Faculty Bibliography

OBJECTIVE:Sinonasal cancer often presents as locoregionally advanced disease. National guidelines recommend management of stage T4b tumors with systemic therapy and radiotherapy, but recent studies suggest that including surgical resection in the multimodal treatment of these tumors may improve local control and survival. We queried the National Cancer Database to examine patterns of care and outcomes in T4b sinonasal squamous cell carcinoma (SCC). STUDY DESIGN/METHODS:Prospectively gathered data. SETTING/METHODS:National Cancer Database. METHODS:Patients with T4b N0-3 M0 sinonasal squamous cell carcinoma diagnosed in 2004 to 2016 were stratified between those who received chemoradiotherapy and those who underwent surgical resection with neoadjuvant or adjuvant treatment. The overall survival of each cohort was assessed via Kaplan-Meier analysis and Cox proportional hazard models, with repeat analysis after reweighting of data via inverse probability of treatment weighting. RESULTS:= .004]). CONCLUSION/CONCLUSIONS:Surgical treatment with neoadjuvant or adjuvant treatment for stage T4b sinonasal SCC was associated with promising survival outcomes, suggesting a role for incorporating surgery in treatment of select T4b SCC, particularly when removal of all macroscopic disease is feasible.

PURPOSE/OBJECTIVE(S): Lacrimal gland cancer is a rare tumor with little data regarding outcomes and optimal management. We performed a large database analysis using the National Cancer Database (NC

PURPOSE/OBJECTIVE(S): Remote training programs have been shown as a cost-effective way to bridge education and training gaps for radiation oncology providers in low- and middle-income countries (LMICs) and could be used to improve contouring skill. Given the expansion of 3D and intensity-modulated radiotherapy and high interest in contouring training in the Philippines, we seek to measure and report the efficacy of a pilot head and neck contouring curriculum. MATERIALS/METHODS: A 13-week, 13-session remote training program on head and neck contouring and plan evaluation was provided at no cost to 8 participating radiation oncology residency programs in the Philippines. The program consisted of weekly 1-hour live video conferencing sessions with interactive didactics and case-based learning through a cloud-based contouring platform. Resident participants were assigned a pre-curriculum and a post-curriculum stage T3N2M0 oropharynx cancer case with 27 OARs. The cases were respectively rated as 2.67/5 and 3.83/5 in difficulty by 6 U.S. educator head and neck radiation oncologists involved in the curriculum. Participants self-rated their confidence in their performance according to a 1-5 Likert scale at the time of each submission regarding three categories: organs at risk (OARs), nodal contouring, and primary target contouring. A team of 4 educators later independently graded contours, according to a 1-5 grading rubric for the same three categories. Cases received 1-2 grades total, which were averaged for analysis. Contour submission was required for a certificate of participation, however no incentives for higher scores were provided.
RESULT(S): 41 residents in the Philippines (10 R1, 12 R2, 11 R3, and 9 R4) participated in the curriculum. Average participation per session was 26 (range 12-39, SD=7.2). 26 (63.4%) participants completed pre-contours for evaluation and 17 (41.5%) post-contours for evaluation. Of these, 14 participants were eligible for paired pre- vs. post-curriculum analysis. Paired pre- and post-curriculum confidence scores (out of 5) were 3.0 and 3.77 for OARs (P=0.003), 3.08 and 3.54 for nodal stations (P=0.056), and 2.85 and 3.31 for primary target contouring (P=0.027), respectively. Overall confidence in contouring the assigned case rose from 2.85 to 3.54 (P < 0.001). Paired pre- and post-curriculum educator grades were 2.96 and 3.38 for OARs (P=0.135), 2.61 and 1.96 for nodal coverage (P=0.019), and 2.54 and 2.73 for primary target contours (P=0.292), respectively. Qualitative observations included greater participant uniformity of left and right parotid glands.
CONCLUSION(S): Longitudinal telehealth training integrating cloud-based tools for radiation oncology professionals is a viable and scalable method for providing head and neck contouring education in a LMIC setting. Our findings suggest that work remains to assess the concordance of confidence with performance, especially in challenging cases, and that further contouring education is needed in LMIC regions.
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Introduction Photobiomodulation therapy has been shown to be an effective treatment for reducing the incidence and severity of oral mucositis (OM). The objective of this study is to determine the range of effective PBM dose, and review the adequacy of reporting irradiation parameters. Methods Online databases were searched to compare efficacy of PBM versus controls for preventing or treating cancer therapy-induced OM. Irradiation parameters were reviewed for accuracy. Results A total of 53 clinical trials were identified and 29 papers were excluded, leaving 24 papers for review. Only 1 study reported all parameters accurately. Seven studies reported a difference in OMgrade >= 3 (WHO) between the placebo and PBM groups greater than 40% when PBM was used prophylactically with greater irradiation parameters (mean energy dose 50%, beam area 58%, irradiance 246%, and treatment time per point 290% greater than the overall mean values).Aplot of effect size (%) vs. total energy per session was created using studies that reported adequate information to determine both total energy per session and the difference in the percent of patients with OMgrade >= 3 between the study group and placebo group. These data points were fit with a quadratic curve to evaluate if the data may resemble the parabolic relationship observed in previous studies. Conclusions This review has reconfirmed the lack of accurate reporting of PBM parameters. Total energy per session may be used to guide PBM dose parameters

Purpose: This research aimed to perform an overview on adjuvant vaginal brachytherapy (VBT) in stage I to II endometrial carcinoma (EC) according to ESMO-ESGO-ESTRO risk group consensus in China from multi-institutional analysis.Materials and Methods: We retrospectively analyze patients with stage I to II EC at 13 institutions in China treated between 2003 and 2015. All patients underwent adjuvant radiotherapy and were divided into low-risk (LR), intermediate-risk (IR), high-intermediate risk (HIR) and high-risk (HR) groups according to ESMO-ESGO-ESTRO risk group consensus. XXResult(s): A total of 1048 cases were included. Stage I disease accounted for 85.9% of the cohort. Proportion of HR disease was 27.6%, HIR 17.7%, IR 27.7% and LR 27.1%. Patients received adjuvant VBT alone (n = 474), pelvic external beam radiotherapy (EBRT) alone (n = 116) or combined EBRT with VBT (n = 458). An increasing trend was found toward referrals for VBT alone. Historical data demonstrate that the clinical practice of adjuvant VBT alone increased significantly in the LR to HIR groups over the past 13 years. However, in the HR group, the proportion of VBT alone or as a boost after EBRT stayed stable in the corresponding period.All institutions commonly use High-dose-rate VBT prescribed to 0.5-cm depth from the vaginal surface with 14 and 17 different dose-fractionation schedules for VBT alone and VBT boost, respectively. The most common fractionation for VBT alone is 5 Gy in six fraction (407/474) and the most common fractionation for VBT as a boost after EBRT is 5 Gy in two fractions (178/458). Proximal 2-3 cm vagina was the most often irradiated vaginal target (61.3%). The most commonly used applicators were the multichannel vaginal cylinder (79.6%). The median follow-up time was 56 months. For LR to HIR patients, VBT alone achieved comparable survival to EBRT. Compared to EBRT, patients receiving VBT had significantly decreased incidence of grade 1-2 early and late gastrointestinal and urinary reactions, and the rate of grade 3-4 acute hematological toxicity. XXConclusion(s): There is remarkable heterogeneity among VBT dose-fractionation schedules. An increasing trend was found toward referrals for VBT alone. The clinical practice of adjuvant VBT alone increased significantly in LR to HIR groups over the past 13 years. In LR to HIR group, VBT alone achieved comparable survival to EBRT.XXCopyright

BACKGROUND:Radiotherapy, along with laser surgery, is considered a standard treatment option for patients with early glottic squamous cell cancer (SCC). Historically, patients have received complete larynx radiotherapy (CL-RT) due to fear of swallowing and respiratory laryngeal motion and this remains the standard approach in many academic institutions. Local control (LC) rates with CL-RT have been excellent, however this treatment can carry significant toxicities include adverse voice and swallowing outcomes, along with increased long-term risk of cerebrovascular morbidity. A recent retrospective study reported improved voice quality and similar local control outcomes with focused vocal cord radiotherapy (VC-RT) compared to CL-RT. There is currently no prospective evidence on the safety of VC-RT. The primary objective of this Bayesian Phase II trial is to compare the LC of VC-RT to that of CL-RT in patients with T1N0 glottic SCC. METHODS:One hundred and fifty-five patients with T1a-b N0 SCC of the true vocal cords that are n ot candidate or declined laser surgery, will be randomized in a 1:3 ratio the control arm (CL-RT) and the experimental arm (VC-RT). Randomisation will be stratified by tumor stage (T1a/T1b) and by site (each site will be allowed to select one preferred radiation dose regimen, to be used in both arms). CL-RT volumes will correspond to the conventional RT volumes, with the planning target volume extending from the top of thyroid cartilage lamina superiorly to the bottom of the cricoid inferiorly. VC-RT volumes will include the involved vocal cord(s) and a margin accounting for respiration and set-up uncertainty. The primary endpoint will be LC at 2-years, while secondary endpoints will include patient-reported outcomes (voice impairment, dysphagia and symptom burden), acute and late toxicity radiation-induced toxicity, overall survival, progression free survival, as well as an optional component of acoustic and objective measures of voice analysis using the Consensus Auditory-Perceptual Evaluation of Voice. DISCUSSION/CONCLUSIONS:This study would constitute the first prospective evidence on the efficacy and safety of VC-RT in early glottic cancer. If positive, this study would result in the adoption of VC-RT as standard approach in early glottic cancer. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov Identifier: NCT03759431 Registration date: November 30, 2018.

PURPOSE/OBJECTIVE:To examine the role age plays in the treatment and prognosis of locally advanced head and neck cancer (LAHNC) treated definitively with radiation alone or combined modality therapy. METHODS:A retrospective analysis was performed of three NRG/RTOG trials examining either radiation alone or combined radiation and systemic therapy for LAHNC. The effect of age (≥70 yrs.) on cause-specific survival (CSS), overall survival (OS), and toxicity was evaluated. RESULTS:A total of 2688 patients were analyzed, of whom 309 patients (11.5%) were ≥ 70. For all studies combined, the hazard ratio (HR) for CSS for patients age ≥ 70 vs. those <70 was 1.33 (95%CI: 1.14-1.55, p < 0.001). For OS, the HR for patients age ≥ 70 vs. those <70 for all studies combined was 1.55 (95% CI 1.35-1.77, p < 0.001). After adjustment for all covariates, age ≥ 70 was associated with worse OS regardless of adjustment for smoking and p16 status. The survival difference was more pronounced in those receiving combined radiation and systemic therapy. Hematologic and renal toxicities were increased in combined modality trials in patients ≥70 years old. CONCLUSIONS:Patients age ≥ 70 with LAHNC were underrepresented in these clinical trials. Their CSS and OS proved inferior to patients <70 years old.

OBJECTIVE:Assess the testing rates and prognostic significance of human papilloma virus (HPV) status in hypopharynx malignancies. STUDY DESIGN/METHODS:Historical cohort study. SETTING/METHODS:National Cancer Database. METHODS:Review of the National Cancer Database was conducted between 2010 and 2017 for squamous cell carcinomas (SCCs) of the hypopharynx. We investigated how often the tumors were tested for HPV and whether it was associated with survival outcomes. RESULTS:< .001). CONCLUSIONS:HPV-positive tumors constitute a sizable minority of hypopharynx tumors and are associated with improved survival. Expansion of HPV testing to hypopharynx malignancies may be warranted.