Optimising Patient Outcomes in Tongue Cancer: A Multidisciplinary Approach.

A multidisciplinary approach to the management of tongue cancer is vital for achieving optimal patient outcomes. Nursing and allied health professionals play essential roles within the team. We developed symposia comprising a series of online lectures offering a detailed perspective on the role each discipline and consumer perspective has in the management of patients with tongue cancer. The topics, including epidemiology and prevention, diagnosis, treatment planning, surgery, adjuvant care, and the management of recurrent or metastatic disease, were thoroughly examined. The symposia highlighted the significance of fostering collaboration and continuous learning through a multidisciplinary approach. This initiative should be relevant to healthcare professionals, researchers, and policymakers striving to enhance patient outcomes in tongue cancer care through innovative collaboration.

Comprehensive profiling identifies tumour and immune microenvironmental differences in clinical subsets of cutaneous squamous cell carcinoma.

BACKGROUND: Cutaneous squamous cell carcinomas (cSCCs) are the second most diagnosed skin cancer worldwide; however, little is known about the pathobiological factors that contribute to the diverse clinical outcomes seen. OBJECTIVES: To profile cSCCs comprehensively and identify the pathological processes that contribute to the disparities seen in their clinical behaviour. METHODS: We characterized the genomic, transcriptomic and immunohistochemical profiles of 211 cSCC tumours, including 37 cSCCs from immunocompromised patients. RESULTS: cSCCs from immunocompromised patients were characterized by a lack of B cells in the peritumoral stroma compared with immunocompetent patients. Further, an abundance of a memory B-cell-like population in the peritumoral stroma was associated with a better prognosis in all patients (immunocompetent and immunocompromised), as well as only immunocompetent patients. No differences in genetic -variants, tumour mutational burden or mutational signatures were observed between cSCCs from immunocompetent and immunocompromised patients. Thus, differences in survival between cSCCs from immunocompromised patients and immunocompetent patients are not likely to be driven by tumour genomic factors, but may be associated with differential host immune response. cSCC not from a primary head and neck site had lower tumour mutational burden and exhibited upregulation of the epithelial-mesenchymal transition programme compared with head and neck cSCC. Both factors were implicated with poorer responses to immune checkpoint inhibition, and the latter with poorer survival. CONCLUSIONS: We identified tumour and host immune factors that contribute to the disparate clinical behaviour of cSCC, with broad translational application, including prognostication, treatment prediction to current therapies and the identification of novel anticancer therapy approaches in cSCC.

Radiotherapy quality assurance in the TROG 12.01 randomised trial and its impact on loco-regional failure.

Introduction: There is no consensus as to what specifically constitutes head and neck cancer radiotherapy quality assurance (HNC RT QA). The aims of this study are to (1) describe the RT QA processes used in the TROG 12.01 study, (2) review the RT QA processes undertaken for all patients with loco-regional failure (LRF), and (3) provide prospective data to propose a consensus statement regarding the minimal components and optimal timing of HNC RT QA. Materials and methods: All patients undergoing RT QA in the original TROG 12.01 study were included in this substudy. All participating sites completed IMRT credentialling and a clinical benchmark case. Real-time (pre-treatment) RT QA was performed for the first patient of each treating radiation oncologist, and for one in five of subsequent patients. Protocol violations were deemed major if they related to contour and/or dose of gross tumour volume (GTV), high dose planning target volume (PTVhd), or critical organs of risk (spinal cord, mandible, and brachial plexus). Results: Thirty HNROs from 15 institutions accrued 182 patients. There were 28 clinical benchmark cases, 27 pre-treatment RT QA cases, and 38 post-treatment cases. Comprehensive RT QA was performed in 65/182 (36%) treated patients. Major protocol violations were found in 5/28 benchmark cases, 5/27 pre-treatment cases, and 6/38 post-treatment cases. An independent review of all nine LRF cases showed major protocol violations in four of nine cases. Conclusion: Only pre-treatment RT QA can improve patient outcomes. The minimal components of RT QA in HNC are GTVs, PTVhd, and critical organs at risk. What constitutes major dosimetric violations needs to be harmonised.

Cutaneous squamous cell carcinoma metastatic to the axilla and groin: Outcomes and prognostic factors.

PURPOSE: This study examined the clinical outcomes and prognostic factors of patients with metastatic cutaneous SCC metastatic to the axilla and groin when managed with curative-intent lymphadenectomy and received (neo)adjuvant treatment. METHODS AND MATERIALS: We conducted a single institution retrospective review. Patients who had nodal disease without distant spread were 18 years or older with no non-cutaneous primary identified. RESULTS: From January 2000 to July 2015, 78 patients were treated for axilla (64, 82%) or inguinal (14, 18%) involvement with cSCC. The median age was 75.5 years (range: 29-95), and 8 patients (11%) were immunosuppressed. The median size of the largest node was 45 mm (range: 8-135), and extracapsular extension was found in 63 (81%) cases. A majority of patients were treated with surgery alone (21, 26.9%) and surgery with adjuvant radiation therapy (54, 69%). The 2-year OS and PFS were 50% (95% CI: 40%-63%) and 43% (95% CI: 33%-56%), and 5-year OS and PFS were 33% (95% CI:23%-47%) and 32% (95% CI:22%-46%) respectively in the entire cohort. On univariable analysis, factors associated with longer OS were as follows: younger age (HR 1.1, 95% CI: 0.9-1.3 P = 0.021), improved performance status (HR 1.5, 95% CI:1.0-2.3 P = 0.026), lack of immunosuppression (HR 3.3, 95% CI: 1.5-7.3 P = 0.001), lower lymph node ratio (HR 1.2, 95% CI:1.0-1.3 P = 0.007), lower number of positive nodes (HR 1.1, 95% CI:1.0-1.2 P = 0.004) and the use of radiation therapy (HR 0.5, 95% CI:0.3-0.9 P = 0.012). CONCLUSION: Metastasis to the axilla and groin with cSCC has poor outcomes with standard treatment. The addition of immunotherapy warrants investigation.

Symptom burden, quality of life, functioning and emotional distress in survivors of human papillomavirus associated oropharyngeal cancer: An Australian cohort.

BACKGROUND: This cross-sectional study examines patient-reported outcomes and functioning-based subgroups in human papillomavirus-associated oropharyngeal cancer survivors treated with chemoradiotherapy ≥12 months prior. METHOD: Survivors completed EORTC QLQ-C30, MDASI-HN and PROMIS-Emotional distress questionnaires. Subgroups were identified via two-step clustering of QLQ-C30 functioning scales. RESULTS: 136 patients were enrolled. Clinicians' graded 19/136 (14%) patients as having at least one severe (Grade 3 CTCAE) toxicity, whereas 68/136 (50%) patients self-reported at least one toxicity in the severe range (MDASI-HN ≥ 7). QLQ-C30 Global health status score (mean 76, SD = 20) was comparable to population norms. Rates of moderate/severe anxiety (10%/1%) and depression (4%/1%) were low. Two functioning-based subgroups were formed based on auto-clustering statistics: high- (n = 93) and low-functioning (n = 41). Differences on all functioning scales were large (d: 1.57-2.29), as were differences on the remaining QLQ-C30 scales/items, most MDASI-HN symptom severity/interference scales, and PROMIS scales (d: 0.80-2.03). Differences and associations with patient/clinical characteristics were not significant. CONCLUSION: In this Australian cohort of HPV-OPC survivors there was significant discordance between clinician- and patient-reported toxicity. We observed population comparable global quality of life and low rates of emotional distress. However, we identified a low-functioning subgroup reporting significantly worse outcomes on a range of patient-reported measures who may benefit from targeted support.

Fear of Cancer Recurrence in Survivors of Human Papillomavirus-Associated Oropharyngeal Carcinoma.

PURPOSE: To estimate the prevalence of and characteristics associated with fear of cancer recurrence (FCR) among human papillomavirus (HPV)-associated oropharyngeal cancer (OPC) survivors. METHODS AND MATERIALS: We conducted a cross-sectional study in HPV-OPC survivors ≥12 months from completion of definitive (chemo)radiation therapy (RT/CRT). Eligible patients completed the Fear of Cancer Recurrence Inventory short-form (FCRI-SF), the European Organisation for research and Treatment of Cancer QLQ-C30, MD Anderson Symptom Inventory-Head and Neck, and PROMIS Anxiety and Depression short forms. Associations between FCRI-SF scores and other variables were investigated using linear regression models. RESULTS: A total of 136 HPV-OPC survivors were enrolled; the median age was 61 years (range, 42-87 years), 84% were male, 72% were currently partnered, 83% were current nonsmokers, 67% were regular alcohol consumers, and the median time since treatment was 2.8 years (range, 1.0-5.5 years). Clinical levels of FCR (≥13) were observed in 72 of 135 patients (53%; 95% confidence interval [CI], 45%-62%). Characteristics significantly associated with increasing FCR scores were younger age (-0.9/5 years; 95% CI, -1.7 to -0.01; P = .031), lower global quality of life (-0.8/10 unit increase; 95% CI, -1.4 to -0.2; P = .012), higher symptom interference (0.8/unit increase; 95% CI, 0.1-1.5; P = .017), and a higher burden of anxiety (0.4/unit; 95% CI, 0.3-0.5; P <.001) and depression (0.3/unit; 95% CI, 0.1-0.4; P <.001). Other sociodemographic tumor- and treatment-related characteristics were not statistically significant. Compared with patients reporting nonclinical levels of FCR, significantly more patients reporting clinical levels of FCR than expected believed professional psychological assistance would have been beneficial (60% vs 33%; P = .002). CONCLUSIONS: Clinical levels of FCR were observed in approximately half of the HPV-OPC survivors. Survivors reporting higher FCR were younger with worse self-reported global quality of life and higher symptom interference and emotional distress. No other patient, tumor, or treatment factors were associated with higher FCR.

Sexual Health and Interpersonal Relationships After Chemoradiation Therapy for Human Papillomavirus-Associated Oropharyngeal Cancer: A Cross-sectional Study.

PURPOSE: To examine sexual health, including sexual satisfaction, and perceived changes in relationships and sexual relationships of human papillomavirus (HPV) oropharyngeal cancer (OPC) survivors ≥12 months after (chemo)radiation therapy. METHODS AND MATERIALS: We undertook a cross-sectional study of HPV-OPC survivors who had completed treatment ≥12 months prior. Eligible patients completed the EORTC QLQ-SHQ22, a customized relationship questionnaire, the EORTC QLQ-C30, MDASI-HN, and PROMIS Anxiety and Depression scales. RESULTS: We enrolled 136 survivors (median age, 61 years [range, 42-87 years]; male, 84%; currently partnered, 72%). The median time from (chemo)radiation therapy completion was 2.8 years (range, 1.0-5.5 years). Most patients (71/131; 60%) reported an active sex life as important; however, only 20% (26/133) reported significant recent sexual activity ("quite a bit"/"very much"). The mean sexual satisfaction score was 47/100 (interquartile range, 27-67; standard deviation 28). On univariable analysis, greater sexual satisfaction was positively associated with greater importance of sexual activity, stronger libido, greater relationship security, and more erection confidence (males). Lower sexual satisfaction was significantly associated with female sex (P = .04), more medical comorbidities (P = .008), and more time since treatment completion (P = .006). Only a few patients reported a change in their marital status (10/136; 7%). The majority (62/109; 57%) of patients partnered at diagnosis reported no change in their precancer relationship. Among those reporting a change, it was more frequently perceived as positive (29/109; 27%) than negative (16/109; 15%). Regarding their sexual relationship, 54 of 107 (50%) reported no change, 40 of 107 (37%) reported a negative change, and 8 of 107 (7%) reported a positive change. CONCLUSIONS: Although an active sex life is important to many HPV-OPC survivors, fewer reported significant recent sexual activity. Sexual satisfaction scores were moderate in this cohort. Although recall bias was possible, most patients reported either no change or a positive change in their interpersonal relationship. Prospective studies evaluating sexual health outcomes and addressing informational needs in HPV-OPC survivors are needed.

Patient-reported quality of life and toxicity in unilateral and bilateral radiotherapy for early-stage human papillomavirus associated tonsillar carcinoma.

PURPOSE: The purpose of this study was to compare self-reported health-related quality of life (QoL) and symptom burden in early stage tonsillar carcinoma patients treated with unilateral (URT) and bilateral radiotherapy (BRT). METHODS AND MATERIALS: This is a secondary analysis of a larger study assessing patient reported outcomes in human papillomavirus (HPV) oropharyngeal cancer (OPC) patients. Recruited patients were ≥12 months from completion of radiotherapy. This analysis included only patients with T1-2, N1-2b tonsil cancer and excluded patients with base of tongue involvement or recurrent disease. QoL and patient reported toxicity was measured using the EORTC QLQ-C30 module and the MDASI-HN. RESULTS: Patients were enrolled from November 2018 to May 2019. Of the 136 patients recruited to the main study, 43 were eligible for this substudy (22 URT, 21 BRT), with a median age and follow up of 58.2 and 3.0 years respectively. The two groups were balanced with respect to patient, tumor and treatment factors with the exception of higher rates of T2 disease (27% v 71%, p = 0.006) and more extensive GTV nodal volumes (11.0 v 25.5cc, p = 0.006) in the BRT group.BRT patients had lower global health status/QoL (84 v 69, p = 0.0005) and social functioning scores (93 vs 78, p = 0.033) on the EORTC QLQ-C30, and higher symptom severity (0.6 vs. 2.0, p = 0.001) and symptom interference scores (0.8 vs. 2.0, p = 0.010) on the MDASI-HN. Four of the six largest differences observed on MDASI-HN items were attributable to radiotherapy technique (dry mouth, mucous, difficulty swallowing/chewing and taste), with corresponding dose differences to the respective organs (contralateral parotid, oral cavity and pharyngeal constrictors). In every instance, severity of symptoms was worse on average for patients treated with BRT. CONCLUSIONS: In the highly conformal radiotherapy era, BRT in early HPV tonsillar cancer survivors has an enduring impact on long-term QoL and toxicity.

Outcomes of curative (chemo)radiotherapy for patients with non-p16 positive head and neck squamous cell carcinoma who are borderline for curative treatment.

INTRODUCTION: Appropriate selection of head and neck squamous cell cancer (HNSCC) patients for curative treatment is difficult, and it is a very understudied issue. The aim of this study was to review the outcomes of curative intent treatment in non-p16 positive HNSCC patients assessed as having borderline curability. METHODS: A single institution retrospective review of the clinical outcomes of non-p16 positive HNSCC patients with borderline curability. Predefined criteria for borderline curability were as follows: (i) T4 and/or N3 disease; or (ii) ECOG status ≥2; or (iii) age ≥75 years. RESULTS: A total of 114 patients were identified. A total of 56 had N3/T4, 32 were >ECOG 2 and 57 were >75 years. A total of 29 had two or more borderline curability criteria. Progression-free survival rate (PFS) at 1 and 2 years was 72% (95% confidence interval (CI), 63-79) and 53% (95% CI, 43-62), respectively. Overall survival (OS) at 1 and 2 years was 76% (95% CI, 67-83) and 61% (95% CI, 51-69), respectively. On multivariable analysis, the only independent prognostic factor for OS was the adult comorbidity evaluation-27 (ACE-27) grade (HR 1.4; 95% CI, 1.1-1.8; P = 0.018). CONCLUSIONS: Patients with borderline curability criteria treated with curative intent achieved good PFS and OS. ACE-27 was an important prognostic factor in this population.

Treatment Package Time in Node-Positive Cutaneous Head and Neck Squamous Cell Carcinoma.

PURPOSE: Treatment package time (TPT) prolongation is associated with lower overall survival and locoregional control in mucosal head and neck squamous cell carcinoma (SCC), but there are few reports in cutaneous HNSCC (cHNSCC). We sought to test the effect of TPT in a cohort of patients with cHNSCC. METHODS: This is a single institution retrospective study of node-positive cHNSCC patients involving either the parotid or cervical nodes treated with curative intent surgery with macroscopic tumor clearance followed by standard fractionation postoperative radiation therapy (PORT) from 2001 to 2014. We assessed the effect of TPT and other prognostic variables on overall survival (OS), cHNSCC specific survival (CSS) progression free survival (PFS), and freedom from locoregional failure (FFLRF). RESULTS: In the present study, 152 patients met the inclusion criteria. The 5-year OS, CSS, PFS, and FFLRF were 62% (95% confidence interval [CI], 54-71), 78% (95% CI, 71-87), 54% (95% CI, 46-64), and 76% (95% CI ,68-85), respectively. In a multivariable model, TPT ≥14 weeks was associated with worse outcomes in all endpoints (OS [hazard ratio (HR) 4.93; 95% CI, 2.54-9.56, P < .001], CSS [HR 6.09; 95% CI, 2.33-15.92; P = .001], PFS [HR 4.29; 95% CI, 2.21-8.34; P < .001], and FFLRF [HR 4.63; 95% CI, 1.71-12.51; P = .007]). Immunosuppression and the presence of ≥2 pathologically involved lymph nodes were also significant adverse factors for both OS and FFLRF, although extracapsular extension was also associated with lower FFRLF. Delays to commencing PORT rather than treatment breaks accounted for the majority of cases with prolonged TPT. CONCLUSIONS: Prolongation of TPT to 14 weeks or longer may confer a lower probability of locoregional control and survival in patients with lymph node-positive cHNSCC treated with surgery and PORT. Timely referral and commencement of PORT is necessary to maximize long-term disease outcomes.

Partial Laryngeal IMRT for T2N0 Glottic Cancer: Impact of Image Guidance and Radiation Therapy Intensification.

PURPOSE: To assess the impact of the radiation therapy (RT) regimen and image guidance (image guided radiation therapy [IGRT]) protocol on local control (LC) for T2N0 glottic cancer treated with partial laryngeal intensity modulated radiation therapy (IMRT). METHODS AND MATERIALS: All patients with T2N0 glottic cancer treated with IMRT from 2006 to 2013 at a single institution were retrospectively reviewed. The gross tumor volume (GTV), delineated from endoscopic and/or radiologic findings, was expanded 0.5 cm for the high-dose clinical target volume and an additional 0.5 cm for the lower-dose clinical target volume (total of 1.0 cm from GTV). The planning target volume margin was 0.5 cm radially and 1 cm superiorly and inferiorly. RT regimens evolved from hypofractionated IMRT (RT-hypo, 60 Gy in 25 fractions over a period of 5 weeks) to moderately accelerated IMRT (RT-acc, 66-70 Gy in 33-35 fractions over a period of 5.5-6 weeks) since 2010. The IGRT matching surrogate changed from cervical vertebral bone (IGRT-bone) to laryngeal soft tissue (IGRT-larynx) in 2008. LC was compared between 3 sequential cohorts: RT-hypo/IGRT-bone, RT-hypo/IGRT-larynx, and RT-acc/IGRT-larynx. Multivariable analysis assessed the relative impact of RT regimen and IGRT technique on local failure separately. RESULTS: Among 139 eligible patients (median follow-up period, 5.03 years [range, 0.8-10.5 years]), we identified 28 local, 6 regional, and 2 distant failures. A higher 3-year LC rate was observed for RT-acc/IGRT-larynx (89% [95% CI: 78%-95%]) versus RT-hypo/IGRT-larynx (80% [95% CI: 54%-91%]) and RT-hypo/IGRT-bone (70% [95% CI: 53%-80%]) (P = .02). Multivariable analysis adjusted for GTV (in cubic centimeters) and smoking status confirmed that IGRT-larynx versus IGRT-bone (hazard ratio, 0.40; P = .019) and RT-acc versus RT-hypo (hazard ratio, 0.34; P = .012) both reduced the risk of local failure. CONCLUSIONS: This single-institution cohort study shows a high LC rate (89%) for T2N0 glottic cancer following moderately accelerated partial laryngeal IMRT with daily laryngeal soft tissue matching IGRT. These results appear to represent an improvement attributable to changes in both IGRT matching and dose delivered, but their independent significance is unknown and further confirmation in a larger cohort is warranted.

Unilateral radiotherapy treatment for p16/human papillomavirus-positive squamous cell carcinoma of unknown primary in the head and neck.

OBJECTIVES/HYPOTHESIS: The outcomes of unilateral radiotherapy treatment for patients with p16/HPV-positive squamous cell carcinomas of unknown primary (SCCUP) affecting cervical lymph nodes are under-reported. Compared to radiating large volumes of the pharyngeal axis (the more common approach), this is potentially a much less toxic treatment for a good prognosis group. STUDY DESIGN: Retrospective cohort study. METHODS: We identified patients with SCCUP who were treated radically at our center and did not have parotid or isolated level IV or V nodal involvement. Failure-free and overall survivals were calculated using Kaplan-Meier methods. RESULTS: From 2004 to 2012, there were 49 radically treated patients with SCCUP. Fourteen patients had bilateral neck treatment (they had bilateral nodal disease or suspected lesions in the base of tongue, though not proven with biopsy), two had surgery alone, whereas 33 had unilateral radiotherapy (after neck dissection, excisional biopsy, or definitively with concurrent chemotherapy). Of the 33 patients, 21 tested positive to p16/HPV and had median follow-up of 57 months. In this group, no isolated contralateral neck failures or putative primaries emerged. There was 1/21 (4.3%) ipsilateral neck failure, 1/21 (4.3%) concurrent contralateral neck and distant failure, and 1/21 (4.3%) patient with distant failure. The 5-year freedom from failure was 78% (95% confidence interval [CI]: 56%-100%) and overall survival was 90% (95% CI: 79%-100%). CONCLUSIONS: With no emergence of putative primaries and no isolated contralateral neck failures, this single-institution experience in p16/HPV-positive SCCUP patients suggests that unilateral radiotherapy may be an underutilized management strategy. LEVELS OF EVIDENCE: 4 Laryngoscope, 128:2076-2083, 2018.

Retrospective audit of patients referred for further treatment following Mohs surgery for non-melanoma skin cancer.

BACKGROUND/OBJECTIVES: To describe the characteristics, subsequent management and outcomes of patients referred for further management following Mohs micrographic surgery (MMS) for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). METHODS: Retrospective analysis of patients referred to a quaternary cancer centre from 2000 to 2015. RESULTS: In total, 83 lesions in 82 patients were referred for further management; 52 (62%) were SCC and 80 (96%) were located in the head and neck. Reasons for referral included high-risk disease for consideration for adjuvant radiotherapy (37/83, 45%), inadequate resection (28/83, 34%) or recurrence following previous MMS (15/83, 17%). Fewer than 40% of the 69 referrals received from MMS surgeons included photos or an operative report and diagram. There was discordance in pathology opinion in 11 (13%) of cases. Histopathology from MMS was reviewed in eight cases and there was discordance with the in-hospital pathology opinion in six of these. In-hospital re-excision was performed in 19 cases and in five of these the pathology report on the paraffin-sectioned re-excised tissue was discordant with prior MMS assessment. Significantly, two cases were associated with a misinterpretation of lymphocytic infiltrate as residual disease in patients with chronic lymphocytic leukaemia (CLL). CONCLUSION: This study highlights some of the challenges and limitations of MMS. Early referral for multidisciplinary management is recommended when MMS resection margins are inadequate or uncertain, especially for high-risk SCC. We recommend that referrals be accompanied by histological material, as well as a detailed report with operative photos and diagrams. CLL can pose an intraoperative diagnostic challenge. Discrepancies in the interpretation of MMS slides present an opportunity for improvement, and our findings support the role of ongoing quality assurance programs.

National survey on image-guided radiotherapy practice in New Zealand.

INTRODUCTION: This survey aimed to assess the use of image-guided radiotherapy (IGRT) within New Zealand (NZ) and evaluate the quality of IGRT delivery. METHOD: All nine centres in NZ were invited to participate in an online survey in November 2015. Questions were asked on type of IGRT technologies available, IGRT use by tumour site and frequency of imaging. In addition, questions were asked in reference to the American Society for Radiation Oncology (ASTRO) White Paper recommendations on safe practice of IGRT. RESULTS: Seven of the nine centres (78%) responded. Kilovoltage cone-beam CT (CBCT), kilovoltage planar imaging and megavoltage electronic portal imaging were the most commonly used IGRT technologies. CBCT was most frequently used in gynaecology (100%), genitourinary (86%) and head and neck (86%) sites. Despite the availability of similar IGRT technologies, there was significant variation in their application between centres. All centres used online IGRT; however, the frequency of imaging varied across the tumour sites and individual centres. Daily online IGRT use ranged from 43% to 86% across the tumour sites. Overall, there was good compliance by the NZ centres to the White Paper recommendations, with at least 71% reached for each element. However, the compliance rates for the individual centres ranged between 50% and 100%. The most commonly identified barrier to IGRT use was lack of guidelines/education (43%). CONCLUSION: Image-guided radiotherapy is widely used in NZ; however, there is a wide variation in its application between centres. Detailed tumour site-specific, imaging modality-specific national guidelines will allow standardization of IGRT practices.

Outcomes of Routine Intensity Modulated Radiation Therapy Quality Assurance in a Large Head and Neck Cancer Center.

PURPOSE: The primary endpoint was to ascertain whether the percentage of major changes implemented from our routine intensity modulated radiation therapy (IMRT) quality assurance (QA) process was more than 10%. The secondary endpoints were to document the percentage of minor changes, ascertain the time taken to perform the IMRT QA process, evaluate potential predictors for major changes, and ascertain the perceived value of the program by the compliance of radiation oncologists (ROs) treating head and neck cancer (HNC). METHODS AND MATERIALS: This was a retrospective analysis of a prospective database for all radically treated HNC patients. Recommended changes were predefined with criteria as either "major changes" or "minor changes." RESULTS: Of 595 patients treated radically between May 21, 2012, and May 21, 2014, 548 patients were entered, giving a compliance of 92.1%. The vast majority were treated with IMRT (470/548, 89%), 49.3% treated definitively and 50.7% treated adjuvantly; overall, 63% had stage IV disease. Eighty-one patients (14.8%) had 1 or more major changes recommended and implemented, and 21 patients (3.8%) had major changes recommended but not implemented because of a lack of consensus. Of minor recommendations, in 115 patients (21%) they were implemented and in 13 patients (2.4%) they were not implemented. No changes were recommended in the remaining 324 patients (59.1%). The only factor correlating with the likelihood of a major change was treatment with IMRT (P=.001). In the vast majority of cases (85%), the time taken for IMRT QA was less than 20 minutes. CONCLUSIONS: Our routine HNC IMRT QA program resulted in the implementation of a significant number of major changes. The high compliance with the program is indicative of the belief in its clinical value. This study can inform discussion on optimal RT QA processes in routine clinical practice.

Prognostic markers in metastatic cutaneous squamous cell carcinoma of the head and neck.

BACKGROUND: The minority of head and neck cutaneous squamous cell carcinomas (SCC) metastasize to regional lymph nodes. The purpose of this study was to describe the clinical outcomes and prognostic factors for patients with node-positive head and neck cutaneous SCC who underwent lymphadenectomy. METHODS: We conducted a retrospective single center study using the Kaplan-Meier method for the investigation of the overall survival (OS) and locoregional control rates. The Cox proportional hazards model was evaluated to identify prognostic factors. RESULTS: The median number of positive lymph nodes from 149 lymphadenectomies was 2 in the neck and 1 in the parotid gland. The 5-year OS and locoregional control rates were 50% and 77%, respectively. OS was worse among older patients (hazard ratio [HR], 1.04; p = .015), immunosuppressed patients (HR, 2.06; p = .034), and patients with a high total lymph node ratio (calculated from the number of positive lymph nodes divided by the total number of nodes; multivariate analysis [MVA]; HR, 1.13; p = .019). CONCLUSION: Low total lymph node ratio is associated with improved outcomes in node-positive head and neck cutaneous SCC. © 2017 Wiley Periodicals, Inc. Head Neck 39: 772-778, 2017.

Faculty of Radiation Oncology Position Paper on the use of Image-Guided Radiation Therapy.

The development of technology such as intensity-modulated radiotherapy (IMRT), volumetric arc therapy (VMAT) and stereotactic ablative body radiotherapy (SABR) has resulted in highly conformal radiotherapy treatments. While such technology has allowed for improved dose delivery, it has also meant that improved accuracy in the treatment room is required. Image-guided radiotherapy (IGRT), the use of imaging prior to or during treatment delivery, has been shown to improve the accuracy of treatment delivery and in some circumstances, clinical outcomes. Allied with the adoption of highly conformal treatments, there is a need for stringent quality assurance processes in a multidisciplinary environment. In 2015, the Royal Australian and New Zealand College of Radiologist (RANZCR) updated its position paper on IGRT. The draft document was distributed through the membership of the Faculty of Radiation Oncology (FRO) for review and the final version was endorsed by the board of FRO. This article describes issues that radiotherapy departments throughout Australia and New Zealand should consider. It outlines the role of IGRT and reviews current clinical evidence supporting the benefit of IGRT in genitourinary, head and neck, and lung cancers. It also highlights important international publications which provide guidance on implementation and quality assurances for IGRT. A set of key recommendations are provided to guide safe and effective IGRT implementation and practice in the Australian and New Zealander context.

Weekly cisplatin and radiotherapy for low risk, locoregionally advanced human papillomavirus-positive oropharyngeal squamous cell carcinoma.

BACKGROUND: There is interest in different treatment strategies, including deintensification in good prognosis human papillomavirus-positive (HPV(+)) oropharyngeal squamous cell carcinoma (SCC). We reviewed our experience with weekly cisplatin in low-risk, locoregionally advanced HPV(+) oropharyngeal SCC since late 2009. METHODS: Data from patients with low-risk HPV(+) oropharyngeal SCC treated with weekly cisplatin (40 mg/m(2) ) and 70 Gy radiotherapy were collected. Low risk was defined as stage III to IV oropharyngeal SCC excluding T1-2N1, T4 or N3 disease, or N2b to N2c disease in patients with >10 pack-year smoking history. RESULTS: Of 31 patients, the median age was 56 years (range, 41-69 years). All patients completed 70 Gy radiotherapy within 51 days and 84% completed at least 5 cycles of cisplatin. Grade 3 mucositis occurred in 22 patients (71%) and grade 3 febrile neutropenia in 6 patients (19%). No patients required enteral feeding at 12 months. The median follow-up was 30 months (range, 21-57 months) with no recurrences or deaths. CONCLUSION: Concurrent weekly cisplatin is relatively well-tolerated and associated with excellent disease control in low-risk, locoregionally advanced HPV(+) oropharyngeal SCC. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1117-E1121, 2016.

A small tolerance for catheter displacement in high-dose rate prostate brachytherapy is necessary and feasible.

PURPOSE: We examined catheter displacement in patients treated with fractionated high-dose rate (HDR) brachytherapy boost for prostate cancer and the impact this had on tumor control probability (TCP). These data were used to make conclusions on an acceptable amount of displacement. METHODS AND MATERIALS: The last 20 patients treated with HDR brachytherapy boost for prostate cancer at our center in 2007 were replanned using simulated interstitial catheter displacements of 3, 6, 9, and 12 mm with originally planned dwell times. The computer-modeled dose-volume histograms for the clinical target volumes were exported and used to calculate the TCP of plans with displaced needles relative to the original plan. Actual catheter displacements were also measured before and after manual adjustment in all patients treated in 2007. RESULTS: In the 20 patients who were replanned for caudal catheter displacements of 3, 6, 9, and 12 mm, the median relative TCP was 0.998, 0.964, 0.797, and 0.265, respectively (p < 0.01 when all medians were compared). All patients replanned with a 3-mm displacement, compared with only 75% with a 6-mm displacement, had a relative TCP greater than 0.950. In the 91 patients treated in 2007, before adjustment, 82.3% of fractions had a displacement greater than 3 mm compared with 12.2% of fractions after adjustment. CONCLUSIONS: Catheter displacement in HDR brachytherapy significantly compromises the TCP. The tolerance for these movements should be small (< or =3 mm). Correcting these displacements to within acceptable limits is feasible.

Health issues in newly arrived African refugees attending general practice clinics in Melbourne.

OBJECTIVE: To identify the most common health issues diagnosed by general practitioners in newly arrived African refugees. DESIGN: Descriptive study based on a purposive sample of six GPs to collate data from medical records of patients from African countries who had attended their clinics for the first time between 1 January and 30 June 2005. SETTING: Two community health centres and two private general practices in metropolitan Melbourne. PARTICIPANTS: African refugee patients who arrived in Australia after 1 June 2004 and were seen by the six participating GPs between 1 January and 30 June 2005. MAIN OUTCOME MEASURES: Demographic characteristics, laboratory test results and final diagnoses. RESULTS: Data were collected from 258 patient files. Most patients were from Sudan (57%) or Liberia (17%). Half were aged under 15 years. The most common health problems identified were inadequate vaccinations, nutritional deficiencies (vitamin D and iron), infectious diseases (gastrointestinal infections, schistosomiasis, and latent tuberculosis) and dental disease. Musculoskeletal, psychological and social problems were common in adults. 37% of patients were tested for latent tuberculosis, and 25% of these tested positive. CONCLUSIONS: African refugees require comprehensive health assessments for undiagnosed and untreated health problems. While most of the common diseases identified are non-communicable, if left untreated they will affect the long-term health and productivity of new settlers.