Abstract Purpose/objective(s) We sought to identify swallowing muscle dose–response thresholds associated with chronic radiation-associated dysphagia (RAD) after IMRT for oropharyngeal cancer. ...Materials/methods T1–4 N0–3 M0 oropharyngeal cancer patients who received definitive IMRT and systemic therapy were examined. Chronic RAD was coded as any of the following ⩾12 months post-IMRT: videofluoroscopy/endoscopy detected aspiration or stricture, gastrostomy tube and/or aspiration pneumonia. DICOM-RT plan data were autosegmented using a custom region-of-interest (ROI) library and included inferior, middle and superior constrictors (IPC, MPC, and SPC), medial and lateral pterygoids (MPM, LPM), anterior and posterior digastrics (ADM, PDM), intrinsic tongue muscles (ITM), mylo/geniohyoid complex (MHM), genioglossus (GGM), masseter (MM), buccinator (BM), palatoglossus (PGM), and cricopharyngeus (CPM), with ROI dose–volume histograms (DVHs) calculated. Recursive partitioning analysis (RPA) was used to identify dose–volume effects associated with chronic-RAD, for use in a multivariate (MV) model. Results Of 300 patients, 34 (11%) had chronic-RAD. RPA showed DVH-derived MHM V69 (i.e. the volume receiving ⩾ 69 Gy), GGM V35, ADM V60, MPC V49, and SPC V70 were associated with chronic-RAD. A model including age in addition to MHM V69 as continuous variables was optimal among tested MV models (AUC 0.835). Conclusion In addition to SPCs, dose to MHM should be monitored and constrained, especially in older patients (>62-years), when feasible.
Objective
For patients with head and neck squamous cell carcinoma (HNSCC), delays in the initiation of radiotherapy (RT) have been closely associated with worse outcomes. We sought to investigate ...whether RT modality (proton vs. photon) is associated with differences in the time to initiation of RT.
Methods
The National Cancer Database was queried for patients diagnosed with nonmetastatic HNSCC between 2004 and 2015 who received either proton or photon RT as part of their initial treatment. Wilcoxon rank‐sum and chi‐square tests were used to compare continuous and categorical variables, respectively. Multivariable logistic regression was used to determine the association between use of proton RT and delayed RT initiation.
Results
A total of 175,088 patients with HNSCC receiving either photon or proton RT were identified. Patients receiving proton RT were more likely to be white, reside in higher income areas, and have private insurance. Proton RT was associated with delayed RT initiation compared to photon RT (median 59 days vs. 45, P < 0.001). Receipt of proton therapy was independently associated with RT initiation beyond 6 weeks after diagnosis (adjusted OR aOR, definitive RT = 1.69; 95% confidence interval CI 1.26–2.30) or surgery (aOR adjuvant RT = 4.08; 95% CI 2.64–6.62). In the context of adjuvant proton RT, increases in treatment delay were associated with worse overall survival (weeks, adjusted hazard ratio = 1.099, 95% CI 1.011–1.194).
Conclusion
Use of proton therapy is associated with delayed RT in both the definitive and adjuvant settings for patients with HNSCC and could be associated with poorer outcomes.
Level of Evidence
2b
Laryngoscope, 122:0000–0000, 2019 Laryngoscope, 130:E598–E604, 2020
We performed this study to assess outcomes of patients with oropharyngeal cancer treated with modern therapy approaches.
Demographics, treatments and outcomes of patients diagnosed with Stage 3- 4B ...squamous carcinoma of the oropharynx, between 2000-2007 were tabulated and analyzed.
The cohort consisted of 1046 patients. The 5-year actuarial overall survival, recurrence-free survival and local-regional control rates for the entire cohort were 78%, 77% and 87% respectively. More advanced disease, increasing T-stage and smoking were associated with higher rates of local-regional recurrence and poorer survival.
Patients with locally advanced oropharyngeal cancer have a relatively high survival rate. Patients' demographics and primary tumor volume were very influential on these favorable outcomes. In particular, patients with small primary tumors did very well even when treatment was not intensified with the addition of chemotherapy.
Oncology has undergone rapid progress, with emerging developments in areas including cancer stem cells, molecularly targeted therapies, genomic analyses, and individually tailored immunotherapy. ...These advances have expanded the tools available in the fight against cancer. Some of these have seen broad media coverage resulting in justified public attention. However, these achievements have only been possible due to rapid developments in the expanding field of biomedical informatics and information technology (IT). Artificial intelligence, radiomics, electronic health records, and electronic patient-reported outcome measures (ePROMS) are only a few of the developments enabling further progress in oncology. The promising impact of IT in oncology will only become reality through a multidisciplinary approach to the complex challenges ahead.
The aim of this study is to develop a methodology to standardize the analysis and reporting of the patterns of loco-regional failure after IMRT of head and neck cancer.
Twenty-one patients with ...evidence of local and/or regional failure following IMRT for head-and-neck cancer were retrospectively reviewed under approved IRB protocol. Manually delineated recurrent gross disease (rGTV) on the diagnostic CT documenting recurrence (rCT) was co-registered with the original planning CT (pCT) using both deformable (DIR) and rigid (RIR) image registration software. Subsequently, mapped rGTVs were compared relative to original planning target volumes (TVs) and dose using a centroid-based approaches. Failures were then classified into five types based on combined spatial and dosimetric criteria; A (central high dose), B (peripheral high dose), C (central elective dose), D (peripheral elective dose), and E (extraneous dose).
A total of 26 recurrences were identified. Using DIR, recurrences were assigned to more central TVs compared to RIR as detected using the spatial centroid-based method (p = 0.0002). rGTVs mapped using DIR had statistically significant higher mean doses when compared to rGTVs mapped rigidly (mean dose 70 vs. 69 Gy, p = 0.03). According to the proposed classification 22 out of 26 failures were of type A (central high dose) as assessed by DIR method compared to 18 out of 26 for the RIR because of the tendencey of RIR to assign failures more peripherally.
RIR tends to assigns failures more peripherally. DIR-based methods showed that the vast majority of failures originated in the high dose target volumes and received full prescribed doses suggesting biological rather than technology-related causes of failure. Validated DIR-based registration is recommended for accurate failure characterization and a novel typology-indicative taxonomy is recommended for failure reporting in the IMRT era.
To investigate the benefit of postoperative radiotherapy (PORT) for low-volume (pN1) nodal disease after resection of oral cavity squamous cell carcinoma.
The National Cancer Database was queried for ...adults with nonmetastatic squamous cell carcinoma of the oral cavity treated by surgical resection with pathologic stage T1-2 N0-2 (American Joint Committee on Cancer 7th edition) and with the maximal exclusion of standard indications for PORT. Overall survival was compared within pN1 for observation versus PORT and then compared for pN1 versus pN0 and versus pN2 stratified by receipt of observation or PORT. Multivariable Cox regression was used to adjust for potential confounders between PORT and survival, including comorbidity and age.
Overall 5017 pN0, 530 pN1, and 253 pN2 patients were identified, of whom 9%, 35%, and 64% received PORT, respectively. Within the pN1 cohort, PORT was associated with improved survival versus observation (adjusted hazard ratio, 0.66; 95% confidence interval, 0.46-0.97; P=0.03). Among observed patients, the prognosis of pN1 was equivalent to pN2 and inferior to pN0; in contrast, among patients treated with PORT, the prognosis of pN1 was equivalent to pN0 and superior to pN2. Without PORT, pN1 remained an adverse risk factor relative to pN0 regardless of the depth of invasion, lymph node size, lymph node location, and extent of lymph node dissection.
PORT was associated with a survival benefit compared with observation. Notably, pN1 was an adverse risk factor relative to pN0 if, and only if, patients did not receive PORT, suggesting pN1 by itself may be an indication for PORT.
Objectives/Hypothesis
To compare the complication rate for osseointegrated hearing aids (OIHA) in patients with or without irradiation.
Study Design
Retrospective case review.
Methods
We studied ...patients with OIHAs implanted between January 1, 2005, and July 15, 2013 in a tertiary university center with a referral otology and neurotology practice. Demographics, history of oncologic surgery, follow‐up length after OIHA implantation, radiation history and dosage, postoperative complications, and chronologic relationship between oncologic resection, OIHA implantation, and irradiation were reviewed to collect information. Soft tissue complications were graded according to a modified Holgers classification.
Results
The study included 48 patients. Twenty‐nine patients (32 implants) did not undergo radiotherapy and 19 patients (19 implants) did. In the radiotherapy group, six patients had OIHAs implanted before radiotherapy, and 13 had OIHAs implanted in irradiated bone. Of these 13 patients, one had OIHA implanted during primary oncologic surgery; 11 had OIHA implanted during secondary surgery; and one patient did not have oncologic surgery. Patients with both OIHA implantation and radiotherapy had more complications than patients without radiotherapy (31.6% vs. 24.1%, P > 0.05) and more major complications than patients without radiotherapy (26.3% vs. 3.4%, P > 0.05). Patients with OIHAs implanted before radiotherapy did not have any complications. There were significantly fewer and less severe complications in patients with OIHAs implanted during primary oncologic resection than in patients with OIHAs implanted secondarily (0/8 vs. 8/11, P < 0.05).
Conclusions
The rate and severity of complications of OIHAs can be minimized by implanting the device before irradiation, ideally at the time of primary oncologic surgery.
Level of Evidence
4. Laryngoscope, 126:1187–1192, 2016
Abstract Background The delineation of clinical target volumes (CTVs) for radiotherapy for nasopharyngeal cancer is complex and varies based on the location and extent of disease. Purpose The current ...study aimed to develop an auto‐contouring solution following one protocol guidelines (NRG‐HN001) that can be adjusted to meet other guidelines, such as RTOG‐0225 and the 2018 International guidelines. Methods The study used 2‐channel 3‐dimensional U‐Net and nnU‐Net framework to auto‐contour 27 normal structures in the head and neck (H&N) region that are used to define CTVs in the protocol. To define the CTV‐Expansion (CTV1 and CTV2) and CTV‐Overall (the outer envelope of all the CTV contours), we used adjustable morphological geometric landmarks and mimicked physician interpretation of the protocol rules by partially or fully including select anatomic structures. The results were evaluated quantitatively using the dice similarity coefficient (DSC) and mean surface distance (MSD) and qualitatively by independent reviews by two H&N radiation oncologists. Results The auto‐contouring tool showed high accuracy for nasopharyngeal CTVs. Comparison between auto‐contours and clinical contours for 19 patients with cancers of various stages showed a DSC of 0.94 ± 0.02 and MSD of 0.4 ± 0.4 mm for CTV‐Expansion and a DSC of 0.83 ± 0.02 and MSD of 2.4 ± 0.5 mm for CTV‐Overall. Upon independent review, two H&N physicians found the auto‐contours to be usable without edits in 85% and 75% of cases. In 15% of cases, minor edits were required by both physicians. Thus, one physician rated 100% of the auto‐contours as usable (use as is, or after minor edits), while the other physician rated 90% as usable. The second physician required major edits in 10% of cases. Conclusions The study demonstrates the ability of an auto‐contouring tool to reliably delineate nasopharyngeal CTVs based on protocol guidelines. The tool was found to be clinically acceptable by two H&N radiation oncology physicians in at least 90% of the cases.
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