Era Of Chemoradiation Research Articles

Management of the “Violated Neck” in the era of chemoradiation

To determine if patients who have undergone an open neck biopsy (a "violated" neck) have improved disease control and survival with completion neck dissection. Retrospective review of patients who underwent open cervical biopsy for diagnosis prior to definitive treatment between February 1997 and February 2010 at two academic tertiary referral centers. Ninety-four patients met study criteria, with completion neck dissection performed in 53 patients (56%). The majority of patients (84%) had oropharyngeal tumors. Human papilloma virus (HPV) status was positive in 55 of 63 patients (87%). Chemotherapy was used more often in patients treated nonoperatively (88%) compared to patients who underwent neck dissection (49%; P < .001). Five-year disease-specific survival (DSS) was 84% for patients treated with neck dissection and 82% for nonoperative treatment (P = .5806), and disease-free survival (DFS) was 82% for patients treated with neck dissection and 70% for nonoperative treatment (P = .6047). Five-year DSS was 84% for patients with HPV-positive disease and 63% for HPV-negative disease (P = .0086), and DFS was 79% for HPV-positive disease and 50% for HPV-negative disease (P = .0004). Only advanced primary tumor (T3/T4) stage (hazard ratio [HR] = 8.8, P = .004) was associated with DSS, whereas advanced primary tumor stage (HR = 5.3, P = .008), N3 disease (HR = 5.6, P = .036), and HPV-positive disease (HR = 0.2, P = .032) were significant predictors of DFS, after controlling for all other variables. In the era of chemoradiation, completion neck dissection following an open cervical biopsy does not appear to provide a survival advantage. A high proportion of HPV-positive oropharyngeal tumors may explain the favorable outcomes observed.

Complications of total laryngectomy in the era of chemoradiation

As more total laryngectomies (TLE) are nowadays performed as salvage procedures, the rate of postoperative complications increases. The primary aim was to report the rates of postoperative local complications for total laryngectomy in patients with previous radiotherapy or chemoradiotherapy (RT/CRT) in comparison with primary TLE data. We attempted to identify patient- and tumor-related factors predictive of postoperative pharyngocutaneous fistula (PCF) formation. The secondary aims were to analyze the survival rate in relation to postoperative complications and to study prognostic factors of survival in TLE patients. A retrospective study was conducted in 208 patients. Logistic regression was used to determine the most significant risk factors for fistula formation. Survival was analyzed by the Kaplan-Meier method, log-rank test, and Cox multivariate regression. PCF developed in 20.7% of cases. In the group of patients with previous RT/CRT, the fistula rate was significantly higher (34%). In multivariate analysis, significant risk factors for fistula formation were previous radiotherapy or chemoradiotherapy (p = 0.02), higher N classification (p = 0.03), and procedure performed by a less experienced surgeon (p = 0.003). The survival and recurrence rates were not influenced by PCF formation. The overall survival rates were lower in patients with previous RT/CRT and in patients with lymph node involvement.

Outcome of stage IVA cervical cancer patients with disease limited to the pelvis in the era of chemoradiation: A Gynecologic Oncology Group study

Objectives To evaluate the outcome of stage IVA cervical cancer treated with radiation and concurrent cisplatin-based chemotherapy. Methods We conducted a retrospective study of stage IVA cervical cancer patients from four trials (Gynecologic Oncology Group protocols 56, 85, 120, and 165) treated with radiotherapy with or without concurrent cisplatin-based chemotherapy. Patient records were reviewed for demographic and tumor features, treatment, and progression-free survival (PFS) and overall survival (OS). Stage IVA patients were compared to stage IIIB patients from these same studies. Results Among the 51 stage IVA patients studied, 92% were stage IVA on the basis of bladder involvement. The median PFS was 10.1 months (95% CI = 6.3–14.5 months) and median OS was 21.2 months (95% CI = 13.3–30.5 months). The 3 year survival was 32%. On univariate analysis, only advanced age was associated with OS ( p = 0.0115) but age had only marginal effect on PFS ( p = 0.083). Pathologic proven pelvic nodal metastasis was of marginal significance for both PFS and OS, p = 0.059 and 0.064, respectively. Despite similar patient characteristics, the use of cisplatin-based chemotherapy had no impact on PFS or OS but was underpowered to address this question. When compared to stage IIIB patients, stage IVA patients had a poorer performance status ( p = 0.0231), larger tumor size ( p = 0.0302), and more frequent bilateral parametrial involvement (0.0063). Conclusion Patients with stage IVA disease had poor median survival of only 21 months with only 32% 3 year survival. Stage IVA patients have larger tumor size, more bilateral parametrial involvement, and poorer survival when compared to stage IIIB patients.

Redefining the Role of the Head and Neck Surgeon in the Era of Chemoradiation

Redefining the Role of the Head and Neck Surgeon in the Era of Chemoradiation

Impact of extent of resection of glioblastoma multiforme (GBM) in the era of chemoradiation

e13029 Background: Controversy remains regarding the impact of the extent of resection (EOR) on survival in patients with GBM (Sanai 2008). The main reason for this is the fact that most studies were based on the surgeon's estimate of the EOR, which is known to be unreliable, rather than early postoperative MRI scans (po-MRI). Data for the current standard of postoperative chemo-radiotherapy (CTRT) have recently been reported, but suffer from the same limitation (Gorlia 2008). We studied the prognostic impact of the EOR using early (&lt;72 hours) po-MRI scans in a cohort of GBM patients treated with CTRT in a single center. Methods: The results of 48 consecutive patients (35 male, 13 female; age 18–73 yrs) treated with surgery, followed by concurrent CTRT (60 Gy plus temozolomide) and adjuvant temozolomide were assessed with respect to survival and relapse patterns. EOR was determined by both the surgeon's estimation and early po-MRI scans that were available in all but two patients. EOR was categorized as biopsy (N = 3), partial resection (N = 24), major resection (N = 11; i.e., total resection according to the surgeon's report, but residual tumor on po-MRI), and total resection (N = 10; i.e. no residual tumor on po-MRI). Results: Median overall survival of the entire cohort was 18.9 months, and EOR was the only significant prognostic factor (p = 0.02) on multivariate analysis, which also included age, gender, performance, and radiotherapy target volume. 2-year survival rates improved significantly with increasing EOR, with 0%, 18.9%, 68.6%, and 100% for biopsy, partial-, major-, and total resection, respectively. In-field progression was the predominant pattern of failure in 27 out of 30 patients (90%) with a recurrence. Time to neurological progression (TNP) was significantly correlated with EOR (p &lt; 0.001). Median TNP was 3.0 months for biopsy, 7.0 months for partial resection, 20.5 months for major resection, and was not reached for total resection. Conclusions: With the use of more effective local therapy in the form of surgery and CTRT, the prognostic impact of the EOR on survival appears to be higher than previously reported. This should be accounted for in future trials. No significant financial relationships to disclose.

Swing of the pendulum: Optimizing functional outcomes in larynx cancer

For years, total laryngectomy was the only treatment option for patients with intermediate to advanced laryngeal cancer. Over the past two decades, great progress has been made in the management of this disease, with multimodality approaches aimed at laryngeal preservation reshaping the treatment landscape. In the era of chemoradiation, greater focus and attention are now directed toward functional laryngeal preservation--not simply "organ preservation." The continued development and integration of new treatment approaches, including organ preservation surgery (eg, transoral minimally invasive surgery of the head and neck, supracricoid partial laryngectomy), intensity-modulated radiotherapy, and targeted molecular therapies, offer the potential to improve clinical outcomes, function, and quality of life. Incorporation of these new approaches advances the concept of personalized medicine, with treatment strategies tailored to the circumstances and future of each patient.

Which clinical/pathologic factors matter in the era of chemoradiation as treatment for locally advanced cervical carcinoma? Analysis of two Gynecologic Oncology Group (GOG) trials

Which clinical/pathologic factors matter in the era of chemoradiation as treatment for locally advanced cervical carcinoma? Analysis of two Gynecologic Oncology Group (GOG) trials

Miniseminar: The Role of Surgery in the Era of Chemoradiation

Miniseminar: The Role of Surgery in the Era of Chemoradiation

Which clinical/pathologic factors matter in the era of chemoradiation as treatment for locally advanced cervical carcinoma? Analysis of two Gynecologic Oncology Group (GOG) trials.

To explore clinical/pathologic factors associated with prognosis of patients with locally advanced cervical carcinoma treated with weekly cisplatin and pelvic radiation. We retrospectively reviewed data from 335 women who received weekly cisplatin and radiation while participating in similar arms of two GOG studies (protocols 120 and 165). Progression-free survival (PFS) and overall survival (OS) were evaluated for associations between clinical/pathologic factors and prognosis. Prognosis and selected toxicities were also compared between studies. Four-year PFS and OS for stage II patients were 64.2% and 68.1%, respectively for those treated on GOG 120 and 65.8% and 73.9% for those treated on GOG 165, compared to 51.4% and 55.4% for stage III/IV patients respectively treated on GOG 120 and 37.7% and 42.7% respectively for those treated on GOG 165. In multivariate analysis, stage, tumor grade, race and age were independently predictive of PFS and OS (for all, p<0.05). Prolonged (delayed for any cause) radiation was associated with poorer PFS (hazard ratio [HR], 1.98; 95% confidence interval [CI], 1.16-3.38; p=0.012) and OS (HR, 1.88; 95% CI, 1.08-3.26; p=0.024) in GOG 165 but not GOG 120. FIGO stage, tumor grade, race and age are prognostic in patients with locally advanced cervical carcinoma treated with concurrent cisplatin and radiation. This exploratory analysis has generated a hypothesis that clinical staging (as per GOG 165) is less sensitive in detecting aortic nodal metastases compared to surgical staging (as per GOG 120) and may be associated with poorer prognosis particularly when radiation is prolonged. Prospective clinical studies are needed to test this hypothesis.

Organ-Preservation Laryngeal Surgery in the Era of Chemoradiation

Organ-Preservation Laryngeal Surgery in the Era of Chemoradiation