Imaging and Biomarker Surveillance for Head and Neck Squamous Cell Carcinoma: A Systematic Review and American Radium Society Appropriate Use Criteria Statement.

Surveillance for survivors of head and neck cancer (HNC) is focused on early detection of recurrent or second primary malignancies. After initial restaging confirms disease-free status, the use of surveillance imaging for asymptomatic patients with HNC is controversial. Our objective was to comprehensively review literature pertaining to imaging and biomarker surveillance of asymptomatic patients treated for head and neck squamous cell carcinoma and to convene a multidisciplinary expert panel to provide appropriate use criteria for surveillance in representative clinical scenarios. The evidence base for the appropriate use criteria was gathered through a librarian-mediated search of literature published from 1990 to 2022 focused on surveillance imaging and circulating tumor-specific DNA for nonmetastatic head and neck squamous cell carcinoma using MEDLINE (Ovid), Embase, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials. The systematic review was reported according to PRISMA guidelines. Using the modified Delphi process, the expert panel voted on appropriate use criteria, providing recommendations for appropriate use of surveillance imaging and human papillomavirus (HPV) circulating tumor DNA. Of 5178 studies identified, 80 met inclusion criteria (5 meta-analyses/systematic reviews, 1 randomized control trial, 1 post hoc analysis, 25 prospective, and 48 retrospective cohort studies [with ≥50 patients]), reporting on 27,525 patients. No large, randomized, prospective trials examined whether asymptomatic patients who receive surveillance imaging or HPV circulating tumor DNA monitoring benefit from earlier detection of recurrence or second primary tumors in terms of disease-specific or quality-of-life outcomes. In the absence of prospective data, surveillance imaging for HNC survivors should rely on individualized recurrence-risk assessment accounting for initial disease staging, HPV disease status, and tobacco use history. There is an emerging surveillance role for circulating tumor biomarkers.

Definitive Chemoradiation Associated with Improved Survival Outcomes in Patients with Synchronous Oligometastatic Esophageal Cancer.

BACKGROUND: The study of oligometastatic esophageal cancer (EC) is relatively new. Preliminary data suggests that more aggressive treatment regimens in select patients may improve survival rates in oligometastatic EC. However, the consensus recommends palliative treatment. We hypothesized that oligometastatic esophageal cancer patients treated with a definitive approach (chemoradiotherapy [CRT]) would have improved overall survival (OS) compared to those treated with a purely palliative intent and historical controls. METHODS: Patients diagnosed with synchronous oligometastatic (any histology, ≤5 metastatic foci) esophageal cancer treated in a single academic hospital were retrospectively analyzed and divided into definitive and palliative treatment groups. Definitive CRT was defined as radiation therapy to the primary site with ≥40 Gy and ≥2 cycles of chemotherapy. RESULTS: Of 78 Stage IVB (AJCC 8th ed.) patients, 36 met the pre-specified oligometastatic definition. Of these, 19 received definitive CRT, and 17 received palliative treatment. With a median follow-up of 16.5 months (Range: 2.3-95.0 months), median OS for definitive CRT and palliative groups were 90.2 and 8.1 months (p < 0.01), translating into 5-year OS of 50.5% (95%CI: 32.0-79.8%) vs. 7.5% (95%CI: 1.7-48.9%), respectively. CONCLUSIONS: Oligometastatic EC patients treated with definitive CRT benefited from that approach with survival rates (50.5%) that vastly exceeded historical standards of 5% at 5 years for metastatic EC. Oligometastatic EC patients treated with definitive CRT had significantly improved OS compared to those treated with palliative-only intent within our cohort. Notably, definitively treated patients were generally younger and with better performance status versus those palliatively treated. Further prospective evaluation of definitive CRT for oligometastatic EC is warranted.

Treatment Patterns in Women Age 80 and Over With DCIS: A Report From the National Cancer Database.

BACKGROUND: Despite an aging population, there are no established treatment guidelines for women with ductal carcinoma in situ (DCIS) age ≥80. Here we describe national treatment patterns and survival outcomes in older women with DCIS. PATIENTS AND METHODS: Women age ≥80 diagnosed with DCIS from 2005 to 2014 were identified using the National Cancer Database. χ2, Fisher's exact test, and logistic regression models were used to identify factors influencing receipt of breast surgery, and Kaplan-Meier method and Cox proportional hazard models were used to evaluate overall survival (OS). RESULTS: A total of 6,070 women with DCIS met inclusion criteria, of which the majority (98%) received surgery. Receipt of surgery was independently associated with age <90. OS was higher for those who received surgery compared to those who did not (HR 2.2 [1.72-2.83] P < .001). CONCLUSION: The vast majority of patients age ≥80 with DCIS in the National Cancer Database received primary surgical management, which was associated with a significant OS benefit. Considering comorbidities and patient fitness, surgical resection should be considered for all patients age ≥80 who are suitable operative candidates.

Invasive Breast Cancer Treatment Patterns in Women Age 80 and Over: A Report from the National Cancer Database.

BACKGROUND: There are no established treatment guidelines for women with breast cancer aged ≥80 despite increasing representation in the US population. Here we identify national treatment patterns and survival outcomes in women with stage I-III invasive breast cancer. PATIENTS AND METHODS: Women age ≥80 diagnosed with stage I-III invasive breast cancer (IBC) were identified from 2005-2014 in the National Cancer Database. χ2, Fisher's exact test, and logistic regression models were used to identify factors influencing receipt of breast surgery, and Cox proportional hazard models were used to evaluate overall survival (OS). RESULTS: A total of 62,575 women with IBC met inclusion criteria, of which the majority received surgery (94%). Receipt of surgery was associated with White race, age <90, lower stage, and fewer comorbidities. OS was higher for those who received surgery compared to those who did not (HR 3.3 [3.18-3.46] P < .001). Molecular subtype analysis demonstrated improved survival with receipt of surgery or radiation for all subtypes, as well as improved survival with chemotherapy for those with triple negative breast cancer. CONCLUSION: The vast majority of breast cancer patients aged ≥80 in the National Cancer Database with IBC received primary surgical management, which was associated with a significant OS benefit. Due to this finding, surgical resection should be considered for all patients ≥80 who are suitable operative candidates.

Evaluation of the current prostate cancer staging system based on cancer-specific mortality in the surveillance, epidemiology, and end results database.

BACKGROUND: Prostate cancer is the most common noncutaneous malignancy diagnosed in men. From a large population-based database, this study aimed to report prostate cancer-specific mortality (PCSM) rates of men diagnosed with various presentations of prostate cancer and to examine the adequacy of the current American Joint Committee on Cancer (AJCC) staging system. PATIENTS AND METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried for all patients diagnosed with prostate cancer from 1997 to 2005. PCSM was reported by the classification of extent of disease provided by the SEER database, for clinically staged and pathologically staged cohorts. RESULTS: Using the cumulative incidence method, PCSM at 10 years for all patients (n = 354,326) was 5% for clinically localized (CL) lesions, 7% for T3aN0M0, 14% for T3bN0M0, 26% for T4N0M0, 27% for TanyN1M0, and 66% for TanyNanyM1. Within the pathologically staged subgroup (n = 108,135), PCSM at 10 years was 1% for CL lesions, 4% for T3aN0M0, 9% for T3bN0M0, 9% for T4N0M0, and 19% for TanyN1M0. CONCLUSION: Staging of any disease site aims to accurately communicate, prognosticate, and guide management for that particular level of disease. Stage IV prostate cancer is a diverse group, with PCSM in the subgroups ranging from 9% to 68% in this study. Considering the favorable outcomes of those with T4 or N1 nonmetastatic prostate cancer relative to those with M1 disease, the authors propose that T4 or N1 M0 prostate cancer should be reclassified into a new stage IIIB and that patients with such disease should be offered curative-intent therapy whenever possible.

Stereotactic body radiotherapy for a large arteriovenous malformation of the head and neck.

Large arteriovenous malformations (AVMs) of the head and neck present a treatment challenge. A 38-year-old woman presented with a large intraoral bleed from longstanding AVMs of the left infratemporal fossa and the right tongue, despite 10 prior surgeries and embolizations. She was treated with stereotactic body radiotherapy with a dose of 24 Gy in three weekly fractions. Four years later, she has had dramatic shrinkage of her AVM, no recurrent bleeding episodes, no further treatment required, and no significant late effects. Level of evidence: NA.

Impact of postmastectomy radiation on locoregional recurrence in breast cancer patients with 1-3 positive lymph nodes treated with modern systemic therapy.

PURPOSE: Postmastectomy radiation therapy (PMRT) remains controversial for patients with 1-3 positive lymph nodes (LN+). METHODS AND MATERIALS: We conducted a retrospective review of all 369 breast cancer patients with 1-3 LN+ who underwent mastectomy without neoadjuvant systemic therapy between 2000 and 2007 at Cleveland Clinic. RESULTS: We identified 271 patients with 1-3 LN+ who did not receive PMRT and 98 who did receive PMRT. The median follow-up time was 5.2 years, and the median number of LN dissected was 11. Of those not treated with PMRT, 79% received adjuvant chemotherapy (of whom 70% received a taxane), 79% received hormonal therapy, and 5% had no systemic therapy. Of the Her2/neu amplified tumors, 42% received trastuzumab. The 5-year rate of locoregional recurrence (LRR) was 8.9% without PMRT vs 0% with PMRT (P=.004). For patients who did not receive PMRT, univariate analysis showed 6 risk factors significantly (P<.05) correlated with LRR: estrogen receptor/progesterone receptor negative (hazard ratio [HR] 2.6), lymphovascular invasion (HR 2.4), 2-3 LN+ (HR 2.6), nodal ratio >25% (HR 2.7), extracapsular extension (ECE) (HR 3.7), and Bloom-Richardson grade III (HR 3.1). The 5-year LRR rate was 3.4% (95% confidence interval [CI], 0.1%-6.8%] for patients with 0-1 risk factor vs 14.6% [95% CI, 8.4%-20.9%] for patients with ≥2 risk factors (P=.0006), respectively. On multivariate analysis, ECE (HR 4.3, P=.0006) and grade III (HR 3.6, P=.004) remained significant risk factors for LRR. The 5-year LRR was 4.1% in patients with neither grade III nor ECE, 8.1% with either grade III or ECE, and 50.4% in patients with both grade III and ECE (P<.0001); the corresponding 5-year distant metastasis-free survival rates were 91.8%, 85.4%, and 59.1% (P=.0004), respectively. CONCLUSIONS: PMRT offers excellent control for patients with 1-3 LN+, with no locoregional failures to date. Patients with 1-3 LN+ who have grade III disease and/or ECE should be strongly considered for PMRT.