Comparing adjuvant radiation to adjuvant chemoradiation in postsurgical p16+ oropharyngeal carcinoma patients with extranodal extension or positive margins

Head & Neck ◽  
2021 ◽  
Author(s):  
Jordan B. Fenlon ◽  
Ryan J. Hutten ◽  
Christopher R. Weil ◽  
Shane Lloyd ◽  
Donald M. Cannon ◽  
...  
Keyword(s):  
Oropharyngeal Carcinoma ◽  
Adjuvant Radiation ◽  
Adjuvant Chemoradiation ◽  
Positive Margins ◽  
Extranodal Extension

Clinical vs Microscopic Extranodal Extension and Survival in Oropharyngeal Carcinoma in the Human Papillomavirus Era

2020 ◽  
Vol 162 (5) ◽  
pp. 693-701
Author(s):  
Thomas J. Gal ◽  
Kaitlin July O’Brien ◽  
Quan Chen ◽  
Bin Huang
Keyword(s):  
Squamous Cell Carcinoma ◽  
Human Papillomavirus ◽  
Cell Carcinoma ◽  
Head And Neck ◽  
Squamous Cell ◽  
Oropharyngeal Carcinoma ◽  
Adjuvant Radiation ◽  
National Cancer Database ◽  
Extranodal Extension ◽  
The Impact

Objective Extranodal extension (ENE) is known to be associated with poor outcomes in head and neck squamous cell carcinoma. The objective of this study is to examine the impact of extent of ENE on survival in oropharyngeal carcinoma in the human papillomavirus (HPV) era. Study Design Retrospective database review. Setting Review of the National Cancer Database. Subjects and Methods The National Cancer Database was used to examine surgically treated head and neck squamous cell carcinoma of the tonsil and base of tongue from 2010 to 2015. Nodes available for pathologic examination were classified as ENE negative (–), ENE clinically (+), or ENE (+) on pathology only. The primary outcome was overall survival. Cox regression modeling was used to examine the effect of ENE on survival while controlling for patient demographics, HPV status, stage, adjuvant radiation, and chemotherapy. Results Of the 66,106 patients identified, 16,845 were treated with surgery ± adjuvant therapy, 8780 of whom were known HPV+. Overall 5-year survival for this group was 86%. Documented ENE was associated with over a 60% decrease in survival for clinical (hazard ratio [HR], 1.63) and pathologic (HR, 1.62) ENE compared to negative ENE, after adjustment for stage, adjuvant radiation ± chemotherapy, HPV, and other variables. No significant differences were found between clinical and pathologic ENE (HR, 1.001). Conclusion While both surgically resected clinical and pathologic ENE are associated with decreased survival, no significant differences are observed between the two. The impact of these observations on potential de-escalation therapeutic strategies requires further study.

A population-based study of factors associated with post-prostatectomy radiation therapy utilization.

2014 ◽  
Vol 32 (4_suppl) ◽  
pp. 182-182
Author(s):  
Matthew J. Maurice ◽  
Hui Zhu ◽  
Robert Abouassaly
Keyword(s):  
Radiation Therapy ◽  
Gleason Score ◽  
Strong Predictor ◽  
Teaching Hospitals ◽  
Time Range ◽  
Adjuvant Radiation ◽  
Cancer Society ◽  
Positive Margins ◽  
Pathologic Features ◽  
To Receive

182 Background: Based on level one evidence, adjuvant radiation therapy (aRT) improves cancer control in post-prostatectomy patients with adverse pathologic features. We sought to evaluate its utilization and to identify factors affecting of its use. Methods: Using the National Cancer Database, a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society, we identified men diagnosed with prostate cancer between 2004 and 2011 who were found to have pT3 disease or pT2 disease with positive margins following prostatectomy. We defined aRT as radiation to the prostate and/or pelvis 6 months or less after prostatectomy. We then used univariate and multivariate logistic regression models to assess potential patient and provider predictors of aRT use. Results: We evaluated 103,092 men who had either pT3 disease (81%) or pT2 with positive margins (19%). Of these, we identified 10,043 men (9.7%) who received aRT. Since 2004, there has been a steady decline in aRT usage with time (range, 11.5% to 7.8%). Compared to 2004, patients diagnosed in 2011 were significantly less likely to receive aRT (odds ratio [OR] 0.78, confidence interval [CI] 0.71-0.85, p<0.0001). Higher Gleason score and T stage were strongly associated with positive aRT utilization (p<0.0001), while increasing age was associated with decreased use (p<0.0001). Another strong predictor of aRT uptake was hospital type. Compared to patients treated at community hospitals, patients treated at comprehensive cancer centers or teaching hospitals were significantly less likely to receive aRT (OR 0.63, 0.58-0.68, p<0.0001 or OR 0.42, CI 0.39-0.46, p<0.0001, respectively). Charlson score and hospital location were significantly but weakly associated with aRT. Other demographic variables were not predictive of aRT. Conclusions: Post-prostatectomy aRT use is declining despite clear proof of its benefit. Consistent with the evidence, patients with risk factors for biochemical relapse (i.e. high Gleason score or T3 disease) and younger patients, who are more likely to benefit, are receiving aRT. Surprisingly, aRT use is lower at teaching hospitals, which may reflect higher usage of salvage radiation.

Redefining the role of adjuvant versus salvage radiation therapy for prostate cancer after radical prostatectomy for T3 disease and/or positive margins.

2020 ◽  
Vol 38 (6_suppl) ◽  
pp. 367-367
Author(s):  
Barry W. Goy ◽  
In-Lu Amy Liu
Keyword(s):  
Prostate Cancer ◽  
Radiation Therapy ◽  
High Risk ◽  
Radical Prostatectomy ◽  
Hormonal Therapy ◽  
Salvage Therapy ◽  
Low Risk ◽  
Adjuvant Radiation ◽  
Positive Margins ◽  
Salvage Radiation Therapy

367 Background: SWOG 8794 recommends adjuvant radiation therapy (ART) after radical prostatectomy (RP) for T3 and/or positive margins. Our purpose was to assess 12-year outcomes on 862 RP patients who had either T3 and/or positive margins who underwent surveillance, salvage radiation therapy (SRT), or hormonal therapy (HT), while categorizing these patients into very low risk (VLR), low risk (LR), high risk (HR), and ultra high risk (UHR) groups. Methods: From 2004 - 2007, 862 RP patients had adverse factors of extracapsular penetration (T3a), seminal vesicle invasion (T3b), positive margins, and/or detectable post-operative PSA. Management included surveillance (54.8%), SRT (36.8%), and HT (8.5%) as first salvage therapy, and 21.5% eventually received hormonal therapy. Twenty patients underwent ART, and were excluded from this analysis. We assessed prognostic factors using multivariable analysis, and 12-year estimates of freedom from biochemical failure (FFBF), freedom from salvage therapy (FFST), distant metastases-free survival (DMFS), prostate cancer-specific survival (PCSS), and overall survival (OS). VLR were those with Gleason Score (GS) of 6. LR were GS 3+4 with only T3a or positive margins, but an undetectable postoperative PSA <0.1. HR were T3b with GS 7-10, any GS 7-10 with T3a/b and positive margins, but an undetectable PSA. UHR were those with a detectable PSA with a GS 7-10. Results: Median follow-up was 12.1 years. Median age was 61.6 years. Median time to first salvage treatment for VLR, LR, HR, and UHR were 10.8, 11.1, 5.3, and 0.6 years, p<0.001. 12-year estimates of FFBF for VLR, LR, HR, and UHR were 60.2%, 52.9%, 28.4%, and 0%, p<0.0001. For FFST, 70.9%, 68.6%, 40.5%, and 0%, p<0.0001. For DMFS, 99.1%, 97.8%, 88.6%, and 63.6%, p<0.0001. For PCSS, 99.4%, 99.5%, 93.5%, and 78.9%, p<0.0001. For OS, 91.8%, 91.8%, 81.0%, and 69.9%, p<0.0001. Conclusions: Outcomes of T3 and/or positive margins using surveillance or SRT as initial management yields excellent outcomes for VLR and LR groups, in which ART should be avoided. For HR, ART can be considered reasonable, since FFBF is only 28.4%. For VHR, these patients may benefit from combined hormonal therapy and ART.

Selective benefit of adjuvant chemoradiation in resectable pancreatic cancer.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. 4122-4122 ◽  
Author(s):  
Jesse P Wright ◽  
Cameron Schlegel ◽  
Rebecca A Snyder ◽  
Liping Du ◽  
Yu Shyr ◽  
...  
Keyword(s):  
Cox Regression ◽  
Margin Status ◽  
Resectable Pancreatic Cancer ◽  
Adjuvant Chemoradiation ◽  
Related Factors ◽  
Large Hospital ◽  
Positive Margins ◽  
Kaplan Meier ◽  
Independent Effects ◽  
The Impact

4122 Background: Although level 1 data supports the use of adjuvant chemotherapy (ACT) in resected pancreatic adenocarcinoma (PDAC), the role of adjuvant chemoradiation (ACRT) remains controversial. The objective of this study is to investigate the impact of adding ACRT to ACT on overall survival (OS), based on lymph node (LN) and margin status. Methods: Resected AJCC Stage I and II PDAC patients from 2004-2013 identified within the National Cancer Database were classified into groups based on treatment: surgery alone (SX), ACT alone, ACT+ACRT, and ACRT only. Kaplan-Meier analyses were performed to determine median OS. Multivariable (MV) Cox regression models with interactions of treatment with LN and margin status were constructed to examine the independent effects of ACT and ACT+ACRT in these subgroups. Results: Of 31,348 patients, 30% were treated with SX, 30% with ACT, 38% with ACT+ACRT, and 2% with ACRT alone. Median OS (mos.) for ACT (22.5, 95% CI 21.9-23.1) and ACT+ACRT (23.7, 23.3-24.2) were significantly longer than SX (14, 13.4-14.5) or ACRT (11.2, 9.8-12.9). MV analysis confirmed a significant OS benefit of both ACT and ACT+ACRT controlling for patient and tumor related factors. ACRT+ACT was associated with improved OS compared to ACT in patients with positive margins and/or LN. Those with negative margins and LN did not benefit from the additional use of ACRT (Table). Conclusions: This large hospital-based study demonstrates that ACT and ACRT are associated with improved OS when compared to SX. The addition of ACRT to ACT, however, was only beneficial in high-risk patients with positive margins and/or LN. ACT+ACRT in patients with both margin and LN negative disease may not be warranted. Future clinical trials should stratify patients based on LN and margin status in order to determine which patients are most likely to benefit from the use of ACRT. [Table: see text]

Adjuvant chemoradiation for node-positive pancreatic adenocarcinoma: A propensity-matched analysis.

2017 ◽  
Vol 35 (4_suppl) ◽  
pp. 347-347 ◽  
Author(s):  
Mustafa Raoof ◽  
Laleh Golkar Melstrom ◽  
Susanne Warner ◽  
Yanghee Woo ◽  
Gagandeep Singh ◽  
...  
Keyword(s):  
Overall Survival ◽  
Pancreatic Adenocarcinoma ◽  
Survival Benefit ◽  
Nearest Neighbor ◽  
Margin Status ◽  
Adjuvant Radiation ◽  
Adjuvant Chemoradiation ◽  
Node Negative ◽  
Node Positive ◽  
Meta Analyses

347 Background: American Society of Clinical Oncology guidelines recommend adjuvant chemoradiation (ACR) for margin-positive(R1) and/or node-positive (N+) pancreatic cancers. However, randomized trials and meta-analyses have have not shown superiority of ACR over AC. Methods: National Cancer Database (NCDB) was used to analyze patients with N+ and/or R1 pancreatic adenocarcinoma who underwent ACR or AC over a ten-year period (2004-2014). Patients who received neoadjuvant radiation, no adjuvant treatment or adjuvant radiation alone were excluded. Propensity score nearest-neighbor 1:1 matching (PSM) was performed between ACR and AC groups based on age, sex, race, insurance, comorbidities, T-stage, nodal status, margin status, grade, and neoadjuvant chemotherapy. Primary outcome was overall survival (OS). Results: A total of 9,732 patients were eligible. After PSM two well-balanced groups of 4000 patients each were analyzed. ACR resulted in superior OS in patients with N+ and/or R1 disease as compared to AC alone (HR: 0.83, 95% CI 0.78-0.87; Median OS 22 vs. 19 months, p<0.001). Subset analyses demonstrated overall survival benefit of ACR compared to AC in N+, margin-negative patients (HR: 0.82, 95% CI 0.77-0.88; Median OS 24 vs. 20 months, p<0.001), as well as N+, R1 patients (HR: 0.77, 95% CI 0.68-0.87; Median OS 17 vs. 15 months, p<0.001); but no benefit in node-negative, R1 patients (HR: 1.12, 95% CI 0.84-1.48; Median OS 18 vs. 22 months, p = 0.43). Conclusions: This is the largest study to date that shows superiority of ACR over AC in N+ patients irrespective of margin status. The study failed to show a survival benefit in R1, node-negative patients.

Human Papillomavirus–Associated Oropharyngeal Cancer: Patterns of Nodal Disease

2018 ◽  
Vol 160 (3) ◽  
pp. 502-509 ◽  
Author(s):  
Karolina A. Plonowska ◽  
Madeleine P. Strohl ◽  
Steven J. Wang ◽  
Patrick K. Ha ◽  
Jonathan R. George ◽  
...  
Keyword(s):  
Human Papillomavirus ◽  
Adjuvant Treatment ◽  
Care Center ◽  
Tertiary Care ◽  
Case Series ◽  
Transoral Robotic Surgery ◽  
Adjuvant Radiation ◽  
Neck Lymph Node ◽  
Extranodal Extension ◽  
Level Ii

Objective To characterize patterns of neck lymph node (LN) metastases in human papillomavirus (HPV)–associated oropharyngeal squamous cell carcinoma, represented by p16 positivity (p16+OPSCC). Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Neck dissection (ND) specimens of nonirradiated p16+OPSCC patients were analyzed for frequencies of clinically evident and occult LNs by neck level. Local, regional, and distant recurrences were reviewed. Results Seventy p16+OPSCC patients underwent primary site transoral robotic surgery and 82 NDs of varying levels. Metastatic pathologic LNs were found at the following frequencies: 0% (0/28) in level I, 75.6% (62/82) in level II with 57.4% (35/61) in level IIA and 13.1% (8/61) in level IIB, 22.0% (18/82) in level III, 7.0% (5/71) in level IV, and 6.3% (1/16) in level V. The level V LN was clinically evident preoperatively. Five of 21 (23.8%) elective NDs contained occult LNs, all of which were in level II and without extranodal extension. Twenty-seven (38.6%) patients underwent adjuvant radiation; 19 (27.1%) patients underwent adjuvant chemoradiation. With a mean follow-up of 29 months, 3 patients had developed recurrences, with all but 1 patient still alive. All patients who recurred had refused at least a component of indicated adjuvant treatment. Conclusions For p16+OPSCC, therapeutic NDs should encompass any levels bearing suspicious LNs and levels IIA-B, III, and IV, while elective NDs should be performed and encompass at least levels IIA-B and III. These selective ND plans, followed by indicated adjuvant treatment, are associated with a low nodal recurrence rate.

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