EORTC QOL Rating, Performance Status, and Oral Outcomes in Head-and-Neck Cancer Patients Treated With Chemoradiation Therapy

Volume 87  Number 2S  Supplement 2013 data from a large surgical series of patients with oropharyngeal carcinoma, the patterns of cervical lymph node metastasis were examined to identify risk factors for subclinical submandibular involvement. Materials/Methods: Using institutional registries and databases, the medical records of 133 newly diagnosed patients with squamous cell carcinoma of the oropharynx (67 tonsil; 53 base of tongue) who underwent primary surgery and neck dissection (116 unilateral; 17 bilateral) were reviewed. No patient had gross or radiographic evidence of submandibular involvement at diagnosis. Based on intraoperative and pathological findings, T stage, N stage, and degree of cervical lymph node involvement were tabulated. Risk factors for subclinical submandibular involvement were identified using multivariate modeling. Testing for statistical significance was performed using the two-proportion z test. Results: Submandibular (level IB) nodal dissection was included as a component of surgery on 128 necks, including 105 ipsilateral necks and 23 contralateral necks. Overall, submandibular nodal involvement was observed in 21% of patients who underwent any neck dissection. The incidence of ipsilateral and contralateral submandibular involvement was 17% and 26%, respectively. Exploratory analysis identified T4 disease and the presence of cervical lymph node metastasis at levels III, IV, and/or V as predicting for submandibular involvement (p < 0.05, for both). Zero of 37 (0%) without either feature had submandibular nodal involvement compared with 24 of 91 (26%) with either identified high-risk factor (p Z 0.0005). Of three patients with large lesions involving both the oropharynx and the oral cavity, 100% had submandibular nodal involvement. There was no difference in submandibular involvement between primaries involving the tonsil and base of tongue (16% versus 22%, p Z 0.42). Conclusions: Subclinical metastases to the submandibular lymph nodes are uncommon in the absence of T4 disease, or involvement of level III-V lymph node stations. These data provide assurances that submandibular gland-sparing IMRT can reasonably be offered to these select patients. Author Disclosure: Y. Yu: None. M.E. Daly: None. G. Farwell: None. Q. Luu: None. J. Bishop: None. P.J. Donald: None. A.M. Chen: None.

2622 Regional Outcome in N2-N3 Patients With Head and Neck Carcinoma in Function of FDG PET/CT Results L. Bernier, J. Archambault, E. Vigneault, and A. Fortin; Hotel-Dieu de Quebec, Quebec, QC, Canada Purpose/Objective(s): This retrospective study was designed to evaluate the regional outcome and overall survival of patients with head and neck carcinoma, N stage 2 or 3 and treated without surgery, in function of the FDG PET/CT exam done approximately 2,5 months after the treatment. Materials/Methods: We reviewed all the cases of head and neck carcinoma, N stage 2 or 3, treated in our center, from January 1, 2006 to June 30, 2012, by radical radiation with or without systemic treatment. Primary tumors from the oral cavity, oropharynx, hypopharynx, nasopharynx and larynx were included. Patients needed to have a FDG PET/CT exam done in the 120 days after the completion of treatment. Our study included 150 patients: 80% male and 20% female with a mean age of 60.4 years (range, 37-85 years); 86% of oropharyngeal cancer (52% tonsils and 34% base of tongue); 30% active smokers, 29.6% non-smokers and 40% ex-smokers. Alcohol intake was noted: 33.3% active, 50% non-drinkers, 15.3% exdrinkers. The stage of the disease at presentation: 16.6% T1, 45.3% T2, 22.6% T3, 12% T4, 3.3% Tx, 90.6% N2, and 9.3% N3. Our mean followup is 2.01 years. Local or regional failure was defined as proven clinical recurrence or histopathological confirmation at salvage surgery. Results: Among the 150 patients, 13 had a positive local and/or regional (nodal) FDG PET/CT result (8.7%), 113 had a negative result (75.3%), and 24 had an inconclusive result (16%). Twelve patients had a positive nodal result (8%), 129 patients had a negative nodal result (86%) and 9 patients had an inconclusive nodal result (6%) on the PET/CT exam. Six patients had a positive local (primary site) result (4%), 121 patients had a negative result (80.7%) and 23 patients had an inconclusive result (15.3%). Primary local control at 2 years was 100%, 90% and 0% with, respectively, negative, inconclusive and positive FDG PET/CT result (p < 0.0001).

Poster Viewing Abstracts S441 Regional control at 2 years was 92%, 75% and 0% with, respectively, negative, inconclusive and positive FDG PET/CT result (p < 0.0001). Overall survival was 92%, 96% and 60% with negative, inconclusive and positive FDG PET/CT result, respectively (p Z 0.00159). A Cox model was done for survival. The only significant variables were T stage (p Z 0.002) and FDG PET/CT result (p Z 0.001, HR Z 6.37). Conclusions: This study clearly demonstrates the excellent negative predictive value of FDG PET/CT scan. Patients with N2-N3 stage cancer should not undergo cervical dissection with a negative PET/CT result (SUV  2). Patients with an inconclusive result should have either neck dissection or a control PET/CT in a short period of time. Author Disclosure: L. Bernier: None. J. Archambault: None. E. Vigneault: None. A. Fortin: None.

2623 Incidence and Impact of Dental Amalgam Artifact on Radiation Therapy Target Volumes in Oropharyngeal and Oral Cavity Cancer P. Richard,1 G. Sandison,1 B. Johnson,2 J. Liao,1 and U. Parvathaneni1; 1 University of Washington, Seattle, WA, 2Seattle Special Care Dentistry, Seattle, WA Purpose/Objective(s): Patients undergoing radiation therapy for head and neck cancers frequently have dental fillings or implants that can introduce significant artifact in diagnostic and treatment planning CT imaging. This may impact the accuracy of clinical target volume (CTV) delineation for highly conformal radiation therapy. However, the scope of the problem has not been quantified. We evaluated the incidence and impact of dental artifact on CTV delineation for patients undergoing curative radiation therapy for oropharyngeal or oral cavity cancer. This work serves as the basis for exploring novel solutions to address this problem. Materials/Methods: We retrospectively reviewed the treatment plans of patients with oropharyngeal or oral cavity cancer who received either postoperative or definitive radiation therapy at our institution from 2010-2012. Treatment planning CT images were evaluated for the presence or absence of dental amalgam streak artifacts. If present, the treatment plan was reviewed for CTV definition interference, defined as extension of the artifact into the high-risk CTV. Results: We identified 110 treatment plans that were available for review, including 71 oropharynx and 39 oral cavity. Dental amalgam artifact was identified in 81 plans (73.6%), including 53 oropharynx (74.6%) and 28 oral cavity (71.8%). Artifacts were easily identified as an abrupt change in the Hounsfield units on the treatment planning CT scan, obscuring visualization of the treatment targets and surrounding normal tissue. Artifact was found to extend into or obscure visualization of the CTV in 77 cases (95%), including 49 of the 53 oropharynx cases (92.5%) and all 28 oral cavity cases (100%). Conclusions: We have identified a high incidence of dental artifact on treatment planning CT scans in patients undergoing head and neck radiation therapy. We confirmed that this artifact obscures and may affect accuracy of target volume delineation in a large percentage of patients. In addition, this may interfere with post-treatment surveillance imaging and dose calculation for both highly conformal radiation therapy and charged particle therapy. There is need for practical approaches to reduce the impact of these artifacts. Image processing strategies have been explored but have not been widely adopted. Our group in collaboration with dental colleagues is currently investigating the effectiveness of a novel composite dental amalgam. Author Disclosure: P. Richard: None. G. Sandison: None. B. Johnson: None. J. Liao: None. U. Parvathaneni: None.

2624 EORTC QOL Rating, Performance Status, and Oral Outcomes in Head-and-Neck Cancer Patients Treated With Chemoradiation Therapy H. Husaini,1 C. Lazarus,2 K. Hu,2 M. Urken,3 A. Jacobson,2 M. Kumar,2 R. Metcalfe-Klaw,2 and L. Harrison2; 1Thyroid, Head and Neck Cancer Foundation, New York, NY, 2Beth Israel Medical Center, New York, NY, 3 Thyroid, Head and Neck Cancer Foundation, Beth Israel Medical Center, New York, NY

S442

International Journal of Radiation Oncology  Biology  Physics

Purpose/Objective(s): This is a prospective study examining functional outcomes and quality of life after chemoradiation therapy over the first 3 months post-treatment. Materials/Methods: Fifty patients with head and neck cancer were treated with IMRT based chemoradiation therapy for various sites (31Oropharynx, 5 unknown primary and 7 patients with larynx/pharynx/ Hypopharynx/Nasopharynx tumors). All were seen baseline and 3 months post-tx. Assessments included the Performance Status Scale (PSS), tongue strength, jaw opening, and saliva weight. Patient-rated QOL utilized the EORTC QLQ 30 and EORTC H&N 35 with significance at p < .05. Results: Significant reductions were noticed from baseline to 3 months post-tx in tongue strength (11%, p Z 0.00), jaw opening (7.7%, p Z 0.00) and saliva weight (58.20%, p Z 0.00). There was a 12% (57.85 kPa at BS and 50.76 kPa at 3 months p Z 0.00) drop in tongue strength in patients with Oropharynx/unknown primary tumors while there was a 7% (54.79 kPa at BS and 50.86 kPa at 3 months, p Z 0.16) drop in tongue strength in patients with larynx/pharynx/Hypopharynx tumors. 5 patients (2 Oropharynx/unknown primary tumor gp and 3 larynx/pharynx/Hypopharynx tumor gp) had PEGs and there was a 19% decrease in tongue strength (59.20 kPa vs 48 kPa, p Z 0.75) while 44 pts did not have PEGS and had a 10% reduction in tongue strength (56.82 kPa vs 51.12 kPa, p Z 0.63) . Patients also performed significantly worse on the, Normalcy of Diet and Eating in Public domains of PSS from baseline to 3 months posttx. On the EORTC H&N35, patients reported significantly worse scores on domains of swallowing, senses, social eating, problems with mouth opening; dry mouth and sticky saliva from baseline to 3 months post-tx. Eating in Public was found to correlate (marginally) with the social functioning domain of EORTC QLQ 30.Normalcy of Diet also negatively and significantly correlated with appetite loss, indicating a more restricted diet with increased appetite loss. Negative correlations (p < 0.05) were seen between Normalcy of Diet and EORTC H&N35 domains of swallowing, social eating and social contact. Tongue strength significantly correlated with the global QOL domain of EORTC QLQ-30 (p Z 0.04) and negatively with appetite loss. Saliva weight was negatively correlated (marginally) with EORTC H&N 35 domain of dry mouth (p Z 0.054) and also with appetite loss (p Z 0.09) on the EORTC QLQ 30. Conclusions: Concomitant chemoradiation therapy for treatment of head and neck tumors can result in impaired performance status, oral outcomes and QOL over the first 3 months post-tx. Multidisciplinary supportive care monitoring of impaired oral function is important to initiate early intervention. PEG placement was associated with greater loss of tongue strength, but further study is needed to determine its impact on function preservation and quality of life measures. Author Disclosure: H. Husaini: None. C. Lazarus: None. K. Hu: None. M. Urken: None. A. Jacobson: None. M. Kumar: None. R. Metcalfe-Klaw: None. L. Harrison: None.

Purpose/Objective(s): Despite good prognosis of HPV+ tumors, a small percentage of these patients (pts) develop distant metastases. We sought to characterize the patterns of metastatic disease in this pt cohort, which appears distinct from failure patterns in patients with HPV-negative (HPV-) SCC-OP. Materials/Methods: We identified pts within our IRB-approved Head and Neck (H&N) Cancer Registry who had HPV + SCC-OP with distant metastatic disease at presentation or at recurrence. All patients stained positive for HPV DNA using in situ hybridization, demonstrated strong and diffuse staining for p16 on immunohistochemical analysis, or both. All patients had histologic confirmation of their first metastasis. HPV testing was done from the primary site or a metastatic focus. Results: Nine patients meeting our inclusion criteria were identified (Table). 3/9 patients presented with distant metastases (patients 1-3). Patient 1 underwent resection of a solitary dural metastasis, adjuvant whole brain radiation, and definitive chemoradiation therapy (CRT) to the H&N. Patient 2 underwent induction chemotherapy (CT) with complete resolution of a solitary metastatic iliac lesion, followed by definitive CRT to the H&N. Both patients are alive without disease (ANED). Patient 3 underwent aggressive induction CT with response at her solitary subcarinal metastases followed by split course CRT to the H&N. This patient died of metastatic disease 28 months (mos) later. The other 6/9 patients developed distant metastases after definitive management of their H&N primaries (Patients 4-9). Time to development of metastasis was 24 mos after diagnosis (range, 5-82 mos). None of these 6 patients failed in the H&N. The crude median survival was 36.5 mos in these 6 patients. Two are ANED, two are alive with disease, and two have died of disease. Of the entire cohort, 6/9 patients had failures outside the lung. Conclusions: Distant metastases in HPV+ SCC-OP appears to demonstrate a unique natural history and distribution compared to pts with HPV- SCCOP. HPV+ SCC-OP patients also appear to have longer time to development of distant metastases. Further study is required to confirm this initial observation and understand the role of aggressive management in these pts. Author Disclosure: S. Guo: None. S. Al-Khudari: None. T. Nwizu: None. J.F. Greskovich: None. B.B. Burkey: None. D.A. Adelstein: None. S.A. Koyfman: None.

2625 Patterns of Metastases in Patients With Human Papillomavirus/ p16-Associated (HPV+) Squamous Cell Carcinoma of the Oropharynx (SCC-OP) S. Guo, S. Al-Khudari, T. Nwizu, J.F. Greskovich, B.B. Burkey, D.A. Adelstein, and S.A. Koyfman; Cleveland Clinic, Cleveland, OH

Poster Viewing Abstract 2625; Table Patient 1 2 3 4 5 6 7 8 9

2626 Decision Tree Predicting the Tumor Shrinkage for Head-and-Neck Cancer: Implications for Adaptive Radiation Therapy M. Surucu,1 K.K. Shah,1 I. Mescioglu,2 J. Roeske,1 J. Breuning,1 D. Dave,1 and B. Emami1; 1Loyola University Medical Center, Maywood, IL, 2Lewis University, Romeoville, IL Purpose/Objective(s): To identify the characteristics of the head and neck cancer patients that will predict for higher tumor shrinkage during the course of radiation therapy, a decision tree induction algorithm was implemented. Materials/Methods: Twenty-five primary head and neck cancer patients treated with definitive chemo-radiation therapy between 2009 and 2012 were analyzed. The sites included: Nasopharynx (3), Oropharynx (12), Oral Cavity (7), Hypopharynx (1), Larynx (1), and unknown primary (1). Due to the changes in the tumor volume and/or patient weight, these patients were re-scanned during the course of radiation therapy. Hence, their plans were adapted to the changes in their anatomy. The gross tumor

Patient characteristics

Primary site

Stage

Site of first metastases

Time to development of metastasis (mo.)

Survival

Overall survival (mo.)

R Tonsil R BOT L BOT L Tonsil R BOT L Tonsil L Posterior Pharyngeal Wall L Tonsil Unknown Primary of H&N

IVC IVC IVC IVB IVA IVA IVA IVB IVA

Dura Hip Subcarinal lymph node T12 spinous process Antecubital fossa soft tissue Lung Lung Lung, bone (T4, manubrium) Bilateral femurs, pelvis, spine

At presentation At presentation At presentation 18 30 31 12 5 82

Alive on treatment Alive NED Died of disease Alive NED Alive w/ disease Alive NED Died of disease Died of disease Alive w/ disease

2 6 28 22 47 54 17 11 84