Multidisciplinary Head & Neck Cancer Care

Head & Neck Surgery

We are the pioneers of major scientific breakthroughs

Organ preservation approaches to head and neck cancer.
New drugs for head and neck squamous cell carcinoma (HNSCC) and extending uses of existing drugs to HNSCC and nasopharyngeal carcinoma (NPC).
Advanced radiation therapy techniques that limit toxicity and improve outcomes.
Minimally Invasive and Robotic Surgery
Stem cell work that extends the findings of the first paper, demonstrating the existence of “cancer stem cells” in HNSCC by researchers from Stanford and Michigan in 2007; and a 2009 Stanford study establishing that stem cell properties of patients’ malignancies correlate with prognosis. This work led to subsequent stem cell papers in 2011 and 2012.
Normal tissue stem cell studies to identify salivary gland stem cells and to manipulate them for preservation and/or restoration of salivary gland function from radiation damage.
HNOP’s breadth of research studies and protocols including treatment of intermediate and advanced disease as well as hypoxia imaging.

Our Innovations

Creation of the first head and neck multidisciplinary tumor patient conference (tumor board; 1976) in the U.S.
Introduction of the first use of chemotherapy with irradiation for head and neck squamous cell carcinoma (HNSCC), which is the basis of organ-preservation chemoradiation in the U.S.
Close working relationships with:
- Neurosurgery, Interventional Radiology, and Neuroradiology,which are critical for complex open and endonasal endoscopic skull base surgery.
- Endocrinology in the treatment of thyroid cancer.
- Dermatology in the treatment of advanced skin cancers.
Innovative research by physicians now at Stanford that demonstrates the utility of the FDA-approved Mobetron for intraoperative radiation therapy.
Contributing research in a Phase II trial of immunotherapy in intermediate and advanced surgically-treated HNSCC. A Phase III trial is now planned.
Leadership in the head and neck disease site committee of the Radiation Therapy Oncology Group to develop new nation-wide clinical trials in head and neck cancer.
Biomarker studies to identify novel circulating biomarkers for prognostication and post-treatment surveillance in head and neck cancer.
Strong links to developmental therapeutics such as the advancement of new drugs to treat cancer.
Provision of a full range of treatment options that include minimally invasive surgery, robotic surgery, stereotactic radiosurgery such as CyberKnife, microvascular reconstruction, intraoperative radiation therapy (IORT), and new chemotherapy trials.

What is Head & Neck Cancer?

Head and neck cancer is a term that can include the broad array of tumors which may arise in this anatomically diverse region of the human body. Most often, the term head and neck cancer refers to tumors that arise from “squamous” cells that line the moist, mucosal surfaces of the mouth and throat. In fact, 95% of head and neck tumors are squamous cell carcinoma.

Tumors of the thyroid, salivary, and parathyroid glands, as well as cancers of the brain, nose and paranasal sinuses, esophagus, and eye, are not usually categorized as head and neck cancer. Furthermore, tumors of the skin, muscle and bone arising in the head and neck are also typically not included in this term.

Head and neck cancer is then further classified by its location within the mouth and throat:

Oral cavity

The lips, the oral tongue” (the forward two-thirds or front part of the tongue), the gums lining the upper and lower jaws, as well as the lining inside the cheek. The area known as the floor of the mouth is a mobile area between the lower jaw and gum and the oral tongue. The roof of the mouth or “hard palate” is also included as part of the oral cavity. Finally, a small triangulated area of mucosa or gum lining the area behind the last wisdom tooth is called the“retromolar trigone” and is also part of the oral cavity.

Pharynx

In medical terminology, the throat is known as the pharynx. In fact, the pharynx is supple tube or funnel that connects both the nose and mouth to the swallowing tube or esophagus. The pharynx is composed of three parts: the nasopharynx (the area just behind the nose); the oropharynx (behind the oral cavity and in the back of the mouth], and the hypopharynx, which surrounds the voice box and leads into the esophagus.

The larynx critical not only for the production of speech, but also breathing and swallowing. The “supraglottic” larynx has a valve called the epiglottis, which covers the larynx during swallowing to prevent “aspiration” of food into the lungs.

Treatments

HNOP offers multi-disciplinary, collaborative and integrated evaluation and care for patients with head and neck cancers.

Minimally invasive or endoscopic head and neck surgery (eHNS) is a dynamic new approach that allows surgeons to remove tumors with use of a specialized endocopes and cameras without external incisions and usually with little or no change in speech, appearance, and swallowing function.

An endoscope is a long, thin tube with special lighting and a narrow lens through which the surgeon can view organs and tissue inside of the body. For throat cancers, the surgeon inserts the endoscope through the patient’s mouth, and a microscope provides an excellent image of the tumor. Using very precise, state-of-the-art surgical instruments that are also inserted through the mouth, the surgeon can perform the operation without an external incision.

eHNS has several advantages in many cases. Some of these advantages are:

Reduced risk of blood loss
Lower pain levels
Fewer days spent in the hospital
Quicker return to a normal diet and faster recovery time
Less scarring, with improved cosmetic appearance

In some cases of throat cancer, eHNS may reduce or even eliminate the need for chemotherapy and radiation therapy.

At Stanford, your team of surgeons, oncologists, and radiologists will work together to determine the best course of action for you. The goal with eHNS is always the same: to eliminate the cancer while minimizing the risks and recovery time associated with traditional cancer care.

Chemotherapy or radiation therapy may still be necessary after eHNS. When chemotherapy and radiation therapy cannot be avoided through surgery, eHNS may still hold advantages for patients. Faster recovery after eHNS means patients can usually begin chemotherapy and radiation therapy earlier. And the smaller incisions with eHNS heal more quickly than larger incisions and are less likely to become infected.

Two types of eHNS, transoral robotic surgery (TORS) and transoral laser CO2microsurgery (TLM), have revolutionized the treatment for throat cancer.

Robotic head and neck surgery is a state-of-the-art procedure that offers the advantages of computer technology, specialized surgical instruments and advanced three-dimensional imaging. At Stanford Medicine, the da Vinci ® Surgical System, created by Intutive Surgical, is now used in select cases of urologic, gynecologic, thoracic and head and neck cancers.

The da Vinci ® system is a highly specialized surgery system. Four robotic arms hold a high-definition video camera and three tiny surgical instruments. The surgeon controls these robotic arms from a computerized operating console, inserting them into the patient’s body through slender tubes (cannulas) and then performing the operation. The surgeon views the entire operation on a large screen. The da Vinci ® system’s sophisticated technology eliminates even very small hand tremors in the surgeon’s movements.

The da Vinci ® system is the only surgical robot approved by the Food and Drug Administration and is most often used for prostate surgery.

In 2007, Dr. Holsinger was among the first surgeons in the world to perform TORS. Since then, Dr. Holsinger has performed more than 100 TORS procedures for tumors of the oropharynx, larynx, and hypopharynx.

TLM was first proposed in 1972 and is now widely used for tumors of the throat and larynx (voice box). At Stanford Medicine, your surgeon will help you decide if TLM is right for you. Patients undergoing TLM for throat of larynx cancer are placed under general anesthesia. The surgery is performed directly through the mouth and therefore does not leave a visible scar. The surgeon inserts a thin endoscope through the mouth and a specially designed microscope lets the surgeon see the tumor and surrounding tissue during the surgery.

With TLM, a highly specialized carbon dioxide (CO₂) laser beam is used instead of a scalpel to cut through the tissue. Unlike other types of lasers, the CO₂ laser beam generates minimal heat energy. This limits damage to normal structures around the tumor, such as important nerves, blood vessels, and muscles which are important for speech and swallowing.

Different CO₂ laser systems are available for use with TLM, if you are diagnosed with early-stage cancer of the larynx (voice box), then Digital AcuBlade laser surgery may be used. With this method, CO₂ laser is delivered through a specialized robotic adapter that creates precise incisions. The system, designed by Lumenis Surgical specifically for larynx and vocal cord surgery, uses a computer with an operating microscope. The surgeon programs the computer by entering information about the specific type of procedure that will be performed, the laser beam pattern, the incision length and the depth that the laser will penetrate. The surgeon positions the laser beam on the larynx or vocal cord and performs the procedure by manipulating a joystick on an operating microscope. The CO₂ laser moves in straight, curved, or circular patterns to sculpt the most precise incision with the least effect on surrounding normal tissue.

Another type of laser used with TLM is flexible fiber-optic CO₂ laser. If your surgery for throat cancer has a high risk of bleeding, surgeons at Stanford Medicine may use thulium laser instead of CO₂ laser. The skilled surgeons at Stanford Medicine will choose between a pulsed laser beam and a continuous laser beam to perform the best surgery for you.

For patients with thyroid cancer or benign (noncancerous) thyroid tumors who need surgery, Stanford Medicine offers traditional thyroid surgery with an open incision in the neck or, in carefully selected cases, robotic thyroidectomy or minimally invasive thyroid surgery. Methods used with robotic thyroidectomies magnify the view of the operative field, increasing the surgical precision and reducing the risk of complications.

Robotic surgery uses state-of-the-art technology that allows surgeons to safely remove certain thyroid tumors through discrete incisions several inches from the neck. Because no incision is made in the neck, the patient avoids a neck scar.

The da Vinci ® surgical system is a highly sophisticated computerized system that is used for robotic thyroid surgery. The surgeon cuts a 1-inch to 2-inch incision in the folds of skin under the patient’s arm and inserts the da Vinci ® system’s robotic arms, which have been customized to resemble standard surgical instruments. The surgeon guides the robotic arms underneath the skin toward the thyroid gland.

The surgeon views the surgical field on a 3-D high-definition screen, magnified up to 10 times. The skilled surgeons at Stanford Medicine control the da Vinci ® system’s robotic arms as one might control conventional surgery. The instruments on the robotic arms can move with seven degrees of movement and rotate 540 degrees, giving the surgeon the ability to manipulate delicate tissues with precision.

Robotic thyroidectomy is not available for all thyroid tumors. If your thyroid tumor is less than 3 cm in size and is likely to be benign (non-cancerous), then robotic surgery may be an option. Your surgeons will help you decide the best approach for you.

Minimally Invasive Video-Assisted Thyroidectomy (MIVAT)uses an incision in the neck that is less than 1-inch long to reach the thyroid glands. This incision is smaller than the incision with conventional thyroid surgery. A tiny scope is used to project the operative field onto a computer screen at 10-times original magnification, improving the surgeon’s view during the surgery.

The skill base is a complex, highly specialized region deep within the cranium (skull). It is surrounded by vital structures of the head and central nervous system. At Stanford Medicine, a team of highly-skilled specialists in head and neck cancer and neurosurgery work together to provide the highest level of care for patients with tumors of the skull base.

Treatment for tumors of the skull base may involve surgery, radiation therapy, chemotherapy, or a combination. For some patients, a conventional open surgical approach provides more advantages. For others, a minimally invasive or endoscopic approach is recommended.

With endoscopic skull base surgery, the skilled surgeons at Stanford Medicine acces the tumor through tiny holes in the skull or the back of the sinuses. Endoscopic skull base surgery may reduce your hospital stay, decrease complications from surgery, and help you recover faster.

Testing Docetaxel-Cetuximab or the Addition of an Immunotherapy Drug, Atezolizumab, to the Usual Chemotherapy and Radiation Therapy in High-Risk Head and Neck Cancer

This phase II/III trial studies how well radiation therapy works when given together with cisplatin, docetaxel, cetuximab, and/or atezolizumab after surgery in treating patients with high-risk stage III-IV head and neck cancer the begins in the thin, flat cells (squamous cell). Specialized radiation therapy that delivers a high dose of radiation directly to the tumor may kill more tumor cells and cause less damage to normal tissue. Drugs used in chemotherapy, such as cisplatin and docetaxel, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Cetuximab is a monoclonal antibody that may interfere with the ability of tumor cells to grow and spread. Immunotherapy with monoclonal antibodies, such as atezolizumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. The purpose of this study is to compare the usual treatment (radiation therapy with cisplatin chemotherapy) to using radiation therapy with docetaxel and cetuximab chemotherapy, and using the usual treatment plus an immunotherapy drug, atezolizumab.

Stanford is currently accepting patients for this trial.

Stanford Investigator(s):

Intervention(s):

radiation: intensity-modulated radiation therapy
drug: cisplatin
drug: docetaxel
biological: cetuximab
other: laboratory biomarker analysis
drug: Atezolizumab
other: Quality-of-Life Assessment
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Eligibility

Inclusion Criteria:

   - PHASE II INCLUSION CRITERIA (COMPLETE AS OF 20-MAR-2020)

   - Pathologically (histologically or cytologically) proven diagnosis of head and neck
   squamous cell carcinoma (HNSCC) involving the oral cavity (excluding lips), oropharynx
   (p16 negative), larynx, or hypopharynx

   - Patients must have undergone gross total surgical resection of high-risk oral cavity,
   oropharynx (p16 negative), larynx, or hypopharynx within 63 days prior to
   registration; Note: patients may have biopsy under general anesthesia in an operating
   room followed by definitive ablative cancer surgery representing gross total
   resection; the gross total resection has to be done within 63 days prior to
   registration; if, however, patients have ablative resection but shortly recur or are
   determined to have persisting disease requiring re-resection to achieve gross total
   resection, then the patient is not eligible

   - Patients must have at least 1 of the following high-risk pathologic features:
   extracapsular nodal extension or invasive cancer at the primary tumor resection margin
   (tumor on ink)

   - Pathologic stage III or IV HNSCC, including no distant metastases, based upon the
   following minimum diagnostic workup:

      - General history and physical examination by a radiation oncologist and/or medical
      oncologist within 84 days prior to registration;

      - Examination by an ear nose throat (ENT) or head & neck surgeon prior to surgery;
      a laryngopharyngoscopy (mirror and/or fiber optic and/or direct procedure), if
      appropriate, is recommended but not required; intra-operative examination is
      acceptable documentation

      - Pre-operative (op) Imaging of the head and neck: A neck computed tomography (CT)
      (with contrast) or CT/positron emission tomography (PET) (with contrast) and/or
      an magnetic resonance imaging (MRI) of the neck (T1 with gadolinium and T2)
      within 84 days prior to surgery; Note: this imaging data (diagnostic
      pre-operative scan showing gross disease) is to be submitted in Digital Imaging
      and Communications in Medicine (DICOM) format via TRIAD; the report is to be
      uploaded into Rave

      - Chest CT scan (with or without contrast) or CT/PET that includes the chest (with
      or without contrast) either within 84 days prior to surgery or within 120 days
      prior to registration; Note: if the CT/PET with or without contrast is done
      within 84 days prior to surgery, it fulfills the chest imaging requirement

   - Zubrod performance status of 0-1 within 14 days prior to registration

   - Age >= 18

   - Absolute granulocyte count (AGC) >= 1,500 cells/mm^3 (obtained within 14 days prior to
   registration on study)

   - Platelets >= 100,000 cells/mm^3 (obtained within 14 days prior to registration on
   study)

   - Hemoglobin >= 8.0 g/dl (Note: the use of transfusion or other intervention to achieve
   hemoglobin [Hgb] >= 8.0 g/dl is acceptable)

   - Total bilirubin < 2 x institutional upper limit of normal (ULN) within 14 days prior
   to registration

   - Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) < 3 x institutional
   ULN within 14 days prior to registration

   - Serum creatinine institutional ULN within 14 days prior to registration or; creatinine
   clearance (CC) >= 50 ml/min within 14 days prior to registration determined by 24-hour
   collection or estimated by Cockcroft-Gault formula

   - Negative urine or serum pregnancy test within 14 days prior to registration for women
   of childbearing potential

   - The following assessments are required within 14 days prior to registration: sodium
   (Na), potassium (K), chloride (Cl), glucose, calcium (Ca), magnesium (Mg), and
   albumin; Note: patients with an initial magnesium < 0.5 mmol/L (1.2 mg/dl) may receive
   corrective magnesium supplementation but should continue to receive either
   prophylactic weekly infusion of magnesium and/or oral magnesium supplementation (e.g.,
   magnesium oxide) at the investigator's discretion

   - Patients with feeding tubes are eligible for the study

   - Women of childbearing potential and male participants who are sexually active must
   agree to use a medically effective means of birth control

   - Patient must provide study specific informed consent prior to study entry, including
   consent for mandatory tissue submission for epidermal growth factor receptor (EGFR)
   analysis and for oropharyngeal cancer patients, human papilloma virus (HPV) analysis

   - PHASE III: Pathologically (histologically or cytologically) proven diagnosis of head
   and neck squamous cell carcinoma (HNSCC) involving the oral cavity (excluding lips),
   oropharynx (p16 negative), larynx, or hypopharynx

   - PHASE III: Patients with oropharyngeal cancer must have p16-negative based on central
   review prior to Step 2 registration; all patients with oropharyngeal primary must
   consent for mandatory tissue submission for central p16 confirmation

   - PHASE III: Patients must have undergone gross total surgical resection of high-risk
   oral cavity, oropharynx (p16 negative), larynx, or hypopharynx within 63 days prior to
   registration; note: patients may have biopsy under general anesthesia in an operating
   room followed by definitive ablative cancer surgery representing gross total
   resection; the gross total resection has to be done within 63 days prior to
   registration; if, however, patients have ablative resection but shortly recur or are
   determined to have persisting disease requiring re-resection to achieve gross total
   resection, then the patient is not eligible

   - PHASE III: Patients must have at least 1 of the following high-risk pathologic
   features: extracapsular nodal extension or invasive cancer at the primary tumor
   resection margin (tumor on ink or tumor in a final separately submitted margin)

   - PHASE III: Pathologic stage III or IV HNSCC (American Joint Committee on Cancer [AJCC]
   7th edition), including no distant metastases, based upon the following minimum
   diagnostic workup:

      - General history and physical examination by a radiation oncologist or medical
      oncologist within 84 days prior to registration;

      - Examination by an ENT or head & neck surgeon prior to surgery; a
      laryngopharyngoscopy (mirror or fiberoptic or direct procedure), if appropriate,
      is recommended but not required. Intra-operative examination is acceptable
      documentation.

      - Pre-op Imaging of the head and neck: A neck CT (with contrast and of diagnostic
      quality) or PET/CT (with contrast and of diagnostic quality) and/or an MRI of the
      neck of diagnostic quality (T1 with gadolinium and T2) within 84 days prior to
      surgery; Note: this imaging data (diagnostic pre-operative scan showing gross
      disease) is to be submitted in DICOM format via TRIAD. The report is to be
      uploaded into Rave.

      - Chest CT scan (with or without contrast) or PET/CT that includes the chest (with
      or without contrast) either within 84 days prior to surgery or within 120 days
      prior to registration; Note: If the PET/CT with or without contrast is done
      within 84 days prior to surgery, it fulfills the chest imaging requirement

   - PHASE III: Zubrod performance status of 0-1 within 14 days prior to registration

   - PHASE III: Leukocytes >= 2,500 cells/mm^3 (obtained within 14 days prior to
   registration on study)

   - PHASE III: Absolute neutrophil count (ANC) >= 1,500 cells/mm^3 (obtained within 14
   days prior to registration on study)

   - PHASE III: Platelets >= 100,000 cells/mm^3 (obtained within 14 days prior to
   registration on study)

   - PHASE III: Hemoglobin >= 8.0 g/dL (Note: The use of transfusion or other intervention
   to achieve Hgb >= 8.0 g/dL is acceptable) (obtained within 14 days prior to
   registration on study)

   - PHASE III: Total bilirubin =< 1.5 x institutional upper limit of normal (ULN)
   (however, patients with known Gilbert disease who have serum bilirubin level =< 3 x
   institutional ULN may be enrolled) (within 14 days prior to registration)

   - PHASE III: AST or ALT =< 3 x institutional ULN (within 14 days prior to registration)

   - PHASE III: Alkaline phosphatase =< 2.5 x institutional ULN (within 14 days prior to
   registration)

   - PHASE III: Creatinine clearance (CrCl) >= 50 mL/min within 14 days prior to
   registration determined by 24-hour collection or estimated by Cockcroft-Gault formula

   - PHASE III: Patients with feeding tubes are eligible for the study

   - PHASE III: Negative urine or serum pregnancy test within 14 days prior to registration
   for women of childbearing potential

   - PHASE III: All patients must provide study specific informed consent prior to study
   entry

   - PHASE III: Patients positive for human immunodeficiency virus (HIV) are allowed on
   study, but HIV-positive patients must have:

      - A stable regimen of highly active anti-retroviral therapy (HAART);

      - No requirement for concurrent antibiotics or antifungal agents for the prevention
      of opportunistic infections;

      - A CD4 count above 250 cells/mcL and an undetectable HIV viral load on standard
      polymerase chain reaction (PCR)-based tests

Exclusion Criteria:

   - PHASE II EXCLUSION CRITERIA (COMPLETE AS OF 20-MAR-2020)

   - Prior invasive malignancy (except non-melanomatous skin cancer) unless disease free
   for a minimum of 1095 days (3 years); noninvasive cancers (for example, carcinoma in
   situ of the breast, oral cavity, or cervix are all permissible) are permitted even if
   diagnosed and treated < 3 years ago

   - Patients with simultaneous primaries or bilateral tumors are excluded, with the
   exception of patients with bilateral tonsil cancers or patients with T1-2, N0, M0
   resected differentiated thyroid carcinoma, who are eligible

   - Prior systemic chemotherapy or anti-epidermal growth factor (EGF) therapy for the
   study cancer; note that prior chemotherapy for a different cancer is allowable

   - Prior radiotherapy to the region of the study cancer that would result in overlap of
   radiation therapy fields

   - Severe, active co-morbidity, defined as follows:

      - Unstable angina and/or congestive heart failure requiring hospitalization within
      6 months prior to registration

      - Transmural myocardial infarction within 6 months prior to registration

      - Acute bacterial or fungal infection requiring intravenous antibiotics at the time
      of registration

      - Chronic obstructive pulmonary disease exacerbation or other respiratory illness
      requiring hospitalization or precluding study therapy at the time of registration

         - Idiopathic pulmonary fibrosis or other severe interstitial lung disease that
         requires oxygen therapy or is thought to require oxygen therapy within 1
         year prior to registration

      - Hepatic insufficiency resulting in clinical jaundice and/or coagulation defects;
      note, however, that laboratory tests for coagulation parameters are not required
      for entry into this protocol

         - Acquired immune deficiency syndrome (AIDS) based upon current Centers for
         Disease and Control and Prevention (CDC) definition; note: human
         immunodeficiency virus (HIV) testing is not required for entry into this
         protocol; the need to exclude patients with AIDS from this protocol is
         necessary because the treatments involved in this protocol may be
         significantly immunosuppressive; protocol-specific requirements may also
         exclude immuno-compromised patients.

   - Grade 3-4 electrolyte abnormalities (Common Terminology Criteria for Adverse Events
   [CTCAE], version [v.] 4):

   - Serum calcium (ionized or adjusted for albumin) < 7 mg/dl (1.75 mmol/L) or > 12.5
   mg/dl (> 3.1 mmol/L) despite intervention to normalize levels

   - Glucose < 40 mg/dl (< 2.2 mmol/L) or > 250 mg/dl (> 14 mmol/L)

   - Magnesium < 0.9 mg/dl (< 0.4 mmol/L) or > 3 mg/dl (> 1.23 mmol/L) despite intervention
   to normalize levels

   - Potassium < 3.0 mmol/L or > 6 mmol/L despite intervention to normalize levels

   - Sodium < 130 mmol/L or > 155 mmol/L despite intervention to normalize levels

   - Pregnancy or women of childbearing potential and men who are sexually active and not
   willing/able to use medically acceptable forms of contraception; this exclusion is
   necessary because the treatment involved in this study may be significantly
   teratogenic

   - Prior allergic reaction to cetuximab

   - PHASE III: Prior invasive malignancy (except non-melanomatous skin cancer) unless
   disease free for a minimum of 1095 days (3 years) with the following exceptions: T1-2,
   N0, M0 resected differentiated thyroid carcinoma; Note that noninvasive cancers (For
   example, carcinoma in situ of the breast, oral cavity, or cervix) are permitted even
   if diagnosed and treated < 3 years ago

   - PHASE III: Patients with simultaneous primaries or bilateral tumors are excluded, with
   the exception of patients with bilateral tonsil cancers or patients with T1-2, N0, M0
   resected differentiated thyroid carcinoma, who are eligible

   - PHASE III: Prior systemic therapy, including cytotoxic chemotherapy, biologic/targeted
   therapy (such as anti-EGF therapy), or immune therapy for the study cancer; note that
   prior chemotherapy for a different cancer is allowable, however, a prior anti-PD-1,
   anti-PD-L1, or anti-PD-L2 agent is not permitted

   - PHASE III: Prior radiotherapy to the region of the study cancer that would result in
   overlap of radiation therapy fields

   - PHASE III: Severe, active co-morbidity, defined as follows:

      - Patients with known history or current symptoms of cardiac disease, or history of
      treatment with cardiotoxic agents, should have a clinical risk assessment of
      cardiac function using the New York Heart Association Functional Classification;
      to be eligible for this trial, patients should be class 2B or better within 6
      months prior to registration

      - Transmural myocardial infarction within 6 months prior to registration;

      - Severe infections within 4 weeks prior to registration including, but not limited
      to, hospitalization for complications of infection, bacteremia, or severe
      pneumonia;

      - Acute bacterial or fungal infection requiring intravenous antibiotics at the time
      of registration; Note: Patients receiving prophylactic antibiotics (e.g., for
      prevention of a urinary tract infection or chronic obstructive pulmonary disease
      exacerbation) are eligible.

      - Chronic obstructive pulmonary disease exacerbation or other respiratory illness
      requiring hospitalization or precluding study therapy at the time of
      registration;

      - History of idiopathic pulmonary fibrosis, pneumonitis (including drug induced),
      organizing pneumonia (i.e., bronchiolitis obliterans, cryptogenic organizing
      pneumonia, etc.), or evidence of active pneumonitis on screening chest computed
      tomography (CT) scan. History of radiation pneumonitis in a prior radiation field
      (fibrosis) is permitted, provided that field does not overlap with the planned
      radiation field for the study cancer;

      - Patients with active tuberculosis (TB) are excluded;

      - Known clinically significant liver disease, including active viral, alcoholic, or
      other hepatitis; cirrhosis; fatty liver; and inherited liver disease;

         - Patients with past or resolved hepatitis B infection (defined as having a
         negative hepatitis B surface antigen [HBsAg] test and a positive anti-HBc
         [antibody to hepatitis B core antigen] antibody test) are eligible.

         - Patients positive for hepatitis C virus (HCV) antibody are eligible only if
         polymerase chain reaction (PCR) is negative for HCV RNA.

      - History of allogeneic bone marrow transplantation or solid organ transplantation.

      - A diagnosis of immunodeficiency:

         - Acquired immune deficiency syndrome (AIDS) based upon current CDC
         definition; note: HIV testing is not required for entry into this protocol;
         the need to exclude patients with AIDS from this protocol is necessary
         because the treatments involved in this protocol may be significantly
         immunosuppressive.

      - Is receiving treatment with systemic immunosuppressive medications (including,
      but not limited to, prednisone, cyclophosphamide, azathioprine, methotrexate,
      thalidomide, and anti-tumor necrosis factor [anti-TNF] agents) within 2 weeks
      prior to registration.

         - Note: Patients who have received acute, low dose, systemic immunosuppressant
         medications (e.g., a one-time dose of dexamethasone for nausea) may be
         enrolled.

         - Note: The use of inhaled corticosteroids and mineralocorticoids (e.g.,
         fludrocortisone) for patients with orthostatic hypotension or adrenocortical
         insufficiency is allowed.

      - History or risk of autoimmune disease, including, but not limited to, systemic
      lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, vascular
      thrombosis associated with antiphospholipid syndrome, Wegener's granulomatosis,
      Sjogren's syndrome, Guillain-Barré syndrome, multiple sclerosis, vasculitis, or
      glomerulonephritis.

         - Patients with a history of autoimmune hypothyroidism who are asymptomatic
         and/or are on a stable dose of thyroid replacement hormone are eligible.

         - Patients with controlled Type 1 diabetes mellitus on a stable insulin
         regimen are eligible.

         - Patients with eczema, psoriasis, lichen simplex chronicus, or vitiligo with
         dermatologic manifestations only (e.g., patients with psoriatic arthritis
         would be excluded) are permitted provided that they meet the following
         conditions:

         - Patients with psoriasis must have a baseline ophthalmologic exam to rule out
         ocular manifestations

         - Rash must cover less than 10% of body surface area (BSA)

         - Disease is well controlled at baseline and only requiring low potency
         topical steroids (e.g., hydrocortisone 2.5%, hydrocortisone butyrate 0.1%,
         flucinolone 0.01%, desonide 0.05%, aclometasone dipropionate 0.05%)

         - No acute exacerbations of underlying condition within the last 12 months
         (not requiring psoralen plus ultraviolet A radiation [PUVA], methotrexate,
         retinoids, biologic agents, oral calcineurin inhibitors; high potency or
         oral steroids)

   - PHASE III: Grade 3-4 electrolyte abnormalities (CTCAE, v. 4) within 14 days prior to
   registration:

      - Serum calcium (ionized or adjusted for albumin) < 7 mg/dL (1.75 mmol/L) or > 12.5
      mg/dL (> 3.1 mmol/L) despite intervention to normalize levels;

      - Glucose < 40 mg/dL (< 2.2 mmol/L) or > 250 mg/dL (> 14 mmol/L);

      - Magnesium < 0.9 mg/dL (< 0.4 mmol/L) or > 3 mg/dL (> 1.23 mmol/L) despite
      intervention to normalize levels;

      - Potassium < 3.0 mmol/L or > 6 mmol/L despite intervention to normalize levels;

      - Sodium < 130 mmol/L or > 155 mmol/L despite intervention to normalize levels.

   - PHASE III: Pregnancy or women of childbearing potential and men who are sexually
   active and not willing/able to use medically acceptable forms of contraception for up
   to 5 months from last study treatment; this exclusion is necessary because the
   treatment involved in this study may be significantly teratogenic. Women who are
   breastfeeding and unwilling to discontinue are also excluded

   - PHASE III: History of severe allergic, anaphylactic, or other hypersensitivity
   reactions to chimeric or humanized antibodies or fusion proteins

   - PHASE III: Patients taking bisphosphonate therapy for symptomatic hypercalcemia. Use
   of bisphosphonate therapy for other non-oncologic reasons (e.g., osteoporosis) is
   allowed

   - PHASE III: Patients requiring treatment with a RANKL inhibitor (e.g. denosumab) for
   non-oncologic reasons who cannot discontinue it before registration

   - PHASE III: Patients with known distant metastatic disease are excluded

   - PHASE III: Known hypersensitivity to Chinese hamster ovary cell products or other
   recombinant human antibodies

   - PHASE III: Major surgical procedure within 28 days prior to registration or
   anticipation of need for a major surgical procedure during the course of the study

   - PHASE III: Administration of a live, attenuated vaccine within 4 weeks prior to
   registration or anticipation that such a live, attenuated vaccine will be required
   during the study and for patients receiving atezolizumab, up to 5 months after the
   last dose of atezolizumab.

      - Influenza vaccination should be given during influenza season only (approximately
      October to March). Patients must not r

Ages Eligible for Study

18 Years - N/A

Genders Eligible for Study

All

Now accepting new patients

Contact Information

Stanford University
School of Medicine
300 Pasteur Drive
Stanford, CA 94305
Martina Steffen
650-498-7061
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