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Stanley Tucci’s tongue cancer

Source: www.medpagetoday.com
Author: Michele R. Berman, MD

Actor Stanley Tucci is known for his roles in films such as “The Devil Wears Prada,” “The Hunger Games,” “The Lovely Bones,” “Spotlight,” and “Julie and Julia.” But now he is becoming known for another role — cancer survivor.

In an interview in the September 2021 issue of Virgin Atlantic’s inflight magazine Vera, 60-year-old Tucci revealed that he was diagnosed with cancer at the base of his tongue 3 years ago. “It was too big to operate, so they had to do high-dose radiation and chemo,” he explained.

Tucci was very reluctant to undergo this treatment, since he had seen the effects of this regimen on his first wife, Kate, who died from breast cancer in 2009. “I’d vowed I’d never do anything like that, because my first wife died of cancer, and to watch her go through those treatments for years was horrible,” he said.

He was equally concerned about how his illness would affect his five children. “The kids were great, but it was hard for them,” he noted. “I had a feeding tube for 6 months. I could barely make it to the twins’ high school graduation.”

Now, Tucci said that he is confident that the cancer is unlikely to return: “[Cancer] makes you more afraid and less afraid at the same time. I feel much older than I did before I was sick. But you still want to get ahead and get things done.”

And that’s exactly what he has done for the past 2 years. He launched a new CNN series, “Stanley Tucci: Searching for Italy,” and has written a book, Taste: My Life Through Food, which is set to be released in October.

Cancer of the Tongue
Cancers of the head and neck can form in the oral cavity (including the lips, the front two-thirds of the tongue, the gums, the lining inside the cheeks and lips, the floor of the mouth under the tongue, the hard palate, and the small area of the gum behind the wisdom teeth), the pharynx, the larynx, the paranasal sinuses and nasal cavity, and the salivary glands.

It should be noted that the anterior two-thirds of the tongue is considered part of the oral cavity, while the base of the tongue is part of the oropharynx. The tongue begins to develop around the fourth week of intrauterine life. The anterior portion of the tongue is derived from the first pharyngeal arch, while the base of the tongue originates from the mesoderm of the second, third, and fourth pharyngeal arches. This difference in origin causes the characteristics of these two cancers to be quite distinct, and therefore treatment for each type is quite different.

According to the Surveillance, Epidemiology, and End Results (SEER) Program, the estimated number of new cases of all types of tongue cancer in 2021 was 17,960 (0.9% of all new cancer cases), with an estimated 2,870 deaths. The 5-year relative survival is 68.1% for all stages. For patients with localized disease, the 5-year survival rate is 82.9%.

Clinical Presentation
Cancers at the base of the tongue can grow in either an infiltrative or exophytic pattern. Because the base of the tongue has no pain fibers, these tumors are often asymptomatic until there is significant progression.

Signs and symptoms may include the following:

Pain
Dysphagia
Weight loss
Referred otalgia secondary to cranial nerve involvement
Trismus secondary to pterygoid muscle involvement
Fixation of the tongue that is caused by infiltration of the deep muscle
A mass in the neck

Lymph node metastases are common. Approximately 70% of patients with advanced base-of-the-tongue cancers have ipsilateral cervical lymph node metastases, while ≤30% have bilateral cervical lymph node metastases.

Risk Factors
The most common risk factors for oropharyngeal squamous cell carcinomas (SCCs) include:

Smoking history of more than 10 pack-years and other tobacco use
Heavy alcohol use
Human papillomavirus (HPV) infection, especially HPV 16
Personal history of head and neck cancer

Because cigarette smoking is declining in the U.S., smoking-related oropharyngeal cancer is decreasing; however, oropharyngeal cancer due to HPV infection is increasing. According to the SEER Program’s tissue repository data from 1988 to 2004, the prevalence of HPV-negative oropharyngeal cancers declined by 50%, while HPV-positive cancers increased by 225%.

HPV-positive oropharyngeal cancers may represent a distinct disease entity associated with an improved prognosis. Several studies have indicated that patients with HPV-positive tumors have significantly improved survival.

Oropharyngeal tumors are more likely to be HPV positive compared with oral cavity tumor sites and non-oropharyngeal sites. HPV-positive oropharyngeal cancers predominantly arise in the palatine or lingual tonsils.

Treatment
As with any cancer, the treatment of patients with base-of-tongue cancer depends on a number of factors, including pathology, histology, clinical stage, patient’s age, and general medical condition. In patients with tongue cancer, immunohistochemical staining for p16 status is important.

For early-stage base-of-tongue SCC, surgical resection and/or radiation therapy is frequently used. For advanced-stage tumors, surgical resection may be paired with radiation and chemotherapy or with chemoradiation therapy (CRT). The typical regimen for early- and advanced-stage lesions involves 6 weeks of radiation with a platinum-based chemotherapy agent.

Although effective, radiation therapy and CRT can have significant side effects and can affect quality of life. Common side effects include dry mouth, mucositis, speech issues, dysphagia, aspiration, or respiratory distress. Patients may require a feeding tube or tracheostomy during treatment to protect their nutritional status or airway.

Studies are also being conducted to assess EGFR inhibitors, such as the monoclonal antibody cetuximab (Erbitux), for SCC of the base of the tongue. Immune checkpoint inhibitors are also being investigated.

It is essential that treatment approaches also include treatment of bilateral lymph nodes, either with radiation therapy or surgical resection.

Author:
Michele R. Berman, MD, is a pediatrician-turned-medical journalist. She trained at Johns Hopkins, Washington University in St. Louis, and St. Louis Children’s Hospital. Her mission is both journalistic and educational: to report on common diseases affecting uncommon people and summarize the evidence-based medicine behind the headlines.

2021-09-15T06:17:25-07:00September, 2021|Oral Cancer News|

World’s largest trial Of “Game-Changer” early cancer test begins in UK

Source: www.iflscience.com
Author: Maddy Chapman

Yesterday, England’s National Health Service (NHS) launched the world’s largest trial of a blood test that can detect more than 50 types of cancer before symptoms appear.

The trial aims to recruit 140,000 volunteers from different ethnic backgrounds, aged between 50 and 77, and living in eight areas across England. The test itself, the Galleri test, is a simple blood test that checks for the earliest signs of cancer. Ideally, it can be used to identify cancers at their earliest stages – stage one or two.

When it comes to detecting cancer, the earlier the better. A diagnosis at stage one can increase chances of survival by five to 10 times, compared to a diagnosis at stage four. The new test, developed by healthcare company GRAIL, is particularly effective at identifying cancers that are difficult to diagnose early – head and neck, bowel, lung, pancreatic, and throat cancers, for example.

“This quick and simple blood test could mark the beginning of a revolution in cancer detection and treatment here and around the world,” NHS chief executive Amanda Pritchard said in a statement.

“By finding cancer before signs and symptoms even appear, we have the best chance of treating it and we can give people the best possible chance of survival.”

The Galleri test works by identifying fragments of DNA that have been shed by tumors into the bloodstream. Participants in the trial, who must not have received a cancer diagnosis in the last three years, will therefore be asked to give an initial blood sample, before returning after 12 months, and then again after two years, to give repeat samples.

The trial is being run by Cancer Research UK and King’s College London Cancer Prevention Trials Unit in partnership with NHS England and GRAIL. It is a randomized control trial, meaning that half of the individuals involved will have their blood sample tested with the Galleri test and half will not. The samples of this latter group will be stored and may be screened in the future, allowing the scientists to find out whether the test does in fact help to identify cancers early. Neither group will know if they’re in the test group, unless early signs of cancer are detected, in which case the individual would be notified and referred for further tests.

Currently, the trial is operating through eight NHS Cancer Alliances spanning Cheshire and Merseyside, Cumbria, Greater Manchester, the North East, West Midlands, East Midlands, East of England, Kent and Medway, and South East London. Results are expected by 2023, and, if successful, it could be rolled out to a further 1 million people in England in 2024 and 2025.

According to the NHS, one in two people will develop some form of cancer in their lifetime. It is therefore hugely important that we develop screening methods capable of identifying these cancers as early as possible, to open up a broader range of treatment options and improve chances of survival.

Previous research in the US has found that the Galleri test identified more than 67 percent of 12 pre-specified stage one to three cancers, which account for approximately two-thirds of annual US cancer deaths. It also picked up around 41 percent of all cancers.

“The test could be a game-changer for early cancer detection and we are excited to be leading this important research,” said Professor Peter Sasieni, Director of The Cancer Research UK & King’s College London Cancer Prevention Trials Unit and one of the trial’s lead investigators.

2021-09-15T06:09:46-07:00September, 2021|Oral Cancer News|

FDA gives ISA101b fast track designation for HPV 16+ oropharyngeal cancer

Source: www.cancernetwork.com
Author: Hayley Virgil

The first patients with human papillomavirus 16–positive oropharyngeal cancer have been dosed with ISA101b, which was given a fast track designation by the FDA, as part of a phase 2 study.

ISA101b has received a fast track designation from the FDA for the treatment of patients with recurrent and metastatic human papillomavirus (HPV) 16–positive oropharyngeal cancer, according to a press release from drug developer ISA Pharmaceuticals.1

The fast track designation is intended to facilitate the development of investigational therapies that may help to address unmet medical needs for serious or life threatening diseases. An ongoing randomized, double-blind phase 2 trial is examining cemiplimab (Libtayo) with or without ISA101b and has an estimated enrollment of 194 patients (NCT03669718).

“Recurrent and metastatic HPV16-positive OPC is a form of head and neck cancer with a high unmet medical need. The Fast Track designation for ISA101b underlines the potential benefit of this immunotherapy for patients suffering from this disease,” Leon Hooftman, chief medical officer at ISA Pharmaceuticals, said in a press release.

ISA101b elicits strong and specific immune responses to HPV16 virus proteins and creates a robust T-cell immune response against cancerous cells or tissues. In the ongoing trial, patients in the experimental arm will receive ISA101b 3 times over 3 weeks plus cemiplimab every 3 weeks for up to 24 months, and the control arm will receive a matched placebo plus cemiplimab at the same dose.

The primary outcome measures are overall response rate and safety, with a key secondary end point of duration of response.

To be eligible for the trial, patients need to be 18 years or older, have a diagnosis of histologically confirmed recurrent or metastatic HPV16-positive oropharyngeal cancer with tumors that express PD-L1, and be candidates for anti–PD-L1 therapy. Patients who have experienced disease progression on or after a platinum-based chemotherapy regimen are also eligible. Additionally, an ECOG performance status of 0 or 1 is required, as well as measurable disease by CT or MRI imaging.

Patients with untreated metastatic or unresectable tumors that do not express PD-L1 and aren’t candidates for an anti–PD-L1 therapy are not eligible for enrollment. Additionally, those with known brain metastases or leptomeningeal metastases or a serious or uncontrolled medical disorder are not allowed. Patients with a history of other malignancies 3 years or fewer prior to entry are also excluded, with the exception of basal cell or squamous cell carcinoma of the skin that was treated with local resection only, carcinoma in situ of the cervix, prostate or breast cancer, or low grade non-muscle invasive superficial bladder cancer in situ.

The compound is currently being studied in HPV16-positive cancers in combination with cemiplimab in several phase 2 clinical trials. Similarly, ISA101b is also being examined as a single agent in HPV16-positive cervical cancer, an indication for which the compound has received an orphan drug designation.2

References
1. ISA Pharmaceuticals receives fast track designation for lead product ISA101b. News release. ISA Pharmaceuticals. September 14, 2021. Accessed September 14, 2021. https://bit.ly/3Aac1Je
2. ISA Pharmaceuticals receives US orphan-drug designation for ISA101b in HPV16-positive cervical cancer. News release. ISA Pharmaceuticals. July 1, 2020. Accessed September 14, 2021. https://prn.to/3zlfun7

2021-09-15T06:04:52-07:00September, 2021|Oral Cancer News|

Chemotherapy and radiation therapy issues: What audiologists need to know

Source: journals.lww.com
Author: A. Croutch, Carl AuD

With hearing loss, tinnitus, and imbalance as among the numerous side-effects of cancer treatment,1 audiologists play a critical role in monitoring patients receiving chemotherapy and radiation therapy. Sensorineural hearing loss (SNHL) attributed to chemotherapy and radiation therapy is usually permanent, making audiometric monitoring essential to detect its early occurrence.2

Cisplatin, carboplatin & radiation therapy
Chemotherapy is used to treat cancer, control the growth and spread of cancer cells, and ease cancer symptoms. Cisplatin and carboplatin are two common antineoplastic agents used to treat testicular, ovarian, breast, esophageal, lung, and head and neck cancers among others. Besides hearing loss, these can cause other side effects including kidney, gastrointestinal disorders, allergic reactions, decreased immunity to infections, and hemorrhaging. Cisplatin was first found to have cytotoxic properties in the 1960s, and in 1978 was the first platinum compound approved by the FDA for cancer treatment.3 On the other hand, carboplatin is less potent than cisplatin and does have fewer side effects, especially on kidney problems.3

Both drugs work by interfering with DNA repair mechanisms causing DNA damage and inducing apoptosis in cancer cells. Cancerous cells cannot limit cell division as do normal cells. Normal cells cease dividing when they encounter similar cells whereas cancerous cells do not. The effectiveness of chemotherapy is determined by its ability to damage the RNA or DNA that gives the cell instructions to copy itself. The cells will die if they are unable to divide. The more quickly they are dividing, the more effective is the chemotherapy.4

The incidence of hearing loss in post-chemotherapy patients is highly variable, ranging from 17% to 80% depending on the age, baseline hearing levels, and cisplatin dosage.5 Generally, those receiving a higher dose of cisplatin showed more hearing loss than those receiving a smaller dose.6,7

In addition to chemotherapy, a cancer patient may also be treated with radiation therapy (RT), which is the use of high-energy X-rays or other types of energy such as protons to kill cancer cells. RT also works by destroying the genetic material that regulates cell growth and division. The objective of RT is to kill fewer normal cells since it can damage both cancerous and normal cells. The incidence of SNHL ranges from 0-43% depending on the radiation dosage to the cochlea as well as age and baseline hearing levels.5 Radiation dosage reaching the cochlea may be higher when treating cancer of the nasopharynx, parotid salivary gland, and paranasal sinuses compared to other sites.7

RT can cause both SNHL and conductive hearing loss (CHL). SNHL may occur if the RT is directed near the cochlea, and CHL if it is near the Eustachian tube. Factors that may influence whether a hearing loss occurs include the strength and direction of the beam, location, size of the tumor, patient age, and pre-treatment hearing levels. The frequency of otitis media with effusion in head and neck cancer patients undergoing RT was found to be 39.3% with retracted tympanic membrane and 7.1% with air-fluid levels seen.8 Treatment of head and neck squamous cell carcinoma (HNSCC) patients using radiation can result in mixed (SNHL and CHL) hearing loss, which can be more severe in those with tumors near the ear as well as those treated with cisplatin.7

Stages & grades of cancer
Cancer has four stages: Stage 0 is when the cancer has not spread from its original location (in situ), Stage 1 is when a small cancer has not spread, Stage 2 is when it has grown but not spread, Stage 3 is when it may have spread to near-by tissues possibly the lymph nodes, and Stage 4 is when it has metastasized and spread to at least another body organ. Cancer is also divided into three grades, with the lower grades indicating a slower-growing malignancy and a high grade, a faster-growing one.9

Nasopharyngeal cancer (NPC) is frequently seen in head and neck clinics and offices. Tumors originating in the nasopharynx may be benign or malignant. The majority of nasopharyngeal cancers are nasopharyngeal carcinoma. A carcinoma is a cancer that originates in the epithelial cells, which line the internal and external surfaces of the body. A patient about to undergo chemotherapy and radiation therapy should be seen for a baseline audiogram prior to the initiation of any treatment. An in-depth history of any occupational or recreational noise exposure is essential.

Audiometric test battery
Both chemotherapy and noise exposure can result in high-frequency SNHL. Distinguishing between the two can be difficult, which is why obtaining a baseline audiogram and careful case history is essential. One tip-off may be the high-frequency notch seen between 3000 and 6000 Hz often present in cases of noise trauma.

Speech-in-noise testing should be done since understanding speech in background noise is a common complaint from most adults. Using the Quick Speech-in-Noise (Q-Sin) test may aid in the treatment of these patients.1 Extended high-frequency pure-tone audiometry (EHF-PT) and distortion-product otoacoustic emissions (DP-OAEs) are useful tests in monitoring these patients. Ototoxic effects frequently occur initially at frequencies above 8 kHz. EHF-PT are tested from 8-20 kHz and can often detect hearing loss in these ranges before it affects the speech frequencies. This will enable the oncologist to monitor the treatment and if possible, conserve the patient’s hearing. DP-OAEs are measured from 0.5-8 kHz. They can determine if the outer hair cells are intact since they are usually damaged prior to inner hair cells (IHC) and can result in a more severe hearing loss compared with outer hair cell damage. This may provide useful information to the oncologist. It is also an objective test and can be used regardless of the patient’s age or state of health.2

Criteria for change
In addition to baseline testing, follow-up testing should occur after each treatment, when the course of treatment is completed, and on an annual basis or sooner if indicated. A significant change is considered per the ASHA 1994 guidelines13:

>= 20 dB change at one frequency
>= 10 dB change at two consecutive frequencies
No response at three consecutive frequencies where responses were previously obtained

Ototoxicity can be grouped by using at least 13 different classification systems based on changes from a baseline audiogram to those that focus on the functional impact of the hearing loss. These scales do not consider high-frequency audiometry.13

Despite these grading scales, most clinicians do not use them on a routine basis. How ototoxicity is defined is a significant part of the inconsistencies between pre- and post-clinical data across patient groups.13

Two commonly used ototoxic grading systems in use are the Common Terminology Criteria for Adverse Events version 4 (CTCAEv4) and the American Speech-Language-Hearing Association (ASHA) system. Each of these systems has certain shortcomings.13

To devise a more comprehensive system, Theunissen et al., purposed the TUNE grading system, which details the shortcomings of both the CTCAEv4 and the ASHA systems14 and propose seven different grade levels:

  • Grade 0: No hearing loss
  • Grade 1a: Threshold shift >= 10 dB at 8, 10, and 12.5 kHz OR subjective complaints in the absence of a threshold shift
  • Grade 1b: Threshold shift >= 10 dB at 1, 2, and 4 kHz
  • Grade 2a: Threshold shift >= 20 dB at 8, 10, and 12.5 kHz
  • Grade 2b: Threshold shift >= 20 dB at 1, 2, and 4 kHz
  • Grade 3: Hearing level >= 35 dB at 1, 2, and 4 kHz
  • Grade 4: Hearing level >= 70 dB at 1, 2, and 4 kHz

They feel this system can better assess the effects of hearing loss in daily life and can distinguish between mild, moderate, and severe degrees of ototoxicity compared to the current systems in use.14

Significant changes in DP-OAE findings were a reduction in the signal-to-noise ratio at f2 frequencies below 1 kHz of > 14 dB and a reduction of 7 dB of f2 frequencies above 1 kHz. These criteria were used by Yu, et.al.,2 but no standard criteria are available for defining changes in the DP-OAEs.15

The potential for hearing loss from chemotherapy and radiation therapy is dependent upon the patient’s baseline hearing levels and the strength and frequency of the treatments. Dosage is often determined by the patient’s body surface area indicated by m2. It is calculated by taking the square root of the product of the weight in kilograms times the height in centimeters divided by 3600. The average body surface area for adult men is 1.9 m2 and for women is 1.6 m2.16 Typical doses vary from 25-100 mg/m2. The frequency of treatments is also patient-specific. Chemotherapy is given in cycles—-typically one week of chemotherapy followed by three weeks of rest.

Treatment Options
SNHL may be treated with hearing aids, and CHL by medicine, myringotomy, or PE tube placement. If any hearing loss is found, treatment options should be discussed with the patient. In cases of SNHL that will benefit from amplification, the patient may wish to postpone it until after the cancer treatment has been completed. Some may wish to obtain hearing aids right away to better participate and understand their treatment options. In patients with CHL, a referral to HNS is usually indicated. At Kaiser Permanente, for example, patients with a unilateral CHL without an NPC diagnosis are referred to HNS as that may be an indication of NPC.

Overall, audiologists need to monitor hearing loss in cancer patients undergoing chemotherapy and radiation therapy and provide treatment and counseling when hearing loss has become inevitable.

References:
1. Baguley D, Prayuenyong P. Looking beyond the audiogram in ototoxicity associated with platinum-based chemotherapy. Cancer Chemother Pharmacol. 2020; 82(2): 245-250.

2. Yu K, Choi, C. et.al. Comparison of the effectiveness of monitoring cisplatin-induced ototoxicity with extended high-frequency pure-tone audiometry or distortion-product otoacoustic emission. Korean J of Audiology. 2014;18(2):58-68.

Source:
The Hearing Journal: September 2021 – Volume 74 – Issue 9 – p 44-45

2021-09-09T06:48:49-07:00September, 2021|Oral Cancer News|

New cancer treatments may be on the horizon – thanks to success in mRNA vaccine trial

Source: www.goodnewsnetwork.org
Author: Andy Corbley

A personalized, mRNA vaccine, given to patients with particular kinds of aggressive cancers could leverage the immune system of the patient to kill the cancer on its own, and in doing so usher in a new epoch of cancer treatment.

Messenger RNA (ribonucleic acid) vaccines were what sparked the COVID-19 vaccine drives, as Pfizer and Moderna adapted the technology to create an emergency treatment to train the body to fight off the viral spike protein.

What most of us won’t know however, is that the mRNA vaccines were originally in development for aggressive cancer types.

Molly Cassidy, a mother studying for the Arizona Bar exam, is living proof that while the approach isn’t a panacea, it can clear away some of the most dreadful and fast cancers we know of.

After being diagnosed with head and neck cancer, she underwent surgery and chemotherapy. However it was only ten days after finishing chemo that she found a marble-like bump on her collarbone from the cancer’s swift return. Later examinations found it had spread from her ear all the way to her lungs, and she was told to get her affairs in order.

Cassidy was told she was eligible to join a clinical trial at the University of Arizona, testing an mRNA vaccine personalized to the cancer mutations of the host. By 27 weeks, Cassidy had received nine vaccine doses paired with an immunotherapy drug, and her CT scans were clear: the cancer had left her body.

Personalized Medicine
A personalized medicine approach to disease is challenging, however it could be said that the rise of cancer and of so many other diseases across the west is a result of the broader Western-health sector adopting a once-size fits all (or one-pill fits all) approach to everything from cancer to diet to mental health.

Precision or personalized medicine is becoming a little more common now, with many functional medicine clinics paying more attention to genetic phenotypes and other biomarkers before drafting a therapy plan. This approach recently broke ground in a huge way in the field of Alzheimer’s, and the USDA is using artificial intelligence based on demographics and other information to make more precise dietary guidelines.

Tailor-made mRNA vaccines are an exciting form of personalized medicine to treat cancer, and involve taking a tissue sample from the patient’s tumor and analyzing it for mutations. This not only hones the immune system into the cancerous cells, but differentiates them from healthy, non-cancerous cells.

The result is that the messenger RNA creates proteins shed from the exterior of the tumor and brings immune cells like T cells up to speed on how to fight it.

“One of the things cancer does is it can turn on signals to tell the immune system to quiet down so the cancer is not detected,” explains Daniel Anderson, a biotech scientist at MIT, to National Geographic. “The goal of an mRNA vaccine is to alert and gear up the immune system to go after the characteristic features of tumor cells and attack them.”

Currently, phase-one clinical trials are running for metastatic melanoma, GI-tract cancer, colorectal cancer, pancreatic and ovarian cancer, and non-small cell lung cancer.

One of the most exciting things, even in these early days of mRNA cancer vaccines, is that they will offer a chance at survival for advanced and incurable cancers, not only because they have the potential to be very effective, but also because patients, like in Cassidy’s case, will have no other options.

It’s likely the personalized mRNA vaccines will in practice be paired with immune checkpoint therapy—a breakthrough class of treatment that won the Nobel Prize in 2018. Similar to stem cell treatment, a patient’s T cells are drawn out before being multiplied in a lab, trained on the target cancer cell, and then reintroduced to help fight off the cancer.

Some animal studies have had success in this way, with one group of rats fighting off triple-negative breast cancer, and another group showing great success against cancer of the lymph nodes.

National Geographic concluded their feature on mRNA vaccines with a suggestion that based on early success, FDA-approval could be given in around five years.

2021-09-07T05:46:03-07:00September, 2021|Oral Cancer News|

Recognizing and treating oral leukoplakia in primary care

Source: www.clinicaladvisor.com
Authors: Christina Alvarez, PA-C, Corinne I. Alois, MS, PA-C, Louise Lee, EdD, MHA, PA-C

Oral leukoplakia is a common premalignant condition most commonly identified in the smoking patient population. Once oral leukoplakia is diagnosed, the fundamental goal is to minimize progression towards invasive carcinoma through the use of various treatment methods such as traditional scalpel excision, cryotherapy, and carbon dioxide (CO2) laser therapy.

Epidemiology and Pathogenesis of Oral Leukoplakia
Leukoplakia is defined as a white, painless, plaque most commonly occurring on the buccal mucosa, lateral tongue, or floor of the mouth.1 Leukoplakia is considered one of the most common oral potentially malignant disorders (OPMDs) with an estimated worldwide prevalence of 1.5% to 2.6%.1 This premalignant condition, which can lead to oral cancer, particularly squamous cell carcinoma, presents with various transformation rates ranging from 0.1% to 17.5%.2 Due to variability in transformation to malignancy, identification, treatment, and monitoring is imperative.

The etiology of oral leukoplakia is multifactorial and many cases are considered idiopathic; however, several strong risk factors are associated with this condition, the most common being chronic exposure to all forms of tobacco products, which cause mucosal irritation over time.1,2 Prolonged use of tobacco products is attributed to the conversion of normal cells to hyperplasia, dysplasia, and eventually carcinoma in situ or invasive carcinoma. It is reported that leukoplakia is 6 times more common in smokers than nonsmokers.1

Oral leukoplakia is most commonly seen in men aged 40 years and older, particularly after years of chronic tobacco use.1,2 Other common contributory risk factors include: alcohol use, betel nut use, genetics, poor oral hygiene, human papillomavirus (HPV), Epstein-Barr virus, and chronic candidiasis.1-6

Clinical Presentation
Because oral leukoplakia is a painless and generally asymptomatic condition, it often goes unnoticed unless careful inspection is taken by both patient and primary care provider. Upon inspection of the tongue, buccal mucosa, and floor of the mouth, a white patch will be seen that can vary in appearance. Leukoplakia presents in 3 different forms:

  • Homogenous: typically presents as a white, thin plaque that is even in color and smooth or wrinkled in appearance and consistent throughout; this form has a lower risk for malignancy1,2
  • Nonhomogenous: presents as a white lesion that is typically irregularly shaped with inconsistencies throughout and may show erythema; this form has a higher risk for malignancy1,2
  • Proliferative verrucous: presents as a white, hyperkeratotic, wart-like lesion. This form is aggressive, associated with HPV and EBV, and has a high malignancy rate.6

Diagnosis of Oral Leukoplakia
The differential diagnosis should include oral candidiasis, oral lichen planus, oral erythroplakia, oral hairy leukoplakia, or nicotine stomatitis in smokers.2,6,11 Scraping the lesion is important during the initial workup. In oral leukoplakia, the lesion will remain intact, while in oral candidiasis the plaque will be removed upon scraping and will bleed.2,11 A potassium hydroxide smear should be performed to identify Candida albicans as the causative agent. HIV testing may also be considered if suspicious of hairy leukoplakia or oral candidiasis without any known risk factors such as recent use of antibiotics, inhaled corticosteroids without use of a spacer, or chemotherapy.12 Other tests to consider for the workup of a white oral lesion may include hepatitis C antigen and antibody, which are linked to oral lichen planus and dermal lesions on the body.13 Lastly, because HPV is a risk factor for leukoplakia cases, clinicians should consider HPV testing.

Once other causes of white plaques have been ruled out through noninvasive testing, biopsy can be performed for a definitive diagnosis.2 Biopsy options include incisional and punch biopsy, which are performed to examine for histologic changes to the cells in the lesion. An excisional biopsy, which includes removal of the whole lesion, may be considered as well if the plaque is small in size. For larger lesions, an incisional biopsy is used and includes adjacent healthy tissue. Common histologic changes that are associated with oral leukoplakia seen on biopsy include loss of polarity of basal cells, nuclear hyperchromatism, nuclear pleomorphism, keratinization of cells, loss of intercellular adherence, increased nuclear-cytoplasmic ratio, and irregular epithelial stratification.2,7 A biopsy can also determine if the white lesion is benign, dysplastic, or has transformed to in situ or invasive carcinoma. The histologic results and lesion staging also play a key role in assessing which treatment options are most appropriate for the patient.

Although brush biopsy, in which a brush is swept along the lesion to collect cells, may be performed before surgical biopsy, evidence of the accuracy of this technique is mixed.2,8-10

Treatment Options for Oral Leukoplakia
As a premalignant condition with a high likelihood of progression to squamous cell carcinoma, immediate treatment of oral leukoplakia is encouraged. The main goal of treatment is to prevent further dysplasia and excision of moderate to severe dysplasia or carcinoma. A key aspect of management is removal of the primary source of irritation.2 This most commonly involves tobacco cessation as well as avoiding alcohol to help prevent further dysplastic changes to the tissue.

Surgical management is the gold standard for treatment of oral leukoplakia, however, patients may inquire about conservative options. Retinoids, beta carotene, and isotretinoin have been used to help reduce lesion size; however, clinical evidence on these treatments is very limited.3,14

A Cochrane review found that clinical improvement of lesions was achieved in studies using systemic vitamin A or retinoids (2 studies) and systemic beta carotene or carotenoids (1 study).14 Meta-analysis of 2 studies showed no benefit of beta carotene or carotenoids on the risk for cancer development.14,15 The review also reported lesion recurrence in 56% of patients treated with vitamin A and 54% of those given carotenoid management.14 Although the success and recurrence rates are variable and limited in study, it is important to discuss medical management as an alternative to surgical procedures. Clinicians should continue to discuss these options to provide patient-centered care, allowing patients to make informed decisions.

Surgical options for the treatment of oral leukoplakia include cryotherapy, diode laser therapy, CO2 laser therapy, and scalpel excision.2 Cryotherapy is a safe and simple selection in which a cryoprobe at a temperature of approximately -65 ºC is applied to the lesion to freeze and destroy the affected tissue.6 Diode laser therapy is another surgical option that involves the use of a concentrated beam of light for precise excision of the lesion with simultaneous hemostasis. Treatment with CO2 laser therapy allows for precise control of margins, minimal bleeding, decreased surgical time, minimal postoperative complications, and minimal scarring.15 Full excision involves the use of a scalpel to completely remove the lesioned area. Although a viable option, traditional scalpel removal is associated with increased intraoperative bleeding, postoperative infection, and possibly disfiguring results.

Comparison of CO2 Laser Therapy vs Cryotherapy
In a 2017 study, Natekar and colleagues compared outcomes of CO2 laser therapy, diode laser therapy, and cryotherapy in the treatment of oral leukoplakia (Figure).16 All 3 treatments were effective in the treatment of oral leukoplakia; however, both CO2 and diode laser therapies were associated with significantly lower rates of pain, hemorrhage, edema, and infection compared with cryotherapy (Table; P >.05). None of the patients in the laser therapy and cryotherapy groups developed scar formation compared with 30% of the cryosurgery group at 3 months; by 6 months all scars had resolved. None of the patients experienced recurrence at 6-month follow-up. While all treatment options should be considered for oral leukoplakia, postoperative risk and benefits should be discussed with patients to aid in the informed decision-making process.

Treatment Challenges With CO2 Laser Therapy
One challenge facing clinicians is deciding which patients may benefit from CO2 laser therapy. In a case study published by Pedrosa and colleagues, 59 patients with oral leukoplakia underwent 3 treatments of CO2 laser therapy, with 4-week intervals between each session.17 Results from this study show that 94% of patients with no or low-grade dysplasia were disease-free at 6-month follow-up. Lesion relapse at the treatment site occurred in 24 people (41%) at approximately 17 months postoperatively, and 25% of those patients (n=6) experienced transformation to squamous cell carcinoma.17

Initial histology from those patients who transformed to SCC revealed moderate- to high-grade dysplasia prior to CO2 laser treatment. CO2 laser therapy can still be used for moderate- to high-grade dysplasia; however, the increased recurrence rate should be discussed with the patient as well as the possible need for additional treatment with the more aggressive modality of traditional scalpel excision.

Another challenge of the CO2 laser, as well as for all therapies, is providing full application and treatment to all dysplastic cells. Due to the possibility of incomplete treatment, an extension of margins should be performed at least 3 mm beyond the lesion.15 The extension of laser therapy can further ensure destruction of dysplastic cells surrounding the lesion and aid in minimizing recurrence rates.

Prevention of Oral Leukoplakia
Primary care providers can aid in the primary prevention of oral leukoplakia by routinely screening their patients for this condition; risk factors include the use of tobacco products and excess alcohol consumption. Additionally, while taking a patient’s history, providers should inquire about oral hygiene routine, regularity of dental care visits, and any barriers that may affect the ability to receive oral health care. The survey by the American Dental Association showed that only 58% of respondents reported visiting a dentist at least once per year.18

If a patient is unable to visit a dentist biannually or maintain proper oral hygiene, the primary care provider can begin dental patient education and refer the patient to alternative and more affordable care options, such as public dental clinics or dental schools that can aid in oral health for minimal fees. Patient education should be offered to all individuals regarding the development of oral cancers caused by tobacco products and heavy alcohol use. If applicable, the provider can develop a treatment plan, counsel, or refer the patient for nicotine and or alcohol dependence.

Secondary prevention refers to monitoring the disease. Patients diagnosed with oral leukoplakia require frequent oral cavity examinations to identify any possible changes; especially because clinically lesions are asymptomatic. Thus, it is essential for primary care clinicians to be proactive and assess the oral cavity in all patients, especially those with risk factors, to promptly diagnose conditions such as oral leukoplakia. The earlier leukoplakia is diagnosed, the sooner treatment options can be discussed and performed.

Conclusion
Leukoplakia is one of the most common oral disorders that may progress to carcinoma. When discussing treatment options with patients, it is essential to discuss the risks and benefits associated with each possible procedure. It is also critical for clinicians to emphasize the importance of health care maintenance, including cessation of smoking and frequent follow-up with primary care providers and dentists, even after treatment, for inspection of new lesions or possible recurrence.Conclusion

Authors:
Christina Alvarez, PA-C, is an Internal Medicine and Pediatrics Physician Assistant and graduate from the St. John’s University Class of 2020 Physician Assistant Program in Queens, New York; Corinne I. Alois, MS, PA-C, is an assistant professor at St. John’s University Physician Assistant Program; Louise Lee, EdD, MHA, PA-C, is an associate professor and director of PA studies at St. John’s University.

References
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3. Guimarães LM, Diniz MG, Rogatto SR, Gomez RS, Gomes CC. The genetic basis of oral leukoplakia and its key role in understanding oral carcinogenesis. J Oral Pathol Med. 2021 Aug;50(7):632-638. doi: 10.1111/jop.13140.

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5. Shang Q, Peng J, Zhou Y, Chen Q, Xu H. Association of human papillomavirus with oral lichen planus and oral leukoplakia: a meta-analysis. J Evid Based Dent Pract. 2020;20(4):101485. doi:10.1016/j.jebdp.2020.101485

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9. Alsarraf A, Kujan O, Farah CS. Liquid-based oral brush cytology in the diagnosis of oral leukoplakia using a modified Bethesda Cytology system. J Oral Pathol Med. 2018;47(9):887-894. doi:10.1111/jop.12759

10. Reddy SG, Kanala S, Chigurupati A, Kumar SR, Poosarla CS, Reddy BV. The sensitivity and specificity of computerized brush biopsy and scalpel biopsy in diagnosing oral premalignant lesions: A comparative study. J Oral Maxillofac Pathol. 2012;16(3):349-353. doi:10.4103/0973-029X.102482

11. Mortazavi H, Safi Y, Baharvand M, Jafari S, Anbari F, Rahmani S. Oral white lesions: an updated clinical diagnostic decision tree. Dent J (Basel). 2019;7(1):15. doi:10.3390/dj7010015

12. Rathee M, Jain P. Hairy leukoplakia. In: StatPearls [Internet]. StatPearls Publishing; 2021 Jan-. Updated April 17, 2021. Accessed August 25, 2021. https://www.ncbi.nlm.nih.gov/books/NBK554591/

13. Arnold DL, Krishnamurthy K. Lichen planus. In: StatPearls [Internet]. StatPearls Publishing; 2021 Jan-. Updated August 11, 2021. Accessed August 25, 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526126/

14. Lodi G, Franchini R, Warnakulasuriya S, et al. Interventions for treating oral leukoplakia to prevent oral cancer. Cochrane Database Syst Rev. 2016;7(7):CD001829. doi:10.1002/14651858.CD001829.pub4

15. Romeo U, Mohsen M, Palaia G, Bellisario A, Del Vecchio A, Tenore G. CO2 laser ablation of oral leukoplakia: with or without extension of margins? Clin Ter. 2020;171(3):e209-e215. doi:10.7417/CT.2020.2215

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18. American Dental Association. Survey: more Americans want to visit the dentist. ADANews. March 21, 2018. Accessed August 25, 2021. https://www.ada.org/en/publications/ada-news/2018-archive/march/survey-more-americans-want-to-visit-the-dentist

2021-09-05T08:19:58-07:00September, 2021|Oral Cancer News|

Study: HPV vaccination will reduce throat and mouth cancers, but overall impact will take 25-plus years to see

Source: www.newswise.com
Author: Johns Hopkins Bloomberg School of Public Health

Vaccinations against human papillomavirus (HPV), a major cause of throat and back of mouth cancers, are expected to yield significant reductions in the rates of these cancers in the U.S., but will not do so until after 2045, according to a new modeling study from researchers at the Johns Hopkins Bloomberg School of Public Health. HPV is the most common sexually transmitted infectious virus worldwide. HPV infections are often silent, and while most infections clear, some are chronic and can trigger cancers including mouth and throat (oropharyngeal), and cervical cancer because they disrupt DNA and inhibit tumor-suppressor proteins in the cells they infect. Although there is no cure for existing HPV infections, new infections are preventable with vaccines, the first of which entered use in the U.S. in 2006.

In the new study, the Bloomberg School researchers analyzed national databases on oropharyngeal cancer cases and HPV vaccinations, and projected the impact of HPV vaccination on the rates of these cancers in different age groups. They estimated that the oropharyngeal cancer rate would nearly halve between 2018 and 2045 among people ages 36–45. However, they also projected that the rate in the overall population would stay about the same from 2018-2045, due to still-rising rates of these cancers in older people, where most of these cancers occur.

The study appears online September 2 in JAMA Oncology.

“We estimate that most of the oropharyngeal cancers from 2018 to 2045 will occur among people who are 55 years and older and have not been vaccinated,” says study lead author Yuehan Zhang, a PhD candidate in the research group of Gypsyamber D’Souza, PhD, professor in the Department of Epidemiology at the Bloomberg School.

“HPV vaccination is going to work to prevent oropharyngeal cancers, but it will take time to see that impact, because these cancers mostly occur in middle age,” D’Souza says.

Oropharyngeal cancer is the most common HPV-related cancer, and according to the Oral Cancer Foundation there are more than 50,000 new cases of it in the U.S. each year. Alcohol and tobacco use also are risk factors, but are seen as increasingly less important than HPV.

Vaccination is a powerful medical weapon against this family of viruses, but has one major shortcoming: It can prevent, but not treat. In other words, it does not work against established HPV infections or against cells that have been transformed by HPV and are on their way to forming tumors. Thus it is recommended chiefly for the young who are not yet exposed to sexually transmitted HPV. (Most people who were already adults when HPV vaccination became available have never been vaccinated, and thus remain at risk for these cancers.)

For the study, the researchers estimated current and future HPV vaccination rates using data from surveys conducted by the U.S. Centers for Disease Control and Prevention, and projected oropharyngeal cancer rates based on past and current incidence data from the National Cancer Institute.

They estimated that the rates of vaccination by 2045, for different age groups—given the emphasis on vaccinating the young—will amount to about 72 percent of people ages 36–45, 37 percent of those ages 46–55, 9 percent of those ages 56–69, and 0 percent of people ages 70–83 being vaccinated.

These projections show continuing high oropharyngeal cancer rates in older, mostly unvaccinated groups, and almost no change in the overall U.S. rate of these cancers—14.3 per 100,000 assuming no vaccination; and 13.8 per 100,000, with vaccination, in 2045.

However, they foresaw the rates of new oropharyngeal cancers would fall substantially in the relatively well vaccinated 36–45 and 46–55 age groups during the 2018–2045 period: from 1.4 to 0.8 per 100,000; and from 8.7 to 7.2 per 100,000, respectively.

The results suggest, though, that by 2045 HPV vaccination will have begun to make a significant impact. “Our projections suggest that by around 2033, nearly 100 cases of oropharyngeal cancer will be prevented each year, but by 2045 that figure will have increased by about ten times,” Zhang says.

Notes:
“Projected Impact of HPV Vaccination on Oropharynx Cancer Incidence in the United States: 2020-2045” was co-authored by Yuehan Zhang, Carole Fakhry, and Gypsyamber D’Souza.

Funding was provided by the National Institute of Dental and Craniofacial Research (R35DE026631).

2021-09-03T12:26:37-07:00September, 2021|Oral Cancer News|

Immunotherapy for HPV+ head and neck cancer: Awakening the force within

Source: medicalxpress.com
Author: Emory University

A new study from scientists at Emory Vaccine Center and Winship Cancer Institute of Emory University reports that the immune cells that are the major targets of immune checkpoint inhibitors are present in tumors from head and neck cancer patients.

The study focuses on head and neck tumors that are positive for human papillomavirus (HPV), which is becoming one of most common types of head and neck cancers treated in the Western world. The results are scheduled for publication in Nature.

It suggests checkpoint inhibitors, which have transformed the treatment of several types of cancer, could be uniquely effective against this type of head and neck cancer. The results also indicate that the experimental approach of therapeutic vaccination for HPV+ cancer could be broadened to include more elements of the virus, to potentially trigger a broader and stronger immune response.

Researchers from Rafi Ahmed’s lab at Emory Vaccine Center collaborated with the co-directors of the Winship Head and Neck Cancers working group, oncologists Nabil Saba, MD and Mihir Patel, MD, to obtain samples from patients with head and neck tumors early in the course of treatment.

“About five years ago, we began to have an influx of patients that sought out our center for surgical treatment,” Patel says. “We often heard some variation of a similar story: I was sick with cold-like symptoms and once that resolved this I noticed swelling in a lymph node on the side of my neck. Stories like this made us think about how the immune system might play a unique role, different than typical smoking-related head and neck cancers.”

The team wanted to learn more about the different kinds of CD8 or “killer” T cells present within the cancers; CD8 T cells are specialized immune cells capable of detecting and killing virus-infected or tumor cells, if they are not constrained by regulatory signals. The inhibitory receptor PD-1 is highly expressed on exhausted CD8 T cells in chronic viral infections and cancer, and stem-like PD-1+ CD8 T cells are crucial for maintaining tumor-specific CD8 T cell responses. The majority of currently available checkpoint inhibitors, such as pembrolizumab and nivolumab, block the PD-1 signaling pathway.

“Our results show that a subset of HPV-specific CD8 T cells in the tumor exhibits a striking resemblance to the stem-like CD8 T cells our lab has previously defined in mouse models as proliferating in response to PD-1 blockade,” says Andreas Wieland, Ph.D., co-lead author of the paper and an instructor in Ahmed’s lab.

“It is reasonable to assume that these cells would similarly provide a proliferative burst in response to PD-1 blockade in these patients. However, this remains to be formally tested.”

HPV-positive tumors do have a relatively good response to conventional forms of treatment such as radiation and chemotherapy, Wieland adds. The group of patients studied at Winship was treatment-naïve when tumor samples were obtained; how radiation and chemotherapy affect the number and phenotype of T cells in the tumor needs additional investigation.

“These findings greatly enhance our understanding of CD8 T cell responses in the tumor micro-environment in HPV-related oropharynx cancers, and likely other virally mediated tumors,” Saba says. “It confirms the existence of the different lineages necessary for an effective T cell specific anti-tumor response. Taking advantage of the local immune-response by avoiding its possible early elimination by traditional therapeutic modalities may pave the way to an improved clinical outcome for patients. It may have implications for how best to incorporate immunotherapy in the treatment of other virally mediated tumors.”

“We now have an inclination that incorporating immune therapy with PD-1 blockade prior to surgery or radiation may benefit patients,” Patel says. “We are actively in the process of developing ‘window of opportunity’ studies to understand this.

Looking at both primary tumors and metastatic lymph nodes, the researchers were able to detect both tumor-specific stem-like CD8 T cells, which can proliferate in response to HPV peptides, and more terminally differentiated cells that do not proliferate. In contrast to significant numbers of tumor-specific CD8 T cells in the tumors, tumor-specific cells appeared at a very low abundance in patients’ blood, suggesting that they preferentially reside in tumors. The team also found that the different CD8 T cell subsets in the tumor microenvironment differ in their localization, with stem-like cells residing in distinct niches within the stroma and away from the tumor cells themselves.

Concentrating on HPV-positive tumors in this study facilitated the study of tumor-specific T cells with defined specificities across several patients as the virus is providing a defined set of tumor-associated antigens, whereas in other types of cancer the antigens caused by mutations will vary from individual to individual.

Note:
Co-first authors of the paper are Haydn Kissick, Ph.D., assistant professor of urology and microbiology and immunology, and Christiane Eberhardt, MD, a former postdoctoral fellow in Ahmed’s lab who is now at the University of Geneva. Patel is also associate professor of otolaryngology at Emory University School of Medicine. Saba is professor and Vice Chair in the Department of Hematology and Medical Oncology.

2021-09-02T20:07:01-07:00September, 2021|Oral Cancer News|

AI can lend a hand in diagnosis, prognosis of oral SCC

Source: www.auntminnie.com
Author: Erik L. Ridley, AuntMinnie.com staff writer

Radiology and pathology artificial intelligence (AI) algorithms can help in diagnosing and assessing the prognosis of oral squamous cell carcinoma (SCC), according to a literature review published August 19 in JAMA Otolaryngology — Head & Neck Surgery.

After reviewing published studies in the literature on the use of AI with pathology and radiology images in patients with oral SCC, researchers from the University of Hong Kong concluded that the technology yielded good classification accuracy.

“The successful use of deep learning in these areas has a high clinical translatability in the improvement of patient care,” wrote the authors, led by first author Chui Shan Chu and senior author Dr. Peter Thomson, PhD.

In radiology applications for oral SCC, a convolutional neural network (CNN) was able to predict disease-free survival with 80% accuracy, sensitivity, and specificity from PET images, the researchers reported. Another CNN showed lower performance — 66.9% sensitivity, 89.7% specificity, and 84% accuracy — when used on CT for predicting disease-free survival. A deep-learning algorithm also yielded 90% sensitivity for detecting lymph node metastasis from oral SCC on CT.

In addition to providing prognosis predictions, AI could help facilitate personalized treatment from CT images, according to the researchers. One model was 76% accurate for predicting xerostomia, or dry mouth, an adverse effect of radiotherapy caused by toxicity. Another study determined that radiation dose distribution is the most crucial factor for predicting toxicity.

The researchers noted that, to the best of their knowledge, no studies have utilized deep learning with MRI in oral SCC applications.

As for pathology, AI has most frequently been used to facilitate oral SCC diagnosis by classifying cell type and differentiating tumor grade on digital hematoxylin and eosin-stained tissue images. A CNN algorithm, for example, achieved 96.4% accuracy for differentiating cancer cells from six different types of nontumor cells. Another algorithm was 84.8% accurate for differentiating head and neck SCC from thyroid cancer and metastatic lymph node from breast cancer.

What’s more, other classifiers stratified oral SCC images into four classes with 97.5% accuracy and classified hematoxylin and eosin-stained oral tissue images as either normal or dysplasia with 89% accuracy. In addition, an algorithm was able to predict survival with an average accuracy of 80%.

“In oral cancer research, particularly that related to SCC, deep learning with the use of readily available clinical images derived from hematoxylin and eosin-stained pathological sections and CT-based radiography is demonstrated to have the potential to aid clinical decision-making with regard to cancer diagnosis, prognosis prediction, and treatment guidance,” the authors wrote.

Once their accuracy is validated in different patient cohorts, deep-learning algorithms could be used as a decision-support tool for clinicians, according to the researchers. More research will be needed, however, to determine how to best implement AI into the routine clinical workflow.

“To expand the application of deep learning, it can be used to infer tumor biology information based on the expression-level alterations or mutations of targetable molecules for immunotherapy and targeted therapy,” the authors wrote. “If this approach is successful, it is economical and time-saving to reveal molecular information of tumors without using additional costly molecular assays.”

UAB adds personalized touch to cancer treatment with adaptive radiation

Source: www.uab.edu
Author: Bob Shepard

They are calling it radiation oncology’s contribution to personalized medicine. — called by some the holy grail of radiation therapy — has come to the University of Alabama at Birmingham O’Neal Comprehensive Cancer Center in the form of the newest radiation delivering tool, a system called Ethos from Varian.

Simply put, a linear accelerator is the machine that is used to deliver radiation therapy to destroy a tumor. In standard radiation therapy, the medical team uses sophisticated imaging to pinpoint the location of a tumor, then develops a precise approach to target that tumor with radiation.

“Patients typically get a CT scan so the radiation team can map out their strategy, a process that can take one to two weeks,” said Dennis Stanley, Ph.D., an assistant professor and medical physicist in the UAB Department of Radiation Oncology. “Then, most patients get radiation for around six weeks, usually five days a week.”

But in that time from initial CT screening to the end of treatment, things can change.

“A patient’s anatomy can change over this time period,” Stanley said. “Weight gain or loss, shifting of tissues following eating and drinking. Anatomy can change as quickly as day-to-day.”

Adaptive therapy simply means the radiation plan can adapt to those changes. The Ethos system is the first machine that can quickly scan a patient while they are on the treatment table prepping for their next treatment, and allow for fine-tuning of the already established treatment plan. Instead of following a rigid treatment plan over the course of several months, adaptive therapy can make adjustments to the plan as needed on a weekly or even daily basis.

“We can re-image the patient while they are on the table, and compare the patient’s initial anatomy to the patient’s current anatomy,” said Samuel Marcrom, M.D., assistant professor in the Dept. of Radiation Oncology. “If there have been changes, we can tweak the plan almost instantaneously. The result is a more accurate radiation treatment based on real-time information, creating an opportunity for more radiation to be delivered to the tumor with less radiation delivered to healthy tissue nearby. It is a personalized medicine approach for radiation oncology.”

UAB Medicine and the Department of Radiation Oncology are among the first in the nation to install an Ethos system. There are only 12 currently operating in the United States.

UAB used the Ethos system for the first time on Aug. 10. Stanley and Marcrom say it can be useful for many types of cancers, especially for prostate and cervical cancers due to the propensity of the internal anatomy to change over time in the pelvis. UAB will first treat pelvic tumors with Ethos, gradually moving toward lung and chest cavity cancers. Ethos is also suited for head and neck cancers.

Ethos is the newest tool in the rapidly advancing field of radiation oncology. UAB added proton therapy in March 2020 when Proton International at UAB became the first proton therapy center in Alabama. Proton therapy uses highly precise proton beams instead of traditional X-rays to treat the tumor, leading to more precise and conformal treatment of the tumor with less dose to normal tissues.

“Ethos is another tool that helps aim radiation at the tumor target and avoid healthy tissue, much as proton therapy does,” Stanley said. “This is a valuable option for patients who are not candidates for protons, or any of our other radiation delivery systems.”

UAB’s Ethos system is the first in the world to use the Varian Identify Surface imaging system in conjunction with the Ethos delivery system for patient monitoring and localization. This allows for more accurate positioning and monitoring of patients throughout the course of treatment without adding any extra radiation.

“Ethos gives us options that we haven’t had before,” Marcrom said. “We are able to treat a patient’s cancer based on what it looks like right now, not what it looked like days or weeks earlier. That is a significant advantage.”

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