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Association Between Number of Positive Lymph Nodes and Outcome Among Patients Treated by Surgery and Postoperative Radiation Therapy for Head-and-Neck Cancer
S464
International Journal of Radiation Oncology Biology Physics
2651
Materials/Methods: After institutional review board approval, patients with oral cavity squamous cell carcinoma with pN1 disease who were treated surgically between 1985 and 2009 were identified. Demographic, clinical and pathologic information were collected and entered into a database. Patients with incomplete data, and those who declined PORT despite its recommendation were excluded. Neck recurrence-free survival (NRFS) and disease specific survival (DSS) were measured. Results: A total of 179 patients met study inclusion criteria (54% underwent elective neck dissection). Of these, 144 were treated with PORT. Clinical observation without PORT was recommended for a group of 35 patients. These patients had a lower incidence of ECS (2.9% versus 27.1% in the group with PORT, pZ0.002). Furthermore, these patients were more frequently older than 60 years (71.4% versus 47.9%, pZ0.012) and had severe medical comorbidities (37% versus 16%, pZ0.005). Otherwise, the two groups did not have significantly different tumor characteristics (margin status, histology grade, tumor thickness, perineural and vascular invasion, T stage). This group of 35 patients, who was observed, did not have worse NRFS or DSS when compared with patients receiving PORT (NRFS: 84% vs 85%, pZ0.94; DSS: 83% vs 65%, pZ0.126). Conclusions: In this retrospective analysis, elderly patients, with severe comorbidities and without extracapsular spread who were treated with close observation had a comparable outcome than pN1 treated with PORT. A highly selected group of oral cancer patients with a pN1 neck could be considered for close observation after surgical resection without PORT in a controlled setting. Author Disclosure: P. Montero: None. P.D. Patel: None. F.L. Palmer: None. A.G. Shuman: None. S.G. Patel: None. N.Y. Lee: None. J.P. Shah: None. I. Ganly: None.
Association Between Number of Positive Lymph Nodes and Outcome Among Patients Treated by Surgery and Postoperative Radiation Therapy for Head-and-Neck Cancer Y. Yu, A. Cho, S.S. Batth, M.E. Daly, E.G. Vazquez, D. Farwell, Q. Luu, P. Donald, and A.M. Chen; University of California, Davis, Comprehensive Cancer Center, Sacramento, CA Purpose/Objective(s): The presence or absence of nodal metastases has consistently been identified as an important prognostic factor for head and neck cancer. However, the current American Joint Committee on Cancer (AJCC) staging system does not differentiate between N-stage based on the absolute number of positive lymph nodes. We hypothesized that a correlation exists between the number of pathologically involved lymph nodes and outcome for patients treated by surgery and post-operative radiation therapy. Materials/Methods: Between July 1996 and January 2012, 177 patients with squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx or larynx, were treated by surgical resection with neck dissection followed by post-operative radiation therapy. Sixty-five (37%) patients received concurrent chemotherapy. Eighty-one (46%) patients had bilateral neck dissection. The nodal ratio, defined as the number of positive lymph nodes divided by the total number examined, was calculated, and cut-points were selected at 5 percentile intervals. Cut-points of 4 and 8 nodes were selected for the number of positive lymph nodes, which represented the 75th and 90th percentiles respectively. Overall and progression-free survival was determined using the Kaplan-Meier method with comparisons performed using the log-rank test. A Cox proportional hazards model was used to assess the significance of various nodal statistics, controlling for lymphovascular space invasion, perineural invasion, extracapsular extension and margin status. Results: With a median follow-up of 40 months, 53 patients (60%) had no evidence of recurrent disease. A significant association was identified between number of pathologically involved lymph nodes and progression-free survival (pZ0.003) with an approximate 8% (95% CI 3%-14%) reduction at 3-years with each lymph node involved. Patients with >4 positive lymph nodes had reduced progression-free survival at 3 years (51% vs 71%, p Z 0.036), and this effect became magnified in patients with >8 positive lymph nodes (71% vs. 37%, p Z 0.025). The 3-year overall survival for patients with greater than 4 positive lymph nodes was 55% compared to 71% for those with 4 or fewer lymph nodes (pZ0.11). Exploratory analyses revealed that a nodal ratio > 10% predicted for disease progression (p Z 0.042, 3-year-PFS 42% vs. 60%). Conclusions: Patients with greater than 4 positive lymph nodes have a significantly worse prognosis after surgery and postoperative radiation for head and neck cancer. Clinical trials investigating more aggressive adjuvant strategies may be appropriate for this group. Author Disclosure: Y. Yu: None. A. Cho: None. S.S. Batth: None. M.E. Daly: None. E.G. Vazquez: None. D. Farwell: None. Q. Luu: None. P. Donald: None. A.M. Chen: None.
2652 Neck Dissection Without Postoperative Radiation Therapy in Select Patients With Oral Cavity Carcinoma and pN1 neck P. Montero, P.D. Patel, F.L. Palmer, A.G. Shuman, S.G. Patel, N.Y. Lee, J.P. Shah, and I. Ganly; Memorial Sloan Kettering Cancer Center, New York, NY Purpose/Objective(s): The role of postoperative radiation therapy (PORT) in the pathologically positive N1 neck after surgical extirpation of oral cavity cancer remains unclear. The objective of this study is to describe the characteristics and results of a cohort of pN1 oral cavity carcinoma patients treated without PORT in a tertiary cancer center.
2653 Can Meaningful and Durable Locoregional Control Be Achieved for Oral Cavity Squamous Cell Carcinoma (OCSCC) Treated With Definitive Radiation Therapy (RT)? C. Chin, N. Riaz, F. Ho, M. Hu, J. Hong, E. Sherman, R. Wong, S. Wolden, S. Rao, and N. Lee; Memorial Sloan-Kettering Cancer Center, New York, NY Purpose/Objective(s): The optimal treatment strategy for loco-regionally advanced OCSCC is complete surgical resection followed by post-operative RT. However, alternative treatment approaches such as definitive RT must be considered if patients are not amenable to surgery. The purpose of this study was to report the prognostic factors and outcomes of OCSCC managed non-surgically at our institution. Materials/Methods: Between December 1989 and April 2011, 75 patients with OCSCC (median age: 65 years) were treated with definitive RT. Surgery was not performed due to loco-regionally advanced unresectable disease (61.3%), significant medical co-morbidities (21.3%), or patient refusal (17.3%). Competing risks analysis was used to calculate the incidence of local control (LC), locoregional control (LRC), and distant metastasis-free (DMF) rates with death as a competing risk. The Kaplan Meier method was used to calculate overall survival (OS). A Cox proportional hazard model was used to determine predictors of outcome. Toxicity was scored per Common Toxicity Criteria. Results: Median follow-up was 26.4 months. Subsites were: oral tongue (35), floor of mouth (15), retromolar trigone (11), gingiva (6), buccal mucosa (4), hard palate (2), and lip (2). There were 5 T1, 10 T2, 11 T3, 49 T4; 26 N0, 11 N1, 33 N2, and 5 N3; 55 (73%) patients had stage IV disease. Fifty-one (68%) patients received conventional RT (convRT), 24 (32%) patients received intensity-modulated radiation therapy (IMRT) (median, 70 Gy). Eight patients received a brachytherapy boost (median, 25Gy). Concurrent chemotherapy was administered to 45 patients, induction chemotherapy to 4, with the majority receiving platinum-based regimens. The 2-year LC, LRC, DMF, OS rates were 67%, 62%, 69%, and
International Journal of Radiation Oncology Biology Physics
2651
Materials/Methods: After institutional review board approval, patients with oral cavity squamous cell carcinoma with pN1 disease who were treated surgically between 1985 and 2009 were identified. Demographic, clinical and pathologic information were collected and entered into a database. Patients with incomplete data, and those who declined PORT despite its recommendation were excluded. Neck recurrence-free survival (NRFS) and disease specific survival (DSS) were measured. Results: A total of 179 patients met study inclusion criteria (54% underwent elective neck dissection). Of these, 144 were treated with PORT. Clinical observation without PORT was recommended for a group of 35 patients. These patients had a lower incidence of ECS (2.9% versus 27.1% in the group with PORT, pZ0.002). Furthermore, these patients were more frequently older than 60 years (71.4% versus 47.9%, pZ0.012) and had severe medical comorbidities (37% versus 16%, pZ0.005). Otherwise, the two groups did not have significantly different tumor characteristics (margin status, histology grade, tumor thickness, perineural and vascular invasion, T stage). This group of 35 patients, who was observed, did not have worse NRFS or DSS when compared with patients receiving PORT (NRFS: 84% vs 85%, pZ0.94; DSS: 83% vs 65%, pZ0.126). Conclusions: In this retrospective analysis, elderly patients, with severe comorbidities and without extracapsular spread who were treated with close observation had a comparable outcome than pN1 treated with PORT. A highly selected group of oral cancer patients with a pN1 neck could be considered for close observation after surgical resection without PORT in a controlled setting. Author Disclosure: P. Montero: None. P.D. Patel: None. F.L. Palmer: None. A.G. Shuman: None. S.G. Patel: None. N.Y. Lee: None. J.P. Shah: None. I. Ganly: None.
Association Between Number of Positive Lymph Nodes and Outcome Among Patients Treated by Surgery and Postoperative Radiation Therapy for Head-and-Neck Cancer Y. Yu, A. Cho, S.S. Batth, M.E. Daly, E.G. Vazquez, D. Farwell, Q. Luu, P. Donald, and A.M. Chen; University of California, Davis, Comprehensive Cancer Center, Sacramento, CA Purpose/Objective(s): The presence or absence of nodal metastases has consistently been identified as an important prognostic factor for head and neck cancer. However, the current American Joint Committee on Cancer (AJCC) staging system does not differentiate between N-stage based on the absolute number of positive lymph nodes. We hypothesized that a correlation exists between the number of pathologically involved lymph nodes and outcome for patients treated by surgery and post-operative radiation therapy. Materials/Methods: Between July 1996 and January 2012, 177 patients with squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx or larynx, were treated by surgical resection with neck dissection followed by post-operative radiation therapy. Sixty-five (37%) patients received concurrent chemotherapy. Eighty-one (46%) patients had bilateral neck dissection. The nodal ratio, defined as the number of positive lymph nodes divided by the total number examined, was calculated, and cut-points were selected at 5 percentile intervals. Cut-points of 4 and 8 nodes were selected for the number of positive lymph nodes, which represented the 75th and 90th percentiles respectively. Overall and progression-free survival was determined using the Kaplan-Meier method with comparisons performed using the log-rank test. A Cox proportional hazards model was used to assess the significance of various nodal statistics, controlling for lymphovascular space invasion, perineural invasion, extracapsular extension and margin status. Results: With a median follow-up of 40 months, 53 patients (60%) had no evidence of recurrent disease. A significant association was identified between number of pathologically involved lymph nodes and progression-free survival (pZ0.003) with an approximate 8% (95% CI 3%-14%) reduction at 3-years with each lymph node involved. Patients with >4 positive lymph nodes had reduced progression-free survival at 3 years (51% vs 71%, p Z 0.036), and this effect became magnified in patients with >8 positive lymph nodes (71% vs. 37%, p Z 0.025). The 3-year overall survival for patients with greater than 4 positive lymph nodes was 55% compared to 71% for those with 4 or fewer lymph nodes (pZ0.11). Exploratory analyses revealed that a nodal ratio > 10% predicted for disease progression (p Z 0.042, 3-year-PFS 42% vs. 60%). Conclusions: Patients with greater than 4 positive lymph nodes have a significantly worse prognosis after surgery and postoperative radiation for head and neck cancer. Clinical trials investigating more aggressive adjuvant strategies may be appropriate for this group. Author Disclosure: Y. Yu: None. A. Cho: None. S.S. Batth: None. M.E. Daly: None. E.G. Vazquez: None. D. Farwell: None. Q. Luu: None. P. Donald: None. A.M. Chen: None.
2652 Neck Dissection Without Postoperative Radiation Therapy in Select Patients With Oral Cavity Carcinoma and pN1 neck P. Montero, P.D. Patel, F.L. Palmer, A.G. Shuman, S.G. Patel, N.Y. Lee, J.P. Shah, and I. Ganly; Memorial Sloan Kettering Cancer Center, New York, NY Purpose/Objective(s): The role of postoperative radiation therapy (PORT) in the pathologically positive N1 neck after surgical extirpation of oral cavity cancer remains unclear. The objective of this study is to describe the characteristics and results of a cohort of pN1 oral cavity carcinoma patients treated without PORT in a tertiary cancer center.
2653 Can Meaningful and Durable Locoregional Control Be Achieved for Oral Cavity Squamous Cell Carcinoma (OCSCC) Treated With Definitive Radiation Therapy (RT)? C. Chin, N. Riaz, F. Ho, M. Hu, J. Hong, E. Sherman, R. Wong, S. Wolden, S. Rao, and N. Lee; Memorial Sloan-Kettering Cancer Center, New York, NY Purpose/Objective(s): The optimal treatment strategy for loco-regionally advanced OCSCC is complete surgical resection followed by post-operative RT. However, alternative treatment approaches such as definitive RT must be considered if patients are not amenable to surgery. The purpose of this study was to report the prognostic factors and outcomes of OCSCC managed non-surgically at our institution. Materials/Methods: Between December 1989 and April 2011, 75 patients with OCSCC (median age: 65 years) were treated with definitive RT. Surgery was not performed due to loco-regionally advanced unresectable disease (61.3%), significant medical co-morbidities (21.3%), or patient refusal (17.3%). Competing risks analysis was used to calculate the incidence of local control (LC), locoregional control (LRC), and distant metastasis-free (DMF) rates with death as a competing risk. The Kaplan Meier method was used to calculate overall survival (OS). A Cox proportional hazard model was used to determine predictors of outcome. Toxicity was scored per Common Toxicity Criteria. Results: Median follow-up was 26.4 months. Subsites were: oral tongue (35), floor of mouth (15), retromolar trigone (11), gingiva (6), buccal mucosa (4), hard palate (2), and lip (2). There were 5 T1, 10 T2, 11 T3, 49 T4; 26 N0, 11 N1, 33 N2, and 5 N3; 55 (73%) patients had stage IV disease. Fifty-one (68%) patients received conventional RT (convRT), 24 (32%) patients received intensity-modulated radiation therapy (IMRT) (median, 70 Gy). Eight patients received a brachytherapy boost (median, 25Gy). Concurrent chemotherapy was administered to 45 patients, induction chemotherapy to 4, with the majority receiving platinum-based regimens. The 2-year LC, LRC, DMF, OS rates were 67%, 62%, 69%, and