[A Case of Nasopharyngeal Cancer with Febrile Neutropenia Followed by Death during Adjuvant Chemotherapy]

Chemotherapy-related death can occur, but is rarely experienced in the case of head and neck cancer. In this report, we present the case of a 55-year-old male who died of a severe febrile neutropenia during adjuvant chemotherapy. He was initially diagnosed as having nasopharyngeal carcinoma (cT2N0M0), and concurrent chemoradiotherapy was used as a primary treatment. He did not show any critical side effects during that therapy. After residual disease was proven by biopsy, docetaxel, cisplatin and 5-fluorouracil (TPF) therapy was introduced as adjuvant chemotherapy. The patient developed a high fever with a decreased neutrophil count on day 8, and went into a state of shock on day 9. He underwent immediate systemic management, but methicillin-resistant Staphylococcus aureus (MRSA) pneumonia and enteritis were uncontrolled, resulting in death on day 43. The autopsy findings suggested that the main cause of death was acute respiratory distress syndrome (ARDS), but cytomegalovirus (CMV) infection was also noted in multiple organs. . Since it is assumed from literature that the mortality rate in TPF therapy is about 2-4%, it was considered that prior sufficient explanations and informed consent should be required before this therapy.

Factors predicting severe infections during chemotherapy in head and neck cancer patients

CONCLUSIONS

The head and neck cancer patients with more co-morbidities and those dependent on tube feeding are at a high risk of severe infections during chemotherapy. Therefore, prophylaxis with colony-stimulating factors and/or antibiotics should be considered for those patients.

OBJECTIVES

To investigate the risk factors for severe infection during chemotherapy in head and neck cancer patients.

METHODS

A retrospective study was conducted of 129 patients with head and neck cancer who received taxane-based and platinum-based chemotherapy between 2008-2013. Logistic regression models were used to evaluate risk factors.

RESULTS

Febrile neutropenia occurred in 50 patients out of the 129 (39%), severe infections occurred in 24 patients (19%), and bacteremia in two patients (2%). In univariate analysis, low serum albumin levels and tube feeding were significantly associated with severe infections (p = 0.015 and < 0.001, respectively). In multivariate analysis, the odds ratios for a higher modified Charlson co-morbidity index and tube feeding were 2.80 and 9.74, respectively. These two were independent predictive factors for severe infections (p = 0.020 and 0.001, respectively).

Prognostic significance of serum squamous cell carcinoma antigen in patients with head and neck cancer

CONCLUSIONS

Serum squamous cell carcinoma antigen (SCC-Ag) level was an independent prognostic factor for survival in patients with head and neck squamous cell carcinoma (HNSCC), and the prognostic value depended on the carcinoma site.

OBJECTIVES

To assess the value of SCC-Ag as a prognostic indicator in patients with HNSCC and to determine the effect of primary tumor site on prognosis.

METHODS

We reviewed 493 patients with HNSCC between 2004 and 2012. The chi-squared test was used to assess associations between SCC-Ag levels and TNM classification. A Cox proportional hazard model was used to assess the hazard ratio of SCC-Ag at different sites for death, and it was analyzed as a continuous variable.

RESULTS

The median serum level of SCC-Ag was 1.1 ng/ml (range 0-20). SCC-Ag was significantly higher in patients with advanced T and N classification tumors. Primary sites in the oral cavity, in the hypopharynx, advanced T and N classification, distant metastasis, and SCC-Ag were negatively associated with survival in univariate analysis. Multivariate analysis revealed that SCC-Ag was a significant risk factor for overall survival in cancers of the oral cavity, hypopharynx, and larynx, but not in oropharyngeal cancer.

L-glutamine decreases the severity of mucositis induced by chemoradiotherapy in patients with locally advanced head and neck cancer: a double-blind, randomized, placebo-controlled trial

The incidence of severe mucositis in the oral cavity, pharynx and larynx is high among patients with head and neck cancer (HNC) receiving chemoradiotherapy (CRT), resulting in significant pain and impairment of quality of life. The present study investigated whether L-glutamine (glutamine) decreases the severity of mucositis in the oral cavity, pharynx and larynx induced by CRT. This double-blind, randomized, placebo-controlled trial included 40 untreated patients with squamous cell carcinoma of the nasopharynx, oropharynx, hypopharynx or larynx. Patients received 66 or 70 Gy of total radiation at the rate of 2 Gy/fraction daily and 5 fractions/week. Cisplatin (20 mg/m²) and docetaxel (10 mg/m²) were intravenously co-administered once a week for 6 weeks. Patients were randomized to orally receive either glutamine (group G) or placebo (group P) at a dose of 10 g 3 times a day throughout the CRT course. Mucositis was assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0. The primary end point was mucositis severity. Mucositis developed in all patients. A maximal mucositis grade of G4 was observed in 0 and 25% group G and P patients, respectively, while that of G2 was observed in 10 and 0% group G and P patients, respectively (p=0.023). Glutamine significantly decreased the maximal mucositis grade (group G, 2.9±0.3; group P, 3.3±0.4; p=0.005) and pain score at weeks 4, 5 and 6. Glutamine significantly decreased mucositis severity in the oral cavity, pharynx and larynx induced by CRT in patients with HNC.

Factors associated with malnutrition in patients with head and neck cancer

CONCLUSIONS

Comorbidities as well as T classification were the primary determinants for the nutritional status of patients with head and neck cancer.

OBJECTIVES

We aimed to elucidate the underlying conditions of malnutrition in patients with head and neck cancer.

METHODS

We retrospectively reviewed 726 patients diagnosed with head and neck cancer between 2004 and 2013. Associations between malnutrition and clinical parameters were assessed using univariate and multivariate analyses.

RESULTS

Median body mass index was 21.5 (range 11.6-38.0). According to World Health Organization criteria, the nutritional status of these patients was classified into four groups: underweight (18%), normal (63%), overweight (17%), and obese (1%). Comorbidities were detected in 40% of patients. Multivariate analysis revealed the following factors to be independent factors associated with malnutrition: advanced T stage, metachronous cancer, collagen disease, gastrointestinal disease, and pulmonary disease.

[Treatment outcome and failure pattern of olfactory neuroblastoma: a clinical analysis of 14 cases and meta-analysis of Japanese cases]

The olfactory neuroblastoma, first described in 1924, is a rare tumor arising from the olfactory epithelium. Because of its rarity, it is difficult to accrue a large individual series. To elucidate the characteristics of olfactory neuroblastomas in Japan, we report herein on our institutional experience of 14 cases and reviewed 104 cases reported from Japan. In our cases, one out of nine surgically treated patients died during treatment and the remaining 8 patients are alive without disease. Among the five non-surgically treated patients, four patients experienced local treatment failure and the other one patient died of metastasis. In the 104 Japanese cases, 54 patients were treated with multimodality treatment including surgery and radiation. The 3-year overall survival rates for surgically treated patients and non-surgically treated patients were 85% and 73%, respectively. The prognostic factors for survival were modified Kadish stage, Hyams' grade and surgical treatment. Further investigation is required for the validation of endoscopic resection.

Volumetric PET/CT parameters predict local response of head and neck squamous cell carcinoma to chemoradiotherapy

It is not well established whether pretreatment ¹⁸F-FDG PET/CT can predict local response of head and neck squamous cell carcinoma (HNSCC) to chemoradiotherapy (CRT). We examined 118 patients: 11 with nasopharyngeal cancer (NPC), 30 with oropharyngeal cancer (OPC), and 77 with laryngohypopharyngeal cancer (LHC) who had completed CRT. PET/CT parameters of primary tumor, including metabolic tumor volume (MTV), total lesion glycolysis (TLG), and maximum and mean standardized uptake value (SUV_max and SUV_mean), were correlated with local response, according to primary site and human papillomavirus (HPV) status. Receiver-operating characteristic analyses were made to access predictive values of the PET/CT parameters, while logistic regression analyses were used to identify independent predictors. Area under the curve (AUC) of the PET/CT parameters ranged from 0.53 to 0.63 in NPC and from 0.50 to 0.54 in OPC. HPV-negative OPC showed AUC ranging from 0.51 to 0.58, while all of HPV-positive OPCs showed complete response. In contrast, AUC ranged from 0.71 to 0.90 in LHC. Moreover, AUCs of MTV and TLG were significantly higher than those of SUV_max and SUV_mean (P < 0.01). After multivariate analysis, high MTV >25.0 mL and high TLG >144.8 g remained as independent, significant predictors of incomplete response compared with low MTV (odds ratio [OR], 13.4; 95% confidence interval [CI], 2.5–72.9; P = 0.003) and low TLG (OR, 12.8; 95% CI, 2.4–67.9; P = 0.003), respectively. In conclusion, predictive efficacy of pretreatment ¹⁸F-FDG PET/CT varies with different primary sites and chosen parameters. Local response of LHC is highly predictable by volume-based PET/CT parameters.

Chemoradiation therapy for squamous cell carcinoma of the external auditory canal: A meta-analysis

BACKGROUND

The standard treatment for advanced external auditory canal squamous cell carcinoma (SCC) is subtotal temporal bone resection and postoperative radiation therapy (RT), whereas chemoradiation therapy (CRT) is used in some institutions to improve patient prognosis. The purpose of this study was to evaluate the efficacy of CRT in external auditory canal SCC treatment.

METHODS

Meta-analyses of external auditory canal SCC studies were performed. We extracted 5-year overall survival rates and number of patients for aggregate patient data, and types of treatment and outcomes for individual patient data.

RESULTS

The 5-year overall survival rate of 752 patients was 57%. In the individual patient data meta-analysis, the 5-year overall survival rates of patients who received surgery ± RT, preoperative CRT, definitive CRT, and postoperative CRT were 53.5%, 85.7%, 43.6%, and 0%, respectively.

CONCLUSION

Our data suggest that preoperative CRT may improve the survival of surgically treated patients with external auditory canal SCC and that definitive CRT may be equivalent to surgical resection.

Human papillomavirus and p53 mutations in head and neck squamous cell carcinoma among Japanese population

We aimed to reveal the prevalence and pattern of human papillomavirus (HPV) infection and p53 mutations among Japanese head and neck squamous cell carcinoma (HNSCC) patients in relation to clinicopathological parameters. Human papillomavirus DNA and p53 mutations were examined in 493 HNSCCs and its subset of 283 HNSCCs. Oropharyngeal carcinoma was more frequently HPV-positive than non-oropharyngeal carcinoma (34.4% vs 3.6%, P < 0.001), and HPV16 accounted for 91.1% of HPV-positive tumors. In oropharyngeal carcinoma, which showed an increasing trend of HPV prevalence over time (P < 0.001), HPV infection was inversely correlated with tobacco smoking, alcohol drinking, p53 mutations, and a disruptive mutation (P = 0.003, <0.001, <0.001, and <0.001, respectively). The prevalence of p53 mutations differed significantly between virus-unrelated HNSCC and virus-related HNSCC consisting of nasopharyngeal and HPV-positive oropharyngeal carcinomas (48.3% vs 7.1%, P < 0.001). Although p53 mutations were associated with tobacco smoking and alcohol drinking, this association disappeared in virus-unrelated HNSCC. A disruptive mutation was never found in virus-related HNSCC, whereas it was independently associated with primary site, such as the oropharynx and hypopharynx (P = 0.01 and 0.03, respectively), in virus-unrelated HNSCC. Moreover, in virus-unrelated HNSCC, G:C to T:A transversions were more frequent in ever-smokers than in never-smokers (P = 0.04), whereas G:C to A:T transitions at CpG sites were less frequent in ever-smokers than in never-smokers (P = 0.04). In conclusion, HNSCC is etiologically classified into virus-related and virus-unrelated subgroups. In virus-related HNSCC, p53 mutations are uncommon with the absence of a disruptive mutation, whereas in virus-unrelated HNSCC, p53 mutations are common, and disruptive mutagenesis of p53 is related with oropharyngeal and hypopharyngeal carcinoma.

Clinical utility of CT and FDG PET/CT in assessing the neck in node-positive head and neck cancer after chemoradiotherapy

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Background: Concurrent chemoradiotherapy has been widely accepted to treat locoregional advanced head and neck cancer, but the need for subsequent neck dissection remains controversial. Our objective was to determine whether CT or fluorodeoxyglucose (FDG) PET/CT is superior in the evaluation of persistent nodal disease after chemoradiotherapy in patients with node-positive head and neck squamous cell carcinoma (HNSCC). Methods: Study entry criteria included node-positive HNSCC treated with concurrent chemoradiotherapy, a local complete response, and post-treatment CT and FDG PET/CT studies 11 weeks after chemoradiotherapy. Fifty-eight patients with 68 node-positive necks were eligible. Nodes larger than 1 cm (minor axis), or with central necrosis on CT, or any visually hypermetabolic nodes on FDG PET/CT were considered clinically positive. Regardless of PET/CT findings, necks with positive CT were subjected to neck dissection, whereas those with negative CT were observed without neck dissection. Results: Seventeen necks showed positive CT, 13 and 4 of which underwent neck dissection and fine needle aspiration cytology, respectively, resulting in pathologic evidence of persistent nodal disease in 5 necks. Four of 51 necks with negative CT developed regional recurrence. Diagnostic accuracy of CT and PET/CT is shown in table. In general, the negative predictive value (NPV) was equivalent between CT and FDG PET/CT, whereas FDG PET/CT was better than CT in the specificity and accuracy. Conclusions: In patients with HNSCC, both CT and FDG PET/CT after chemoradiotherapy have a high NPV for excluding residual regional disease and avoiding unnecessary neck dissection. Although the NPV is similarly high, PET/CT has superior utility compared with CT because the number of false positive findings is less in PET/CT than CT. [Table: see text]

[Head and neck soft tissue sarcoma]

Soft tissue sarcoma arising as a head and neck lesion is very rare in adults. Therefore, no standardized treatment exists for this entity of disease. We retrospectively analyzed 11 cases of head and neck soft tissue sarcomas treated at Osaka University Hospital from 1991 to 2011. They were pathologically classified as follows: 5 cases with rhabdomyosarcoma, 2 cases with liposarcoma, 2 cases with undifferentiated sarcoma and one each of epithelioid hemangioendothelioma and malignant fibrous histocytoma. Rhabdomyosarcomas were treated with multimodality therapy. Other sarcomas were treated mainly with surgery. The prognosis of patients with sarcoma depended on the histology, histological grade, tumor size and tumor stage. Patients with larger tumors, high grade tumors and advanced stage tumors had a poor prognosis, while those with rhabdomyosaracoma had a better prognosis. Further investigation is required to establish the new treatment protocol for adult soft tissue sarcoma and to improve survival.

P3-07-46: Accuracy of SPIO-Enhanced MR Imaging Alone for the Diagnosis of Sentinel Node Metastases in Patients with Breast Cancer

Background

Superparamagnetic iron oxide (SPIO)-enhanced MR imaging has been reported to be promising for the detection of metastases in sentinel nodes localized by CT lymphography in patients with breast cancer (Motomura, Ann Surg Oncol 2011). The current SPIO technique involves imaging before and after contrast administration. This study evaluated the accuracy of SPIO-enhanced MR imaging alone without unenhanced imaging.

Methods: This study included 120 patients with breast cancer demonstrating clinically negative nodes. Sentinel nodes were identified by CT lymphography, and MR imaging of the axilla before and 18–24 hr after interstitial administration of SPIO was performed. A node was considered non-metastatic if it showed a homogenous low signal intensity and metastatic if there was an absence of low signal intensity either in the entire node or in a focal area on SPIO-enhanced MR imaging. The diagnostic accuracy of the SPIO-enhanced imaging alone was compared with that of combined unenhanced and SPIO-enhanced imaging.

Results: The mean number of sentinel nodes identified by CT lymphography was 1.2 (range 1–3). Pathologic evaluation demonstrated that 28 (23.3%) of 120 patients showed metastasis to at least one node. One false negative result was added when the evaluation was based solely on SPIO-enhanced MR imaging. Consequently, the sensitivity decreased from 84.0% to 80.0% and the accuracy decreased from 89.2% to 88.3%, respectively, in the SPIO-enhanced MR imaging alone. However, the differences in sensitivity and accuracy between SPIO-enhanced MR imaging alone and the combined unenhanced and SPIO-enhanced imaging were not significant (McNemar's test; p=1.0). The specificity of enhanced imaging alone and that of combined unenhanced and SPIO-enhanced imaging were both 90.5%.

Conclusions: A single MR imaging examination performed after SPIO administration can be used for accurate diagnosis of sentinel node metastases, and thus reduce the time and cost of imaging.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-46.

A case of myxofibrosarcoma of the maxilla with difficulty in preoperative diagnosis

Myxofibrosarcoma (MFS) is a very rare fibroblast-derived sarcoma that occurs in the head and neck region. Here, we report the case of a 52-year-old man in whom MFS generated from the maxilla and whose beginning of treatment was considerably delayed because he was initially diagnosed as having a benign inflammatory lesion. Because a definite diagnosis was not obtained via 2 independent biopsies, total maxillectomy was used for both diagnosis and treatment. Histopathological and immunohistochemical analyses suggested that the tumor was a low-grade MFS. Because soft tissue tumors in the head and neck region are rare and a definite diagnosis is relatively difficult, surgical excision is indispensable if malignancy of the tumor is suspected.

Enhanced epithelial-mesenchymal transition-like phenotype in N-acetylglucosaminyltransferase V transgenic mouse skin promotes wound healing

N-Acetylglucosaminyltransferase V (GnT-V) catalyzes the β1,6 branching of N-acetylglucosamine on N-glycans. GnT-V expression is elevated during malignant transformation in various types of cancer. However, the mechanism by which GnT-V promotes cancer progression is unclear. To characterize the biological significance of GnT-V, we established GnT-V transgenic (Tg) mice, in which GnT-V is regulated by a β-actin promoter. No spontaneous cancer was detected in any organs of the GnT-V Tg mice. However, GnT-V expression was up-regulated in GnT-V Tg mouse skin, and cultured keratinocytes derived from these mice showed enhanced migration, which was associated with changes in E-cadherin localization and epithelial-mesenchymal transition (EMT). Further, EMT-associated factors snail, twist, and N-cadherin were up-regulated, and cutaneous wound healing was accelerated in vivo. We further investigated the detailed mechanisms of EMT by assessing EGF signaling and found up-regulated EGF receptor signaling in GnT-V Tg mouse keratinocytes. These findings indicate that GnT-V overexpression promotes EMT and keratinocyte migration in part through enhanced EGF receptor signaling.

Interfacial Structure and Stability in GexSi1−x/Si Strained Layers

High resolution electron microscopy is used to probe the atomic scale structure of interfaces and defects in the GexSi1−x/Si system. By careful quantification of lattice images, it is shown that molecular beam epitaxy may be used to grow GexSi1−x/Si (100) and (111) interfaces which are sharp on the scale of the unit cell and flat to within a few atomic planes when about 5000 Å2 of the interface are sampled. Interfacial quality is retained in single and multiple quantum well structures. Conditions for superlattice stability against misfit dislocations are discussed. It is shown that GexSi1−x/Si interfaces produced by molecular beam epitaxy at 550°C can exist in a metastable state which relaxes upon thermal annealing.

A Technique for Preparing Transmission Electron Microscope Specimens Using Cleavage

A technique for observing both plan view and cross sections of a specimen directly in a transmission electron microscope (TEM) without relying on a tedious thinning operation was developed. This technique involves cleaving a specimen perpendicular to the plane, so that the thin (electron transparent) section of the cleaved edge can be directly imaged by TEM. The only limitations of this technique are that a specimen must be readily criacked or cleaved and that, since the transparent region is often bounded by a 90° corner, the extent of electron transparent region is somewhat localized. Nevertheless, the technique has the advantages of the ease of specimen preparation, and the absence of contamination or damage introduced in other conventional thinning methods. The geometry of the cleaved specimen is also suitable for reflection electron microscopy.