Effect of early detection of recurrent disease by FDG PET/CT on management of patients with squamous cell cancer of the head and neck (HNSCC)

6062

Background: Despite the increasing cure rates a substantial fraction of HNSCC patients (pts) will present with locoregional and/or distant relapse within 3 years of definitive therapy. The prognosis of HNSCC pts after failure of first-line therapy has been poor but recent changes in the biology of HNSCC, advances in surgical techniques and radiotherapy; and new drugs may lead to improved salvage therapy. Notably, the success of these developments are implicitly dependent on early diagnosis disease. Our objective was to compare the efficacy of surveillance FDG-PET/CT to that of high resolution CT (HRCT) and physical exam (PE/E) for detection of early relapse in HNSCC after completion of primary treatment. Methods: A retrospective analysis of FDG-PET/CT, neck HRCT and PE/E was performed in 99 curatively treated HNSCC pts during post-therapy surveillance (PTS) to compare the performance characteristics of the tests in the detection of early recurrence or metachronous cancer. Results: A total of 19/99 (20%) pts had recurrence during a median follow-up of 21mo (range:9-52). Median time to first PET/CT was 3.5mo. The median time to radiological recurrence was 6 mo (range:2.3-32). PET/CT detected more disease recurrences or second primaries and did so earlier than HRCT and PE/E. Sensitivity, specificity, PPVand NPV for detecting locoregional and distant recurrence or metachronous cancer : 100%, 87.3%, 56.5% and 100% for PET/CT vs. 61.5%, 94.9%, 66.7% and 93.8% for HRCT vs. 23.1%, 98.7%, 75% and 88.6% for PE/E. In all 19 pts with a true positive PET/CT there was a significant management change prompting either salvage or definitive surgery or initiation of systemic therapy. Of the 14 recurrent pts treated with curative intent, 11 were alive with no evidence of disease at a median follow up of 31.5 mo. Conclusions: FDG-PET/CT has a high sensitivity in the early detection of relapse or second primary cancer in HNSCC, associated with significant management implications. Given improvements in therapy and changes in HNSSC biology, appropriate modifications in the current recommended algorithms of the NCCN for PTS may be required to engage effective salvage or definitive therapies.

A patient-centered approach to counseling patients with head and neck cancer undergoing human papillomavirus testing: a clinician's guide

The International Agency for Research on Cancer and the National Cancer Institute have acknowledged human papillomavirus (HPV)-16 as an independent risk factor for oropharyngeal cancer (OPC). HPV-positive oropharyngeal cancer (HPVOPC) is a sexually transmitted entity that is on the rise; within the next 10 years, the annual number of HPV-associated OPC cases is projected to exceed the annual number of cervical cancer cases in the United States. Recognition of HPV status in OPC has broad implications beyond the traditional oncological concerns of timely diagnosis, accurate staging, and appropriate treatment of cancer patients. The National Comprehensive Cancer Network recommends testing the tumor site for HPV-status during OPC management; it is likely this will become a standard component of care for patients with high-probability tumors of the oropharynx. As the practice of HPV testing becomes more common, it behooves providers to be able to adequately address the concerns of patients with HPVOPC. Although there are currently few relevant studies focusing on this population, existing literature on HPV-infected women and patients with cervical cancer strongly supports the concept that patients with HPVOPC need education to optimally address concerns such as self-blame, guilt, intimacy, and interpersonal relationships. When HPV testing is done, it should be accompanied by evidence-driven and patient-centered counseling to best minimize negative psychosocial outcomes and ensure optimum health promotion. Based on the current state of the literature, this article is intended to be a reference for physicians to effectively manage psychosocial outcomes when diagnosing patients with HPV-associated OPC.

A combined evaluation strategy of FDG PET/CT and contrast-enhanced diagnostic CT (ceCT) for lymph nodes in the neck

5578

Background: Accurate assessment of cervical lymph nodes (LNs) for determination of metastatic involvement is of prime importance for management. Our objective was to determine the incremental value of combining metabolic and morphologic information in the differentiation between benign and malignant LNs. Methods: A total of101 pts with head and neck squamous cell (n=91) or thyroid cancer (n=6) or lymphoma (n=4) were included in the study. PET/CT and neck ceCT were acquired simultaneously or sequentially at staging (n=48) or restaging (n=53). In 131 LNs, variables evaluated includes SUVmax, size, shape (elliptical vs non-elliptical), presence of extracapsular extension (Ecext-irregular margins), necrosis, and fatty hilum. Histopathology (n=96) and 12 mo follow-up (n=35) were used for confirmation of the findings. ROC analyses determined the SUVmax cut-off. Results: Of131 LNs, malignancy wasconfirmed in 49 (37%).Results are shown in table. In the detection of malignancy, SUVmax of 4.5 yielded the best balance between the sensitivity and specificity, performing better than all CT variables alone. Combination analysis improved results only when SUVmax (4.5) was added to Ecext. However, best combination results were obtained at a SUV cut-off of 3.7. Higher SUV cut-off did not significantly improve overall performance of SUVmax alone (Table). Conclusions: In the differentiation of malignant from benign LNs, SUVmax (4.5) yields better results than CT variables alone. However combining a lower SUVmax (3.7) with Ecext produced the best results. Increasing SUVmax cut-off only produced a gain in specificity at a significant cost of sensitivity. [Table: see text]

Analysis of marker-defined HNSCC subpopulations reveals a dynamic regulation of tumor initiating properties

Head and neck squamous carcinoma (HNSCC) tumors carry dismal long-term prognosis and the role of tumor initiating cells (TICs) in this cancer is unclear. We investigated in HNSCC xenografts whether specific tumor subpopulations contributed to tumor growth. We used a CFSE-based label retentions assay, CD49f (α6-integrin) surface levels and aldehyde dehydrogenase (ALDH) activity to profile HNSCC subpopulations. The tumorigenic potential of marker-positive and -negative subpopulations was tested in nude (Balb/c nu/nu) and NSG (NOD.Cg-Prkdc^scid Il2rg^tm1Wjl/SzJ) mice and chicken embryo chorioallantoic membrane (CAM) assays. Here we identified in HEp3, SQ20b and FaDu HNSCC xenografts a subpopulation of G0/G1-arrested slow-cycling CD49f^high/ALDH1A1^high/H3K4/K27me3^low subpopulation (CD49f+) of tumor cells. A strikingly similar CD49f^high/H3K27me3^low subpopulation is also present in primary human HNSCC tumors and metastases. While only sorted CD49f^high/ALDH^high, label retaining cells (LRC) proliferated immediately in vivo, with time the CD49f^low/ALDH^low, non-LRC (NLRC) tumor cell subpopulations were also able to regain tumorigenic capacity; this was linked to restoration of CD49f^high/ALDH^high, label retaining cells. In addition, CD49f is required for HEp3 cell tumorigenicity and to maintain low levels of H3K4/K27me3. CD49f+ cells also displayed reduced expression of the histone-lysine N-methyltransferase EZH2 and ERK1/2phosphorylation. This suggests that although transiently quiescent, their unique chromatin structure is poised for rapid transcriptional activation. CD49f− cells can “reprogram” and also achieve this state eventually. We propose that in HNSCC tumors, epigenetic mechanisms likely driven by CD49f signaling dynamically regulate HNSCC xenograft phenotypic heterogeneity. This allows multiple tumor cell subpopulations to drive tumor growth suggesting that their dynamic nature renders them a “moving target” and their eradication might require more persistent strategies.

Circumferential watertight dural repair using nitinol U-clips in expanded endonasal and sublabial approaches to the cranial base

BACKGROUND

In recent years, significant advances have been made in the field of expanded endonasal approaches that permit treatment of different cranial base intradural lesions.

OBJECTIVE

To report our technique of cranial base dural repair by the application of nitinol U-Clips in endoscope-assisted extended endonasal or sublabial approaches. Closure techniques and postoperative cerebrospinal (CSF) leaks are reported.

METHODS

We reviewed 11 patients with different kinds of cranial base tumors or vascular diseases (2 tuberculum sellae meningiomas, 1 planum sphenoidale meningioma, 4 craniopharyngiomas, 1 recurrent clival chordoma, 1 esthesioneuroblastoma, 1 ethmoidal melanoma metastasis, 1 basilar trunk aneurysm) who underwent an endoscope-assisted extended endonasal or sublabial approach. Dural repair was performed using nitinol U-Clips to circumferentially suture AlloDerm or fascia lata directly to the existing dural borders. Lumbar drainage was not used in 9 patients and was used in 2 patients for 5 days. Patients were evaluated for the appearance of CSF leaks.

RESULTS

Postoperative CSF leak was observed in 1 patient (9%). This required a second transnasal repair.

CONCLUSION

Circumferential dural closure with U-Clips is a useful adjunct to prevent CSF leaks after expanded endonasal or sublabial approaches to the cranial base for treatment of intracranial pathology.

Extracervical approaches to endoscopic thyroid surgery

There is increasing demand for surgical procedures which avoid visible scars while maintaining optimal functional and ideal cosmetic results, without compromising the safety or effectiveness of the procedure. Endoscopic techniques have been adapted to abdominal and pelvic surgery and increasingly employed over the past three decades. Although hampered by the absence of a natural cavity, endoscopic techniques have been adapted to surgery in the neck for the past 15 years, particularly for the thyroid gland. While earlier attempts at endoscopic thyroid surgery were performed through incisions in or near the midline of the neck, recent techniques have been developed to place the incisions and endoscopic ports extracervically, or at least away from the midline region of the neck, rendering the cosmetic result more acceptable. Most of these approaches are through the axilla, breast, chest wall or a combination of approaches. Visualization of the thyroid and rate of complications with these approaches are equal to those attained with older endoscopic approaches. Careful patient selection is important for endoscopic surgery. Complications unique to the endoscopic approach are mostly related to insufflation of cervical tissues with pressurized CO(2).

Papanicolaou stain may not be necessary in majority of head and neck fine-needle aspirations: evidence from a correlation study between Diff-Quik-based onsite diagnosis and final diagnosis in 287 head and neck fine-needle aspirations

Fine-needle aspiration (FNA) is a useful tool for immediate assessment of palpable lesions, especially in the head and neck region. The objective of this study is to evaluate the degree of correlation between Diff-Quik-based onsite diagnosis (OD) and final diagnosis (FD) and further improve the efficiency of FNA practice. Two hundred and eighty-seven cytopathologist-performed FNAs from the head and neck region were evaluated. Number of passes, number and type of slides and correlation (agreement, modified final diagnosis and disagreement) between OD and FD were evaluated. Among 287 FNAs, the average number of passes per FNA case was 2 (range, 1-5&.rpar;). The mean number of slides reviewed per case was 5 including 2 Diff-Quik (D-Q)-stained slides, 2 Papanicolaou (Pap)-stained slides, and 1 cell block (CB)/1 cytospin (Cy). 247 of 287 (86%) cases showed agreement between OD and FD. FD on 36 out of 287 cases (12.5%) was slightly modified or refined after reviewing additional slides. A major diagnostic discrepancy was noted in four cases (1.5%), three of which were classified as squamous cell carcinoma on final diagnosis, and confirmed on surgical follow-up. Accurate diagnosis can be achieved in the majority (86%) of head and neck FNAs based on immediate examination of D-Q stained slides alone. In a small number of cases (12.5%), reviewing additional slides may refine the final diagnosis. In rare cases, especially cystic squamous lesions, Pap-stained slides appeared to be helpful. It is plausible to use D-Q-stained slides alone with most head and neck FNAs in order to provide more cost effective and efficient triaging and patient management.

Phase II trial of concurrent 5-fluorouracil, hydroxyurea, cetuximab, and intensity moduled radiation therapy (IMRT) for locally advanced head and neck cancer

6014

Background: This phase II study was conducted to evaluate the tolerability and efficacy of incorporating cetuximab and simultaneous integrated boost intensity modulated radiation (SIB-IMRT) into a well-described 5-fluorouracil (5-FU) and hydroxyurea (HU)-based chemoradiation regimen. Endpoints included overall survival (OS), locoregional (LRC) and (DC), quality of life and toxicity. Methods: Patients with stage IVa-IVb or high-risk stage III squamous cell carcinomas were enrolled on a phase II trial. Prior organ-conserving surgical therapy or induction chemotherapy was allowed off protocol. SIB-IMRT was prescribed to low (43.2 to 48 Gy) and intermediate (54 to 63 Gy) risk volumes. A separate IMRT conedown plan was targeted to gross disease (72 Gy). The median radiation dose was 72 Gy (range 60 to 72 Gy) administered in 1.5 Gy fractions BID on weeks 1, 3, 5, 7 ± 9. Concurrent systemic therapy consisted of 5-FU (600 mg/m2), HU (500 mg BID) and cetuximab (250 mg/m2). Results: From January 2007 to April 2008, 33 subjects enrolled. Characteristics included 24 males; median age 59; ECOG performance status was 0 in 12. Disease was stage IVa-b disease in 31 (94%), T3–4 in 16 (48%), N2–3 in 23 (70%), and oropharynx primary in 15 (45%). Median follow-up in surviving patients is 15 months (range 6 to 22 months). The 1 year LRC, DC and OS is 91%, 82%, and 92%, respectively. Grade 3 toxicity consisted of mucositis (33%), radiation dermatitis (15%), anemia (15%), and leukopenia (15%), and neutropenia (9%). There were no grade 4–5 events. The majority of patients (64%) were able to tolerate treatment without a feeding tube. Median patient reported University of Washington QOL-R scores before, immediately after, 3 months and 8 months after chemoradiation were 85.5 (±14), 65 (±13), 76.5 (±15), and 84.5 (±9), respectively. Conclusions: Concurrent 5-FU, HU, cetuximab, and SIB-IMRT is a promising and reasonably well tolerated approach to incorporating molecularly targeted therapy in the curative therapy of locally advanced head and neck cancer.

[Table: see text]

Palliative care for patients with head and neck cancer: "I would like a quick return to a normal lifestyle"

Head and neck cancers constitute a diverse group of diseases including malignancies of the oral cavity, oropharynx, larynx, sinuses, and skull base. Treatment of these cancers includes a combination of surgical resection, chemotherapy, and radiation. Due to both the patterns of disease recurrence and the adverse effects of treatments, patients with head and neck cancer often have a complex and prolonged course of illness that is marked by periods of freedom from disease and symptoms interspersed with bouts of serious illness, debility, and numerous physical and psychological symptoms including pain, dysphagia, weight loss, disfigurement, depression, and xerostomia. Thus, management of this disease is best provided by an interdisciplinary team that includes individuals from the disciplines of otolaryngology, palliative care, radiation oncology, oncology, nutrition, speech, and physical and occupational therapy. Using the case of Mr K, we describe the symptoms encountered by patients with head and neck cancer and suggest options for management. We discuss the psychological aspects that affect these patients, including issues such as changes in body image, quality of life, anxiety, and guilt. Finally, we discuss the importance of the interdisciplinary team in the care of these patients and outline the roles of each team member. By providing comprehensive care to patients with malignancies of the head and neck, clinicians can increase the likelihood that patients and their families will be able to obtain the best possible outcomes and quality of life.

Effect of adjuvant radiotherapy (RT) on overall survival (OS) for node positive head and neck squamous cell carcinoma (HNSCC)

6087

Background: Although adjuvant RT is often recommended for locally advanced HNSCC, its effect on OS or cancer-specific survival (CSS) has not been clearly demonstrated. Methods: Within the Surveillance, Epidemiology, and End Results (SEER) Database, we selected patients with locally invasive but node negative (SEER stage 2) or node positive HNSCC (SEER stage 3–4) treated either with surgery alone (S) or surgery and radiation (S+RT). This analysis included 13,145 patients from the SEER 17 database diagnosed between 1988 and 2001. Exclusion criteria included distant metastases, no RT records or death within 3 months of surgery. The median follow-up was 4.7 years. Results: Adjuvant RT was utilized in 55% of patients with stage 2 and 84% of stage 3–4 HNSCC. For Stage 2 HNSCC, adjuvant RT was associated with lower 5 year OS on univariate analysis (46.32% for S+RT vs. 49.76% for S, p=0.016) but not on multivariate analysis (HR 1.00, p=0.93). For Stage 3 HNSCC, RT improved 5 year OS associated with RT on univariate analysis (52% for S + RT vs. 41% for S, p<0.001) and multivariate analysis (HR 0.80, p=0.002). For Stage 4 HNSCC, RT significantly improved 5 year OS on univariate analysis (35% for S + RT vs. 25% for S, p<0.001) and multivariate analysis (HR 0.75, p<0.001). The addition of RT improved 5 year CSS for both stage 3 (59.7% vs. 51.4%) and stage 4 HNSCC (42.1% vs. 32.8%). Conclusions: In the largest reported analysis of adjuvant RT in locally advanced HNSCC, adjuvant RT results in an approximately 10% absolute increase in 5-year CSS and OS for node-positive HNSCC compared to S alone. The absolute benefit of RT is underestimated on univariate analysis because patients with poor prognostic factors are more frequently selected for adjuvant RT. Outcomes in this high-risk population remain suboptimal, emphasizing the need for continued investigation of innovative treatment approaches.

No significant financial relationships to disclose.

Lymphotoxin beta receptor signaling is required for inflammatory lymphangiogenesis in the thyroid

Infiltration of lymphocytes into the thyroid gland and formation of lymph node-like structures is a hallmark of Hashimoto's thyroiditis. Here we demonstrate that lymphatic vessels are present within these infiltrates. Mice overexpressing the chemokine CCL21 in the thyroid (TGCCL21 mice) developed similar lymphoid infiltrates and lymphatic vessels. TGCCL21 mice lacking mature T and B cells (RAGTGCCL21 mice) did not have cellular infiltrates or increased number of lymphatic vessels compared with controls. Transfer of CD3(+)CD4(+) T cells into RAGTGCCL21 mice promoted the development of LYVE-1(+)podoplanin(+)Prox-1(+) vessels in the thyroid. Genetic deletion of lymphotoxin beta receptor or lymphotoxin alpha abrogated development of lymphatic vessels in the inflamed areas in the thyroid but did not affect development of neighboring lymphatics. These results define a model for the study of inflammatory lymphangiogenesis in the thyroid and implicate lymphotoxin beta receptor signaling in this process.

Palatal enlargement in chronic lymphocytic leukemia

Palatal involvement in chronic lymphocytic leukemia (CLL) is rare and has only been reported 3 previous times in the non-radiology literature. To our knowledge this is the first imaging description of this entity. Based on our experience, when smoothly lobulated, homogeneous masses are identified on the oral surface of the hard palate, the diagnosis of CLL should be considered.

A Comparative Study of 200 Fine Needle Aspiration Biopsies Performed by Clinicians and Cytopathologists

Fine needle aspiration (FNA) biopsy is a useful tool in the diagnosis and management of suspicious masses. Most FNA biopsies of palpable masses can be performed without radioguidance by either clinicians or cytopathologists; however, it is unclear if there is a difference in the diagnostic yield of the procedure based on who performs the FNA. We reviewed the FNA biopsy results of 200 patients presenting with head and neck masses to a tertiary care center from 2003 to 2004. One hundred FNA biopsies were performed by clinicians and 100 performed by cytopathologists. Seventy-one underwent subsequent surgical biopsy or definitive surgery. Results of the FNA biopsies performed by the clinicians and the cytopathologists were compared based on the percentages of FNAs that were diagnostic, suspicious/suggestive, and nondiagnostic. Additionally, the pathology results of the 71 surgical biopsies or resections were compared with the preoperative FNA results. Of the 100 FNA biopsies performed by cytopathologists, 83% were diagnostic, 10% were suspicious/suggestive, and 7% were nondiagnostic. Of the 100 FNA biopsies performed by clinicians, 24% were diagnostic, 43% were suspicious/suggestive, and 33% were nondiagnostic. Cytopathologists achieved significantly better results (P<.0001, two-tailed t-test). Of the 71 cases with surgical follow up (50 by cytopathologists and 21 by clinicians), 94% of cases performed by cytopathologists and 67% of those performed by clinicians show agreement with final surgical pathology results. Overall, the FNAs performed by cytopathologists show significantly better diagnostic accuracy (P=.0002134, two-tailed t-test). FNA provides valuable information in the workup of suspicious head and neck masses. Cytopathologists may achieve significantly better results.

Oral squamous cell carcinoma: histologic risk assessment, but not margin status, is strongly predictive of local disease-free and overall survival

To analyze the impact of resection margin status and histologic prognosticators on local recurrence (LR) and overall survival (OS) for patients with oral squamous cell carcinoma (OSCC). This study was both retrospective and prospective in design. Cohort 1 refers to the entire group of 292 patients with OSCC. The slides from the earliest resection specimens from Cohort 1 were examined in an exploratory manner for multiple parameters. Cohort 2 refers to a subset of 203 patients, who did not receive any neoadjuvant therapy and had outcome data. Cohort 3 represents a subset of Cohort 2 (n = 168) wherein the histologic resection margin status could be reconfirmed. Cohort 4 refers a subset of 85 patients with tongue/floor of mouth tumors. Margin status was designated as follows: group 1, clearance of > or =5 mm with intraoperative analysis, no need for supplemental margins (n = 46); group 2, initial margins were measured as <5 mm during intraoperative frozen section; supplemental resection margins were negative on final pathology (n = 73); group 3, the final pathology revealed resection margins <5 mm (n = 30); group 4, the final pathology revealed frankly positive resection margins (n = 19). The endpoints of LR and OS were queried with respect to T stage, tumor site, margin status, and numerous histologic variables, by Cox regression and Kaplan-Meier survival analyses. Tumor stage (T) was significantly associated with LR (P = 0.028). Kaplan-Meier analysis for stage and for intraoral site was significantly associated with LR for T4 tumors. The increased likelihood of LR was higher for T4 OSCC of the buccal mucosa (75%), sinopalate (50%), and gingiva (100%) compared with mobile tongue (27%), and oropharynx (13%) (P = 0.013). Margin status was not associated with LR or OS (Cohort 3). This was so when all tumors were grouped together and when separate analyses were performed by tumor stage and oral subsite. No significance was demonstrated when margin status was examined for patients with similar treatment (surgery alone or surgery with adjuvant RT). However, the administration of adjuvant RT did significantly increase local disease-free survival (P = 0.0027 and P = 0.001 for T1 and T2 SCC, respectively). On exploratory analyses of histologic parameters, worst pattern of invasion was significantly associated with LR (P = 0.015) and OS (P < 0.001). Perineural invasion involving large nerves (>1 mm) was associated with LR (P = 0.005) and OS (P = 0.039). Limited lymphocytic response was also significantly associated with LR (P = 0.005) and OS (P = 0.001). When used as covariates in a multivariate Cox regression model, worst pattern of invasion, perineural invasion, and lymphocytic response were significant and independent predictors of both LR and OS, even when adjusting for margin status. Thus, these factors were used to generate our risk assessment. Our risk assessment classified patients into low-, intermediate-, or high-risk groups, with respect to LR (P = 0.0004) and OS (P < 0.0001). This classification retained significance when examining patients with uniform treatment. In separate analyses for each risk group, we found that administration of adjuvant radiation therapy is associated with increased local disease-free survival for high-risk patients only (P = 0.0296) but not low-risk or intermediate-risk patients. Resection margin status alone is not an independent predictor of LR and cannot be the sole variable in the decision-making process regarding adjuvant radiation therapy. We suggest that the recommendation for adjuvant radiation therapy be based on, not only traditional factors (inadequate margin, perineural invasion, bone invasion) but also histologic risk assessment. If clinicians want to avoid the debilitation of adjuvant radiation therapy, then a 5-mm margin standard may not be effective in the presence of high-risk score.