A Comprehensive Analysis of Prognostic Factors in Head and Neck Squamous Cell Carcinoma: Experience from a Single-center

Curative Radiation Therapy for Locally Advanced Cervical Cancer: Brachytherapy Is NOT Optional

Angiogenesis in squamous cell carcinoma in situ and microinvasive carcinoma of the uterine cervix

Leukocyte adherence inhibition (LAI) assay was used to evaluate cell-mediated immunity in patients with invasive squamous cell carcinoma of the cervix. The reactivity of the peripheral blood leukocytes of these patients was evaluated after incubation with pooled extracts of allogeneic squamous cell carcinoma of the cervix. One hundred sixty-seven sets of LAI assays were performed on 54 individuals, including 23 patients with Stage I squamous cell carcinoma of the cervix, 9 patients with other stages of this tumor, 9 patients with unrelated tumors and 13 normal healthy volunteers. A protein concentration of one milligram per milliliter in the tumor extract and 10% fetal bovine serum in the feeding media gave the best results. Eighty-seven percent (28/32) of patients with squamous cell carcinoma of the cervix showed marked specific reactivity. No difference was found in the LAI indices of different stages of the disease.

Expression of ADAM9 in CIN3 lesions and squamous cell carcinomas of the cervix

CHK1 plays a critical role in DNA damage repair (DDR) pathways as well as in coordinating DNA replication. Selective CHK1/CHK2 compounds are being tested in clinical trials but predictive biomarkers of patient response are lacking. A phase 1b expansion cohort study (I4D-MC-JTJA, NCT01115790) with the CHK 1 inhibitor, prexasertib, included patients with advanced, metastatic head and neck squamous cell carcinoma (HNSCC) or squamous cell carcinoma of the anus (SCCA). To identify genomic biomarkers associated with single-agent drug response, pre-treatment tissues (archived or biopsy) from 71 consented patients (HNSCC=47, SCCA=24) were subjected to next-generation sequencing (NGS) using the FoundationOne gene panel. In this subset of patients, the disease control rate (DCR) (Complete Response (CR) + Partial Response (PR) + Stable Disease (SD) based on RECIST Criteria (v 1.1)) was 60% (28/47) and 75% (18/24), respectively. We present here the observed genetic alterations corresponding to three pathways, Cell Cycle, DNA Damage Repair (DDR) and PI3K. In addition, patients’ human papillomavirus (HPV) carrier status was inferred from DNA sequencing using HPV-specific capture probes. HPV+ was 47% for HNSCC and 87% for SCCA. HPV+ and TP53 mutations were mutually exclusive across the two patient cohorts. In HNSCC patients with evaluable progression-free survival (PFS) data, greater clinical efficacy was observed in the HPV+ cohort (median PFS: 4.5 vs 1.4 months, log-rank p = 0.0008). Known or likely loss-of-function (LOF) mutations in FBXW7 and PARK2, two genes implicated in Cyclin E1 proteolysis, were noted in patients with favorable response in both tumor types. Across both HNSCC and SCCA cohorts, mutations and/or germline variants in the DDR genes BRCA1, BRCA2, MRE11A and ATR but not in Fanconi (FANC) pathway genes, were found in patients with treatment benefit. Whereas PIK3CA mutations were infrequent in the HNSCC cohort, in SCCA, mutations occurred in 5/8 (63%) patients with disease control vs 1/6 (17%) with PD. All 7 PI3KCA mutations observed in HPV+ HNSCC and SCCA patients mapped to the helical domain suggestive of Apobec-induced mutagenesis as their source of origin. The enhanced clinical benefit to prexasertib associated with HPV+ in HNSCC may reflect a prognostic effect. Alternatively, the clinical biomarker findings may support the hypothesis that oncogene-induced replication stress (RS) (i.e. arising from HPV E6/E7 and/or FBXW7 loss-dependent Cyclin E1 dysregulation) in the context of attenuated DDR (i.e. BRCA1/2, MRE11A mutations) may sensitize patients to prexasertib monotherapy. Citation Format: Ricardo Martinez, Sameera R. Wijayawardana, David Hong, Johanna Bendell, Anna Maria Russell, Richard P. Beckmann, Aimee Bence Lin. A clinical genomic biomarker study of the CHK1 inhibitor prexasertib in advanced head and neck squamous cancer and squamous cell carcinoma of the anus [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1778. doi:10.1158/1538-7445.AM2017-1778

Human chorionic gonadotropin (beta-hCG) has been detected within tissue homogenates, culture fluid, and sera of patients with squamous cell carcinoma of the cervix. Studies regarding in vivo localization of beta-hCG in squamous cell carcinoma of the cervix are scant and conflicting. Cervical samplings (biopsy and/or curettage specimens) of 63 cases of poorly differentiated invasive squamous cell carcinoma of the cervix were initially stained by the immunoperoxidase technique for the presence of beta-hCG and human placental lactogen (hPL). Based on beta-hCG reactivity, patients were divided into beta-hCG-positive and beta-hCG-negative groups. Thirty-three of the 63 (52%) cases showed localization of beta-hCG in tumor cells. Subsequent specimens of patients, who underwent surgical treatment, were likewise examined for beta-hCG reactivity. These surgical specimens showed focal beta-hCG reactivity in the beta-hCG-positive group only. The beta-hCG reactivity was seen in both high-grade SIL (CIN III), invasive squamous cell carcinoma, and its metastases. The focal beta-hCG reactivity was predominantly confined to the peripheral tumor cells at the stromal-epithelial interface in noninvasive and invasive lesions. Intensity of immunostaining was moderate to strong. The beta-hCG staining was observed in different cancer stages and in various age groups. No hPL reactivity was seen in any cases. Poorly differentiated squamous cell carcinoma of uterine cervix showing immunoreactivity for beta-hCG should be distinguished from choriocarcinoma and other trophoblastic tumors.

Major research objectives

See accompanying articles by Kawaguchi, Shimura and colleagues on pages 313 and 321. Serum tumor markers can have several roles in many aspects of cancer management including early detection or diagnostic confirmation of cancers, predicting prognosis and/or response of specific treatment, and disease monitoring after primary treatment. Because the most of tumor markers have showed variable sensitivity and specificity in various conditions of specific cancers, there has been no ideal tumor marker in current clinical practice in oncology and squamous cell carcinoma antigen (SCC-Ag) in squamous cell carcinoma of cervix (SCC) is not exceptional. Since SCC-Ag, which can be produced through squamous formation of the uterine cervix and increased during the neoplastic transformation of the cervical squamous epithelium, was discovered in 1997 [1,2], many researches have been performed to investigate the role of serum SCC-Ag in SCC. However the clinical implementation of serum SCC-Ag is still controversial. Serum SCC-Ag levels are elevated in 28%-88% of patients with SCC [3]. In early stage of SCC, higher levels of serum SCC-Ag is associated with the pathological risk factors for recurrence such as lymph node metastasis, deep stromal tumor invasion, lymph-vascular space invasion, and larger size of primary tumor in cervix. For example, the positive predictive value for lymph node metastases at >2, >4, and >8.6 ng/mL SCC-Ag is 51.4%, 70.0%, and 100% but the level of SCC-Ag itself was not an independent risk factor for recurrence [4]. On the contrary SCC-Ag level before treatment was reported to be independent risk factors for disease free survival and/or overall survival at multivariate analysis in other studies [5,6]. In a cohort study of 337 patients with IB1-IIA who were surgically treated, it was suggested that serum SCC-Ag level before surgery allows more refined preoperative estimation of the likelihood for adjuvant radiotherapy than pathological risk factors for recurrence representing clinical relevance of serum SCC-Ag in early stage SCC [7]. In locally advanced SCC, pre- and postradiotherapy serum SCC-Ag levels showed the prognostic significance. Hong et al. reported that pretreatment SCC-Ag levels higher than 10 ng/mL are an independent predictor for poor prognosis and persistently elevated SCC-Ag level at 2-3 months after radiotherapy had a significantly higher incidence of treatment failure in their large cohort [8]. In a Japanese study, the SCC-Ag level cut-off point for three-year overall survival rates, calculated using a receiver operating characteristic curve, was 1.15 ng/mL with the sensitivity of 80.0% and specificity of 74.0% [9]. In a retrospective study of 788 patients with SCC, clinical significance as a prognostic marker for progression free and/or overall survival was higher in locally advanced SCC than in early stage SCC [10]. Increasing serum SCC-Ag can precede the clinical diagnosis of relapse in 46%-92% of cases, with a median lead time ranging from 2 to 8 months [3]. However, there is still no strong evidence that the earlier intervention due to early detection of relapse is associated with better survival in recurrent SCC. In a previous study, serum SCC-Ag analysis results in earlier recurrence detection in a small proportion (14%) of patients but did not contribute to better survival [11]. On the other hand, another study reported that salvage treatment with radiotherapy or surgery resulted in improved survival compared with chemotherapy or palliative care in patients with serum SCC-Ag levels of less than <14.0 ng/mL at the time of recurrence [12]. With the limitation of serum SCC-Ag as an ideal biomarker for SCC, other biomarkers such as CYFRA 21-1, immunosuppressive acidic protein, and vascular endothelial growth factor in patients' serum have been investigated but the results were modest or are still investigating [13]. And more recently there have been developments in the use of molecular imaging technology in oncological applications and the use of magnetic resonance imaging or positron emission tomography with or without combination of biomarkers in the management of cervical cancer [14]. In conclusion, serum SCC-Ag is a commonly used and may be the most promising biomarkers in patients with SCC until now. However, clinical relevance of serum SCC-Ag in SCC is still on debate and there should be more researches investigating the clinical application of SCC-Ag and developing new biomarkers in SCC in the future.

Role of Hyaluronan-Mediated CD44 Signaling in Head and Neck Squamous Cell Carcinoma Progression and Chemoresistance

p16 is a widely used immunohistochemical marker in gynecologic pathology. Strong and diffuse cytoplasmic and nuclear expression of p16 in squamous cell carcinomas (SCC) of the female genital tract is strongly associated with high-risk human papilloma virus infection and neoplasms of cervical origin. However, p16 can be expressed in other neoplasms and in several normal human tissues. Occasionally, SCCs may involve both uterine cervix and urinary bladder. Accurate identification of the site of origin in such cases has therapeutic and prognostic implications. We investigate the potential value of p16 expression in this distinction. We reviewed 74 SCCs, 38 (51%) from urinary bladder and 36 (49%) from uterine cervix obtained between 2003 and 2008. Of the 38 cases of bladder carcinoma, 21 occurred in females and 17 in males. Immunohistochemical analysis for p16 (DAKO M7247, clone 484, dilution of 1:50) expression was done in all cases using the labeled streptavidin-biotin method. Strong and diffuse nuclear and cytoplasmic p16 positivity was observed in 45 cases (61%). Of the 38 SCCs of urinary bladder, 14 (37%) expressed p16 (8 males, 6 females). Of the 36 SCCs of uterine cervix, 31 (86%) were positive for p16. (1) The majority of SCCs of uterine cervix express p16. (2) More than a third of urinary bladder SCCs express p16. (3) SCCs of urinary bladder express p16 independent of gender. (4) p16 immunohistochemical expression alone cannot be used to discriminate between SCCs arising from uterine cervix versus urinary bladder.

As the third most common cancer in women, cervical cancer usually spreads to adjacent organs. Distant metastasis from the cervix to the gastrointestinal tract is an extremely rare occurrence. Herein, we present a rare case of a 57-year-old woman who was treated by hysterectomy and bilateral salpingo-oophorectomy with pelvic lymphadenectomy for squamous cell carcinoma (SCC) of the uterine cervix. A metastatic location in the sigmoid colon was revealed after 8 years causing an acute intestinal obstruction in this patient. Final surgical pathology showed an invasive lesion with squamous differentiation in full thickness of the colon wall from mucosa to serosa. Meanwhile, the results of immunohistochemistry (IHC) showed the cancer cells were positive for CK5/6, P63, P40, and P16 confirming the diagnosis of metastatic sigmoid colonic carcinoma originating from SCC of the uterine cervix. Sigmoid colon resection with lymph node dissection followed by adjuvant chemotherapy (paclitaxel, carboplatin, and paprillizumab) was performed on the patient. The patient was disease-free 16 months after surgery. SCC is one of the rare malignant tumors of the gastrointestinal tract occurring as either a primary or secondary lesion. However, the secondary SCC of the colon has a poorer prognosis compared with the primary SCC. Therefore, colonic metastasis must be considered in the differential diagnosis of acute intestinal obstruction, especially in patients with the medical history of SCC in other organs.

Low-Level Expression of miR-375 Correlates with Poor Outcome and Metastasis While Altering the Invasive Properties of Head and Neck Squamous Cell Carcinomas

Background: Since FDA approval in 2014, PD-1 blocking antibodies including Keytruda (pembrolizumab) have been used in the treatment of different types of malignancies including head and neck squamous cell, urothelial and renal cell carcinoma. Each solid tumor type not only varies patient-to-patient, but also varies in its heterogeneity, including but not limited to, its immune cell infiltrate. The impact of checkpoint inhibitor treatment on tumor immune landscape is not fully understood in solid tumors. In this study, we used an integrated comprehensive strategy to interrogate tumor immune cell compositions and T-cell activation in intact tumors before and after ex vivo treatment with checkpoint inhibitors utilizing Nilogen Oncosystems' 3D-EX drug screening platform. Methods: For the 3D-EX platform, 3D tumor microspheres were produced from fresh head and neck squamous cell carcinoma, urothelial carcinoma and renal cell carcinoma tumor tissue obtained from consented patients at the time of surgical resection. Flow cytometry, Nanostring's PanCancer Immune Profiling Panel and bioplex multiplex human cytokine assay were used to analyze tumor immune microenvironment and treatment-mediated changes by checkpoint inhibitors. Results: The flow cytometry analysis revealed a significant heterogeneity in immune cell composition (TILs, macrophages and MDSCs), T-cell activation status and checkpoint expressions between different tumor types. In our studies tumor responses to treatment ex vivo varied significantly for each tumor types, as assessed by activation of CD8 and CD4 T-cells by flow. Furthermore, Nanostring analysis revealed increased expression of genes involved in T-cell activation as well as genes with compensatory regulatory functions such as IDO1, LAG3, TIM3 and PD-L1 in tumor samples responsive to treatment ex vivo. Bioplex cytokine assays performed on the media demonstrated increased release of cytokines such as IFNg, TNFa, IL2, IL1b, IL6, GM-CSF and MIP1 that closely correlated with T-cell activation. Conclusion: 3D-EX platform can successfully detect checkpoint inhibitor-mediated activation in T-cells within microspheroids prepared from surgical samples obtained from fresh patient tumors. 3D-EX platform is versatile and provide valuable information on mechanisms involved in drug sensitivity and resistance. This approach might aid in development of rational mechanism-based combination strategies to block compensatory signaling mechanisms to impart clinical benefit. Citation Format: Melba Marie Page, Melanie Mediavilla Varela, Jenny Kreahling, Soner Altiok. Integrated Comprehensive Analysis of Immune Cell Subsets and Assessment of Checkpoint Inhibitor Response in Head and Neck Squamous Cell Carcinoma, Urothelial Carcinoma and Renal Cell Carcinoma 3D Ex Vivo [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr LB-347.

Worldwide, squamous cell carcinoma of the uterine cervix is the most common gynecologic malignancy. The squamous cell carcinoma of the human uterine cervix can serve as an ideal model to study host-tumor interrelationships. Due to the ease of accessibility of the cervix for inspection and evaluation by colposcopy, cytologic and tissue sampling, the entire spectrum of the malignancy can be studied. Squamous cell carcinoma of the cervix probably starts as intraepithelial neoplastic lesions which will gradually progress into different stages of dysplasia (mild, moderate and severe), carcinoma in situ, microinvasive and frankly invasive lesions. By using this spontaneous, dynamic human model, immunologic host-tumor interaction can be easily investigated.

Infection with human papillomavirus (HPV) is considered to be the principal causal agent in the development of squamous cell carcinoma of the uterine cervix. Although adenocarcinoma of the cervix originates adjacent to the squamous epithelial neoplastic lesions, the etiopathogenesis of adenocarcinoma is not yet clearly understood. Recent studies have raised more controversy, rather than answering the question of whether specific HPV infection also plays a role in the development of adenocarcinoma of the cervix. Molecular DNA hybridization techniques were used to detect HPV types prevalent in both adenocarcinoma and squamous cell carcinoma of the uterine cervix, which is the most common cancer in Indian women. Histologically confirmed, formaldehyde-fixed, paraffin-embedded tissue sections from 12 cases of adenocarcinoma and 30 cases of squamous cell carcinoma of the uterine cervix were analyzed retrospectively for the presence of HPV DNA types 6b, 11, 16, and 18 by both Southern blot hybridization and in situ hybridization. Of 12 adenocarcinomas, 5 (41.67%) tumors were positive for HPV DNA: All five cases were positive for HPV 16, and two (16.6%) of these were hybridized again to the HPV 18-specific DNA probe. All tumors were negative for HPV 6b and 11. In addition, no biopsy specimens were positive after hybridization with a mixed probe of HPV 31, 33, 35, 39, and 45. These results were compared to those obtained for 30 squamous cell carcinomas of the cervix. Although 20 (66%) were exclusively positive for HPV 16 and 6 (20%), more tumors were of HPV 16 related types as detected under nonstringent conditions of hybridization, only one (3%) was positive for HPV 18. The results of in situ hybridization were found to be in good agreement with those of Southern blotting. HPV 16 is the type present almost exclusively in squamous cell carcinoma of Indian women. A higher frequency of HPV 16 in adenocarcinoma of Indian women, in contrast to HPV 18, as reported from other regions, may be attributed to geographic variation rather than to histologic differences only, and both HPV 16 and 18 may be present in adenocarcinoma of the uterine cervix.