July - August 2017
Hepatitis C and Head and Neck Cancer
Vlad C. Sandulache, M.D., Ph.D.
Aug. 21 - 25, 2017
Specific question: Should hepatitis C screening be considered in patients with a new diagnosis of head and neck cancer?
Based on data from the Centers for Disease Control and Prevention the incidence of acute Hepatitis C (HCV) infection in 2010 was 0.3/100,000 persons in the United States. Mortality for HCV disproportionately affects African-Americans with an average of approximately 7/100,000 persons. Because HCV has now become a potentially curable disease, increased efforts are being made to provide patients with an early diagnosis; this has led to increased screening efforts. Current recommendations of the U.S. Preventive Services Task Force include the following as risk factors for HCV: long-term hemodialysis, percutaneous exposures, unregulated tattoos and high-risk sexual behaviors. In addition to patients at risk, the USPSTF recommends a 1-time screening for HCV infection of all adults born between 1945 and 1965.
In 2016, Mahale and colleagues published an analysis of nearly 35,000 cancer patients who underwent screening for HCV at The University of Texas MD Anderson Cancer Center. This analysis identified an increased prevalence of HCV seropositivity in patients with oropharyngeal cancer, in particular, HPV-positive oropharyngeal cancer (~17 percent) as well as patients with non-oropharyngeal head and neck cancers (20 percent). These data raise many questions about potential mechanistic interactions between HCV and other head and neck cancer risk factors which may impact disease biology and/or treatment response. However, the data clearly indicate that clinicians must consider a concomitant HCV infection in the setting of a new head and neck cancer diagnosis. Institutions should consider HCV screening at the time of cancer diagnosis.
Mahale P, Sturgis EM, Tweardy DJ, Ariza-Heredia EJ, Torres HA. Association Between Hepatitis C Virus and Head and Neck Cancers. J Natl Cancer Inst. 2016 Apr 13; 108(8). PMID: 27075854
Vlad C. Sandulache, M.D., Ph.D.
Aug. 14 - 18, 2017
Specific question: What is the impact of immunosuppressed status on clinical outcomes for skin cancer?
Skin cancers are one of the most common malignancies encountered by clinicians. Because of the large potential area of distribution (entire body), skin cancers are often diagnosed and managed by a variety of physicians including dermatologists, general surgeons, plastic surgeons, otolaryngologists and primary care physicians. Although the rarest of the three most common skin cancers, melanoma is a deadly disease which should be managed by physicians with dedicated oncologic training whenever possible. The more common skin cancers such as basal cell carcinoma and squamous cell carcinoma often are and can be successfully treated in the community setting using surgical excision, with appropriate surgical technique and surgical margins.
Cutaneous squamous cell carcinoma (cSCC) can exhibit aggressive behavior in patients which are immunosuppressed (i.e. transplant recipients, chronic lymphocytic leukemia patients, patients actively treated for auto-immune diseases). Although most cancers can behave aggressively in the context of a malfunctioning immune system (Falchi et al. 2016), skin cancers represent a particularly challenging problem due to their relatively high incidence. In these patients, treatment often requires multiple modalities and should be delivered in the setting of a well-integrated, multi-disciplinary tumor board at institutions which can provide not only the required surgical expertise, but also support in the form of adjuvant external beam radiotherapy and systemic treatments as well as clinical trial options for patients with advanced disease.
The articles listed below provide in-depth analysis of cancer behavior in patients which are immunosuppressed, with a particular focus on cSCC. They confirm the experience of clinicians with experience in this area and the importance of timely diagnosis and multi-modality treatment delivery, especially in the setting of advanced disease. Velez et al (2014) also provide the much needed insight that for patients with chronic lymphocytic leukemia, skin cancers contribute almost equally to patient mortality compared to the primary disease itself.
Manyam BV, Garsa AA, Chin RI, Reddy CA, Gastman B, Thorstad W, Yom SS, Nussenbaum B, Wang SJ, Vidimos AT, Koyfman SA. A multi-institutional comparison of outcomes of immunosuppressed and immunocompetent patients treated with surgery and radiation therapy for cutaneous squamous cell carcinoma of the head and neck. Cancer. 2017 Jun 1;123(11):2054-60. PMID: 28171708
Velez NF, Karia PS, Vartanov AR, Davids MS, Brown JR, Schmults CD. Association of advanced leukemic stage and skin cancer tumor stage with poor skin cancer outcomes in patients with chronic lymphocytic leukemia. JAMA Dermatol. 2014 Mar;150(3):280-7. PMID: 24429548
Falchi L, Vitale C, Keating MJ, Lerner S, Wang X, Elhor Gbito KY, Strom S, Wierda WG, Ferrajoli A. Incidence and prognostic impact of other cancers in a population of long-term survivors of chronic lymphocytic leukemia. Ann Oncol. 2016 Jun;27(6):1100-6. PMID: 26912560
Head and Neck Cancers
Vlad C. Sandulache, M.D., Ph.D.
Aug. 7 - 11, 2017
Specific question: What are the major recent changes in staging of head and neck cancers?
Cancers of the upper aero-digestive tract (UADT) include malignancies of the oral cavity, nasopharynx, oropharynx, larynx, hypopharynx and sino-nasal cavity. The American Joint Committee on Cancer (AJCC) Staging Manual is revised on a regular basis to provide staging information for patients and clinicians which is consistent with the most recent information regarding disease biology and treatment effectiveness.
The 8th edition of the staging manual contains important changes that must be incorporated into clinical practice. The article by Lydiatt et al summarizes some of these key changes and the evidence supporting each change. Of note, staging for HPV+ oropharyngeal squamous cell carcinoma has been changed to reflect the excellent prognosis associated with this disease despite what, under the old staging system, would have been considered adverse features (i.e. nodal metastases). The new staging system also reflects two adverse features associated with poor clinical outcomes in patients with oral cavity squamous cell carcinoma, namely extra nodal extension (ENE) and depth of invasion of the primary tumor.
Changes in staging will be accompanied by upcoming changes in pathology synoptic reports. From a research standpoint, it will important to note and maintain adequate records of changes in staging which will still allow for retrospective data analysis in future years.
Lydiatt WM, Patel SG, O'Sullivan B, Brandwein MS, Ridge JA, Migliacci JC, Loomis AM, Shah JP. Head and Neck cancers-major changes in the American Joint Committee on cancer eighth edition cancer staging manual. CA Cancer J Clin. 2017 Mar;67(2):122-37. PMID: 21828848
Salivary Gland Tumors
Vlad C. Sandulache, M.D., Ph.D.
July 31 - Aug. 4, 2017
Specific question: What is the value of pre-treatment needle biopsy in parotid tumors?
Management of parotid tumors can often be challenging for residents, fellows and young surgeons. One frequently discussed topic is the value of pre-operative biopsy whether performed using a fine needle aspiration (FNA) or a core biopsy protocol. Although there are dozens of specific, histopathologically defined benign and malignant salivary gland tumors, clinical management is largely driven by four biological phenomena: 1) tumor grade, 2) propensity for perineural spread, 3) relative sensitivity to radiation and 4) targetable molecular alterations which can guide systemic treatment. The primary goal of pre-treatment tissue sampling is to provide maximal information regarding phenomenon #1 and at the very least, differentiate benign from malignant tumors and low-grade cancers from high-grade cancers. Distinguishing the specific histopathologic origin is generally less useful than this basic, somewhat dichotomous separation.
Four recent articles provide readers with a comprehensive review of existing prospective and retrospective studies which analyze the sensitivity and specificity of FNA and core needle biopsy in the setting of parotid tumors. The article by Schmidt et al (2011) includes a superb discussion of bias and how different types of bias can impact data analysis and interpretation. This discussion will be particularly helpful for trainees as they develop the skills required to critically review published clinical datasets.
The scope and size of the analyses included in these articles provides a robust starting point for clinicians who wish to counsel their patients on the potential utility of pre-treatment needle biopsy in parotid tumors. Given the wide geographic distribution of the individual studies, and the extended time period over which the various studies were conducted, the aggregate data should provide a reasonable average sensitivity and specificity for both FNA and core biopsy protocols.
Schmidt RL, Hunt JP, Hall BJ, Wilson AR, Layfield LJ. A systematic review and meta-analysis of the diagnostic accuracy of frozen section for parotid gland lesions. Am J Clin Pathol. 2011 Nov; 136(5):729-38. PMID: 22031311
Witt BL, Schmidt RL. Ultrasound-guided core needle biopsy of salivary gland lesions: a systematic review and meta-analysis. Laryngoscope. 2014 Mar; 124(3):695-700. PMID: 23929672
Liu CC, Jethwa AR, Khariwala SS, Johnson J, Shin JJ. Sensitivity, Specificity, and Posttest Probability of Parotid Fine-Needle Aspiration: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2016 Jan; 154(1):9-23. PMID: 26428476
Kim HJ, Kim JS. Ultrasound-guided core needle biopsy in salivary glands: A meta-analysis. Laryngoscope. 2017 Jul 12. PMID: 28699165