Surgical Treatment in Very Advanced (T4b) Adenoid Cystic Carcinoma of the Head and Neck
Papazian, Michael R; Chow, Michael; Oliver, Jamie; Gordon, Alex J; Jacobson, Adam; Vaezi, Alec; Tam, Moses; Givi, Babak
OBJECTIVE:To compare treatment outcomes for T4b head and neck adenoid cystic carcinoma (ACC). STUDY DESIGN/METHODS:Historical cohort study. SETTING/METHODS:National Cancer Database (NCDB). METHODS:Identified all T4b ACC of head and neck origin diagnosed 2004 to 2019 in the NCDB. Demographics, clinical characteristics, treatment details, and survival were analyzed. Treatment outcomes were analyzed using univariable and multivariable Cox regression. RESULTS:We identified 606 cases of T4b ACC. Less than half (284, 47.0%) underwent curative-intent treatment. Among these, most were treated with primary surgery: surgery + radiotherapy (RT) (122, 43.0%) or surgery + chemoradiotherapy (CRT) (42, 14.8%). The positive margin rate was 78.7%, and 90-day postoperative mortality was zero. Nonsurgical patients were treated with definitive RT (60, 21.1%) or definitive CRT (60, 21.1%). The median follow-up was 51.5 months. Overall survival was 77.8% at 3 years. Three-year survival was higher for patients treated with surgery compared to those treated nonsurgically (84% vs 70%; p = .005). Surgical treatment remained associated with higher survival on multivariable analysis (hazard ratio [HR]: 0.47, p = .005). This effect was most pronounced for oral cavity tumors (HR: 0.17, p = .01). Among matched cohorts of surgically treated patients, there was no difference in 3-year survival between clinical T4a and T4b tumors (83.3% vs 83.0%, p = .99). CONCLUSION/CONCLUSIONS:Long-term survival for T4b ACC of the head and neck could be expected. Primary surgical treatments can be performed safely and are associated with longer survival. A carefully selected subset of patients with very advanced ACC might benefit from the consideration of surgical treatments.
Adoption of adjuvant chemotherapy in high-risk salivary gland malignancies
Gordon, Alex J; Chow, Michael S; Patel, Aneek; Hu, Kenneth S; Li, Zujun; Jacobson, Adam S; Vaezi, Alec E; Tam, Moses M; Givi, Babak
BACKGROUND:The present study characterizes national trends in the utilization of adjuvant chemotherapy to treat salivary gland malignancies. METHODS:The National Cancer Database was queried for salivary gland malignancies treated by surgery with radiation in 2004-2019. Proportions of patients receiving adjuvant chemotherapy over the study period were analyzed by linear regression. The impact of chemotherapy on overall survival was assessed using Kaplan-Meier and Cox proportional hazards analyses. RESULTS:Among 15â€‰965 patients meeting inclusion criteria, 2355 (14.8%) received adjuvant chemotherapy. Chemotherapy utilization significantly increased from 4.9% to 16.5% over the study period (pâ€‰<â€‰0.001). No survival benefit was observed with adjuvant chemotherapy on propensity score-matched Kaplan-Meier analysis (HR: 0.98; 95% CI: 0.86-1.11; pÂ =Â 0.72) or multivariable Cox regression (HR: 0.92; 95% CI: 0.78-1.09; pÂ =Â 0.34). CONCLUSIONS:Adjuvant chemotherapy has been increasingly utilized to treat salivary gland malignancies in recent years. Our findings highlight the importance of obtaining high-quality prospective data regarding the benefit of chemotherapy.
Repeat re-irradiation with interstitial HDR-brachytherapy for an in-field isolated nodal recurrence in a patient with HPV-positive squamous cell carcinoma of the head and neck [Case Report]
Kim, Joseph K; Hardy-Abeloos, Camille; Purswani, Juhi M; Kamen, Emily; Concert, Catherine M; Duckworth, Tamara; Tam, Moses; Haas, Jonathan; Rybstein, Marissa; Vaezi, Alec; Jacobson, Adam; Hu, Kenneth S
PURPOSE/OBJECTIVE:Locoregionally recurrent head and neck cancer is a complex clinical scenario that often requires multimodality treatment. These patients have often previously received definitive treatment with a combination of surgery, radiation therapy, and systemic therapy, which can make further management difficult. A second isolated locoregional failure is rare and clinicians are faced with a challenge to optimize disease control while minimizing treatment-related toxicity. METHODS AND MATERIALS/METHODS:In this report, we present the diagnosis, management, and outcomes of a patient with an isolated locoregional recurrence who was previously treated with two courses of radiation. The patient was treated with a second course of reirradiation using interstitial brachytherapy as well as a discussion regarding patient selection and optimal management for recurrent head and neck cancer. RESULTS:Repeat reirradiation using interstitial HDR-brachytherapy with the use of an alloderm spacer was successfully delivered to the patient for an in-field right neck nodal recurrence. He received a total EQD2/BED dose of 127.70/153.24 Gy. At 1-year followup, the patient was without evidence of recurrent disease or new significant side effects. CONCLUSION/CONCLUSIONS:Recurrent head and neck cancer should be managed with a multidisciplinary approach given the complex clinical scenario. Reirradiation is a commonly used salvage measure for recurrent head and neck cancer that requires careful planning and patient selection due to prior treatment-related effects and dose constraints. We reported a case of a second course of reirradiation using interstitial HDR-brachytherapy for locoregionally recurrent head and neck cancer and showed no recurrence of disease or worsening long term side effects at 1 year.
Circulating Tumor HPV-DNA Kinetics in p16+ Oropharyngeal Cancer Patients Undergoing Adaptive Radiation De-Escalation Based on Mid-Treatment Nodal Response [Meeting Abstract]
Kim, J K; Tam, M; Oh, C; Feron-Rigodon, M; Joseph, B; Vaezi, A E; Li, Z; Tran, T; Kim, G; Zan, E; Corby, P; Vecchio, Fitz C D; Goldberg, J D; Hochman, T; Givi, B; Jacobson, A; Persky, M; Hu, K S
Purpose/Objective(s): Human-papilloma virus-positive (HPV+) OPSCC is known to have an excellent prognosis with a favorable response to CRT. Several studies have shown that de-intensified treatment in select patients (pts) can achieve similar survival outcomes to standard treatment while reducing acute and long-term toxicity. Additionally, rapid clearance of circulating tumor HPV DNA may be useful in predicting the likelihood of disease control. Materials/Methods: We evaluated pts enrolled on a phase II institutional clinical trial. Pts with HPV+ OPSCC were included and were treated with definitive CRT with cisplatin. All pts were initially planned to receive standard radiation dose (S-RT) to 70 Gy; those who achieved a favorable mid-treatment response (FMTR) of >40% lymph node shrinkage at week 4 of radiation (RT) received a de-escalated dose (D-RT) to 60 Gy. Blood samples were taken at screening, week 4 of RT, and at follow-up visit after RT and circulating tumor tissue modified viral HPV NDA (TTMV) was qualtified. We define a "substantial TTMV clearance" as either >95% reduction in TTMV from screening to week 4 (screening level >200 copies/ml) or undetectable ctHPVDNA at week 4 (any detectable screening level). Fisher tests were used to evaluate the association of TTMV and treatment group.
Result(s): At the time of this analysis, 35 pts were enrolled in the clinical trial with a median age of 60 years at diagnosis (range 38 to 76). 25 pts achieved a FMTR and received D-RT while 10 pts received S-RT. 29 pts (7 S-RT, 18 D-RT) had detectable screening TTMV and week 4 TTMV samples available for analysis. D-RT pts had a significantly higher rate of substantial TTMV clearance at week 4 compared to S-RT: 14.3% (1/7) pts in the S-RT vs. 61.1% (11/18) pts in the D-RT (OR 0.090 [0.002 - 0.105], p=0.036). 6 of 25 pts (24%) had a flare in their TTMV from screening to week 4 including 57.1% (4/7) of the S-RT and 11.1% (2/18) of the D-RT; there was a significantly higher likelihood of TTMV flare in the S-RT group (OR 9.34 [0.898 - 150.960], p=0.032). 24 pts (6 S-RT, 18 D-RT) with initial detectable screening TTMV also had a follow-up TTMV sample available. The median time from screening to follow-up was 81.0 days for all pts (76.5 days for D-RT, 84.0 days for S-RT). 95.7% of pts (83.3% of S-RT, 100%% of D-RT) had complete TTMV clearance at follow-up.
Conclusion(s): We report a statistically significant correlation between substantial TTMV clearance and a FMTR of >40% nodal shrinkage. 61.1% of D-RT pts achieved a substantial TTMV clearance compared to 14.3% in the S-RT group. Additionally, we observed that pts who did not achieve a FMTR had a higher likelihood of TTMV flare at week 4. Nearly all pts achieved a complete TTMV clearance by follow-up. Mid-treatment TTMV clearance may help identify pts who may benefit from further de-escalation as well as those who should continue with standard therapy. This study has the ClinicalTrials.gov identifier NCT03215719.
Disease Characteristics, Patterns of Care and Survival Outcomes in Patients with Synovial Cell Sarcoma of the Head and Neck (HNSCS) [Meeting Abstract]
Kim, J K; Karp, J M; Hu, K S; Vaezi, A E; Liu, C Z; Rybstein, M; Li, Z; Jacobson, A; Persky, M; Givi, B; Tam, M
Purpose/Objective(s): HNSCS is a rare diagnosis with an overall poor prognosis. Due to its rarity, our understanding of HNSCS and its optimal management is mainly derived from retrospective and single-institution studies. We aimed to evaluate the disease characteristics, patterns of care, and survival outcomes in patients with HNSCS. Materials/Methods: Using the National Cancer Database (NC
Non-Squamous Cell Malignancies of the Larynx
Rotsides, Janine M; Patel, Evan; Oliver, Jamie R; Moses, Lindsey E; Jacobson, Adam S; Hu, Kenneth S; Vaezi, Alec; Tam, Moses; Givi, Babak
OBJECTIVES/HYPOTHESIS/OBJECTIVE:Non-squamous cell carcinoma (SCC) malignancies are rare, but well described laryngeal pathologies. However, the epidemiology and clinical behavior of these tumors is not well studied. STUDY DESIGN/METHODS:Retrospective cohort study. METHODS:Patients diagnosed with non-squamous cell larynx cancer from 2004 to 2017 in the National Cancer Database were selected. Demographic, clinicopathologic factors, treatments, and survival were analyzed. Univariable and multivariable cox regression were performed. Survival was compared with a propensity score-matched (PSM) population of laryngeal SCC patients. RESULTS:A total of 136,235 cases of larynx cancer were identified. After excluding SCC variants, 2,172 (1.6%) patients met inclusion criteria. The most common histology was chondrosarcoma (374, 17.2%), followed by small cell (345, 15.9%), and spindle cell carcinoma (268, 12.3%). The most common treatment was surgery (683, 31.4%) followed by chemoradiation (409, 18.8%) and surgery and adjuvant radiation (288, 13.3%). Overall, 3- and 5-year survival was 67.9% and 59.4%, respectively. In multivariate analysis controlling for age, stage, comorbidity, histology, and treatment modality; chondrosarcoma had the best survival (hazard ratio [HR] 0.11, confidence interval [CI] 0.07-0.19, Pâ€‰<â€‰.001). In a PSM population, matched for age, stage, comorbidity, and treatments; non-SCC patients had significantly lower survival (51.5% vs. 59.9%, Pâ€‰<â€‰.001). CONCLUSION/CONCLUSIONS:A diverse range of non-squamous cell malignancies occur in the larynx. In general, these tumors have poor survival, with few exceptions such as chondrosarcoma. While the majority of these histologies undergo surgical-based treatments in other sites, only 53% of patients underwent surgical-based treatment in the larynx. These data could guide clinicians in determining the outcome of treatment in these patients. LEVEL OF EVIDENCE/METHODS:4 Laryngoscope, 2022.
Patterns of Care and Outcomes of Carcinosarcoma of the Major Salivary Glands
Talwar, Abhinav; Patel, Evan; Tam, Moses; Zhou, Fang; Hu, Kenneth; Persky, Michael; Vaezi, Alec; Jacobson, Adam; Givi, Babak
OBJECTIVE:Carcinosarcoma of the salivary gland is a rare malignant biphasic tumor. The present study investigates the epidemiology and clinical behavior of carcinosarcoma of the major salivary glands using the National Cancer Database (NCDB). STUDY DESIGN/METHODS:Historical cohort study. SETTING/METHODS:NCDB. METHODS:All tumors were selected between 2004 and 2018. Patient demographics, tumor characteristics, treatments, and survival were analyzed. Cox regression analysis was performed in surgically treated patients. RESULTS:= .008) remained significant. CONCLUSION/CONCLUSIONS:Carcinosarcoma is a rare salivary gland tumor that frequently presents at a locally advanced stage. Despite multimodality treatments, the outcomes are poor. In the absence of clinical trial data, these data from the NCDB could guide clinicians in the management of this rare disease.
Nodal Metastases in Pediatric and Adult Acinic Cell Carcinoma of the Major Salivary Glands
Dublin, Jared C; Oliver, Jamie R; Tam, Moses M; Persky, Michael J; Jacobson, Adam S; Liu, Cheng; Hu, Kenneth S; Vaezi, Alec E; Morris, Luc G T; Givi, Babak
OBJECTIVE:Acinic cell carcinoma (AciCC) is a rare, usually low-grade salivary malignancy. Evidence on rates of lymph node metastases (LNMs) is limited in pediatric patients and varies significantly (4%-45%) in adults. We set out to determine and compare rates of LNMs in pediatric and adult AciCC and to analyze their impact on survival, using the National Cancer Database. STUDY DESIGN/METHODS:Historical cohort study. SETTING/METHODS:National Cancer Database. METHODS:All AciCCs of the major salivary glands with complete clinical and pathologic nodal staging were selected between 2010 and 2016. Patient demographics, tumor characteristics, treatment, and survival were analyzed. Univariable and multivariable regression were performed to determine factors associated with LNMs and survival. RESULTS:< .001) were associated with LNM in adult patients. CONCLUSION/CONCLUSIONS:LNMs in AciCC of the major salivary glands are rare in children and adults. However, high-grade and T3-T4 tumors are associated with an increased risk of LNM. LNM is associated with worse survival.
Circulating Tumor HPV-DNA Kinetics in p16+Oropharyngeal Cancer Patients Undergoing Adaptive Radiation De-Escalation Based on Mid-Treatment Nodal Response [Meeting Abstract]
Kim, J. K.; Tam, M.; Oh, C.; Feron-Rigodon, M.; Joseph, B.; Vaezi, A. E.; Li, Z.; Tran, T.; Kim, G.; Zan, E.; Corby, P.; Fitz, C. Del Vecchio; Goldberg, J. D.; Hochman, T.; Givi, B.; Jacobson, A.; Persky, M.; Persky, M.; Hu, K. S.
Including Surgical Resection in the Multimodal Management of Very Locally Advanced Sinonasal Cancer
Karp, Jerome M; Hu, Kenneth S; Persky, Michael; Persky, Mark; Jacobson, Adam; Tran, Theresa; Li, Zujun; Givi, Babak; Tam, Moses M
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.