Becky Massey

CLINICAL OUTCOMES OF PATIENTS RECEIVING INTEGRATED PET/CT-GUIDED RADIOTHERAPY FOR HEAD AND NECK CARCINOMA

PURPOSE We previously reported the advantages of (18)F-fluorodeoxyglucose-positron emission tomography (PET) fused with CT for radiotherapy planning over CT alone in head and neck carcinoma (HNC). The purpose of this study was to evaluate clinical outcomes and the predictive value of PET for patients receiving PET/CT-guided definitive radiotherapy with or without chemotherapy. METHODS AND MATERIALS From December 2002 to August 2006, 42 patients received PET/CT imaging as part of staging and radiotherapy planning. Clinical outcomes including locoregional recurrence, distant metastasis, death, and treatment-related toxicities were collected retrospectively and analyzed for disease-free and overall survival and cumulative incidence of recurrence. RESULTS Median follow-up from initiation of treatment was 32 months. Overall survival and disease-free survival were 82.8% and 71.0%, respectively, at 2 years, and 74.1% and 66.9% at 3 years. Of the 42 patients, seven recurrences were identified (three LR, one DM, three both LR and DM). Mean time to recurrence was 9.4 months. Cumulative risk of recurrence was 18.7%. The maximum standard uptake volume (SUV) of primary tumor, adenopathy, or both on PET did not correlate with recurrence, with mean values of 12.0 for treatment failures vs. 11.7 for all patients. Toxicities identified in those patients receiving intensity modulated radiation therapy were also evaluated. CONCLUSIONS A high level of disease control combined with favorable toxicity profiles was achieved in a cohort of HNC patients receiving PET/CT fusion guided radiotherapy plus/minus chemotherapy. Maximum SUV of primary tumor and/or adenopathy was not predictive of risk of disease recurrence.

Analysis of pepsin in tracheoesophageal puncture sites.

Objectives: Tracheoesophageal puncture (TEP) and prosthesis insertion is a well-established method of voice rehabilitation after laryngectomy. Maintenance of the prosthesis and tract can be challenging, and reflux to the TEP site has been proposed as a cause. The sites of TEP were evaluated for the presence of pepsin in tissue biopsy specimens and tract secretions to explore this association. Methods: Patients with TEP were interviewed for a history of symptoms related to reflux, medication use history, TEP voice quality, and incidence of TEP complications. Tissue biopsy specimens and tract secretions were obtained from TEP sites and analyzed for the presence of pepsin via sodium dodecyl sulfate–polyacrylamide gel electrophoresis Western blot analysis. Results: Twelve of 17 patients (47%) had some history of preoperative or postoperative symptoms of gastroesophageal reflux disease or laryngopharyngeal reflux. Pepsin was present within the TEP site in a total of 10 of 17 patients (58%; 7 of 17 tissue biopsy specimens and 6 of 7 secretion samples). There were no statistically significant associations between the presence of pepsin and sex, reflux history, use of acid suppressive medicine, or time since laryngectomy. Conclusions: Reflux with subsequent pepsin deposition into the TEP tract occurs in a majority of laryngectomy patients. Further studies on the effect of reflux on the health and function of the TEP tract are warranted.

A Phase I Trial of Aminolevulinic Acid-Photodynamic Therapy for Treatment of Oral Leukoplakia

BACKGROUND Photodynamic therapy with aminolevulinic acid (ALA PDT) for oral leukoplakia has shown promising effects in regression of oral leukoplakia. Although ALA has been extensively studied and is an ideal photosensitizer, the optimal light dose for treatment of oral leukoplakia has not been determined. We conducted a phase I study to determine MTD and DLT of PDT in patients treated with ALA for leukoplakia. METHODS Patients with histologically confirmed oral leukoplakia received a single treatment of ALA PDT in cohorts with escalating doses of light (585nm). Clinical, histologic, and biologic markers were assessed. RESULTS Analysis of 11 participants is reported. No significant toxicity from ALA PDT was observed in patients who received ALA with a light dose of up to 4J/cm(2). One participant experienced transient grade 3 transaminase elevation due to ALA. One participant had a partial clinical response 3months after treatment. Biologic mucosal risk markers showed no significant associations. Determination of MTD could not be accomplished within a feasible timeframe for completion of the study. CONCLUSIONS ALA PDT could be safely administered with a light dose up to 4J/cm(2) and demonstrated activity. Larger studies are needed to fully elucidate the MTD and efficacy of ALA-PDT.

Survivorship Care Plans for Patients With Head and Neck Cancer

OBJECTIVE To determine the perceived value of survivorship care plans (SCPs) (cancer treatment summaries and follow-up recommendations). DESIGN Survey of patients and their physicians between 3 and 4 years after receipt of the SCP. SETTING Ambulatory, tertiary care medical center. PATIENTS A convenience sample of head and neck cancer survivors living 3 years after each had been mailed a personal SCP shortly after completion of cancer treatment. Twenty survivors were contacted, and all agreed to participate. INTERVENTIONS Institutional review board-approved, scripted telephone survey to determine whether patients and their primary care physicians still had their SCPs and found them useful. MAIN OUTCOME MEASURES Survey responses. RESULTS Only 2 of 20 survivors and 11 of 21 physicians or dentists were able to locate or remember having received the SCPs 3 years later. Eighteen of 20 survivors were unsure of the value of SCPs. CONCLUSIONS Despite a widely held belief that patients benefit from receiving SCPs, our initial attempt found little awareness of these documents by either the head and neck cancer survivors or their primary care physicians.

Dysphagia Due to Adenoid Cystic Carcinoma of the Base of the Tongue

Objectives: Although oropharyngeal neoplasia can often lead to dysphagia, salivary gland tumors rarely grow within the tongue base. We present the case of a 75-year-old man with adenoid cystic carcinoma of the base of the tongue causing profound dysphagia and weight loss, and provide a current literature review and update on the management of these rare tumors. Methods: We present a case report and a literature review. Results: Physical examination performed at the initial visit revealed a firm right base-of-tongue mass with no palpable lymphadenopathy. Flexible fiberoptic laryngoscopy confirmed a large submucosal mass at the right base of the tongue that obscured the right vallecula. Histopathologic analysis of the operative biopsy specimens revealed the classic features of adenoid cystic carcinoma. Treatment included radical pharyngotomy with wide local excision and primary closure, followed by postoperative radiation treatment. Conclusions: We demonstrate the clinical examination findings and histopathologic characteristics of this disease, and review the literature for clinical treatment recommendations for this rare cause of dysphagia.

Oncocytic papillary thyroid cancer has similar prognosis to matched classical papillary thyroid cancer controls

BACKGROUND Previous studies have suggested that oncocytic variant papillary thyroid carcinoma (PTC) may be more aggressive, with higher rates of recurrent disease. The aim of this study was to evaluate characteristics and outcomes of patients with oncocytic variant PTC compared to classical PTC. METHODS Patients with oncocytic variant PTC were retrospectively identified from 519 patients who underwent thyroidectomy for PTC between January 2009 and August 2015. Data collected included patient demographics, laboratory and pathology findings, imaging studies, treatment, and follow-up. Patients were matched 1:1 by age, sex, and TNM stage with patients who underwent total thyroidectomy for classical PTC during the same time period. RESULTS The cohort included 21 patients, of whom 18 (86%) were female, with a median age of 53 years (range 23-68 years). All patients underwent total thyroidectomy, and 17 (81%) had a central compartment neck dissection (8 [38%] prophylactic). The median tumor size was 2.0 cm (range 0.9-6.5 cm), and four (19%) patients had extrathyroidal extension. There was no significant difference in histopathologic characteristics, including extrathyroidal extension and lymphovascular invasion, between the two groups except for an increased incidence of thyroiditis in oncocytic variant PTC (90.5% vs. 57%; p = 0.01). In oncocytic variant PTC patients who underwent central compartment neck dissection, malignant lymph nodes were found in 12 (57%) patients compared to 13 (62%) classical (p = 0.75). Lateral neck dissection was performed in 5 (24%) oncocytic variant and classical PTC patients, with metastatic lymphadenopathy found in four (a median of four malignant lymph nodes; range 1-6) and five (a median of 2.5 malignant lymph nodes; range 1-9), respectively. Radioactive iodine was administered to 18 (86%) oncocytic variant PTC and 18 (86%) classical PTC patients. At a median follow-up of 51 months (interquartile range 38-61), one oncocytic variant PTC patient had recurrent disease and underwent reoperation at 24 months. In classical PTC patients with a median follow-up time of 77 months (range 56-87 months), two (9.5%) patients had detectable thyroglobulin levels indicating early recurrence, but neither has undergone reoperation. CONCLUSIONS Oncocytic variant PTC was present in 5% of PTC patients. Most (95%) patients remain disease-free at four years, similar to classical PTC outcomes, suggesting that oncocytic variant may not represent a more aggressive variant.

Functional Impairments after Neck Dissection and Adjuvant Treatment: Patternsof Care

Objective: Shoulder pain or weakness, lymphedema, and xerostomia are known treatment-related impairments of head and neck cancer, often leading to significant disability. The purpose of this study is to determine the referral patterns to rehabilitation for these impairments in patients who underwent primary surgery that included neck dissection and to identify potential predictors of need for rehabilitation. Design: Retrospective chart review. Setting: Tertiary hospital. Patients: Patients who had ten or more lymph nodes removed via neck dissection. Methods and Outcome Measurements: Demographics, cancer history, symptoms and referrals to rehabilitation for shoulder pain or weakness, lymphedema, and xerostomia were recorded. Results: 155 patients with a mean age of 61.4 were identified. 29 patients (20.1%) had shoulder pain or weakness, 39 patients (27.9%) had lymphedema, and 72 subjects (50.7%) had xerostomia. No rehabilitation referrals were made for 24.1% of patients with shoulder pain or weakness, 51.3% with lymphedema, and 61.1% with xerostomia. Adjuvant radiation was associated with shoulder pain or weakness (p=0.0004), lymphedema (p=0.001), and xerostomia (p 4 days post-operatively (p=0.002) were associated with lymphedema. Conclusion: The majority of patients with shoulder pain or weakness were referred to rehabilitation, but less than half of patients with lymphedema or xerostomia were referred for appropriate rehabilitation treatment. In addition to radiation, which is a known association for these common impairments after HNC treatment, greater number of lymph nodes removed and prolonged drain placement may identify patients at risk of lymphedema.

Diagnosis to Treatment Interval and Outcome in Patients with Locally- Advanced Squamous Cell Carcinoma of the Head and Neck in a Veterans Affairs Medical Center

Background: Treatment of locally-advanced squamous cell carcinoma of the head and neck (SCCHN) requires multi-disciplinary care often resulting in a prolonged diagnosis to treatment interval (DTI). This study aims to identify factors that influence DTI and to assess the impact of DTI on treatment outcomes. Methods: The medical records of 135 patients with SCCHN who were treated with definitive chemoradiotherapy between 2000 and 2009 at the Clement J Zablocki VA Medical Center were reviewed and analyzed. Results: Median DTI was 44 days. A Cox-Model identified that transfer patients had prolonged DTI. Longer DTI had a significant negative impact on overall survival (RR 1.009, p = 0.0386) but did not impact distant (RR 0.99, p = 0.89) or local control (0.99, p = 0.23). Conclusion: Increased DTI in patients with SCCHN results in a statistically significant negative survival impact. Efforts need to be directed to improving DTI and on expediting and streamlining the care of transfer patients.