Risk Stratification for Oropharyngeal Squamous Cell Carcinoma Using Texture Analysis on CT - A Step Beyond HPV Status.

Background and Purpose: Human papillomavirus-associated oropharyngeal squamous cell carcinoma (OPSCC) is increasingly prevalent. Despite the overall more favorable outcome, the observed heterogeneous treatment response within this patient group highlights the need for additional means to prognosticate and guide clinical decision-making. Promising prediction models using radiomics from primary OPSCC have been derived. However, no model/s using metastatic lymphadenopathy exist to allow prognostication in those instances when the primary tumor is not seen. The aim of our study was to evaluate whether radiomics using metastatic lymphadenopathy allows for the development of a useful risk assessment model comparable to the primary tumor and whether additional knowledge of the HPV status further improves its prognostic efficacy. Materials and Methods: 80 consecutive patients diagnosed with stage III-IV OPSCC between February 2009 and October 2015, known human papillomavirus status, and pre-treatment CT images were retrospectively identified. Manual segmentation of primary tumor and metastatic lymphadenopathy was performed and the extracted texture features were used to develop multivariate assessment models to prognosticate treatment response. Results: Texture analysis of either the primary or metastatic lymphadenopathy from pre-treatment enhanced CT images can be used to develop models for the stratification of treatment outcomes in OPSCC patients. AUCs range from .78 to .85 for the various OPSCC groups tested, indicating high predictive capability of the models. Conclusions: This preliminary study can form the basis multi-centre trial that may help optimize treatment and improve quality of life in patients with OPSCC in the era of personalized medicine.

TRK Inhibition with Entrectinib in Metastatic Salivary Secretory Carcinoma (SC): A Case Report.

NTRK gene fusions are rare oncogenic driver mutations that can be found in a broad range of neoplasms. In secretory carcinoma (SC), ETV6-NTRK3 gene fusion is seen in a majority of the cases and represents a druggable target for patients with advanced disease in the absence of a currently accepted standard of care. In our case, we describe a patient with recurrent, metastatic SC treated with first line entrectinib with clinically meaningful, durable ongoing response after 49 months. The patient experienced grade 1 fatigue, dysgeusia, skin sensitivity, arthralgias, an increase in serum creatinine, and weight-gain as well as grade 2 hypotension which resolved after a dose reduction. Entrectinib is a well-tolerated treatment with the potential for durable responses and TRK inhibition should be considered the standard of care in SC and other NTRK gene fusion-positive advanced neoplasms without acceptable alternative treatment options.

Novel imaging classification system of nodal disease in human papillomavirus-mediated oropharyngeal squamous cell carcinoma prognostic of patient outcomes.

BACKGROUND: Matted nodes in human papillomavirus (HPV)-mediated oropharyngeal squamous cell carcinoma (OPC) is an independent predictor of distant metastases and decreased overall survival. We aimed to classify imaging patterns of metastatic lymphadenopathy, analyze our classification system for reproducibility, and assess its prognostic value. METHODS: The metastatic lymphadenopathy was classified based on radiological characteristics for 216 patients with HPV-mediated OPC. Patient outcomes were compared and inter-rater reliability was calculated. RESULTS: The presence of ≥3 abutting lymph nodes with imaging features of surrounding extranodal extension (ENE), one subtype of matted nodes, was associated with worse 5-year overall survival, overall recurrence-free survival, regional recurrence-free survival, and distant recurrence-free survival (p ≤ 0.03). Other patterns were not significantly associated with outcome measures. Overall inter-rater agreement was substantial (κ = 0.73). CONCLUSION: One subtype of matted nodes defined by ≥3 abutting lymph nodes with imaging features of surrounding ENE is the radiological marker of worst prognosis.

Volumetric changes in pharyngeal structures following head and neck cancer chemoradiation therapy.

OBJECTIVES/HYPOTHESIS: To determine the volumetric changes in pharyngeal structures in patients with head and neck squamous cell carcinoma (HNSCC) treated with curative chemoradiation therapy (CRT). Patients treated with CRT for esophageal carcinoma (EC), where pharyngeal structures were not part of the radiation treatment fields, were controlled for dysphagia-associated weight loss. We hypothesize that tissue volume alteration is a contributing factor of post-CRT dysphagia. STUDY DESIGN: Case series. METHODS: This study measured pre- and 1-year posttreatment volumes of the base of tongue (BOT), parapharyngeal spaces, posterior pharyngeal constrictors (PCs), and retropharyngeal space (RPS) in patients undergoing CRT for HNSCC or EC treated January 1, 2012 to December 31, 2015. All HNSCC patients were treated to doses of 66 to 70 Gy in 30 to 33 fractions using intensity-modulated radiotherapy techniques. RESULTS: Our cohort included 49 HNSCC and 11 EC patients. Within the HNSCC cohort, the PCs volume increased 1.55 cm3 (95% confidence interval [CI]: 0.77 to 2.34 cm3 , P = .0002), RPS increased 1.22 cm3 (95% CI: 0.67 to 1.77 cm3 , P < .0001), and BOT decreased 2.29 cm3 (95% CI: -0.20 to 4.79 cm3 , P = .070). The EC cohort showed no significant volumetric changes for any anatomic space, with combined PCs and RPS volume changes statistically less than the HNSCC cohort (P = .031). There was no difference in mean body mass index reduction between groups (P = .10). CONCLUSIONS: Volumetric changes following CRT may play a role in posttreatment dysphagia. Our findings support loss of physiologic function from posterior pharynx tissue thickening combined with reduced pharyngeal constriction capacity, and BOT atrophy secondary to radiation effects contribute to dysphagia. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:597-602, 2020.

Improved transoral surgical tool design by CT measurements of the oral cavity and pharynx.

The majority of head and neck cancers arise from the oral cavity and oropharynx. Many of these lesions will be amenable to surgical resection using transoral approaches including transoral robotic surgery (TORS). To develop and control TORS tools, precise dimensions of the oral cavity and pharynx are desirable. CT angiograms of 76 patients were analyzed. For the oral cavity, only the maximum length and width were measured, while for the pharynx, the width, length, and areas of the airway were all measured and the volume calculated. A prototype TORS tool was developed and tested based on the findings and dimensions. The design modification of the tool is in progress. The mean male oral cavity width and length were 93.3 ± 4.3 and 77.0 ± 7.2 mm, respectively, and the mean male pharyngeal width, length, area, and volume were 26.5 ± 7.2 mm, 16.2 ± 8.8 mm, 325 ± 149 mm2, and 28,440 ± 14,100 mm3, respectively, while the mean female oral cavity width and length were 84.5 ± 12.9 and 71.0 ± 6.3 mm, respectively, and the mean female pharyngeal width, length, area, and volume were 24.8 ± 5.6 mm, 13.7 ± 3.2 mm, 258 ± 98 mm2, and 17,660 ± 7700 mm3, respectively. The developed TORS tool was tested inside the oral cavity of an intubation mannequin. These data will also be used to develop an electronic no-go cone-shape tunnel to improve the safety of the surgical field. Reporting the oral cavity and pharyngeal dimensions is important for design of TORS tools and creating control zones for the workspace of the tool inside the oral cavity.

Diagnostic utility of central node necrosis in predicting extracapsular spread among oral cavity squamous cell carcinoma.

BACKGROUND: Oral cavity squamous cell carcinoma (SCC) represents the most common SCC affecting the head and neck region. Long-term survival of patients with oral cavity SCC is adversely affected by lymph node metastasis and further decreased by the presence of lymph node extracapsular spread (ECS). METHODS: Using a case-control design, preoperative CT scans from patients with oral cavity SCC and metastatic lymphadenopathy were evaluated by 2 independent neuroradiologists, blinded to the study, for a number of radiologic parameters, including central node necrosis. Multivariate logistic regression was used to identify parameters independently predicting pathologic ECS. RESULTS: For both neuroradiologists, central node necrosis was a significant predictor of ECS, with high interrater agreement (kappa = 0.71). On multivariate analysis, only central node necrosis independently predicted ECS (odds ratio [OR] = 12.1; 95% confidence interval [CI] = 1.24-119). Central node necrosis predicted ECS with 91% sensitivity and 88% negative predictive values. CONCLUSION: Our findings suggest that central node necrosis on preoperative CT scans is strongly associated with the presence of ECS.

Impact of neuroradiologist second opinion on staging and management of head and neck cancer.

OBJECTIVE: Patients with head and neck cancer frequently present to academic tertiary referral centers with imaging studies that have been performed and interpreted elsewhere. At our institution, these outside head and neck imaging studies undergo formal second opinion reporting by a fellowship-trained academic neuroradiologist with expertise in head and neck imaging. The purpose of this study was to determine the impact of this practice on cancer staging and patient management. METHODS: Our institutional review board approved the retrospective review of randomized original and second opinion reports for 94 consecutive cases of biopsy proven or clinically suspected head and neck cancer in calendar year 2010. Discrepancy rates for staging and recommended patient management were calculated and, for the 32% (30/94) of cases that subsequently went to surgery, the accuracies of the reports were determined relative to the pathologic staging gold standard. RESULTS: Following neuroradiologist second opinion review, the cancer stage changed in 56% (53/94) of cases and the recommended management changed in 38% (36/94) of patients with head and neck cancer. When compared to the pathologic staging gold standard, the second opinion was correct 93% (28/30) of the time. CONCLUSION: In a majority of patients with head and neck cancer, neuroradiologist second opinion review of their outside imaging studies resulted in an accurate change in their cancer stage and this frequently led to a change in their management plan.

Impact of newer generation multidetector computed tomography on the diagnosis of abscesses in the head and neck.

OBJECTIVE: To understand how newer generation multidetector computed tomographic (NGCT) scanner technology (≥ 16 slices) has affected the imaging characteristics of head and neck abscesses. DESIGN: Retrospective chart review. SETTING: Tertiary referral centre. METHODS: Forty-eight patients with a head and neck abscess who underwent a soft tissue neck computed tomographic (CT) scan were identified from September 1, 2001, to December 1, 2008. The degree of rim enhancement, delta (Δ), was graded using mean Hounsfield units (HU) from five peripheral points and five central points from a representative CT slice. The difference was then calculated and compared between older generation computed tomography (OGCT; < 16 slices) and newer generation multidetector computed tomography (NGCT; ≥ 16 slices) using the Student t-test. A p value < .05 was considered significant. RESULTS: Forty-eight patients met our inclusion criteria. Of these, 20 were scanned with OGCT and 28 were scanned with NGCT. The mean peripheral point values were OGCT  =  78 HU (95% CI 71-86 HU), NGCT  =  74 HU (95% CI 68-80 HU); p  =  .3. The mean central point values were OGCT  =  24 HU (95% CI 21-28 HU), NGCT  =  26 HU (95% CI 21-31 HU), p  =  0.7. The mean delta values (mean peripheral HU--mean central HU) were OGCT  =  52 HU (95% CI 43-61 HU), NGCT  =  46 HU (95% CI 41-52 HU), p  =  .2. CONCLUSION: There is no significant difference between OGCT and NGCT in the amount of rim enhancement seen on CT scans of head and neck abscesses.