Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
In a parallel universe, we would have just concluded our 10th International Conference in Chicago. As you are all aware, this conference is postponed until next summer, where hopefully we will meet in person. However, conducting the business of the society is still a priority of many of the AHNS leaders and even the global pandemic did not stop the AHNS Council from meeting and discussing the initiatives and action items our services and sections have been working on (please click here to see the AHNS Council donning our fashionable masks).
I wanted to briefly update you on the work and progress of our leaders, as it’s vast and impressive! It wouldn’t be possible without their dedication and commitment to the mission of our society.
Some of the AHNS initiatives include:
As it turns out, and as no surprise, surgeons are even more productive during a global crisis. Thank you to the AHNS Council, Service Chairs, Section Leaders and Representatives and to all members who are coming together to produce impactful work for our specialty. If you have any suggestions for the society or would like to become more involved, please reach out to our Executive Director, Christina Kasendorf, at christina@ahns.info.
Stay safe and well,
Cherie-Ann Nathan, MD
AHNS President
For patients with early-stage oral cavity squamous cell carcinoma (OCSCC), there is a 20-30% risk for occult metastatic cervical disease despite clinical and radiographic ima Tirging. The debate surrounding management of the node-negative neck has spanned multiple decades initially centered around elective neck dissection (END) versus “watchful waiting” with subsequent therapeutic neck dissection. Recently, sentinel lymph node biopsy (SLN Bx) has emerged as a viable option for active management of the node-negative neck in these patients.
NRG Oncology has just activated a National Cancer Institute (NCI)-approved international, multi-institutional prospective trial comparing SLN Bx versus END for early-stage oral cavity cancer. The study is NRG-HN006 “Randomized Phase II/III Trial of Sentinel Lymph Node Biopsy Versus Elective Neck Dissection for Early-Stage Oral Cavity Cancer.” (Clinicaltrials.gov: NCT04333537)
The trial divides patients to two surgical arms, SLN Bx and END, following a PET/CT scan with a central reading as an integral biomarker supported by the NCI. The trial builds upon the recent results of the ACRIN 6685 trial, which demonstrated the relatively high negative predictive value of PET/CT for neck disease in patients with T2-4N0 head and neck cancers. Patients with a positive central read of their PET/CT for neck disease will still have their neck pathology results recorded to understand the functional performance of PET/CT in accurately assessing neck nodal status.
Patients with a negative central read of their PET/CT for neck disease will be randomized to the two surgical arms with stratification based on T-stage and performance status (Zubrod). The Phase II portion of the trial will test the hypothesis that SLN biopsy will have superior patient-reported neck and shoulder function and quality of life (QOL), as measured by the Neck Dissection Impairment Index (NDII), compared to END at 6 months post-surgery. Comparing the difference in the two arms from baseline and 6 months will serve to determine the “Go/No-Go” decision to proceed to Phase III. Phase III has co-primary endpoints and will test the hypothesis that SLN Bx will achieve non-inferior disease-free survival (DFS) compared to END, and that SLN Bx will have superior patient-reported neck and shoulder function and QOL, as measured by the NDII.
NRG-HN006 has an ambitious patient accrual target of 224 patients for Phase II who will be included as part of the 618 patients total for Phase III. The trial represents an opportunity to address the performance of SLN Bx and END in a definitive manner relative to QOL and patient survival. The collection of high-quality prospective data in this study will also permit the assessment of issues that continue to be raised with regard to extent of treatment for early-stage OCSCC, including extent of END, distribution of occult metastatic disease, and practice variations in adjuvant radiation therapy.
Site activation is currently in process and additional details, including the complete protocol, can be obtained here: CTSU website. Surgeon credentialing will require completion of an education course and case review. Please feel free to contact the study PI at sylai@mdanderson.org if you have additional questions and/or issues.
The AHNS Journal Club reviews the leading head and neck cancer-related journals, sharing with AHNS members some of the most relevant and important manuscripts, and providing summaries and critiques of the work.
The Journal Club for the July issue: AHNS Skull Base Surgery Edition
This Issue of the AHNS Journal Club has been compiled and reviewed by members of the
AHNS Skull Base Surgery Section (Ivan El-Sayed, Chair; Ian Witterick, Co-Chair)
Meghan Turner
Marilene Wang
Shirley Su
Harishanker Jeyarajan
Dear Colleagues,
The AHNS Skull Base Surgery Section is very pleased to present its first AHNS Journal Club Issue. Our ultimate goal for the Skull Base Surgery Section issues will be to provide insight into contemporary management of skull base tumors through themed issues. This particular issue will address controversies in the recently published literature on nodal metastases in olfactory neuroblastoma (ONB) by reviewing the recently published literature.
Traditionally, elective treatment of cervical nodal metastases for head and neck primaries is advocated when the risk of occult metastases reaches > 20%. However, sinonasal malignancy (as a group) has been shown to have a lower incidence of cervical metastases on presentation making elective treatment of the neck in sinonasal malignancy controversial and somewhat rare. With respect to ONB, the incidence of nodal metastases at the time of diagnosis (modified Kadish stage D) is low, approximately 8%.1,2 In spite of this rare incidence at diagnosis, up to 20.2% of patients with ONB will develop nodal disease within 5 years of diagnosis.3
Single institution studies have tried to identify risk factors for nodal recurrence (positive margins, modified Kadish C Staging, Hyam’s grade, the presence of dural invasion) and identify patients who might benefit from elective treatment of the neck.4-6 This has led to more recent studies examining elective treatment of high-risk nodal basins including retropharyngeal, level IB and level II lymph nodes.7 Elective neck irradiation provides 100% locoregional control in small, single-institution series, but was associated with worse overall survival in patients over 50. Salvage treatment of the delayed nodal recurrence has 5-year LRC rates of 30-80% and is highest when both surgery and radiation are used.3,6 It remains unclear whether or not elective treatment of the neck reduces distant metastasis or has meaningful impact on survival as metastases are largely found in the brain, leptomeningeal spine, or the spinal skeleton.6,7
In this issue, we present recent evidence regarding nodal metastases in ONB. It is suggested you read them in the order presented. We believe this evidence may impact future trends in the treatment of ENB and hope you enjoy this issue. Comments are welcome and can be sent to meghan.turner@hsc.wvu.edu.
Sincerely,
Meghan T. Turner, MD
Assistant Professor of Head and Neck Surgery
West Virginia University Health Sciences Center
Marilene Wang, MD
Professor of Head and Neck Surgery
Ronald Reagan UCLA Medical Center
Harishanker Jeyarajan, MD
Assistant Professor of Head and Neck Surgery
University of Alabama Birmingham School of Medicine
Shirley Y. Su, MBBS
Associate Professor of Head and Neck Surgery
Associate Professor of Neurosurgery
The University of Texas M.D. Anderson Cancer Center
CLICK THE ARTICLES BELOW TO ACCESS THE CURRENT ISSUE
Patterns of Regional and Distant Metastasis in Esthesioneuroblastoma
Victoria E Banuchi, MD Laura Dooley, MD, Nancy Y Lee, MD, David G. Pfister, Sean McBride, MD MPH, Nadeem Riaz, MD, Mark H Bilsky, MD, Ian Ganly, MD, Jatin P Shah, MD, Dennis H Kraus, MD, and Luc GT Morris, MD MSc
From The Laryngoscope, July 2016
A Population-Based Analysis of Nodal Metastases in Esthesioneuroblastomas of the Sinonasal Tract
Edward C Kuan, Hassan B Nasser, Ryan M Carey, Alan D Workman, Jose E Alonso, Marilene B Wang, Maie A St John, James N Palmer, Nithin D Adappa, Bobby A Tajudeen
From The Laryngoscope, May 2019
The Role of Elective Nodal Irradiation for Esthesioneuroblastoma Patients with Clinically Negative Neck
Wen Jiang, Abdallah S R Mohamed , Clifton David Fuller, Betty Y S Kim, Chad Tang , G Brandon Gunn, Ehab Y Hanna, Steven J Frank, Shirley Y Su, Eduardo Diaz, Michael E Kupferman, Beth M Beadle, William H Morrison, Heath Skinner, Stephen Y Lai , Adel K El-Naggar, Franco DeMonte, David I Rosenthal, Adam S Garden, Jack Phan
From the Practical Radiation Oncology, July-August 2016
Olfactory Neuroblastoma: Fate of the Neck–A Long-term Multicenter Retrospective Study
Sunny B Nalavenkata, Raymond Sacks, Nithin D Adappa, James N Palmer, Michael T Purkey, Michael D Feldman, Rodney J Schlosser, Carl H Snyderman, Eric W Wang, Bradford A Woodworth, Robert Smee, Thomas E Havas, Richard Gallagher, Richard J Harvey
From the Otolaryngology and head and neck surgery, February 2016
From the Practical Radiation Oncology, July-August 2016
Neck Recurrence and Mortality in Esthesioneuroblastoma: Implications for Management of the NO Neck
James G Naples , Jeffrey Spiro, Belachew Tessema, Clinton Kuwada, Chia-Ling Kuo, Seth M Brown
From The Laryngoscope, June 2016
Dural Invasion Predicts the Laterality and Development of Neck Metastases in Esthesioneuroblastoma
John P Marinelli, Jeffrey R Janus, Jamie J Van Gompel, Michael J Link, Eric J Moore, Kathryn M Van Abe, Brandon W Peck, Christine M Lohse, Daniel L Price
From the Journal of neurological surgery. Part B, Skull Base, October 2018.
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Olfactory Neuroblastoma: Fate of the Neck–A Long-term Multicenter Retrospective Study
Sunny B Nalavenkata, Raymond Sacks, Nithin D Adappa, James N Palmer, Michael T Purkey, Michael D Feldman, Rodney J Schlosser, Carl H Snyderman, Eric W Wang, Bradford A Woodworth, Robert Smee, Thomas E Havas, Richard Gallagher, Richard J Harvey
From the Otolaryngology and head and neck surgery, February 2016
Anthony C Nichols, Julie Theurer, Eitan Prisman, Nancy Read, Eric Berthelet….David A Palma
From Clinical Trial. The Lancet. Oncology, October 2019; 20(10):1349-1359.
Article Review by Natalie Silver, MD
Background/Hypothesis:
Design: Investigator-initiated, multicenter, international, open label, parallel-group, phase 2, randomized clinical trial comparing T1-T2, N0-2 OPSCC patients randomized to either primary radiotherapy (70Gy, chemotherapy if N1-N2) or TORS plus neck dissection (with/without pathologic based adjuvant chemo/radiotherapy). The primary endpoint was swallowing-related QOL at 1 year as established by the MD Anderson Dysphagia Inventory (MDADI) score, powered to detect a 10 point improvement (a clinically meaningful change).
Summary of results: 68 patients (34 per group) were randomized over a 5 year period (following stratification by p16 status). MDADI total scores at 1 year were: mean 86.9 (SD 11.4) in the radiotherapy (RT) group and 80.1 (SD 13.0) in the TORS plus neck dissection group (p=0.042), which did not meet the prescribed threshold (10 points) for a clinically meaningful difference. Toxicity patterns differed between the two groups with neutropenia, hearing loss and tinnitus being more common in the in the RT group and more cases of trismus in the TORS plus neck dissection group. The most common adverse events in the RT group were dysphagia (n=6), hearing loss (n-6), and mucositis (n=4) and in the TORS plus neck dissection group, dysphagia was the most common adverse event (n=9) and there was one patient death caused by bleeding after TORS. Oncologic outcomes were similar in both groups.
Strengths:
Weaknesses
Key Points:
From the Basic Science/Translational Service
Jeffrey C. Liu MD Vice Chair
Richard Wong MD Chair
