Phase II trial of the histone deacetylase inhibitor romidepsin in patients with recurrent/metastatic head and neck cancer

OBJECTIVES

Patients with advanced squamous cell carcinoma of the head and neck (SCCHN) have limited treatment options. Inhibition of histone deacetylases (HDACs) represents a novel therapeutic approach warranting additional investigation in solid tumors.

METHODS

A phase II trial of single agent romidepsin, an HDAC inhibitor, was performed in 14 patients with SCCHN who provided consent for pre- and post-therapy samples of accessible tumor, blood and uninvolved oral mucosa. Romidepsin was administered at 13 mg/m(2) as a 4-h intravenous infusion on days 1, 8 and 15 of 28 day cycles, with response assessment by RECIST every 8 weeks.

RESULTS

Objective responses were not observed, although 2 heavily pretreated patients had brief clinical disease stabilization. Observed toxicities were expected, including frequent severe fatigue. Immunohistochemical analysis of 7 pre- and post-treatment tumor pairs demonstrated induction of p21(Waf1/Cip1) characteristic of HDAC inhibition, as well as decreased Ki67 staining. Exploratory microarray analyses of mucosal and tumor samples detected changes in gene expression following romidepsin treatment that were most commonly associated with regulation of transcription, cell cycle control, signal transduction, and electron transport. Treatment with romidepsin did not alter the extent of DNA methylation of candidate gene loci (including CDH1 and hMLH1) in SCCHN tumors.

CONCLUSIONS

Single agent romidepsin has limited activity for the treatment of SCCHN but can effectively achieve tumor-associated HDAC inhibition. Although tolerability of romidepsin in this setting may be limiting, further evaluation of other HDAC inhibitors in combination with active therapies may be justified.

Prospective analysis of qol in patients undergoing concurrent chemotherapy and radiation therapy for locally advanced head and neck cancer

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Background: This is a prospective analysis of quality of life (QoL) in patients undergoing concurrent chemotherapy and IMRT for locally advanced head and neck cancers. Methods: In a prospective IRB approved study, patients undergoing concurrent chemotradio therapy for head and neck cancers at AECOM/MMC completed a QoL survey (EORTC QLQ-C30 and QLQ-H&N 35) pretreatment, during radiation therapy, and at 1, 3 and 6 months after completion. The patients were re-simulated for adaptive planning midway through their treatment. Patients were treated to 66-70Gy (2-2.12 Gy/Fraction) to the primary and 54 to 60Gy (1.64-1.8 Gy/fraction) to the subclinical and high risk areas. Swallowing complex (SC) (base of tongue, constrictor muscles, proximal esophagus and oral cavity) were contoured as avoidance structures along with other critical structures. QoL scores were correlated with radiation dose to swallowing complex to evaluate relationships. Results: The Global Heath Status and Physical Functioning scores fell (mean 58.33 SD 35.36) during the first week of therapy before recovering at the end of second week. There is a 2nd dip in functioning scores at 4th week subsequent to which the scores rise and stabilized. The nausea/vomiting scores correlate with the timing of chemotherapy whereas the pain scores are highest at the second week mark before declining gradually. The mean swallowing specific score is worst at 5 weeks (61.11 SD 31.43) and recover gradually thereafter to level better than pre-RT score at 6-months follow-up. Conclusions: Most studies have reported QoL changes before and after treatment and have not looked at the changes during RT. One would imagine that QoL scores would gradually deteriorate throughout radiation therapy and should be the worst towards the end. In our experience, most of the QoL scores stabilize during the latter half of radiation therapy. This may be a result of multidisciplinary patient care, adaptive radiation therapy as well as tumor response to chemo-radiation therapy. Matched pair analysis is underway to compare dosimetric data and correlate this with QoL results.

Cytoplasmic ezrin and moesin correlate with poor survival in head and neck squamous cell carcinoma

Members of the 4.1 superfamily of proteins, including ezrin, moesin, merlin, and willin regulate many normal physiologic processes such as cellular shape, motility, and proliferation. In addition, they contribute both to tumor development and tumor progression. We reported previously that strong cytoplasmic ezrin expression was independently associated with poorer patient survival. One hundred and thirty-one histologically confirmed primary head and neck squamous cell carcinomas were examined prospectively for cancer progression and survival at a large health care center in the Bronx, NY, USA. Immunohistochemical analysis of ezrin, moesin, merlin, and willin expression in tissue microarray samples of primary head and neck squamous cell carcinoma revealed a significant association of increased cytoplasmic ezrin with poor cancer survival. Global RNA analyses suggest that cancers with high cytoplasmic ezrin have a more invasive phenotype. This study supports our previous findings associating cytoplasmic ezrin with more aggressive behavior and poorer outcome and indicates the need for a multi-institutional study to validate the use of cytoplasmic ezrin as a biomarker for treatment planning in head and neck squamous cell carcinoma.

A comparison of clinically utilized human papillomavirus detection methods in head and neck cancer

Detection of human papillomavirus (HPV) in head and neck cancer has therapeutic implications. In situ hybridization and immunohistochemistry for p16 are used by surgical pathologists. We compared the sensitivity and specificity of three popular commercial tests for HPV detection in head and neck squamous cell carcinomas with a 'gold standard' HPV PCR assay. A total of 110 prospectively collected, formalin-fixed tumor specimens were compiled onto tissue microarrays and tested for HPV DNA by in situ hybridization with two probe sets, a biotinylated probe for high-risk (HR) HPV types 16/18 (Dako, CA, USA) and a probe cocktail for 16/18, plus 10 additional HR types (Ventana, AZ, USA). The p16(INK4) expression was also assessed using a Pharmingen immunohistochemistry antibody (BD Biosciences, CA, USA). Tissue microarrays were stained and scored at expert laboratories. HPV DNA was detected by MY09/11-PCR, using Gold AmpliTaq and dot-blot hybridization on matched-fresh frozen specimens in a research laboratory. HPV 16 E6 and E7-RNA expression was also measured using RT-PCR. Test performance was assessed by a receiver operating characteristic analysis. HR-HPV DNA types 16, 18 and 35 were detected by MY-PCR in 28% of tumors, with the majority (97%) testing positive for type 16. Compared with MY-PCR, the sensitivity and specificity for HR-HPV DNA detection with Dako in situ hybridization was 21% (95% confidence interval (CI): 7-42) and 100% (95% CI: 93-100), respectively. Corresponding test results by Ventana in situ hybridization were 59% (95% CI: 39-78) and 58% (95% CI: 45-71), respectively. The p16 immunohistochemistry performed better overall than Dako (P=0.042) and Ventana (P=0.055), with a sensitivity of 52% (95% CI: 32-71) and specificity of 93% (95% CI: 84-98). Compared with a gold standard HPV-PCR assay, HPV detection by in situ hybridization was less accurate for head and neck squamous cell carcinoma on tissue microarrays than p16 immunohistochemistry. Further testing is warranted before these assays should be recommended for clinical HPV detection.

ACR appropriateness criteria retreatment of recurrent head and neck cancer after prior definitive radiation expert panel on radiation oncology-head and neck cancer

Recurrent and second primary head-and-neck squamous cell carcinomas arising within or in close proximity to previously irradiated fields are a common clinical challenge. Whereas surgical salvage therapy is recommended for resectable disease, randomized data support the role of postoperative reirradiation in high-risk patients. Definitive reirradiation is an established approach for patients with recurrent disease who are medically or technically inoperable or decline radical surgery. The American College of Radiology Expert Panel on Head and Neck Cancer reviewed the relevant literature addressing re-treatment after prior definitive radiation and developed appropriateness criteria for representative clinical scenarios. Examples of unresectable recurrent disease and microscopic residual disease after salvage surgery were addressed. The panel evaluated the appropriateness of reirradiation, the integration of concurrent chemotherapy, radiation technique, treatment volume, dose, and fractionation. The panel emphasized the importance of patient selection and recommended evaluation and treatment at tertiary-care centers with a head-and-neck oncology team equipped with the resources and experience to manage the complexities and toxicities of re-treatment.

Otolaryngology resident selection: do rank lists matter?

OBJECTIVES

To examine the relationship between National Residency Matching Program (NRMP) rank list position and future otolaryngology residency performance.

STUDY DESIGN

Cohort study.

METHODS

Eight consecutive residency classes (starting 2001-2008; 4 residents/y) were reviewed. Three hundred and thirty-three applicants (40.6 applicants/y) were interviewed, and 316 (94.9%) were ranked. Residents matching with our program were divided 3 different ways: into quarters, thirds, and halves, based on their rank order. Correlation coefficients were obtained to compare resident rank number and rank group (quarter, third, half) to faculty evaluation, coresident evaluation, and in-service score. Chi-square tests were conducted comparing rank group to chief resident selection and annual teaching award.

RESULTS

Resident NRMP rank number was not significantly correlated with faculty evaluation, coresident evaluation, or in-service exam score (-0.21 < r < 0.05; P > .28). There was also no significant correlation between resident quarter, third, or half rank group and faculty evaluation; coresident evaluation; or in-service exam score (-0.29 < r < 0.10; P > .13). Chi-square analysis found no relationship between resident rank group and chief resident (P > .35) or teaching award (P > .13) selection.

CONCLUSIONS

Applicant rank number and rank group did not correlate with performance of this otolaryngology residency cohort as assessed by faculty evaluation, coresident evaluation, in-service exam score, or selection for chief resident or the annual teaching award. Resident selection committees should consider reallocating manpower hours from creating rank order to recruiting applicants and selecting interview candidates.

Gene expression in the oropharynx of children exposed to secondhand smoke

OBJECTIVES/HYPOTHESIS

To compare gene expression in oropharyngeal mucosa of children with (ex+) and without (ex-) secondhand smoke exposure.

STUDY DESIGN

Prospective case-control.

METHODS

Forty-one age- and gender-matched children (2-6 years old) undergoing tonsillectomy for sleep disordered breathing at a tertiary care children's hospital were assessed for secondhand smoke exposure. Parental response to a validated questionnaire relating to secondhand smoke exposure governed inclusion. Sixteen samples were selected for microarray analysis (7 ex+, 9 ex-). Following tonsillectomy, ex vivo brushing of the mucosa isolated total RNA. Genome-wide expression profiles were generated by comparing sample RNA to a reference of all samples, assessing 27,323 cDNA clones. Microarray clones were ranked according to their ability to distinguish between the two groups using a Student t test.

RESULTS

A total of 318 cDNA clones distinguished the two groups (P < .01); 180 genes were overexpressed and 138 underexpressed in ex+ samples relative to the ex- group. Independent analysis of these two groups sorted genes into disease processes and molecular functional groups, including cancer (34 genes in the overexpressed group, 29 underexpressed, P < .05), cell cycle (14 and 10), and cell growth and proliferation (7 and 11). Two of the upregulated genes, LCN2 and IQGAP1, have been previously linked to inflammation in smokers and response/repair to cellular injury in bronchial epithelium.

CONCLUSIONS

Findings in this pilot study support the hypothesis that secondhand smoke exposure seems to induce gene expression changes in the oropharyngeal mucosa of exposed children, which may have significant implications for current and future disease processes.

Mentoring in otolaryngology training programs

Objective: The Accreditation Council for Graduate Medical Education's focus on outcome-based training has made the mentoring process critical for resident education. It is unknown how otolaryngology training programs mentor residents. Our objective was to determine the current state of mentoring in otolaryngology training programs and describe resident perceptions of mentoring.

Study Design: Cross-sectional survey.

Setting: Accredited U.S. otolaryngology training programs.

Subjects and Methods: All U.S. otolaryngology residents and program directors were contacted via e-mail with a link to an online survey.

Results: Of the 1411 residents contacted, 27.7 percent responded, representing 71 of the 103 accredited otolaryngology programs. Of the 103 program directors contacted, 37.9 percent responded. Of these programs, 26 had formal mentoring programs, 45 did not have formal mentoring programs, and 12 programs were listed in both categories. Fifty-one percent of male residents and 49 percent of female residents had mentors. The most important mentor characteristics were personality match, good clinical role model, and similar subspecialty interests. Least important characteristics were race, gender, and age. Twenty-six percent of residents felt that mentoring was critical to their training, while 63 percent of residents listed mentoring as important but not critical. Programs with fewer faculty and residents were less likely to offer formal mentoring ( P = 0.007 and 0.054, respectively). Of residents who did not have mentors, 80 percent lacked a mentor because their residency had no formal mentoring program.

Conclusion: Residents perceive mentoring as important, and formal mentoring programs should be incorporated into otolaryngology training programs.

Head and neck squamous cell carcinomas in HIV-positive patients: a preliminary investigation of viral associations

Oncogenic human papillomaviruses (HPVs) are associated with oropharyngeal squamous cell carcinoma (SCC). Infection with human immunodeficiency virus (HIV) increases susceptibility to opportunistic infections and viral-promoted cancers. The prevalences of HPV, herpes simplex virus (HSV), Epstein-Barr virus (EBV), and human herpesvirus-8 (HHV-8) have not been established for head and neck squamous cell carcinoma in HIV-positive patients (HIV+ HNSCC). We have observed that HIV+ HNSCC tend to contain numerous multinucleated tumor giant cells, this finding has not been described previously. The goal of this study is to test for these oncogenic viruses in a small cohort of retrospectively identified patients with HIV infection, and to compare histologically these cancers to a control group of HNSCC patients. Tumors were reviewed histologically and compared to a control group of 102 patients with HNSCC (serologically untyped or HIV negative). Polymerase chain reaction (PCR) was performed on formalin-fixed, paraffin-embedded HIV+ HNSCC samples from combined 25 patients in two institutions. In situ hybridization was performed to identify EBV (EBER) and immunohistochemistry was performed to detect HSV-1, HSV-2, HHV-8, and HIV-related proteins (Nef, p24). The study sample consisted of 34 HIV+ patients with HNSCC from Montefiore Medical Center, and six HIV+ HNSCC patients from Hospital Clinic, University of Barcelona; 24 (60%) men and 16 (40%) women. The larynx was most commonly involved (65%, n = 26); followed by the oropharynx (22.5%, n = 9). Four carcinomas arose from the oral cavity (10%) and one from the nasal cavity (2.5%). Histologically, multinucleated tumor giant cells were more common in the HIV+ group (39/40, 97.5%) than the control group (27/102, 26%, p 0.001, chi-square). HPV was detected in 6 of 25 (24%) HNSCC tumors by PCR, five were typed as HPV 16 and one as HPV 26/69; five of these tumors (83%) were located in the oropharynx. EBV, HSV-1, HSV-2, and HHV-8 were detected only infrequently in tumor cells. Nef protein was detected in tumor cells in 7 of 21 (33.3%) cases; p24 was not detectable in 6 tumors studied. There were no significant associations between HPV positive tumors and co-infections with other viruses. This study is consistent with other reports that suggest an increased incidence of laryngeal carcinoma for HIV+ patients. HPV was detected in 24% of HIV+ HNSCC, however, the number of tumors with amplifiable DNA (n = 25) is too small to allow for conclusions. EBV, HSV-1, HSV-2, and HHV-8 are uncommon in HIV+ HNSCC; it is unlikely that these viruses have a promoting effect. MNTCG are significantly common in HIV+ HNSCC, but there is overlap in MNTCG counts with the control group and therefore this finding cannot be used as a biomarker of HIV infection.

Thyroid fine needle aspiration cytology: follicular lesions and the gray zone

OBJECTIVE

To identifiy categories of potentially neoplastic, nonpapillary follicular lesions of the thyroid that would reduce the number of lobectomies for nonneoplastic disease.

STUDY DESIGN

The literature regarding fine needle aspiration (FNA) of follicular lesions is difficult to interpret largely due to the poor standardization of diagnostic categories. Based on our categorization scheme, which is directly comparable to the new system proposed by the National Cancer Institute (NCI), we quantitatively evaluated the cytomorphologic features of 99 "atypical" cases.

RESULTS

Histologic evaluation revealed a 63% neoplasia rate and a 26% malignancy rate. Lesions with an abundance of macrophages and colloid on FNA were significantly less likely to be neoplastic or malignant. The strongest predictors of any neoplasia included absence of colloid and increased cellularity, which remained significant even after adjustment for all selected variables.

CONCLUSION

Unlike similar studies, ours statistically significant variables that may assist how to manage follicular lesions better. Further, our current diagnostic scheme is equivalent to that recently proposed by the NCI, and, herein, we not only illustrate its application in clinical practice but also highlight potential pitfalls of this system.

The histone deacetylase inhibitor LBH589 inhibits expression of mitotic genes causing G2/M arrest and cell death in head and neck squamous cell carcinoma cell lines

Head and neck squamous cell carcinoma represents a complex set of neoplasms arising in diverse anatomical locations. The site and stage of the cancer determine whether patients will be treated with single or multi-modality therapy. The HDAC inhibitor LBH589 is effective in treating some haematological neoplasms and shows promise for certain epithelial neoplasms. As with other human cancer cell lines, LBH589 causes up-regulation of p21, G2/M cell cycle arrest, and cell death of human HNSCC cell lines, as measured using flow cytometry and cDNA microarrays. Global RNA expression studies following treatment of the HNSCC cell line FaDu with LBH589 reveal down-regulation of genes required for chromosome congression and segregation (SMC2L1), sister chromatid cohesion (DDX11), and kinetochore structure (CENP-A, CENP-F, and CENP-M); these LBH589-induced changes in gene expression coupled with the down-regulation of MYC and BIRC5 (survivin) provide a plausible explanation for the early mitotic arrest and cell death observed. When LBH589-induced changes in gene expression were compared with gene expression profiles of 41 primary HNSCC samples, many of the genes that were down-regulated by LBH589 showed increased expression in primary HNSCC, suggesting that some patients with HNSCC may respond to treatment with LBH589.

Low-level expression of microRNAs let-7d and miR-205 are prognostic markers of head and neck squamous cell carcinoma

Small noncoding microRNAs (miRNAs) have been shown to be abnormally expressed in every tumor type examined. The importance of miRNAs as potential cancer prognostic indicators is underscored by their involvement in the regulation of basic cellular processes such as cell proliferation, differentiation, and apoptosis. In this study, miRNA expression profiles of head and neck squamous cell carcinoma (HNSCC) tumor and adjacent normal tissue were examined by microarray analysis and validated by quantitative TaqMan real-time polymerase chain reaction. Using TaqMan real-time polymerase chain reaction we measured the quantitative associations between a subset of miRNAs identified on microarrays in primary tumors at diagnosis and cancer survival in a cohort of 104 HNSCC patients undergoing treatment with curative intent. The majority of miRNAs exhibiting altered expression in primary human HNSCC tumors (including miR-1, miR-133a, miR-205, and let-7d) show lower expression levels relative to normal adjacent tissue. In contrast, hsa-miR-21 is frequently overexpressed in human HNSCC tumors. Using univariate and multivariable statistical models we show that low levels of hsa-miR205 are significantly associated with loco-regional recurrence independent of disease severity at diagnosis and treatment. In addition, combined low levels of hsa-miR-205 and hsa-let-7d expression in HNSCC tumors are significantly associated with poor head and neck cancer survival Our results show that miRNA expression levels can be used as prognostic markers of head and neck cancer.

Low-grade papillary adenocarcinoma of the palate: the significance of distinguishing it from polymorphous low-grade adenocarcinoma

Low-grade papillary adenocarcinoma (LGPA) represents a relatively rare histological variant of polymorphous low-grade adenocarcinoma (PLGA). There has been a debate as to whether LGPA is associated with greater aggressive potential compared to PLGA; this is further obfuscated by the fact that diagnostic criteria for LGPA have not been well-defined. We believe that this is the first report of a patient with LGPA who developed metastases to the femur and scalp. We review the published evidence for classifying LGPA as distinct from PLGA. The weight of published data does support the idea that LGPA is oncologically distinct from LGPA. However, as uniform diagnostic criteria are lacking, we suggest a cut-off value of 10% or greater papillary formation as being necessary to separate LGPA from PLGA.

Gene expression profiles in HPV-infected head and neck cancer

Epidemiological and laboratory evidence indicate that, in addition to tobacco and alcohol, human papillomaviruses (HPV) play an important aetiological role in a subset of head and neck squamous cell carcinoma (HNSCC). To evaluate the molecular pathogenesis of HPV-infected HNSCC, we compared gene expression patterns between HPV-positive and -negative HNSCC tumours using cDNA microarrays. Tumour tissue was collected from 42 histologically confirmed HNSCC patients from an inner-city area of New York. Total DNA and RNA were extracted and purified from frozen tumour samples and gene expression levels were compared to a universal human reference RNA standard using a 27 323 cDNA microarray chip. HPV detection and genotyping were performed using an MY09/11-PCR system and RT-PCR. HPV was detected in 29% of HNSCC tumours. Most harboured only HPV16 and expressed the HPV16-E6 oncogene. HPV prevalence was highest in pharyngeal tumours (45%). Gene expression patterns that differentiated HPV-positive from negative tumours were compared by supervised classification analysis, and a multiple-gene signature was found to predict HPV16 prevalence in primary HNSCC with a false discovery rate < 0.2. Focusing on never-smokers, we further identified a distinct subset of 123 genes that were specifically dysregulated in HPV16-positive HNSCC. Overexpressed genes in HPV-positive HNSCC tumours included the retinoblastoma-binding protein (p18), replication factor-C gene, and an E2F-dimerization partner transcription factor (TFDP2) that have also been found to be overexpressed in cervical cancer. An additional subset of genes involved in viral defence and immune response, including interleukins and interferon-induced proteins, was found to be down-regulated in HPV-positive tumours, supporting a characteristic and unique transcriptional profile in HPV-induced HNSCC.