Prognostic Performance of Current Stage III Oral Cancer Patients After Curative Intent Resection: Evidence to Support a Revision of the American Joint Committee on Cancer Staging System

BACKGROUND

The American Joint Committee on Cancer (AJCC) stage III classification of oral cavity squamous cell carcinoma (OCSCC) represents a heterogeneous group of patients with early local disease with regional metastases (T1N1 and T2N1) and advanced local disease with or without regional metastasis (T3N0 and T3N1).

OBJECTIVE

The aim of this study was to evaluate prognostic heterogeneity in the stage III category.

METHODS AND PATIENTS

An international retrospective multicenter study of 1815 patients who were treated for OCSCC from 2003 to 2011.

RESULTS

Kaplan-Meier survival analysis and multivariate models of stage III patients revealed better overall survival (OS; HR 2.12, 95 % CI 1.03-4.15; p = 0.01) and disease-specific survival (DSS; HR 1.7, 95 % CI 1.16-4.12; p = 0.04) rates for patients with T1-2N1/T3N0 disease than for patients with T3N1 disease. The outcomes of patients with T3N1 and stage IVa disease were similar (p = 0.89 and p = 0.78 for OS and DSS, respectively). Modifying stage classification by transferring the T3N1 category to the stage VIa group resulted in a better prognostic performance [Harrell's concordance index, C index 0.76; Akaike's Information Criterion (AIC) 4131.6] compared with the AJCC 7th edition staging system (C index 0.65; AIC 4144.9) for OS. When DSS was assessed, the suggested staging system remained the best performing model (C index 0.71; AIC 1061.3) compared with the current AJCC 7th edition staging (C index 0.64; AIC 1066.2).

CONCLUSIONS

The prognosis of T3N1 and stage IVa disease are similar in OCSCC, suggesting that these categories could be combined in future revisions of the nodal staging system to enhance prognostic accuracy.

Revision of endemic Marquesas Islands Bidens (Asteraceae, Coreopsideae)

During the preparation of the Vascular Flora of the Marquesas Islands four new species of Bidens (Coreopsideae, Asteraceae) have come to light and are described herein: Bidens woodii W.L. Wagner, J.R. Clark & Lorence, sp. nov. from Ua Pou, and Bidens microcephala W.L. Wagner, J.R. Clark & Lorence sp. nov., Bidens evapelliana W.L. Wagner, J.R. Clark & Lorence, sp. nov., and Bidens wichmanii W.L. Wagner, J.R. Clark & Lorence, sp. nov. from the undercollected island of Fatu Hiva. In addition to these new species, we recognize the following six species of Bidens previously described from the Marquesas Islands: Bidens beckiana (F. Br.) Sherff (Eiao and Hatutaa), Bidens bipontina Sherff and Bidens cordifolia Sch. Bip. (both in Nuku Hiva), Bidens henryi Sherff (Hiva Oa, Tahuata), Bidens uapensis (F. Br.) Sherff (Ua Pou), and Bidens polycephala Sch. Bip. (Nuku Hiva, Ua Huku, Hiva Oa, Tahuata, and Mohotani). Two names are reduced to synonymy under Bidens polycephala: Bidens collina Degener & Sherff, syn. nov. and Bidens jardinii Sch. Bip., syn. nov. Bidens polycephala has the widest distribution of the Marquesan species on five of the islands and exhibits considerable variation.

Mutation frequency in 15 common cancer genes in high-risk head and neck squamous cell carcinoma

BACKGROUND

With prior studies having looked at unselected cohorts, we sought to explore the mutational landscape in a high-risk group of head and neck squamous cell carcinoma (HNSCC) tumors.

METHODS

A multiplexed polymerase chain reaction (PCR) assay evaluating 68 loci in 15 genes was performed on 64 patients with high-risk HNSCC. Because of the frequent PIK3CA and AKT1 mutations in patients with oropharyngeal carcinoma, we evaluated the relationship between mutation status and both clinical/pathologic variables and tumor control in this subgroup.

RESULTS

Seventeen of 64 patients harbored mutations in the assayed loci: 16% in PIK3CA, 9% in TP53, 2% in AKT1, and 2% in epidermal growth factor receptor (EGFR). The frequency of PIK3CA/AKT1 mutations in oropharyngeal and sinonasal primaries was increased compared to other primary sites (35% vs 6%; p = .005). There was no relationship between mutation status and overall survival (OS), disease-specific death, or progression in the oropharyngeal cohort.

CONCLUSION

We identified frequent PIK3CA mutations in patients with high-risk HNSCC confined predominantly to the oropharyngeal and sinonasal subsites; for the first time, mutation in AKT1 has been identified in HNSCC.

Long-term survival after distant metastasis in patients with oropharyngeal cancer

OBJECTIVES

For patients with oropharyngeal squamous cell carcinoma (OPSCC), especially for those with HPV-positive tumors, locoregional control is excellent. Distant metastasis, however, remains a substantial problem. The purpose of our study was to evaluate outcomes and predictors of survival after distant metastasis in OPSCC.

MATERIALS AND METHODS

Between June 2002 and January 2011, 25 OPSCC patients treated with curative intent subsequently developed distant metastasis. The primary end-points evaluated were time-to-distant metastasis and overall survival after development of distant metastasis. Predictors of outcome were evaluated with median regression analysis or Cox regression. Best subset models were chosen to minimize the Bayesian Information Criterion (BIC). A prognostic index for survival after distant failure was created based on the selected model.

RESULTS

Median time-to-distant metastasis after completion of radiation was 7.9 months (range, 1.6-25.4). Median overall survival from distant metastasis was 18.3 months (95% CI, 14.3-39.8). The overall survival rates at 1- and 2-year after development of distant metastasis were 72.0% (95% confidence interval [CI], 53.4-89.6) and 40.8% (95% CI, 20.6-61.0), respectively. In multivariate analysis, Karnofsky Performance Status score (KPS) > or = 80 (p=0.01, hazard ratio [HR] 0.15, 95% CI, 0.04-0.52) and limited, single-organ disease (p=0.003, HR 0.13, 95% CI 0.03-0.61) predicted for increased survival from distant metastasis. Patients with both limited disease and good KPS formed the most favorable risk group with a 2-year survival of 100%. Two patients with human papilloma virus (HPV)-positive tumors were alive without any evidence of disease at 64.6 and 60.4 months, respectively, after aggressive local treatment of solitary metastasis.

CONCLUSION

For OPSCC patients with limited, single-organ disease and good KPS, long-term survival can be achieved.

Genetic map of the primocane-fruiting and thornless traits of tetraploid blackberry

Blackberry primocane fruiting, fruiting on first-year canes, has the potential to expand blackberry production both seasonally and geographically. The incorporation of the primocane-fruiting trait into cultivars with desirable horticultural attributes is challenging due to its recessive nature and tetrasomic inheritance. Molecular marker-assisted selection has high potential to facilitate incorporation, because breeders already use morphological marker-assisted selection of seedlings without marginal cotyledonary hairs to identify progeny that will be thornless when mature. The development of a genetic linkage map with these two traits is the first step to utilizing molecular markers in breeding for thornless primocane-fruiting blackberry cultivars. A full-sib family segregating for thornlessness and primocane fruiting, from a cross between 'APF-12' and 'Arapaho', was used to construct the first genetic map of tetraploid blackberry. Segregation patterns of several dominant markers and the two phenotypic traits fit those expected uniquely with tetrasomic inheritance (e.g., 5:1, 11:1 and 35:1). Some loci showed significant double reduction frequencies, but genotypes that could have originated only from double reduction were not found. The map consists of seven linkage groups (LG) in each parent, consistent with the basic number of chromosomes (2n = 4x = 28). Naming of LG1-LG6 followed that of the recently revised system for raspberry using SSR markers in common between blackberry and raspberry, and LG7 was tentatively defined by default. The loci controlling primocane fruiting and thornlessness were not linked to each other; thornless/thorny, the S Locus, was mapped on LG4, and the primocane-/floricane-fruiting locus, named in this work the F Locus, on LG7.

Initial Clinical Findings of a Mathematical Model to Predict Survival of Head and Neck Cancer

Objectives

(1) Identify clinical features that impact survival for head and neck cancer. (2) Determine the individual contribution to mortality of significant clinical features. (3) Develop a web-based calculator to integrate clinical features and predict survival outcome for individual patients.

Study Design

Analysis of a national cancer database. We fit patient data to the binary-biological model of cancer lethality, a mathematical model designed to predict cancer outcome. The model predicts the risk of cancer death, using information on tumor size, nodal status, and other prognostic factors.

Subjects and Methods

Analysis was carried out on a cohort of ~50,000 patients with head and neck cancer from the Survey, Epidemiology and End-Results (SEER) 2009 data set and validated with a cohort of ~1300 patients from an institutional Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary database. We developed a web-based calculator written in JavaScript, PHP, and HTML.

Results

The risk of death due to head and neck cancer increases monotonically with tumor size. Each positive lymph node is associated with ~14% extra risk of death. Anatomical site, age, race, tumor extension, N stage, and extracapsular spread contribute to mortality. The lethal impact of these prognostics factors can be accurately estimated by the Size + Nodes + PrognosticMarkers (SNAP) method.

Conclusions

This predictive cancer model and web-based calculator provide a basis for estimating the risk of death for head and neck cancer patients by assigning values to the lethal contributions of tumor size, number of positive nodes, anatomical site, tumor extension, N stage, extracapsular spread, age at diagnosis, and race.

Ventricular fibrillation cardiac arrest due to 5-fluorouracil cardiotoxicity

The antimetabolite chemotherapeutic agent 5-fluorouracil is used to treat a variety of cancers. Although 5-fluorouracil is generally well tolerated, its toxicity profile includes potential cardiac ischemia, vasospasm, arrhythmia, and direct myocardial injury. These actual or potential toxicities are thought to resolve upon cessation of the medication; however, information about the long-term cardiovascular effects of therapy is not sufficient. We present the case of a 58-year-old man who had 2 ventricular fibrillation cardiac arrests, with evidence of coronary vasospasm and myocarditis, on his 4th day of continuous infusion with 5-fluorouracil. External defibrillation and cessation of the 5-fluorouracil therapy resolved the patient's electrocardiographic abnormalities. In addition to reporting the clinical manifestations of 5-fluorouracil-associated cardiotoxicity in our patient, we discuss management challenges in patients who develop severe 5-fluorouracil-induced ventricular arrhythmias.

Biomarkers of HPV in head and neck squamous cell carcinoma

Human papillomavirus (HPV) is an accepted cause of head and neck squamous cell carcinoma (HNSCC), and patients with HPV-associated HNSCC have a favorable prognosis. Currently, there is no general guidance on the most appropriate biomarkers for clinical assessment of HPV in these malignancies. We compared PCR-based and serologic HPV assays, as well as p16 immunohistochemistry, individually and in combination in a single population-based study to assess their associations with overall survival among patients with HNSCC, and thus their potential value as biomarkers. HPV16 serology was determined for 488 patients; immunohistochemical detection of p16 expression in tumors was conducted in a subset of 233 cases, and PCR-based methods to assess the presence of HPV16 DNA in a subset of 179 cases of tumors. Considering each biomarker individually in the subset of patients studied for all endpoints, seropositivity for the E6 and E7 proteins was significantly associated with enhanced all-cause survival in oropharyngeal disease [HR(E6/E7+) = 0.1, 95% confidence interval (CI) = 0.02-0.3]. Neither the presence of HPV16 DNA nor p16 immunostaining was associated with significant enhanced overall survival in oropharyngeal disease (HR(DNA) = 0.9, 95% CI = 0.3-2.9; HR(p16) = 0.3, 95% CI = 0.1-1.1). However, the combination of HPV-positive DNA and E6 or E7 serology was associated with enhanced overall survival in oropharyngeal disease (HR(DNA+/E6/E7+) = 0.1, 95% CI = 0.02-1.0), whereas E6/E7 seronegative patients with evidence of HPV in tumor DNA did not show any evidence of favorable survival (HR(DNA+/E6-/E7-) = 3.4, 95% CI = 0.6-18.1). Furthermore, patients with p16 staining and E6 or E7 seropositivity had favorable survival from oropharyngeal disease (HR(p16+/E6/E7+) = 0.1, 95% CI = 0.02-0.4), whereas patients who were p16 positive and E6/E7 seronegative had significantly increased hazard of all causes of death (HR(p16+/E6-/E7-) = 3.1, 95% CI = 1.2-7.7). A stronger association of HPV presence with prognosis (assessed by all-cause survival) is observed when "HPV-associated" HNSCC is defined using tumor status (HPV DNA status or P16) and HPV E6/E7 serology in combination rather using tumor HPV status alone.

Abstract 4497: Biomarkers of HPV in head and neck squamous cell carcinoma

Human papillomavirus (HPV) is an accepted cause of head and neck squamous cell carcinoma (HNSCC) and patients with HPV-associated disease have a favorable prognosis. Currently there is no general guidance on the most appropriate biomarkers for clinical assessment of HPV. We measured DNA-based and serological markers in a single population-based study to assess their associations with disease outcome and to determine the most relevant biomarker for clinical use. HPV16 serology was determined using an immunoassay for the capsid protein L1, and multiplex serology based on the capsid protein L1 and the early oncoproteins E6/E7 for 488 patients. Immunohistochemical detection of p16 expression in tumors was performed in a subset of 233 cases, and we used two different methods to assess the presence of HPV16 DNA in a subset of 179 cases’ tumors. Seropositivity for the E6 and E7 proteins (individually) was significantly associated with enhanced survival (HRE6 or HRE7=0.3, 95%CI=0.2-0.5). Neither the presence of HPV16 DNA or p16 overexpression was associated with significant enhanced overall survival (HRDNA=0.8, 95%CI=0.5-1.3; HRp16=0.8, 95%CI=0.5-1.4). However the combination of HPV positive DNA and E6/E7 serology was associated with similarly enhanced overall survival (HRDNA+/E6+/E7+=0.1, 95%CI=0.01-0.6), while E6/E7 seronegative patients with evidence of HPV in tumor DNA did not show any evidence of favorable survival (HRDNA+/E6-/E7-=1.2, 95%CI = 0.7-2.2). Further, the combination of p16 staining and early gene seropositivity showed a favorable survival (HRp16+/E6+/E7+=0.3, 95%CI=0.1-0.9), while those who were p16 positive and early gene seronegative had significantly increased hazard of death (HRp16+/E6-/E7-=2.1, 95%CI=1.1-4.2). Determination of only HPV16 DNA status or p16 immunostaining is not an effective prognostic biomarker for HNSCC. However the combination of measurement of HPV16 DNA and p16 immunostaining with E6/E7 antibodies has high predictive clinical value, strongly suggesting that a combined biomarker approach is necessary for the assessment of the prognosis of HNSCC patients.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4497. doi:1538-7445.AM2012-4497