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BACKGROUND: Emerging randomized data, mostly from phase II trials, have suggested that patients with oligometastatic cancers may benefit from ablative treatments such as stereotactic ablative radiotherapy (SABR). However, phase III data testing this paradigm are lacking, and many studies have examined SABR in the setting of metachronous oligometastatic disease. The goal of the SABR-SYNC trial is to assess the effect of SABR in patients with oligometastatic cancers and a synchronous primary tumor. METHODS: One hundred and eighty patients will be randomized in a 1:2 ratio between standard of care (SOC) palliative-intent treatments vs. SOC + ablative therapy (SABR preferred) to all sites of known disease. Randomization will be stratified based on histology and number of metastases at enrollment. SABR may be delivered in 1-, 3- and 5-fraction regimens, with recommended doses of 20 Gy, 30 Gy, and 35 Gy, respectively. Non-SABR local modalities (e.g. surgery, thermal ablation, conventional radiation) may be used for treatment of the primary or metastases at the discretion of the treating physicians, if those modalities are clinically preferred. The primary endpoint is overall survival, and secondary endpoints include progression-free survival, time to development of new metastatic lesions, time to initiation of next systemic therapy, quality of life, and toxicity. Translational endpoints include assessment of circulating tumor DNA and immunological predictors of outcomes. DISCUSSION: SABR-SYNC will provide phase III data to assess the impact of SABR on overall survival in a population of patients with synchronous oligometastases. The translational component will attempt to identify novel prognostic and predictive biomarkers to aid in clinical decision making. TRIAL REGISTRATION: Clinicaltrials.gov NCT05717166 (registration date: Feb. 8, 2023).
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Radiocirurgia , Humanos , Radiocirurgia/métodos , Metástase Neoplásica , Feminino , Masculino , Neoplasias Primárias Múltiplas/radioterapia , Idoso , Ensaios Clínicos Fase III como Assunto , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Radiation-induced mucositis (RIM) pain confers substantial morbidity for head and neck cancer (HNC) patients undergoing radiotherapy alone (RT) or chemoradiotherapy (CRT), often reducing treatment compliance. However, no standard currently exists for the treatment of RIM, and high dose opioid therapy, with its associated side effects and increased risk for chronic opioid use, remains the cornerstone of HNC pain management. The goal of this randomized clinical trial is to compare multimodal analgesia using analgesic medications with different mechanisms of action, to the institutional standard of opioid analgesia alone, in order to ascertain the optimal analgesic regimen for the management of RIM pain in HNC patients. METHODS: In this open-label, single-institution, non-inferiority, randomized clinical trial, sixty-two patients with mucosal head and neck malignancies treated with curative-intent radiation will be randomized in a 1:1 ratio, stratified by RT or CRT, between Arm 1: opioid analgesia alone as per the institutional standard, or Arm 2: multimodal analgesia using Pregabalin, Acetaminophen, and Naproxen, in addition to opioids, if required. The primary endpoint is the average 11-Numeric Rating Scale (11-NRS) score for pain during the last week of radiation treatment. Secondary endpoints include: average weekly opioid use, duration of opioid requirement, average daily 11-NRS score for pain, average weekly opioids dispensed, quality of life, hospitalizations for analgesic medication-induced complications, time to feeding tube insertion, weight loss, toxicity, treatment interruptions, and death within 3 months of completing RT treatment. Patients are eligible once analgesia is required for moderate 4/10 pain. DISCUSSION: This study will assess the efficacy and safety of multimodal analgesia and its impact on opioid requirements, clinical outcomes, and quality of life, as a potential new standard treatment for RIM pain in HNC patients undergoing definitive RT or CRT. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04221165 . Date of registration: January 9, 2020. Appendix 2 reports the World Health Organization trial registration dataset.
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Analgesia , Neoplasias de Cabeça e Pescoço , Analgésicos Opioides/uso terapêutico , Neoplasias de Cabeça e Pescoço/complicações , Neoplasias de Cabeça e Pescoço/tratamento farmacológico , Neoplasias de Cabeça e Pescoço/radioterapia , Humanos , Dor , Manejo da Dor , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
Lung cancer remains the most common cause of cancer death worldwide. Recent advances in lung cancer screening, radiotherapy, surgical techniques, and systemic therapy have led to increasing complexity in diagnosis, treatment decision-making, and assessment of recurrence. Artificial intelligence (AI)-based prediction models are being developed to address these issues and may have a future role in screening, diagnosis, treatment selection, and decision-making around salvage therapy. Imaging plays an essential role in all components of lung cancer management and has the potential to play a key role in AI applications. Artificial intelligence has demonstrated value in prognostic biomarker discovery in lung cancer diagnosis, treatment, and response assessment, putting it at the forefront of the next phase of personalized medicine. However, although exploratory studies demonstrate potential utility, there is a need for rigorous validation and standardization before AI can be utilized in clinical decision-making. In this review, we will provide a summary of the current literature implementing AI for outcome prediction in lung cancer. We will describe the anticipated impact of AI on the management of patients with lung cancer and discuss the challenges of clinical implementation of these techniques.
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Inteligência Artificial , Tomada de Decisão Clínica/métodos , Diagnóstico por Imagem/métodos , Interpretação de Imagem Assistida por Computador/métodos , Neoplasias Pulmonares/diagnóstico por imagem , Humanos , Pulmão/diagnóstico por imagemRESUMO
Artificial intelligence (AI)-based models have become a growing area of interest in predictive medicine and have the potential to aid physician decision-making to improve patient outcomes. Imaging and radiomics play an increasingly important role in these models. This review summarizes recent developments in the field of radiomics for AI in head and neck cancer. Prediction models for oncologic outcomes, treatment toxicity, and pathological findings have all been created. Exploratory studies are promising; however, validation studies that demonstrate consistency, reproducibility, and prognostic impact remain uncommon. Prospective clinical trials with standardized procedures are required for clinical translation.
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Inteligência Artificial , Diagnóstico por Imagem/métodos , Neoplasias de Cabeça e Pescoço/diagnóstico por imagem , Interpretação de Imagem Assistida por Computador/métodos , Humanos , PrognósticoRESUMO
BACKGROUND: Patients with human papillomavirus-positive (HPV+) oropharyngeal squamous cell carcinoma (OPC) have substantially better treatment response and overall survival (OS) than patients with HPV-negative disease. Treatment options for HPV+ OPC can involve either a primary radiotherapy (RT) approach (± concomitant chemotherapy) or a primary surgical approach (± adjuvant radiation) with transoral surgery (TOS). These two treatment paradigms have different spectrums of toxicity. The goals of this study are to assess the OS of two de-escalation approaches (primary radiotherapy and primary TOS) compared to historical control, and to compare survival, toxicity and quality of life (QOL) profiles between the two approaches. METHODS: This is a multicenter phase II study randomizing one hundred and forty patients with T1-2 N0-2 HPV+ OPC in a 1:1 ratio between de-escalated primary radiotherapy (60 Gy) ± concomitant chemotherapy and TOS ± de-escalated adjuvant radiotherapy (50-60 Gy based on risk factors). Patients will be stratified based on smoking status (< 10 vs. ≥ 10 pack-years). The primary endpoint is OS of each arm compared to historical control; we hypothesize that a 2-year OS of 85% or greater will be achieved. Secondary endpoints include progression free survival, QOL and toxicity. DISCUSSION: This study will provide an assessment of two de-escalation approaches to the treatment of HPV+ OPC on oncologic outcomes, QOL and toxicity. Results will inform the design of future definitive phase III trials. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT03210103. Date of registration: July 6, 2017, Current version: 1.3 on March 15, 2019.
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Carcinoma de Células Escamosas/etiologia , Carcinoma de Células Escamosas/terapia , Protocolos Clínicos , Procedimentos Cirúrgicos Bucais , Neoplasias Orofaríngeas/etiologia , Neoplasias Orofaríngeas/terapia , Infecções por Papillomavirus/complicações , Radioterapia Adjuvante , Carcinoma de Células Escamosas/diagnóstico , Terapia Combinada , Feminino , Humanos , Masculino , Procedimentos Cirúrgicos Bucais/métodos , Neoplasias Orofaríngeas/diagnóstico , Infecções por Papillomavirus/virologia , Radioterapia Adjuvante/métodos , Projetos de PesquisaRESUMO
The oligometastatic and oligoprogressive disease states have been recently recognized as common clinical scenarios in the management of non-small cell lung cancer (NSCLC). As a result, there has been increasing interest in treating these patients with locally ablative therapies including surgery, conventionally fractionated radiotherapy, stereotactic ablative radiotherapy, and radiofrequency ablation. This article provides an overview of oligometastatic and oligoprogressive disease in the setting of NSCLC and reviews the evidence supporting ablative treatment. Phase II randomized controlled trials and retrospective series suggest that ablative treatment of oligometastases may substantially improve progression-free survival and overall survival, and additional large randomized studies testing this hypothesis in a definitive context are ongoing. However, several challenges remain, including quantifying the possible benefits of ablative therapies for oligoprogressive disease and developing prognostic and predictive models to assist in clinical decision making.
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Carcinoma Pulmonar de Células não Pequenas/cirurgia , Ablação por Cateter , Neoplasias Pulmonares/cirurgia , Radiocirurgia , Carcinoma Pulmonar de Células não Pequenas/secundário , Progressão da Doença , Humanos , Neoplasias Pulmonares/patologia , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
NUT carcinoma is a rare, aggressive malignancy defined as a carcinoma with a chromosomal rearrangement affecting the nuclear protein in testis (NUTM1) gene. This small round blue cell tumor classically exhibits focal abrupt keratinization and immunohistochemical positivity for keratin and squamous markers. However, keratinization is not always present and reports of positivity for other markers that may obscure the diagnosis are increasing. It is also noteworthy that gene fusions involving NUTM1 are not restricted to NUT carcinoma. Herein, we report a NUT carcinoma arising in the mediastinum of a male patient in his 40â s with morphological and immunohistochemical overlap with Ewing family sarcoma and poorly differentiated synovial sarcoma given a round cell morphology, diffuse strong immunoreactivity for CD99, and patchy strong immunoreactivity for TLE1. Squamous differentiation by morphology and p40 expression were notably absent in this case. Classification as NUT carcinoma was ultimately possible when the morphological and immunohistochemical findings were considered in the context of a BRD4::NUTM1 gene fusion identified by next-generation sequencing. While the patient initially responded to palliative radiotherapy, he died approximately one month later. To our knowledge, this is the first report of TLE1 immunoreactivity in NUT carcinoma. This case highlights a potential diagnostic pitfall and emphasizes the need for molecular confirmation in equivocal situations.
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Biomarcadores Tumorais , Proteínas Correpressoras , Proteínas Nucleares , Proteínas de Fusão Oncogênica , Humanos , Masculino , Biomarcadores Tumorais/genética , Biomarcadores Tumorais/metabolismo , Biomarcadores Tumorais/análise , Adulto , Proteínas Nucleares/genética , Proteínas Nucleares/metabolismo , Proteínas de Fusão Oncogênica/genética , Diagnóstico Diferencial , Neoplasias do Mediastino/diagnóstico , Neoplasias do Mediastino/patologia , Neoplasias do Mediastino/genética , Neoplasias do Mediastino/metabolismo , Proteínas de Neoplasias/genética , Proteínas de Neoplasias/metabolismo , Carcinoma/diagnóstico , Carcinoma/patologia , Carcinoma/genética , Sarcoma Sinovial/diagnóstico , Sarcoma Sinovial/patologia , Sarcoma Sinovial/genética , Sarcoma Sinovial/metabolismo , Evolução Fatal , Imuno-Histoquímica , Proteínas Repressoras/genética , Proteínas Repressoras/metabolismoRESUMO
BACKGROUND: Patients with oropharyngeal cancer (OPC) treated with chemoradiation can experience weight loss and tumor shrinkage, altering the prescribed treatment. Treatment replanning ensures patients do not receive excessive doses to normal tissue. However, it is a time- and resource-intensive process, as it takes 1 to 2 weeks to acquire a new treatment plan, and during this time, overtreatment of normal tissues could lead to increased toxicities. Currently, there are limited prognostic factors to determine which patients will require a replan. There remains an unmet need for predictive models to assist in identifying patients who could benefit from the knowledge of a replan prior to treatment. PURPOSE: We aimed to develop and evaluate a CT-based radiomic model, integrating clinical and dosimetric information, to predict the need for a replan prior to treatment. METHODS: A dataset of patients (n = 315) with OPC treated with chemoradiation was used for this study. The dataset was split into independent training (n = 220) and testing (n = 95) datasets. Tumor volumes and organs at risk (OARs) were contoured on planning CT images. PyRadiomics was used to compute radiomic image features (n = 1218) on the original and filtered images from each of the primary tumor, nodal volumes, and ipsilateral and contralateral parotid glands. Nine clinical features and nine dose features extracted from the OARs were collected and those significantly (p < 0.05) associated with the need for a replan in the training dataset were used in a baseline model. Random forest feature selection was applied to select the optimal radiomic features to predict replanning. Logistic regression, Naïve Bayes, support vector machine, and random forest classifiers were built using the non-correlated selected radiomic, clinical, and dose features on the training dataset and performance was assessed in the testing dataset. The area under the curve (AUC) was used to assess the prognostic value. RESULTS: A total of 78 patients (25%) required a replan. Smoking status, nodal stage, base of tongue subsite, and larynx mean dose were found to be significantly associated with the need for a replan in the training dataset and incorporated into the baseline model, as well as into the combined models. Five predictive radiomic features were selected (one nodal volume, one primary tumor, two ipsilateral and one contralateral parotid gland). The baseline model comprised of clinical and dose features alone achieved an AUC of 0.66 [95% CI: 0.51-0.79] in the testing dataset. The random forest classifier was the top-performing radiomics model and achieved an AUC of 0.82 [0.75-0.89] in the training dataset and an AUC of 0.78 [0.68-0.87] in the testing dataset, which significantly outperformed the baseline model (p = 0.023, testing dataset). CONCLUSIONS: This is the first study to use radiomics from the primary tumor, nodal volumes, and parotid glands for the prediction of replanning for patients with OPC. Radiomic features augmented clinical and dose features for predicting the need for a replan in our testing dataset. Once validated, this model has the potential to assist physicians in identifying patients that may benefit from a replan, allowing for better resource allocation and reduced toxicities.
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Neoplasias Orofaríngeas , Radiometria , Tomografia Computadorizada por Raios X , Neoplasias Orofaríngeas/diagnóstico por imagem , Neoplasias Orofaríngeas/radioterapia , Neoplasias Orofaríngeas/terapia , Humanos , Dosagem Radioterapêutica , Órgãos em Risco/efeitos da radiação , Planejamento da Radioterapia Assistida por Computador/métodos , Quimiorradioterapia , Masculino , Feminino , Pessoa de Meia-Idade , Carga Tumoral/efeitos da radiação , Idoso , RadiômicaRESUMO
PURPOSE: Because SABR therapy is being used to treat greater numbers of lung metastases, selecting the optimal dose and fractionation to balance local failure and treatment toxicity becomes increasingly challenging. Multilesion lung SABR therapy plans include spatially diverse lesions with heterogeneous prescriptions and interacting dose distributions. In this study, we developed and evaluated a generative adversarial network (GAN) to provide real-time dosimetry predictions for these complex cases. METHODS AND MATERIALS: A GAN was trained to predict dosimetry on a data set of patients who received SABR therapy for lung lesions at a tertiary center. Model input included the planning computed tomography scan, the organs at risk (OARs) and target structures, and an initial estimate of exponential dose fall-off. Multilesion plans were split 80/20 for training and evaluation. Models were evaluated on voxel-voxel, clinical dose-volume histogram, and conformality metrics. An out-of-sample validation and analysis of model variance were performed. RESULTS: There were 125 multilesion plans from 102 patients with 357 lesions. Patients were treated for 2 to 7 lesions, with 19 unique dose-fractionation schemes over 1 to 3 courses of treatment. The out-of-sample validation set contained an additional 90 plans from 80 patients. The mean absolute difference and gamma pass fraction between the predicted and true dosimetry was <3 Gy and >90% for all OARs. The absolute differences in lung V20 and CV14 were 1.40% ± 0.99% and 75.8 ± 42.0 cc, respectively. The ratios of predicted to true R50%, R100%, and D2cm were 1.00 ± 0.16, 0.96 ± 0.32, and 1.01 ± 0.36, respectively. The out-of-sample validation set maintained mean absolute difference and gamma pass fraction of <3 Gy and >90%, respectively for all OARs. The median standard deviation of variance in V20 and CV14 prediction was 0.49% and 22.2 cc, respectively. CONCLUSIONS: A GAN for predicting the 3-D dosimetry of complex multilesion lung SABR therapy is presented. Rapid dosimetry prediction can be used to assess treatment feasibility and explore dosimetric differences between varying prescriptions.
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PURPOSE: Response EvaluationCriteriain Solid Tumors (RECIST) is commonly used to assess response to anti-cancer therapies. However, its application after lung stereotactic ablative radiotherapy (SABR) is complicated by radiation-induced lung changes. This study assesses the frequency of progressive disease (PD) by RECIST following lung SABR and correlates this with actual treatment outcomes as determined by longitudinal follow-up. METHODS AND MATERIALS: We reviewed patients treated with lung SABR for primary lung tumors or oligometastases between 2010 and 2015. Patients were treated with SABR doses of 54-60 Gy in 3-8 fractions. All follow-up scans were assessed and the treated lesion was serially measured over time, with the maximum diameter on axial CT slices used for RECIST calculations. Lesions demonstrating PD by RECIST criteria were identified and subsequently followed for long-term outcomes. The final 'gold-standard' assessment of response was based on size changes after PD and, as available, positron emission tomography scan and/or biopsy. RESULTS: Eighty-eight lesions met inclusion criteria. Seventy-five were lung primaries and thirteen were lung metastases. Median follow-up was 52 months (interquartile range: 33-68). Two-thirds (66 %, 58/88) of treated lesions met RECIST criteria for PD; however, local recurrence was only confirmed in 16 % (9/58) of cases. Most lesions that triggered PD by RECIST (47/58, 81 %) were ultimately found not to represent recurrence, while a minority (2/58, 3 %) had an uncertain response. The positive predictive value [PPV] of a RECIST defined PD event was 0.16. If PD was triggered within 12-months post-treatment, PPV was 0.08, compared to 0.21 for lesions triggering PD after 12-months. CONCLUSION: Using RECIST criteria, two-thirds of patients treated with lung SABR met criteria for PD. However, only a minority had recurrence, leading to a poor PPV of RECIST. This highlights the limitations of RECIST in this setting and provides context for physicians when interpreting post-lung SABR imaging.
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Neoplasias Pulmonares , Radiocirurgia , Humanos , Critérios de Avaliação de Resposta em Tumores Sólidos , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/radioterapia , Neoplasias Pulmonares/patologia , Resultado do Tratamento , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/métodos , Radiocirurgia/métodos , Pulmão/diagnóstico por imagem , Pulmão/patologiaRESUMO
PURPOSE: This phase 1 study aimed to assess the safety and feasibility of SABR therapy delivery to all sites of polymetastatic disease (>10 metastases). METHODS AND MATERIALS: A 3 + 3 study design was used with 5 dose levels from 6 Gy (6 Gy × 1) to 30 Gy (6 Gy weekly × 5). Dose-limiting toxicity (DLT) was defined as any grade 4 or 5 toxicity or more than 3 grade 3 toxicities within 6 weeks of treatment. The primary endpoint was the maximal tolerated dose, defined as the dose level where ≥2/6 of patients experienced DLT. Secondary endpoints included quality of life (Functional Assessment of Cancer Therapy - General and European Quality of Life 5 Dimension 5 Level) at 6 weeks posttreatment, progression-free survival, and overall survival. RESULTS: Thirteen patients were accrued: 12 Gy (n = 3), 18 Gy (n = 3), 24 Gy (n = 4), and 30 Gy (n = 3), and 207 lesions were treated. Nine patients (69%) had acute toxicity: grade 1 (n = 6, 46%), grade 2 (n = 2, 15%; n = 1 pneumonitis and n = 1 fatigue), and grade 3 (n = 1, 7.7% neutropenia). There were no grade 4 or 5 toxicities. Mean ± SD quality of life (Functional Assessment of Cancer Therapy - General and European Quality of Life 5 Dimension 5 Level health state) was 80.4 ± 21.9 and 77.4 ± 20.9 at baseline versus 76.4 ± 21.8 and 68.0 ± 24.2 at 6-week follow-up, respectively (p = .009 and p = .055, respectively). With a median follow-up of 8.7 months posttreatment (IQR, 2.4-24 months), 8 of 13 patients had disease progression (62%). The median and 12-month progression-free survival were 3.6 months and 11.3%, respectively. The median and 12-month overall survival were 13.8 months and 62%, respectively. CONCLUSIONS: In this phase 1 trial, SABR therapy for polymetastatic disease was technically feasible with acceptable acute toxicity at dose levels up to 30 Gy (6 Gy weekly × 5). DLT was not observed.
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Importance: Patients with interstitial lung disease (ILD) and early-stage non-small cell lung cancer (NSCLC) have been reported to be at high risk of toxic effects after stereotactic ablative radiotherapy (SABR), but for many patients, there are limited alternative treatment options. Objective: To prospectively assess the benefits and toxic effects of SABR in this patient population. Design, Setting, and Participants: This prospective cohort study was conducted at 6 academic radiation oncology institutions, 5 in Canada and 1 in Scotland, with accrual between March 7, 2019, and January 12, 2022. Patients aged 18 years or older with fibrotic ILD and a diagnosis of T1-2N0 NSCLC who were not candidates for surgical resection were enrolled. Intervention: Patients were treated with SABR to a dose of 50 Gy in 5 fractions every other day. Main Outcomes and Measures: The study prespecified that SABR would be considered worthwhile if median overall survival-the primary end point-was longer than 1 year, with a grade 3 to 4 risk of toxic effects less than 35% and a grade 5 risk of toxic effects less than 15%. Secondary end points included toxic effects, progression-free survival (PFS), local control (LC), quality-of-life outcomes, and changes in pulmonary function. Intention-to-treat analysis was conducted. Results: Thirty-nine patients enrolled and received SABR. Median age was 78 (IQR, 67-83) years and 59% (n = 23) were male. At baseline, 70% (26 of 37) of patients reported dyspnea, median forced expiratory volume in first second of expiration was 80% (IQR, 66%-90%) predicted, median forced vital capacity was 84% (IQR, 69%-94%) predicted, and median diffusion capacity of the lung for carbon monoxide was 49% (IQR, 38%-61%) predicted. Median follow-up was 19 (IQR, 14-25) months. Overall survival at 1 year was 79% (95%, CI 62%-89%; P < .001 vs the unacceptable rate), and median overall survival was 25 months (95% CI, 14 months to not reached). Median PFS was 19 months (95% CI, 13-28 months), and 2-year LC was 92% (95% CI, 69%-98%). Adverse event rates (highest grade per patient) were grade 1 to 2: n = 12 (31%), grade 3: n = 4 (10%), grade 4: n = 0, and grade 5: n = 3 (7.7%, all due to respiratory deterioration). Conclusions and Relevance: In this trial, use of SABR in patients with fibrotic ILD met the prespecified acceptability thresholds for both toxicity and efficacy, supporting the use of SABR for curative-intent treatment after a careful discussion of risks and benefits. Trial Registration: ClinicalTrials.gov Identifier: NCT03485378.
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Carcinoma Pulmonar de Células não Pequenas , Doenças Pulmonares Intersticiais , Neoplasias Pulmonares , Radiocirurgia , Humanos , Carcinoma Pulmonar de Células não Pequenas/radioterapia , Carcinoma Pulmonar de Células não Pequenas/patologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Doenças Pulmonares Intersticiais/etiologia , Masculino , Neoplasias Pulmonares/radioterapia , Neoplasias Pulmonares/patologia , Feminino , Radiocirurgia/efeitos adversos , Radiocirurgia/métodos , Idoso , Estudos Prospectivos , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Qualidade de Vida , CanadáRESUMO
PURPOSE: The use of stereotactic body radiation therapy for tumors in close proximity to the central mediastinal structures has been associated with a high risk of toxicity. This study (NCT03306680) aimed to determine the maximally tolerated dose of stereotactic body radiation therapy for ultracentral non-small cell lung carcinoma, using a time-to-event continual reassessment methodology. METHODS AND MATERIALS: Patients with T1-3N0M0 (≤6 cm) non-small cell lung carcinoma were eligible. The maximally tolerated dose was defined as the dose of radiation therapy associated with a ≤30% rate of grade (G) 3 to 5 prespecified treatment-related toxicity occurring within 2 years of treatment. The starting dose level was 60 Gy in 8 daily fractions. The dose-maximum hotspot was limited to 120% and within the planning tumor volume; tumors with endobronchial invasion were excluded. This primary analysis occurred 2 years after completion of accrual. RESULTS: Between March 2018 and April 2021, 30 patients were enrolled at 5 institutions. The median age was 73 years (range, 65-87) and 17 (57%) were female. Planning tumor volume was abutting proximal bronchial tree in 19 (63%), esophagus 5 (17%), pulmonary vein 1 (3.3%), and pulmonary artery 14 (47%). All patients received 60 Gy in 8 fractions. The median follow-up was 37 months (range, 8.9-51). Two patients (6.7%) experienced G3-5 adverse events related to treatment: 1 patient with G3 dyspnea and 1 G5 pneumonia. The latter had computed tomography findings consistent with a background of interstitial lung disease. Three-year overall survival was 72.5% (95% CI, 52.3%-85.3%), progression-free survival 66.1% (95% CI, 46.1%-80.2%), local control 89.6% (95% CI, 71.2%-96.5%), regional control 96.4% (95% CI, 77.2%-99.5%), and distant control 85.9% (95% CI, 66.7%-94.5%). Quality-of-life scores declined numerically over time, but the decreases were not clinically or statistically significant. CONCLUSIONS: Sixty Gy in 8 fractions, planned and delivered with only a moderate hotspot, has a favorable adverse event rate within the prespecified acceptability criteria and results in excellent control for ultracentral tumors.
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BACKGROUND AND PURPOSE: Radiomics is a high-throughput approach that allows for quantitative analysis of imaging data for prognostic applications. Medical images are used in oropharyngeal cancer (OPC) diagnosis and treatment planning and these images may contain prognostic information allowing for treatment personalization. However, the lack of validated models has been a barrier to the translation of radiomic research to the clinic. We hypothesize that a previously developed radiomics model for risk stratification in OPC can be validated in a local dataset. MATERIALS AND METHODS: The radiomics signature predicting overall survival incorporates features derived from the primary gross tumor volume of OPC patients treated with radiation +/- chemotherapy at a single institution (n = 343). Model fit, calibration, discrimination, and utility were evaluated. The signature was compared with a clinical model using overall stage and a model incorporating both radiomics and clinical data. A model detecting dental artifacts on computed tomography images was also validated. RESULTS: The radiomics signature had a Concordance index (C-index) of 0.66 comparable to the clinical model's C-index of 0.65. The combined model significantly outperformed (C-index of 0.69, p = 0.024) the clinical model, suggesting that radiomics provides added value. The dental artifact model demonstrated strong ability in detecting dental artifacts with an area under the curve of 0.87. CONCLUSION: This work demonstrates model performance comparable to previous validation work and provides a framework for future independent and multi-center validation efforts. With sufficient validation, radiomic models have the potential to improve traditional systems of risk stratification, treatment personalization and patient outcomes.
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Neoplasias Orofaríngeas , Tomografia Computadorizada por Raios X , Humanos , Prognóstico , Neoplasias Orofaríngeas/diagnóstico por imagem , Neoplasias Orofaríngeas/terapia , Estudos RetrospectivosRESUMO
OBJECTIVE: We aimed to analyze risk factors associated with poor survival outcomes for metastatic cutaneous head-and-neck SCC to the parotid. METHODS: All patients undergoing surgery for metastatic cutaneous SCC to the parotid with curative intent between 2011 and 2018, were reviewed. Demographic and clinical characteristics were evaluated. Histopathological data including tumor size and histology, tumor grade, TNM stage, resection margins, lymphovascular invasion, and perineural invasion, were analyzed. Overall survival (OS), disease-specific survival (DSS), and freedom from locoregional recurrence (LRR) were assessed. RESULTS: Ninety patients were included (mean age, 77 years; 75 men [83.3%]). A total parotidectomy was performed in 48 patients (53.3%), and 42 (46.7%) underwent a superficial parotidectomy. Seventy patients (77.8%) underwent adjuvant RT. The median follow-up was 31 months (20-39 months). Tumor volume ≥ 50 cm3 and a shorter RT duration (<20 days) were associated with reduced OS (p = 0.002 and p = 0.01, p = 0.02 and p = 0.009, respectively), and DSS (p = 0.004 and p = 0.02, p = 0.04 and p = 0.02, respectively) on univariable and multivariable analysis, respectively. Only a shorter RT duration was associated with worse freedom from LRR on univariable and multivariable analysis, (p = 0.04 and p < 0.001, respectively). However, with death as a competing risk, a shorter duration of RT was not significantly associated with freedom from LRR. CONCLUSION: A shorter duration of adjuvant RT, and excised tumor volume ≥50 cm3 were predictive factors of reduced OS and DSS, and a shorter duration of RT was also associated with reduced freedom from LRR in patients with metastatic SCC to the parotid gland. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1163-1168, 2023.
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Carcinoma de Células Escamosas , Neoplasias Parotídeas , Neoplasias Cutâneas , Masculino , Humanos , Idoso , Carcinoma de Células Escamosas/patologia , Neoplasias Cutâneas/patologia , Glândula Parótida/cirurgia , Glândula Parótida/patologia , Neoplasias Parotídeas/patologia , Estadiamento de Neoplasias , Radioterapia Adjuvante , Recidiva Local de Neoplasia/patologia , Fatores de Risco , Estudos RetrospectivosRESUMO
Background: Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) has increased in incidence in recent decades. With higher cure rates in younger populations, long-term survivors may live with acute- and long-term toxicity, leading to increased interest in de-escalation treatment strategies for HPV-related OPSCC. Herein, we have examined the current landscape of clinical trials in this context. Methods: A review of active clinical trials related to de-escalation of HPV-associated OPSCC treatment was performed using the clinicaltrials.gov database from inception to January 2022. A search using the key words "oropharyngeal cancer" and "HPV" was completed. Three investigators independently reviewed each trial, with any discrepancies settled by a fourth. Data collected from each study included study phase, study design, primary, and secondary endpoints, and de-escalation treatment strategies. A final 24 articles were selected for full text review. Results: Many trials (n=19, 79%) were non-randomized, and most studies employed a phase II design (n=14, 58%). Only 13% (n=3) were randomized trials, and 8% (n=2) included a phase III component. The most frequent primary endpoint was progression-free survival (PFS) (n=9, 37.5%). With regards to the identified de-escalation strategies, all the studies (n=24) had at least one component assessing changes in RT dose/fractionation and/or a reduction in RT volumes. A smaller percentage of trials assessed surgical interventions (n=9, 37.5%) and/or changes in systemic therapy (n=8, 33.3%). Conclusion: A small number of randomized trials are underway, and a transition to more randomized phase III trials in the future will be important to change clinical practice.
RESUMO
PURPOSE: Primary radiation therapy with or without chemotherapy (RT/CRT) is the most common treatment for oropharyngeal squamous cell carcinomas (OPSCC), but there has been an increase in transoral surgery (TOS) for T1-2 tumors. Because only a subset of T1-2 tumors are TOS-favorable, nonrandomized comparisons between RT/CRT and TOS could be confounded by indication. We aimed to compare outcomes of potential TOS-candidates versus non-TOS candidates, among patients who underwent RT/CRT for early T-stage OPSCC. METHODS AND MATERIALS: For patients treated with RT/CRT for early-stage human papilloma virus positive OPSCC between 2014 and 2018, pretreatment imaging was reviewed by 3 head and neck surgeons, blinded to outcomes, to assess primary-site appropriateness for TOS, and extracapsular extension (ECE) was scored by a head and neck neuroradiologist. We compared outcomes based on surgical favorability pertaining to (1) the primary site tumor alone and (2) the primary site and an absence of ECE. Kaplan-Meier estimates for overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were compared using the log-rank test, with Cox regression used for multivariable modeling. RESULTS: One hundred and forty-three patients were evaluated, of which 121 were male (84.6%), the median age was 59.4 years, and all of them were p16 positive (100%). The primary site was TOS-favorable in 115 of 143 (80.4%). Patients with TOS-favorable primary site experienced superior 5-year OS (89.8% vs 71.2%, P = .017), DSS (90.4% vs 63.4%, P = .022), and RFS (83% vs 49.4%, P = .04) compared with TOS-unfavorable patients. Similarly, patients with a TOS-favorable primary site and no ECE on imaging 101 of 143 (70.6%), had improved OS, DSS, and RFS (P < .05) compared with TOS-unfavorable patients. CONCLUSIONS: In this first study to assess surgical favorability as a prognostic factor among patients with T1/2 p16+ OPSCC, patients with TOS-favorable early-stage OPSCC have better outcomes than TOS-unfavorable patients. This provides valuable prognostic information for patients, and also suggests the risk of confounding by indication in nonrandomized comparisons of treatment modalities.
Assuntos
Alphapapillomavirus , Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Orofaríngeas , Carcinoma de Células Escamosas/diagnóstico por imagem , Carcinoma de Células Escamosas/radioterapia , Carcinoma de Células Escamosas/cirurgia , Extensão Extranodal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Orofaríngeas/diagnóstico por imagem , Neoplasias Orofaríngeas/radioterapia , Neoplasias Orofaríngeas/cirurgia , Papillomaviridae , Carcinoma de Células Escamosas de Cabeça e PescoçoRESUMO
BACKGROUND: Numerous studies of head and neck squamous cell carcinoma (HNSCC) have demonstrated disparate outcomes by race and ethnicity. Beyond known associations with socioeconomic variables, whether these are also associated with differences in tumor molecular composition has thus far been poorly explored. METHODS: We downloaded clinical and multiplatform molecular data from The Cancer Genome Atlas and other published studies. These were compared between non-Hispanic Black (n = 43) and White (n = 354) patients with non-HPV-related tumors, using multivariable models. Publicly available validation cohorts were used. RESULTS: Black patients had poorer progression-free survival than White patients. Tumors of Black patients had greater copy number aberrations, and increased SFRP1 methylation and miRNA-mediated PRG4 silencing associated with poor survival. PI3K/AkT/mTOR pathway proteins were differentially expressed. CONCLUSIONS: There are molecular differences between tumors of Black and White patients that may partially account for differences in survival. These may inform targeted treatment decisions to achieve equitable outcomes.
Assuntos
População Negra , Neoplasias de Cabeça e Pescoço , Disparidades nos Níveis de Saúde , Carcinoma de Células Escamosas de Cabeça e Pescoço , Neoplasias de Cabeça e Pescoço/etnologia , Neoplasias de Cabeça e Pescoço/terapia , Humanos , Carcinoma de Células Escamosas de Cabeça e Pescoço/etnologia , Carcinoma de Células Escamosas de Cabeça e Pescoço/terapia , Taxa de Sobrevida , População Branca/genéticaRESUMO
BACKGROUND: There is significant interest in treatment de-escalation for human papillomavirus-associated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC) patients given the generally favourable prognosis. However, 15-30% of patients recur after primary treatment, reflecting a need for improved risk-stratification tools. We sought to develop a molecular test to risk stratify HPV+ OPSCC patients. METHODS: We created an immune score (UWO3) associated with survival outcomes in six independent cohorts comprising 906 patients, including blinded retrospective and prospective external validations. Two aggressive radiation de-escalation cohorts were used to assess the ability of UWO3 to identify patients who recur. Multivariate Cox models were used to assess the associations between the UWO3 immune class and outcomes. FINDINGS: A three-gene immune score classified patients into three immune classes (immune rich, mixed, or immune desert) and was strongly associated with disease-free survival in six datasets, including large retrospective and prospective datasets. Pooled analysis demonstrated that the immune rich group had superior disease-free survival compared to the immune desert (HR = 9.0, 95% CI: 3.2-25.5, P = 3.6 × 10-5) and mixed (HR = 6.4, 95% CI: 2.2-18.7, P = 0.006) groups after adjusting for age, sex, smoking status, and AJCC8 clinical stage. Finally, UWO3 was able to identify patients from two small treatment de-escalation cohorts who remain disease-free after aggressive de-escalation to 30 Gy radiation. INTERPRETATION: With additional prospective validation, the UWO3 score could enable biomarker-driven clinical decision-making for patients with HPV+ OPSCC based on robust outcome prediction across six independent cohorts. Prospective de-escalation and intensification clinical trials are currently being planned. FUNDING: CIHR, European Union, and the NIH.
Assuntos
Neoplasias de Cabeça e Pescoço , Neoplasias Orofaríngeas , Infecções por Papillomavirus , Humanos , Infecções por Papillomavirus/complicações , Estudos Retrospectivos , Recidiva Local de Neoplasia , Neoplasias Orofaríngeas/terapia , Carcinoma de Células Escamosas de Cabeça e Pescoço , Prognóstico , Biomarcadores , Papillomavirus Humano , PapillomaviridaeRESUMO
In 2010, the annual general meeting of the Clinical Investigator Trainee Association of Canada - Association des cliniciens-chercheurs en formation du Canada (CITAC-ACCFC) and the Canadian Society for Clinician Investigators (CSCI) was held between September 20 and 22 in Ottawa. Several globally-renowned scientists, including this year's CSCI/Royal College Henry Friesen Award recipient, Dr. Paul Kubes, Distinguished Scientist Award recipient, Dr. Gideon Koren and Joe Doupe Young Investigator Award recipient, Dr. Torsten Neil, discussed a variety of topics relating to the role of technology in medicine. The meeting was well attended by clinician scientists and trainees from across Canada and offered trainees mentorship and networking opportunities in addition to showcasing their research at the young investigator forum. The aim of this scientific overview is to highlight the research presented by trainees at both the oral plenary session as well as the poster presentation sessions of this meeting. Similar to last year's meeting [1], research questions being investigated by trainees covered the spectrum of medical disciplines, encompassing both basic science as well as clinical areas, and are summarized below.