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Up-Front Neck Dissection Followed by Definitive Chemoradiation in Patients with Regionally Advanced Head and Neck Cancer
I. J. Radiation Oncology d Biology d Physics
S546
2699
Volume 81, Number 2, Supplement, 2011
PET-CT Performance Characteristics May Be Early Predictors of Recurrence in Head and Neck Cancers Treated with IMRT
A. C. Olson, G. Kubicek, D. E. Heron Department of Radiation Oncology, University of Pittsburgh School of Medicine, Pittsburgh, PA Purpose/Objective(s): PET scans are increasingly used as a diagnostic tool in evaluating local recurrence in head and neck cancer (HNC). It is unclear which PET scan metrics (maximum SUV, SUV threshold, etc) correlate with cancer recurrence and also which PET metric radiologists use to determine recurrence. We sought to evaluate the use of PET-CT and various parameters in predicting recurrences post-IMRT. Materials/Methods: 29 HNC patients treated with intensity-modulated radiation therapy (IMRT) from 2003 - 2005 were reviewed. Pre-treatment and post-treatment PET-CTs scans were assessed with Velocity Medical Solution’s VelocityAIÒ imaging informatics software. Gross tumor volumes (GTV) were generated for each individual scan. The pre-treatment GTV was defined using an absolute threshold of standardized uptake values (SUV) of 2.5. Post-treatment GTVs were defined as 40% of the maximum SUV in the locoregional area of the primary tumor. Obvious physiologic uptake was manually removed from each GTV. For each GTV, a curve of SUV vs. % GTV was generated. The area under the curve (SAUC) was calculated using trapezoidal integration. The radiologist’s interpretation of post-treatment scans as ‘‘complete response,’’ ‘‘partial response,’’ ‘‘stable disease,’’ ‘‘progressive disease,’’ and ‘‘new lesions’’ were collected and correlated with percent changes in the area under the curve using ordinal regression. Results: The median time to initial post treatment scan after completion of radiation therapy was 49 days (range 28 - 121). There was a significant association with radiologist interpretation and percent change in the area under the curve between the pretreatment PET-CT and the initial post-treatment PET-CT (p = 0.036, 95% CI -0.47 - -0.002). There was no significant correlation between radiologist interpretation and percent changes of max SUV from pre-treatment PET-CT to post-treatment PET-CT (p = 0.386, 95% CI -0.168 - 0.177). Conclusions: The strongest PET-CT predictor for recurrence post-treatment in HNC was SUV area (SAUC). Changes in the area under the curve of SUV x % GTV were the only PET metric to correlate with a radiologist’s interpretation of PET-CTs in HNC patients. Max SUV changes do not significantly correlate. Further analysis of SUV metrics may yield early post-treatment prognostic information predictive of the risk of locoregional recurrence. These findings may be of value and an objective way to evaluate outcomes in the post-treatment management of patients with HNC. Author Disclosure: A.C. Olson: None. G. Kubicek: None. D.E. Heron: None.
2700
Up-Front Neck Dissection Followed by Definitive Chemoradiation in Patients with Regionally Advanced Head and Neck Cancer
P. A. Paximadis1, M. Christensen1, D. Kamdar1, G. Dyson2, A. Sukari2, H. Lin1,2, H. Kim1, G. Yoo1,2 1
Wayne State University, Detroit, MI, 2Barbara Ann Karmanos Cancer Center, Detroit, MI
Purpose/Objective(s): To retrospectively analyze our institutional experience with up-front neck dissection followed by definitive chemoradiotherapy (CRT) in patients with regionally advanced head and neck squamous cell cancer (HNSCC). Materials/Methods: 56 patients with radiographic evidence of large (.3 cm) or necrotic lymph nodes underwent up-front neck dissection without resection of the primary tumor. Surgical procedures included either radical (19.6%) or modified radical (80.4%) neck dissections, with contralateral selective neck dissections performed in 4 cases. Post-operatively, patients went on to receive definitive radiotherapy (RT), with or without concurrent systemic therapy. RT was delivered either via three-field technique or with intensity modulated radiation therapy. Patients received 70 Gy to the primary tumor, 60 - 66 Gy to the postoperative neck, and 50 Gy to the elective neck. The proportion of patients receiving CRT was 94.6%, with cisplatin the most commonly used agent. Induction chemotherapy was given prior to radiation in 4 patients. Rates of overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method. Results: The median age for all patients was 53 years (40 - 74). Primary site was oropharynx in 38 (67.9%), hypopharynx in 8 (14.3%), larynx in 7 (12.5%) and oral cavity in 3 (5.4%). Pathologic nodal stage was N1 in 3 (5.4%), N2a in 10 (17.9%), N2b in 22 (39.3%), N2c in 9 (16.1%), and N3 in 11 (19.6%). One patient had a pathologically negative dissection (N0). Median follow up for all patients was 4.3 years (0.1 - 9.8). There were 17 recorded deaths at last follow up. The fiveyear OS and PFS rates were estimated at 70.1% (95% CI:58.3 - 84.3) and 63.5% (95% CI:51.9 - 77.7), respectively. There were 2 failures in the dissected neck, for a control rate of 96.4%. There were 8 locoregional failures and 10 distant failures, for locoregional and distant control rates of 85.7% and 82.1%, respectively. The median delay between neck dissection and the initiation of definitive treatment was 21 days (10 - 48), with 8 patients experiencing a delay of greater than 30 days. Immediate post-operative complications were limited to 1 case of persistent drainage from the incisional site. There were no incidences of post-radiation wound complications. Conclusions: Our institutional results demonstrate that up-front neck dissection followed by CRT in patients with regionally advanced HNSCC resulted in excellent locoregional control, OS and PFS. Surgery was well tolerated and did not significantly delay the initiation of definitive treatment beyond the standard delay due to dental extraction. Utilization of this strategy should be considered in carefully selected patients with a high likelihood of nodal failure after CRT. Author Disclosure: P.A. Paximadis: None. M. Christensen: None. D. Kamdar: None. G. Dyson: None. A. Sukari: None. H. Lin: None. H. Kim: None. G. Yoo: None.
S546
2699
Volume 81, Number 2, Supplement, 2011
PET-CT Performance Characteristics May Be Early Predictors of Recurrence in Head and Neck Cancers Treated with IMRT
A. C. Olson, G. Kubicek, D. E. Heron Department of Radiation Oncology, University of Pittsburgh School of Medicine, Pittsburgh, PA Purpose/Objective(s): PET scans are increasingly used as a diagnostic tool in evaluating local recurrence in head and neck cancer (HNC). It is unclear which PET scan metrics (maximum SUV, SUV threshold, etc) correlate with cancer recurrence and also which PET metric radiologists use to determine recurrence. We sought to evaluate the use of PET-CT and various parameters in predicting recurrences post-IMRT. Materials/Methods: 29 HNC patients treated with intensity-modulated radiation therapy (IMRT) from 2003 - 2005 were reviewed. Pre-treatment and post-treatment PET-CTs scans were assessed with Velocity Medical Solution’s VelocityAIÒ imaging informatics software. Gross tumor volumes (GTV) were generated for each individual scan. The pre-treatment GTV was defined using an absolute threshold of standardized uptake values (SUV) of 2.5. Post-treatment GTVs were defined as 40% of the maximum SUV in the locoregional area of the primary tumor. Obvious physiologic uptake was manually removed from each GTV. For each GTV, a curve of SUV vs. % GTV was generated. The area under the curve (SAUC) was calculated using trapezoidal integration. The radiologist’s interpretation of post-treatment scans as ‘‘complete response,’’ ‘‘partial response,’’ ‘‘stable disease,’’ ‘‘progressive disease,’’ and ‘‘new lesions’’ were collected and correlated with percent changes in the area under the curve using ordinal regression. Results: The median time to initial post treatment scan after completion of radiation therapy was 49 days (range 28 - 121). There was a significant association with radiologist interpretation and percent change in the area under the curve between the pretreatment PET-CT and the initial post-treatment PET-CT (p = 0.036, 95% CI -0.47 - -0.002). There was no significant correlation between radiologist interpretation and percent changes of max SUV from pre-treatment PET-CT to post-treatment PET-CT (p = 0.386, 95% CI -0.168 - 0.177). Conclusions: The strongest PET-CT predictor for recurrence post-treatment in HNC was SUV area (SAUC). Changes in the area under the curve of SUV x % GTV were the only PET metric to correlate with a radiologist’s interpretation of PET-CTs in HNC patients. Max SUV changes do not significantly correlate. Further analysis of SUV metrics may yield early post-treatment prognostic information predictive of the risk of locoregional recurrence. These findings may be of value and an objective way to evaluate outcomes in the post-treatment management of patients with HNC. Author Disclosure: A.C. Olson: None. G. Kubicek: None. D.E. Heron: None.
2700
Up-Front Neck Dissection Followed by Definitive Chemoradiation in Patients with Regionally Advanced Head and Neck Cancer
P. A. Paximadis1, M. Christensen1, D. Kamdar1, G. Dyson2, A. Sukari2, H. Lin1,2, H. Kim1, G. Yoo1,2 1
Wayne State University, Detroit, MI, 2Barbara Ann Karmanos Cancer Center, Detroit, MI
Purpose/Objective(s): To retrospectively analyze our institutional experience with up-front neck dissection followed by definitive chemoradiotherapy (CRT) in patients with regionally advanced head and neck squamous cell cancer (HNSCC). Materials/Methods: 56 patients with radiographic evidence of large (.3 cm) or necrotic lymph nodes underwent up-front neck dissection without resection of the primary tumor. Surgical procedures included either radical (19.6%) or modified radical (80.4%) neck dissections, with contralateral selective neck dissections performed in 4 cases. Post-operatively, patients went on to receive definitive radiotherapy (RT), with or without concurrent systemic therapy. RT was delivered either via three-field technique or with intensity modulated radiation therapy. Patients received 70 Gy to the primary tumor, 60 - 66 Gy to the postoperative neck, and 50 Gy to the elective neck. The proportion of patients receiving CRT was 94.6%, with cisplatin the most commonly used agent. Induction chemotherapy was given prior to radiation in 4 patients. Rates of overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method. Results: The median age for all patients was 53 years (40 - 74). Primary site was oropharynx in 38 (67.9%), hypopharynx in 8 (14.3%), larynx in 7 (12.5%) and oral cavity in 3 (5.4%). Pathologic nodal stage was N1 in 3 (5.4%), N2a in 10 (17.9%), N2b in 22 (39.3%), N2c in 9 (16.1%), and N3 in 11 (19.6%). One patient had a pathologically negative dissection (N0). Median follow up for all patients was 4.3 years (0.1 - 9.8). There were 17 recorded deaths at last follow up. The fiveyear OS and PFS rates were estimated at 70.1% (95% CI:58.3 - 84.3) and 63.5% (95% CI:51.9 - 77.7), respectively. There were 2 failures in the dissected neck, for a control rate of 96.4%. There were 8 locoregional failures and 10 distant failures, for locoregional and distant control rates of 85.7% and 82.1%, respectively. The median delay between neck dissection and the initiation of definitive treatment was 21 days (10 - 48), with 8 patients experiencing a delay of greater than 30 days. Immediate post-operative complications were limited to 1 case of persistent drainage from the incisional site. There were no incidences of post-radiation wound complications. Conclusions: Our institutional results demonstrate that up-front neck dissection followed by CRT in patients with regionally advanced HNSCC resulted in excellent locoregional control, OS and PFS. Surgery was well tolerated and did not significantly delay the initiation of definitive treatment beyond the standard delay due to dental extraction. Utilization of this strategy should be considered in carefully selected patients with a high likelihood of nodal failure after CRT. Author Disclosure: P.A. Paximadis: None. M. Christensen: None. D. Kamdar: None. G. Dyson: None. A. Sukari: None. H. Lin: None. H. Kim: None. G. Yoo: None.