The Head & Neck journal has a new special issue, COVID-19 versus Cancer: Impact on Head and Neck Oncology, to help head and neck oncologists all over the world in dealing with the pertinent issues surrounding the challenges they face during this pandemic. The issue is available for free full content download, globally using this link https://authorea.com/inst/20973

Dr. Ehab Hanna, the Editor in Chief, introduced the issue in his Editorial, How Fragile We Are, highlighting the impact on health care systems, cancer care, and education. The editorial also discussed the issues of routine testing prior to cancer care, and our collective response to this pandemic. You can read the Editorial by using this link https://authorea.com/users/5588/articles/441050-how-fragile-we-are?commit=23e42f11eac47d7863d8b36ff84b737ecf247c68

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Ehab Hanna

Ehab Y. Hanna, MD FACS is Professor and Vice Chair of the Department of Head and Neck Surgery at The University of Texas MD Anderson Cancer Center in Houston, Texas. He is currently the President of the American Head & Neck Society.

Latest posts by Ehab Hanna (see all)

• COVID vs Cancer: Impact on Head and Neck Oncology - April 20, 2020
• What a Year!! - April 26, 2019
• Welcome to Heads Up! - April 25, 2019

Pathologic response to neoadjuvant chemotherapy in HPV-associated oropharynx cancer

Sadeghi N, Khalife S, Mascarella MA, Ramanakumar AV, Richardson K, Joshi AS, Bouganim N, Taheri R, Fuson A, Siegel R.

From Head and Neck, March 2020;42(3):417-425.

Article Review by Joe Goodman, MD

Background / Hypothesis
According to the authors, a paradigm shift is underway leading to de-escalation trials for HPV-associated oropharynx cancer (OPC). Because of the excellent prognosis for most HPV OPC, efforts have been made to improve quality-of-life after treatment and reduce treatment-related morbidity. While most de-escalation trials have looked at reducing radiation dose or eliminating chemotherapy, this trial uses neoadjuvant chemo therapy plus transoral surgery (NAC+S) with the goal of avoiding post-op radiation based on surgical pathology.

Design
This is a prospective cohort of patients with p16+ OPC (stage III/IV AJCC 7th) treated with chemotherapy consisting of 3 cycles of cisplatin/docetaxel every 3 weeks followed by transoral surgery and neck dissection. N3 disease was excluded. All 54 patients demonstrated at least partial response to the chemotherapy regimen based on preoperative post-treatment imaging. Goal was to correlate reduction in tumor volume with likelihood of complete pathologic response pCR. Surgical pathology was assessed for presence of primary tumor and neck metastases to determine yTNM restaging and assess need for postoperative XRT. Partial response was defined as any residual tumor. MRI response of tumor was also correlated with pathological response, but not RECIST criteria because often pathological response was underpredicted by imaging response.

Summary of Results
Surgical pathology showed overall pCR of 44%, with 72% pCR at the primary and 57% pCR in the neck.

96% had negative margins. There were 3 mortalities. Preop imaging volume reduction of 90% or greater had predictive value for pCR (sensitivity 0.82 and specificity 0.73). More patients at all stages showed pCR than PR on surgical pathology although this was not specifically analyzed.

Strengths

• Building on several other small series to show efficacy of neoadjuvant chemotherapy regimen based on surgical pathology, justifying de-escalation strategies
• Since transoral robotic surgery involves en bloc resections of radical tonsil or base of tongue, as well as neck dissection, less likelihood of missing a small discontiguous positive margin vs endoscopic partial resection

 Weaknesses

• Mortality of 5.6% seems high, not well explained if they declined recommended post-op treatment
• Survival outcomes not analyzed but this data is forthcoming
• No real attempt at understanding cellular mechanisms for this phenomenon
• Not powered to analyze based on smoking status as possible contributor to biological response in p16+ OPC
• While toxicity seems acceptable, long-term studies will need to be done

Key Points

• There seems significant biological response of p16+ OPC to this particular neoadjuvant chemotherapy regimen of cisplatin and taxotere. Other regimens have been studied, for instance the Weiss article from UNC, as well as bioselection papers from UM for larynx cancer.
• Even the original VA study showed 30% CR.
• While the current treatment paradigm states that chemotherapy is never sufficient for primary treatment of squamous cell carcinoma, in many cases in this series there was no evidence of tumor at the primary site or in the neck as assessed on surgical pathology. This speaks to the possible for bioselection strategies using NAC+S for de-escalation in p16+ OPC.
• Also supports an increased role for transoral surgery with good functional outcomes after neoadjuvant chemotherapy, avoiding “triple-therapy”—unless dictated by adverse features on surgical pathology – Supports role of post-chemotherapy pre-operative imaging to predict likelihood of pathologic complete response to further refine the treatment algorithm
• Long term, multi-institutional studies of disease free survival and toxicity will need to be done

From the Basic Science/Translational Section
Jeffrey C. Liu MD Vice Chair
Richard Wong Md Chair

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Joseph Goodman

Dr. Goodman is currently Assistant Professor of Otolaryngology and Associate Residency Program Director at The George Washington University in Washington, DC. He serves as a member of the Basic and Translational Science Service of the AHNS and is a working group member of the Salivary Gland Section. His research interests include HPV-related oropharyngeal cancer and reconstructive surgery of the Head and Neck.

Latest posts by Joseph Goodman (see all)

• AHNS Basic Science/Translational Newsletter Vol 1 - April 17, 2020

In light of the recent concerns about COVID-19 and the growing number of travel bans placed on both international and domestic colleagues, the AHNS Leadership has elected to postpone the AHNS 10th International Conference until July 22nd-25th 2021. This decision was made to preserve the health and safety of our attendees and patients.

Abstract Submissions

We will release all submitted oral and poster submissions and re-open abstract submissions in the Summer of 2020 if you would like to re-submit your abstract with our without updates or new research for consideration at the 2021 International Meeting.

We realize you’ve worked hard on your research and don’t want to delay disseminating the information for another year; therefore we encourage you to submit your manuscripts to JAMA Otolaryngology – Head & Neck Surgery.

Faculty Assignments

If you have been invited as faculty for the July 2020 Conference, look for your invitation over the next several months!  We anticipate that the vast majority of program will be the same.  The Program Committee will review the revised 2021 scientific program and re-assign and schedule faculty soon.

Hotel Reservations

If you have made your hotel reservations, please contact the Hyatt Regency Chicago directly to cancel.  You may contact them at (877) 803-7534 or use the Passkey link provided below.

https://www.hyatt.com/en-US/group-booking/CHIRC/G-GAHN

Registration Fees

For those who Have paid your registration to attend the July 2020 Conference, your fees will be refunded to the payment option you provided when registering.

We apologize for any inconvenience to our members and attendees.

Thank you for your understanding and continued support.

Robert Ferris, MD, PhD – AHNS 2021 Conference Chair
Eben Rosenthal, MD – AHNS 2021 Program Chair
Cherie-Ann Nathan, MD, FACS – AHNS President