Head And Neck Squamous Cell Cancer Patients Research Articles

No statistical impact of intra-tumoral overexpression of EGFR, VEGF and p53 on the overall survival in head and neck squamous cell cancer (HNSCC): Preliminary results of the GORTEC 99–02 randomized trial

6010 Background: Predictive and prognostic factors are warranted to improve the management of HNSCC patients. We designed a prospective study to analyze the p53 status, vascular endothelial growth factor (VEGF) and epidermal growth factor receptor (EGFR) tumoral overexpression of the patients included in the GORTEC 99–02 prospective phase III trial which compared conventional radiotherapy (RT) plus 5FU and carboplatin (FUP) vs RT with concomitant boost and FUP vs very accelerated RT Methods: This propective study has been designed to include 820 patients. We present here the results in a sub group of 219 patients for whom the immunohistochemical overexpression of EGFR, P53 and VEGF was analyzed. Association beetween these markers and TNM staging, age, sex,disease progression and survival was evaluated. Tumor overexpression was assessed by immunohistochemistry for EGFR (Dako EGFR pharmDx™ kit), VEGF (Santa Cruz Biotech), P53 (Dako). EGFR status was defined as positive or negative.If positive, we evaluated the percentage of cells presenting the same intensity of staining. Staining pattern was qualified as “diffuse” if more than 95% of cancer nests were stained with the same intensity, and as “mosaic” if the staining was heterogeneous Statistical analysis were performed using Spearman correlation coefficient, Kruskal-Wallis test for quantitative variables, chi2 and Fisher exact test for qualitative variables and Logrank test and cox model for survival analysis. Multivariate analysis of survival took into account T and N status, tumor localisation and the type of treatment. Results: Positive expression for P53, VEGF and EGFR were respectively found in 56.4%, 61.1% and 94%.Diffuse EGFR status was associated with higher T status (p=0.0141). VEGF(+) status was associated with increased EGFR staining (p=0.0017). Patients with p53+ status were younger than p53(-) (p=0.0362). P53,VEGF and EGFR expressions were not significatively related to survival Conclusions: These preliminary results don’t found any relationship between intra-tumoral markors and survival in HNSCC.Work supported by a french PHRC from the national Institute of Health No significant financial relationships to disclose.

Targeting epidermal growth factor receptor signaling in the treatment of head and neck cancer

In this review, key aspects of epidermal growth factor receptor (EGFR) biology and the fruitful translation of these fundamental findings into recent treatment advances in head and neck squamous cell cancer (HNSCC) are highlighted. In contrast to a number of contemporary reviews of the EGFR, many of which focus on colorectal and nonsmall cell lung cancer, this review discusses the EGFR as a validated therapeutic target in HNSCC. Recent data confirm a survival advantage for the addition of the anti-EGFR monoclonal antibody cetuximab to definitive radiation therapy in locoregionally advanced HNSCC patients, as well as palliative benefits for patients with incurable recurrent and metastatic HNSCC. Small-molecule EGFR tyrosine kinase inhibitors also show considerable promise in this disease, both alone and in combination with radiation and chemotherapy. Both classes of anti-EGFR agent are generally well tolerated, with side effects (notably skin rash) that are distinct from the toxicities of conventional chemotherapy. Ongoing clinical trials will more clearly define the role for EGFR inhibitors in all treatment phases of HNSCC.

Analysis of EGFr, VEGF and p53 in serum of head and neck squamous cell cancer (HNSCC) : Preliminary results of the GORTEC 99–02 randomized trial

5509 Background: Predictive and prognostic markers are warranted in HNSCC. We designed a prospective study to analyze EGFr, VEGF and P53 both in the serum and in the tumor of HNSCC patients included in the GORTEC 99–02 prospective phase III trial which compared conventional radiotherapy (RT) plus 5FU and carboplatin (FUP) vs RT with a concomitant boost and FUP vs a very accelerated RT. Methods: This prospective study has been designed to include 820 patients, we present here the results in a sub group of 216 patients for whom the biological markers were analyzed. Association between these markers and TNM staging, age, sex, disease progression and survival was evaluated. Serum analysis was performed for serum EGFr (Oncogene Science), VEGF (R&D systems) and p53 serum-autoantibodies (Immunotech). Statistical analysis were performed using Spearman correlation coefficient, Kruskal-Wallis test for quantitative variables, chi2 and Fischer exact test for qualitative varaibles and Logrank test and cox model for survival analysis. Multivariate analysis of survival took into account T and N status, tumor localisation and the type of treatment. Results: No correlation was found between the serum levels of VEGF and EGFr, neither between EGFr and p53. There was a borderline significant association (p = 0.07) towards higher VEGF serum levels in p53 negative, compared to p53 positive patients. No correlation was found between age, sex, T and N staging and all the serum markers. The VEGF level was significantly higher in laryngeal and hypopharyngeal primaries and lower in oropharyngeal and buccal primaries (p = 0.04). The EGFr level seemed also associated with the tumor localisation (p = 0.055). The median follow up was 2 years. High levels of serum EGFR were associated with better overall survival in univariate and multivariate analysis (p < 0.01). Overall survival was not significantly higher in positive serum p53 patients than in negative p53 patients (p = 0.11 in multivariate analysis). VEGF was not associated with survival. Conclusions: These preliminary resulst suggest that high levels of serum EGFr was associated with a better outcome in this homogenous, prospective series of HNSCC. Work supported by a french PHRC from the National Institutes of Health. No significant financial relationships to disclose.

Utility of Positron Emission Tomography‐Computed Tomography in Identification of Residual Nodal Disease after Chemoradiation for Advanced Head and Neck Cancer

Planned neck dissection after chemoradiation (CR) is often advocated in patients with head and neck squamous cell cancer (HNSCC) with advanced nodal disease who demonstrate a clinical complete response to CR because identification of residual occult nodal disease is difficult. We sought to investigate the utility of positron emission tomography-computed tomography (PET-CT) in identifying patients with occult nodal disease after CR. Nonrandomized retrospective cohort analysis. The medical records of all patients treated with primary CR for advanced HNSCC with N2 or N3 disease from December 2003 to June 2005 were reviewed. Patients with a clinical complete response were eligible for inclusion if PET-CT performed at 8 to 10 weeks after CR showed no evidence of distant disease and they were treated with a planned neck dissection. Seventeen patients met study criteria. PET-CT was positive for residual nodal disease in 11 (64.7%) patients, with a standardized uptake value (SUV) range of 1.7 to 3.8. Pathologic examination revealed residual viable carcinoma in five (29.4%) patients, with tumor size ranging from 2.0 to 9.5 mm. Carcinoma was present in 2 of 11 (18.2%) patients with positive PET-CT scans and 3 of 6 (50%) patients with negative PET-CT scans. The sensitivity and specificity of PET-CT in predicting occult nodal disease was 40% and 25%, respectively. There was no correlation between PET-CT findings and histologic findings (P = .26) or between SUV and size of viable tumor (P = .67). A significant proportion of HNSCC patients with advanced neck disease harbor residual occult metastases after CR. PET-CT is not sufficiently specific or sensitive to reliably predict the need for posttreatment neck dissection.

Randomized Phase III Trial of Low-dose Isotretinoin for Prevention of Second Primary Tumors in Stage I and II Head and Neck Cancer Patients

Isotretinoin (13-cis-retinoic acid) is a synthetic vitamin A derivative, or retinoid, widely used in the treatment of cystic acne. Preclinical and clinical studies of high-dose isotretinoin in patients with head and neck squamous cell cancer (HNSCC) have produced encouraging results. We conducted a phase III randomized trial of low-dose isotretinoin versus placebo in early-stage HNSCC patients to assess its effect on second primary tumor incidence and survival. We randomly assigned 1190 patients who had been treated for stage I or II HNSCC to receive either low-dose isotretinoin (30 mg/day) or placebo for 3 years. The patients were monitored for up to 4 more years. Survival was analyzed by the Kaplan-Meier method, and Cox proportional hazards models were used for multivariable survival analysis. All statistical tests were two-sided. Isotretinoin did not statistically significantly reduce the rate of second primary tumors (hazard ratio [HR] = 1.06, 95% confidence interval [CI] = 0.83 to 1.35) or increase survival (HR = 1.03, 95% CI = 0.81 to 1.32) compared with placebo in patients with early-stage HNSCC. Current smokers had a higher rate of second primary tumors than that of never (HR = 1.64, 95% CI = 1.08 to 2.50) or former (HR = 1.32, 95% CI = 1.01 to 1.71) smokers. The hazard ratio of death from any cause for current smokers versus never smokers was 2.51 (95% CI = 1.54 to 4.10) and for current smokers versus former smokers was 1.60 (95% CI = 1.23 to 2.07). Major sites of second primary tumors (n = 261) included lung (31%), oral cavity (17%), larynx (8%), and pharynx (5%). Low-dose isotretinoin was not effective in reducing the rate of second primary tumors or death or smoking-related disease. Smoking statistically significantly increased the rate of second primary tumors and death. Ongoing trials are testing higher doses of isotretinoin as part of combination bioadjuvant therapeutic methods for patients with locally advanced HNSCC.

Cyclin A as a Predictive Factor for Chemotherapy Response in Advanced Head and Neck Cancer

Overall survival of head and neck squamous cell cancer (HNSCC) patients has not improved despite advances in our understanding of the biology and molecular features of this disease. In particular, patients with advanced HNSCC have the poorest prognosis. To understand more about the contribution of cell cycle alterations to HNSCC development and their possible value in predicting prognosis and response to chemotherapy, we evaluated the levels of proteins involved in cell cycle control in patients diagnosed with advanced HNSCC. A tissue microarray was made with 122 HNSCC specimens obtained from biopsy material. Protein expression was evaluated by immunohistochemistry and correlated with clinical and pathological characteristics. Multiple alterations at various checkpoints of cell cycle progression were observed. Loss of P16 protein was less common in oropharyngeal tumors than at other HNSCC locations (P = 0.02). Evaluation of the simultaneous expression of different proteins highlighted direct correlations (P < 0.05) such as that of the cyclin-dependent kinases with their cyclin-partners, and the Ki-67 protein with cyclin-dependent kinases 1, cyclin A (CA) and cyclin B1. Median overall survival and time-to-progression were longer in patients with CA-expressing tumors (not reached versus 34.4 months, P = 0.02) and (47.3 versus 14.6 months, P = 0.006), respectively. Moreover, expression of CA in tumors predicted a better response to chemotherapy. Positive expression of cyclin E in tumors was also associated with an increased median time-to-progression (14.6 versus 25.8 months, P = 0.04). Finally, patients with cyclin D1-expressing tumors had shorter median overall survival (29.6 months versus not reached, P = 0.05) and shorter median time-to-progression (21.5 months versus not reached, P = 0.06). However, in a multivariate analysis a CA-negative-expressing tumor was the only independent poor prognostic factor in the entire cohort of HNSCC patients [odds ratio, 2.3; 95% confidence interval (CI) = 1.2-4.5; P = 0.01]. Our results provide detailed information on the molecular profile of cell cycle components in HNSCCs and identify CA-negative-expressing tumors as an independent marker of tumor progression and poor response to chemotherapy in patients diagnosed with advanced HNSCC.

Changes in quality of life of head-and-neck cancer patients following postoperative radiotherapy

The purpose of this study was to investigate the longitudinal changes in quality of life (QoL) for 77 head-and-neck squamous cell cancer (HNSCC) patients receiving postoperative radiotherapy (RT). The data pertaining to their QoL were collected using the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) and the EORTC Head and Neck Module (QLQ-H&N35) before and two years after postoperative RT. The differences in all the QLQ-C30 scales between the two time points were not statistically (p<0.01) or clinically (difference ≧+10 points) significant. Of all the scales in the QLQ-H&N35, only problems in social eating, teeth, dry mouth, and sticky saliva became worse with both statistical and clinical significance. Clinical cancer stage and marital status were the only variables significantly associated with the change in global QoL. The subjects with stage IV disease (5.0-fold) and those with a spouse (5.5-fold) had a lower risk of reporting negative changes in global QoL. The study indicates that some individual HNSCC patients, after receiving postoperative RT, suffered from a deterioration of QoL scales, especially in some specific head-and-neck symptoms. Meanwhile, we found some patients, especially those with more advanced HNSCC, might have developed somewhat tougher coping abilities to deal with the adverse effects of adjuvant RT on their global QoL.

Generation of dendritic cells from HNSCC cancer patients

Problem: Dendritic cells (DCs) are the key antigen-presenting cells (APC) for inducing an antigen-specific immune response. Generating DCs from head and neck squamous cell cancer (HNSCC) patients may be a very important initial step in manipulating the patient’s immune system to fight their cancer. In this study we test our ability to generate functional DCs from advanced-stage HNSCC patients’ peripheral blood mononuclear cells (PBMC) or lymph node mononuclear cells (LNMC). Methods: Mononuclear cells were stimulated for 10 days in vitro with soluble IL-4 (90hg/mL)/GM-CSF (100U/mL), then soluble TNFa (20 hg/mL) for 48 hours. Flow cytometry was performed to measure the population of cells, which were CD1a+, CD14-, CD15-, CD80+, CD83+, CD86+, HLA-DR++, and CD4+. DCs were then pulsed with Flu-peptide at increasing concentrations (25, 50, and 100 mg/mL) and used to stimulate Flu-specific T cells from HLA-A2+ individuals. Expansion of Flu-specific T cells was measured by re-exposing T cells to Flu-peptide for 24 hours and measuring intra-cellular expression of IFNg. Experiments were also performed in parallel with normal HLA-A2 donors PBMC. Results: Mononuclear cells from HNSCC patients were able to generate a population of cells expressing CD1a+, CD14-, CD15-, CD80+, CD83+, CD86+, HLA-DR++, and CD4+, consistent with DCs. DCs were effective at stimulating Flu-specific T cells from HLA-A2 positive individuals and increased the percentage of T cells (CD4/CD8) expressing intracellular IFNg after re-exposure to Flu-peptide. Conclusion: DCs could be generated from HNSCC patients’ mononuclear cells. Functionality of these DCs to induce a Flu-specific immune response was demonstrated by increased intra-cellular expression of IFNg in CD4 and CD8 cell populations after re-priming. Significance: DCs may be useful in generating an antigen-specific anti-cancer immune response in HNSCC patients. Support: None reported.

Molecular characterization of the PI3/Akt pathway in head and neck squamous cell cancer (HNSCC)

9643 Background: Molecular cancer therapeutics are based on the concept that key molecular abnormalities or pathways drive cancer cell growth. The PI3/Akt pathway, is a regulator of cell growth, proliferation and survival. Akt is overexpressed or constitutively activated in many human tumors including HNSCC in which Akt activation has been associated with increased local treatment failure. The goal of the present study was to dissect the PI3K/Akt pathway in vivo in HNSCC in order to recognize patterns that could be used as the basis for molecularly-targeted therapeutics. Methods:Biopsies obtained from primary, recurrent or second primary tumor of HNSCC patients were placed on a tissue micro-array and subjected to immunohistochemistry with activation state-specific (phospho-) antibodies for multiple components of the PI3K/Akt pathway. We estimated correlations among Akt activation and its downstream effectors FHKR, mTOR, pGSK3β and p70S6 kinase and 4EBP1 operating downstream from mTOR and evaluated differe...

Molecular characterization of the PI3/Akt pathway in head and neck squamous cell cancer (HNSCC)

9643 Background: Molecular cancer therapeutics are based on the concept that key molecular abnormalities or pathways drive cancer cell growth. The PI3/Akt pathway, is a regulator of cell growth, proliferation and survival. Akt is overexpressed or constitutively activated in many human tumors including HNSCC in which Akt activation has been associated with increased local treatment failure. The goal of the present study was to dissect the PI3K/Akt pathway in vivo in HNSCC in order to recognize patterns that could be used as the basis for molecularly-targeted therapeutics. Methods:Biopsies obtained from primary, recurrent or second primary tumor of HNSCC patients were placed on a tissue micro-array and subjected to immunohistochemistry with activation state-specific (phospho-) antibodies for multiple components of the PI3K/Akt pathway. We estimated correlations among Akt activation and its downstream effectors FHKR, mTOR, pGSK3β and p70S6 kinase and 4EBP1 operating downstream from mTOR and evaluated differences in expression between patients with primary versus recurrent tumor. Results: Tumor specimens from 38 patients (27 males, 11 females), median age 55 (range, 27–53 yrs), 23 from primary, 12 from recurrent and 3 from second primary tumor, 2 (5%) stage I, 5 (13%) stage II, 2 (5%) stage III and 27 (71%) (2 not available) at initial diagnosis, were analysed. Akt activation was detected in 30 (79%) of cases. Statistically significant Spearman correlations of activity between Akt and FKHR (p=0.03), mTOR (p=0.04) and GSK3β (p=0.01) and between FKHR and GSK3β (p<0.01) were detected. Only GSK3β showed significantly higher activity in recurrent tumors (p=0.02) Conclusions: PI3/Akt pathway activation is frequent in HNSCC and Akt activation correlates positively with known downstream signaling molecules, establishing the relevance of the pathway in head and neck tumorigenesis. The impact of pathway activation on treatment outcome and survival remains to be determined but molecular PI3K/Akt pathway targeting should be of particular importance for the treatment of the disease (supported by the ASCO CDA to VP). No significant financial relationships to disclose.

Real-time PCR analysis of the N-acetyltransferase NAT1 allele *3, *4, *10, *11, *14 and *17 polymorphism in squamous cell cancer of head and neck.

Although tobacco smoke has been established as a main risk factor in the development of head and neck squamous cell cancer (HNSCC), genetic polymorphisms of xenobiotic metabolizing enzymes are supposed to modulate an individual's susceptibility to smoking-related HNSCC. N-acetyltransferase (NAT) 1 gene is known to be polymorphic and its protein product is implicated in the activation and detoxification of carcinogens, such as aromatic amines, present in tobacco smoke. We developed a rapid and reproducible LightCycler-assisted real-time polymerase chain reaction (PCR) for NAT1 genotyping, which allowed the parallel differentiation of NAT1*3, *4, *10 and *11 alleles and separately of NAT1*14 and *17 alleles within 60 min without the need for further post-PCR processing. In order to investigate the role of the NAT1 gene polymorphism as a risk-modifying factor in HNSCC, we tested for the presence of NAT1*3, *4, *10, *11, *14 and *17 alleles in a case-control study of 291 HNSCC patients and 300 healthy controls of Caucasian origin. Our findings suggest that in Caucasians, the risk of HNSCC is not associated with NAT1 polymorphism. The overall distribution of NAT1 allele frequencies was not significantly different among cases and controls. The presence of the fast acetylator NAT1*10 and NAT1*11 alleles did not significantly increase the risk of HNSCC and no modifying effect of NAT1*10 was observed among smokers. This new approach in NAT1 genotyping substantially increases throughput of sample analysis and, therefore, enhances opportunities to study NAT1 as a risk factor in different cancers in large-scale studies.

Loss of 18q predicts poor survival of patients with squamous cell carcinoma of the head and neck.

Tumor suppressor genes play an important role in normal growth regulation. Loss or inactivation of these genes has been implicated in the development of squamous cell cancer and progression of neoplasia. Previous studies in our laboratories have implicated chromosome 18 long-arm deletions as a possible marker of progression in head and neck squamous cell cancer (HNSCC). To test this hypothesis, we evaluated DNA from 67 HNSCC patients for loss of heterozygosity (LOH) at 18q loci, and for association of LOH with survival. Tumor and normal DNA were extracted from fresh tissue and paraffin blocks and were amplified by PCR using primers for three microsatellite repeat polymorphisms in 18q (D18S336, D18S34, and MBP). A total of 27 (40%) patients had LOH of 18q, and these patients had a statistically significantly poorer two-year survival compared to those without 18q LOH (30% vs. 63%; P = 0.008). In a Cox proportional hazards model in which time from diagnosis to death was the outcome variable, patients with 18q LOH had an unadjusted relative risk (RR) of death of 2.46 (P = 0.005). When 18q LOH was placed in a multivariate model controlling for possible confounders in the study, the RR for death was still elevated (RR = 2.10; P = 0.025). The observation of a prognostic association between 18q LOH and poor patient survival suggests that loss of an 18q tumor suppressor gene or genes is important in the progression of HNSCC.

Autopsy findings in patients with head and neck squamous cell cancer and their therapeutic relevance.

A series of 63 autopsied patients with a history of head and neck squamous cell cancer (HNSCC) is reported with emphasis on the importance of locoregional disease (LRD) versus distant metastasis (DM) in the terminal course of the disease. There were 49 males and 14 females; mean age 64.9 years (range 35-94 years). Locoregional disease was present in 39 patients (62%), in 25 (40%) without tumour at other body sites outside the head and neck region. Distant metastasis was observed in 15 patients (24%); in 12 (19%), it occurred with concomitant LRD. Second primary tumours (SPT) were observed in 20 patients (32%). They occurred in the head and neck region (n = 7; 11%), the lung (n = 9; 14%) and at miscellaneous other sites (n = 4; 6%). Of the 13 patients with SPT outside the head and neck region, 2 had concomitant LRD. 11 patients (17%) died due to other causes, no tumour being found at autopsy. These figures indicate that still a major part of HNSCC patients die with LRD as the single tumour manifestation, which means that improvement of local tumour control will result in a significant therapeutic gain.

DNA heterogeneity in metastasizing squamous cell head and neck cancer

This study was carried out to determine whether analysis of DNA content of tumour cells (expressed as DNA-index: DI) from patients with head and neck squamous cell cancer (HNSCC) and lung squamous cell cancer (LSCC) could be helpful in distinguishing HNSCC patients with LSCC as a second primary from those in which LSCC represents a distant metastasis. Based on the assumption that metastasizing tumours retain their original DNA content, the same DI at both locations would suggest LSCC to be a distant metastasis from HNSCC, whereas a difference in DI at both tumour locations makes LSCC to be a second primary more likely. The study comprised 21 cases with HNSCC as well as LSCC. However, the basic assumption that the identity of a tumour can be inferred from its DI proved to be false as 7 of the 21 cases were characterized by more than one DI signifying several tumour cell populations. This DNA heterogeneity was further substantiated by differences in DI between the primary tumour and cervical lymph node metastasis in a second series composed of 16 HNSCC patients. These data indicate that due to variation in DI within one and the same tumour, DNA-analysis does not offer reliable information when trying to differentiate between lung cancer as a second primary or a distant metastasis in HNSCC patients.