accepted: 09/30/2019] [Indexed: 01/26/2023]
Abstract
PURPOSE IL12 promotes adaptive type I immunity and has demonstrated antitumor efficacy, but systemic administration leads to severe adverse events (AE), including death. This pilot trial investigated safety, efficacy, and immunologic activity of intratumoral delivery of IL12 plasmid DNA (tavo) via in vivo electroporation (i.t.-tavo-EP) in patients with Merkel cell carcinoma (MCC), an aggressive virus-associated skin cancer. PATIENTS AND METHODS Fifteen patients with MCC with superficial injectable tumor(s) received i.t.-tavo-EP on days 1, 5, and 8 of each cycle. Patients with locoregional MCC (cohort A, N = 3) received one cycle before definitive surgery in week 4. Patients with metastatic MCC (cohort B, N = 12) received up to four cycles total, administered at least 6 weeks apart. Serial tumor and blood samples were collected. RESULTS All patients successfully completed at least one cycle with transient, mild (grades 1 and 2) AEs and without significant systemic toxicity. Sustained (day 22) intratumoral expression of IL12 protein was observed along with local inflammation and increased tumor-specific CD8+ T-cell infiltration, which led to systemic immunologic and clinical responses. The overall response rate was 25% (3/12) in cohort B, with 2 patients experiencing durable clinical benefit (16 and 55+ months, respectively). Two cohort A patients (1 with pathologic complete remission) were recurrence-free at 44+ and 75+ months, respectively. CONCLUSIONS I.t.-tavo-EP was safe and feasible without systemic toxicity. Sustained local expression of IL12 protein and local inflammation led to systemic immune responses and clinically meaningful benefit in some patients. Gene electrotransfer, specifically i.t.-tavo-EP, warrants further investigation for immunotherapy of cancer.
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Affiliation(s)
- Shailender Bhatia
- Department of Medicine/Medical Oncology, University of Washington Medical Center, Seattle, Washington,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Natalie V. Longino
- Department of Medicine/Dermatology, University of Washington Medical Center, Seattle, Washington
| | - Natalie J. Miller
- Department of Medicine/Dermatology, University of Washington Medical Center, Seattle, Washington
| | - Rima Kulikauskas
- Department of Medicine/Dermatology, University of Washington Medical Center, Seattle, Washington
| | - Jayasri G. Iyer
- Department of Medicine/Dermatology, University of Washington Medical Center, Seattle, Washington
| | - Dafina Ibrani
- Department of Medicine/Dermatology, University of Washington Medical Center, Seattle, Washington
| | - Astrid Blom
- Department of Medicine/Dermatology, University of Washington Medical Center, Seattle, Washington
| | - David R. Byrd
- Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington
| | | | - Jean S. Campbell
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington,OncoSec Medical Incorporated, San Diego, California
| | - Mai H. Le
- OncoSec Medical Incorporated, San Diego, California
| | | | - Robert H. Pierce
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington,OncoSec Medical Incorporated, San Diego, California
| | - Richard Heller
- Old Dominion University, Frank Reidy Research Center for Bioelectrics, Norfolk, Virginia
| | - Adil I. Daud
- Department of Medicine/Medical Oncology, University of California San Francisco School of Medicine, San Francisco, California
| | - Paul Nghiem
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington,Department of Medicine/Dermatology, University of Washington Medical Center, Seattle, Washington
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Aljabab S, Liu A, Wong T, Liao JJ, Laramore GE, Parvathaneni U. Proton Therapy for Locally Advanced Oropharyngeal Cancer: Initial Clinical Experience at the University of Washington. Int J Part Ther 2019; 6:1-12. [PMID: 32582809 DOI: 10.14338/ijpt-19-00053.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 10/26/2019] [Indexed: 12/16/2022] Open
Abstract
Purpose Proton therapy can potentially improve the therapeutic ratio over conventional radiation therapy for oropharyngeal squamous cell cancer (OPSCC) by decreasing acute and late toxicity. We report our early clinical experience with intensity-modulated proton therapy (IMPT). Materials and Methods We retrospectively reviewed patients with OPSCC treated with IMPT at our center. Endpoints include local regional control (LRC), progression-free survival (PFS), overall survival (OS), tumor response, and toxicity outcomes. Toxicity was graded as per the Common Terminology Criteria for Adverse Events v4.03. Descriptive statistics and Kaplan-Meier method were used. Results We treated 46 patients from March 2015 to August 2017. Median age was 58 years, 93.5% were male, 67% were nonsmokers, 98% had stage III-IVB disease per the 7th edition of the AJCC [American Joint Committee on Cancer] Cancer Staging Manual, and 89% were p16 positive. Twenty-eight patients received definitive IMPT to total dose of 70 to 74.4 Gy(RBE), and 18 patients received postoperative IMPT to 60 to 66 Gy(RBE) following transoral robotic surgery (TORS). Sixty-four percent of patients received concurrent systemic therapy. There were no treatment interruptions or observed acute grade 4 or 5 toxicities. Eighteen patients had percutaneous endoscopic gastrostomy (PEG) tube placement; the majority (14) were placed prophylactically. The most common grade 3 acute toxicities were dermatitis (76%) and mucositis (72%). The most common late toxicity was grade 2 xerostomia (30%). At a median follow-up time of 19.2 months (interquartile range [IQR], 11.2-28.4), primary complete response was 100% and nodal complete response was 92%. One patient required a salvage neck dissection owing to an incomplete response at 4 months. There were no recorded local regional or marginal recurrences, PFS was 93.5%, and OS was 95.7%. Conclusion Our early results for IMPT in OPSCC are promising with no local regional or marginal recurrences and a favorable toxicity profile. Our data add to a body of evidence that supports the clinical use of IMPT. Randomized comparative trials are encouraged.
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Affiliation(s)
- Saif Aljabab
- Department of Radiation Oncology, Roswell Park Cancer Center, Buffalo, NY, USA
| | - Andrew Liu
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA, USA
| | - Tony Wong
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
| | - Jay J Liao
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA, USA
| | - George E Laramore
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA, USA
| | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA, USA
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Likhacheva A, Awan M, Barker CA, Bhatnagar A, Bradfield L, Brady MS, Buzurovic I, Geiger JL, Parvathaneni U, Zaky S, Devlin PM. Definitive and Postoperative Radiation Therapy for Basal and Squamous Cell Cancers of the Skin: Executive Summary of an American Society for Radiation Oncology Clinical Practice Guideline. Pract Radiat Oncol 2019; 10:8-20. [PMID: 31831330 DOI: 10.1016/j.prro.2019.10.014] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/01/2019] [Indexed: 01/21/2023]
Abstract
PURPOSE This guideline reviews the evidence for the use of definitive and postoperative radiation therapy (RT) in patients with basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC). METHODS The American Society for Radiation Oncology convened a task force to address 5 key questions focused on indications for RT in the definitive and postoperative setting for BCC and cSCC, as well as dose-fractionation schemes, target volumes, basic aspects of treatment planning, choice of radiation modality, and the role of systemic therapy in combination with radiation. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS The guideline recommends definitive RT as primary treatment for patients with BCC and cSCC who are not surgical candidates while conditionally recommending RT with an emphasis on shared decision-making in those situations in which adequate resection can lead to a less than satisfactory cosmetic or functional outcome. In the postoperative setting, a number of indications for RT after an adequate resection are provided while distinguishing the strength of the recommendations between BCC and cSCC. One key question is dedicated to defining indications for regional nodal irradiation. The task force suggests a range of appropriate dose-fractionation schemes for treatment of primary and nodal volumes in definitive and postoperative scenarios. The guideline also recommends against the use of carboplatin concurrently with adjuvant RT and conditionally recommends the use of systemic therapies for unresectable primaries where treatment may need escalation. CONCLUSIONS Defining the role of RT in the management of BCC and cSCC has been hindered by a lack of high-quality evidence. This document synthesizes available evidence to define practice guidelines for the most common clinical situations. We encourage practitioners to enroll patients in prospective trials and to approach care in a multidisciplinary fashion whenever possible.
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Affiliation(s)
- Anna Likhacheva
- Department of Radiation Oncology, Sutter Medical Center, Sacramento, California.
| | - Musaddiq Awan
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christopher A Barker
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ajay Bhatnagar
- Department of Radiation Oncology, Alliance Oncology, Casa Grande, Arizona
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Mary Sue Brady
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ivan Buzurovic
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Jessica L Geiger
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | | | - Sandra Zaky
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Phillip M Devlin
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
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Parvathaneni U, Lavertu P, Gibson MK, Glastonbury CM. Advances in Diagnosis and Multidisciplinary Management of Oropharyngeal Squamous Cell Carcinoma: State of the Art. Radiographics 2019; 39:2055-2068. [PMID: 31603733 DOI: 10.1148/rg.2019190007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
During the past decade and a half, the most common cause of oropharyngeal squamous cell carcinoma (OPSCC) has shifted from tobacco and alcohol to the human papillomavirus (HPV). HPV-driven p16-positive OPSCC and tobacco-related OPSCC differ in their underlying molecular and genetic profiles, socioeconomic demographics, and response to treatment. HPV-related OPSCC tends to occur in younger patients and has a significantly better response to treatment and excellent prognosis. The stark contrast in prognosis-with around 90% overall 5-year survival for HPV-related p16-positive OPSCC and 40% for non-HPV-related p16-negative OPSCC-has prompted major changes in the eighth edition of the staging manual of the AJCC (American Joint Committee on Cancer). The past 10-15 years have also witnessed major advances in surgery, radiation therapy (RT), and systemic therapy. Minimally invasive surgery has come of age, with transoral robotic procedures and laser microsurgery. Intensity-modulated RT (IMRT) and more recently proton-beam RT have markedly improved the conformity of RT, with an ability to precisely target the cancer and cancer-bearing regions while sparing normal structures and significantly reducing long-term treatment-related morbidity. Progress in systemic therapy has come in the form of immunotherapy and targeted agents such as cetuximab. Owing to the better prognosis of HPV-driven OPSCC as well as the morbidity associated with treatment, de-escalation of therapy via multiple strategies is being explored. The article reviews the advances in diagnosis and multidisciplinary management of OPSCC in the HPV era.©RSNA, 2019.
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Affiliation(s)
- Upendra Parvathaneni
- From the Department of Radiation Oncology, University of Washington, 1959 NE Pacific Ave, Seattle, WA 98195-6043 (U.P.); Ear Nose and Throat Institute, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio (P.L.); Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tenn (M.K.G.); and Department of Radiology, University of California, San Francisco, San Francisco, Calif (C.M.G.)
| | - Pierre Lavertu
- From the Department of Radiation Oncology, University of Washington, 1959 NE Pacific Ave, Seattle, WA 98195-6043 (U.P.); Ear Nose and Throat Institute, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio (P.L.); Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tenn (M.K.G.); and Department of Radiology, University of California, San Francisco, San Francisco, Calif (C.M.G.)
| | - Michael K Gibson
- From the Department of Radiation Oncology, University of Washington, 1959 NE Pacific Ave, Seattle, WA 98195-6043 (U.P.); Ear Nose and Throat Institute, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio (P.L.); Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tenn (M.K.G.); and Department of Radiology, University of California, San Francisco, San Francisco, Calif (C.M.G.)
| | - Christine M Glastonbury
- From the Department of Radiation Oncology, University of Washington, 1959 NE Pacific Ave, Seattle, WA 98195-6043 (U.P.); Ear Nose and Throat Institute, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio (P.L.); Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tenn (M.K.G.); and Department of Radiology, University of California, San Francisco, San Francisco, Calif (C.M.G.)
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Dinh T, Aljabab S, Wong T, Rodriguez C, Liao J, Laramore G, Parvathaneni U. High Dose Re-Irradiation of Recurrent or Secondary Head and Neck Cancers with Proton Beam Therapy. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.1622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Michikawa C, Torres-Saavedra PA, Silver NL, Harari PM, Kies MS, Rosenthal DI, Le QT, Jordan RC, Duose DY, Mallampati S, Trivedi S, Luthra R, Wistuba II, Lichtarge O, Foote RL, Parvathaneni U, Hayes DN, Pickering CR, Myers J. Evolutionary action score of TP53 analysis in pathologically high-risk HPV-negative head and neck cancer from a phase II clinical trial: NRG Oncology RTOG 0234. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.6010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6010 Background: An evolutionary action scoring algorithm (EAp53) based on phylogenetic sequence variations and speciation stratifies head and neck squamous cell carcinoma (HNSCC) patients bearing TP53 missense mutations as high-risk (high, EAp53≥75), associated with poor outcomes, or low-risk (low), with similar outcomes as TP53 wild-type (wt), and has been validated as a reliable prognostic marker. This study is designed to further validate prior findings that EAp53 is a prognostic marker for locally advanced HNSCC patients, and assess its predictive value for treatment outcomes to adjuvant bio-chemoradiotherapy. Methods: Eighty one resection specimens from patients treated surgically for stage III or IV human papillomavirus-negative (HPV(-)) HNSCC with high-risk pathologic features, who received either Arm 1) radiotherapy(RT)+cetuximab(CTX)+cisplatin or Arm 2) RT+CTX+docetaxel, as adjuvant treatment in a phase II randomized clinical trial (RTOG 0234) underwent TP53 targeted sequencing, and EAp53 scoring. The EAp53 scores were correlated with clinical outcomes. Due to limited sample sizes, patients were combined into 2 EAp53 groups: wt/low and high/other. Results: At median follow-up of 10 years, there was a significant interaction between treatment and EAp53 group for overall survival (OS) (p = 0.008), disease-free survival (DFS) (p = 0.05) and distant metastasis (DM) (p = 0.004). Within arm 2, high/other showed worse OS [HR 4.69 (1.52-14.50)], DFS [HR 2.69 (1.16-6.21)], and had higher DM [HR 11.71 (1.50-91.68)] than wt/low. Within arm 1, there was no significant difference by EAp53 in OS, DFS and DM. Within the wt/low group, arm 2 had better OS [HR 0.11 (0.03-0.36)], DFS [HR 0.24 (0.09-0.61)], and DM [HR 0.04 (0.01-0.31)] than arm 1 but this was not found in high/other. Conclusions: High/other EAp53 scores were associated with worse survival for patients in arm 2. Arm 2 is associated with better survival than arm 1 for patients with wt/low EAp53. This benefit appears to be largely driven by a reduction in DM. Further validation is required to determine whether EAp53 can be used for personalized post-operative treatment decisions in HPV(-) HNSCC.
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Affiliation(s)
- Chieko Michikawa
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Natalie L. Silver
- Department of Otolaryngology-Head and Neck Surgery, University of Florida, Gainesville, FL
| | - Paul M. Harari
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Merrill S. Kies
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David Ira Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Quynh-Thu Le
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, CA
| | - Richard C. Jordan
- NRG Oncology Biospecimen Bank, University of California, San Francisco, San Francisco, CA
| | - Dzifa Yawa Duose
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Saradhi Mallampati
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sanchit Trivedi
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rajyalakshmi Luthra
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ignacio Ivan Wistuba
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Olivier Lichtarge
- Departments of Molecular and Human Genetics, Pharmacology, and Biochemistry and Molecular Biology, Baylor College of Medicine, Houston, TX
| | | | | | - David N. Hayes
- Division of Medical Oncology, The University of Tennessee Health Science Center, Memphis, TN
| | - Curtis R. Pickering
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey Myers
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
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Cook M, Schaub S, Park S, Hippe D, Liao J, Apisarnthanarax S, Bhatia S, Nghiem P, Tseng Y, Parvathaneni U. 550 Efficacy and toxicity of hypofractionated adjuvant radiotherapy in Merkel cell carcinoma. J Invest Dermatol 2019. [DOI: 10.1016/j.jid.2019.03.626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Sasidharan BK, Aljabab S, Saini J, Wong T, Laramore G, Liao J, Parvathaneni U, Bowen SR. Clinical Monte Carlo versus Pencil Beam Treatment Planning in Nasopharyngeal Patients Receiving IMPT. Int J Part Ther 2019; 5:32-40. [PMID: 31773039 PMCID: PMC6871622 DOI: 10.14338/ijpt-18-00039.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 03/07/2019] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Pencil beam (PB) analytical algorithms have been the standard of care for proton therapy dose calculations. The introduction of Monte Carlo (MC) algorithms may provide more robust and accurate planning and can improve therapeutic benefit. We conducted a dosimetric analysis to quantify the differences between MC and PB algorithms in the clinical setting of dose-painted nasopharyngeal cancer intensity-modulated proton radiotherapy. PATIENTS AND METHODS Plans of 14 patients treated with PB analytical algorithm optimized and calculated (PBPB) were retrospectively analyzed. The PBPB plans were recalculated using MC to generate PBMC plans and, finally, reoptimized and recalculated with MC to generate MCMC plans. The plans were compared across several dosimetric endpoints and correlated with documented toxicity. Robustness of the planning scenarios (PBPB, PBMC, MCMC) in the presence of setup and range uncertainties was compared. RESULTS A median decrease of up to 5 Gy (P < .05) was observed in coverage of planning target volume high-risk, intermediate-risk, and low-risk volumes when PB plans were recalculated using the MC algorithm. This loss in coverage was regained by reoptimizing with MC, albeit with a slightly higher dose to normal tissues but within the standard tolerance limits. The robustness of both PB and MC plans remained similar in the presence of setup and range uncertainties. The MC-calculated mean dose to the oral avoidance structure, along with changes in global maximum dose between PB and MC dosimetry, may be associated with acute toxicity-related events. CONCLUSION Retrospective analyses of plan dosimetry quantified a loss of coverage with PB that could be recovered under MC optimization. MC optimization should be performed for the complex dosimetry in patients with nasopharyngeal carcinoma before plan acceptance and should also be used in correlative studies of proton dosimetry with clinical endpoints.
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Affiliation(s)
| | - Saif Aljabab
- Radiation Oncology, University of Washington/Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
| | - Jatinder Saini
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
| | - Tony Wong
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
| | - George Laramore
- Radiation Oncology, University of Washington/Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
| | - Jay Liao
- Radiation Oncology, University of Washington/Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
| | - Upendra Parvathaneni
- Radiation Oncology, University of Washington/Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
| | - Stephen R. Bowen
- Radiation Oncology and Radiology, University of Washington School of Medicine, Seattle, WA, USA
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Cook M, Baker K, Redman M, Lachance K, Nguyen MH, Parvathaneni U, Bhatia S, Nghiem P, Tseng YD. Differential Outcomes Among Immunosuppressed Patients With Merkel Cell Carcinoma: Impact of Immunosuppression Type on Cancer-specific and Overall Survival. Am J Clin Oncol 2019; 42:82-88. [PMID: 30211723 PMCID: PMC8666386 DOI: 10.1097/coc.0000000000000482] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine skin cancer with higher incidence among whites, elderly, and immunosuppressed patients. Although immunosuppressed MCC patients are at higher risk of recurrence and MCC-related death, it is unknown whether immunosuppression type is associated with differential outcomes. MATERIALS AND METHODS We retrospectively evaluated 89 nonmetastatic MCC patients with a diagnosis of chronic immunosuppression. Immunosuppression was categorized as chronic lymphocytic leukemia (31% of cohort), other hematologic malignancies (18%), solid organ transplant (21%), autoimmune disease (21%), and human immunodeficiency virus acquired deficiency syndrome (8%). Progression-free survival (PFS) and MCC-specific survival (MSS) were estimated with the cumulative incidence function. Overall survival (OS) was estimated by the Kaplan-Meier method. RESULTS With a median follow-up of 52 months, 53 deaths occurred (42 from MCC, 7 unknown, and 4 non-MCC). Two-year PFS, MSS, and OS were 30%, 55%, and 52%, respectively. Human immunodeficiency virus/acquired deficiency syndrome and solid organ transplant patients were diagnosed with MCC at a younger age (median 55 and 59 y, respectively) and with more advanced stage disease compared with other immunosuppressed subgroups. PFS did not significantly differ among the 5 immunosuppression subgroups (P=0.30), but significant differences were observed in MSS and OS (both P=0.01). Controlling for potential confounders for OS, including age and stage, immunosuppression type was still significantly associated with risk of death (P=0.01). CONCLUSIONS Among immunosuppressed MCC patients, recurrent MCC is the major cause of mortality. The risk of death from MCC differs among immunosuppression types, suggesting important biological differences in host-tumor immune interactions.
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Affiliation(s)
| | - Kelsey Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center
| | - Mary Redman
- Clinical Research Division, Fred Hutchinson Cancer Research Center
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