Squamous cell carcinoma of the nasal columella: a retrospective study of 66 cases from the GETTEC

Squamous cell carcinoma of the nasal columella (SCCNC) is a rare disease. We aimed to define a strategy for the diagnosis and management of nasal columella squamous cell carcinoma. Medical records of 66 patients presenting with columella squamous cell carcinoma in nine French hospitals, from 1980 to 2003, were evaluated to determine the clinical characteristics and current treatment of the disease. Mean age was 69 years. The sex ratio was one female for three males. Majority of the lesions were T1 N0 according to the classification international union against cancer. Patients underwent one of the three treatments: surgery alone for the T1 lesions, radiotherapy for tumors of T2-T3 and combined (surgery and radiotherapy) for T4 lesions. The 5-year Kaplan-Meier survival test was 39% and no difference was found between the therapeutic groups. Thirty-five (53%) tumor recurrences were observed with a median time of 43 months. As regards TNM classification and treatment, no significant difference between the two groups disease free/recurrence was found. Prognosis of early lesions was considered better than the advanced lesions. SCCNC is difficult to manage and has a poor prognosis. No therapeutic solution has yet been confirmed in the treatment of this pathology.

Antitumor activity of imatinib in progressive, highly expressing KIT adenoid cystic carcinoma of the salivary glands: A phase II study

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Background: Adenoid cystic carcinoma (ACC) of the salivary glands is a rare orphan disease of the head and neck usually resistant to conventional chemotherapy, that was found to express KIT in 87% (39/45) of cases in our institutions. Methods: This study explored the antitumor effects of imatinib given at 800 mg daily in a phase II study for patients (pts) with recurrent or metastatic ACC failing locoregional treatments, presenting CT-scan documented progressive disease and highly (50–100% of tumor cells) expressing KIT. Primary endpoint of this study was time to tumor progression, secondary endpoints were tumor response and safety. Results. Since 2004, 17 pts (M/F: 5/12, median age 48, range 33–71) were included. Target lesions were pulmonary metastasis (13 pts), renal metastasis (1 pt), locoregional (2 pts) and pulmonary + locoregional (1 pt) recurrences. Previous treatment with chemotherapy was reported in 5 pts. Median duration of treatment was 6 months (range, 1–14 months). Toxicity was mild to moderate except for 2 pts who had grade 3–4 anemia/neutropenia and asthenia requiring dose reduction and early study withdrawal, respectively. Among 15 evaluable pts with tumor progression at study entry, 5 pts were stable after 6+, 8, 9, 12+ and 18+ months of follow-up and 2 pts displayed partial responses of 42% and 35% (RECIST). These objective responses were associated with early symptomatic improvement (dyspnea/pain) and occurred in platinum- resistant pulmonary metastasis and a radiation-pre-treated locoregional recurrence, lasting 14 months and 9+ months, respectively. Final accrual and TTP determinations are ongoing. Conclusion. Although sporadic, objective responses can be observed in patients with progressive ACC treated with imatinib as well as long-lasting tumor stabilisations.

No significant financial relationships to disclose.

[Molecular markers of head and neck cancer]

Molecular markers can be used for the diagnostic (early detection, assessment of tumor extent, detection of residual disease), for the prognostic (disease classification and therapeutic indications), for the treatment (treatment target and predictive factors of tumor response to treatment) and for the prevention (identification of the at-risk population and chemoprevention). Molecular markers have to be validated by prospective studies using appropriate methods. Currently, no molecular marker is used in routine practice for the management of upper aerodigestive tract cancers, but new techniques are being developed to analyze simultaneously tens of thousands of markers; they should expand our knowledge of the biology of these cancers.

Hyperselective intra-arterial preoperative chemotherapy in patients with squamous cell carcinoma of the oral cavity: preliminary results

OBJECTIVES

To investigate radiological response and findings after Intra Arterial Chemotherapy (IAC) for patients with Squamous Cell Carcinoma (SCC) of the oral cavity.

MATERIALS AND METHODS

Patients received 1-2 cycles of IAC. Radiological assessment was performed on day 7 and day 21 after each cycle using CT scan and MRI.

RESULTS

Six patients (median age: 52, ranging 46-60; male/female: 5/1) received 10 cycles (4 patients received 2 cycles). Primary tumors were floor of the mouth (4 patients) and oral tongue (2 patients). TNM classification was T2N0-2b in 3 patients and T4N0-1 in 3 patients. All patients had good locoregional/systemic tolerance and 3 showed clinical objective response (OR). Four patients were evaluable on both CT and MRI, 1 patient on MRI only and 1 patient did not tolerate imaging. Three patients showed OR both on CT and MRI, 1 patient showed stable disease (SD) on CT and OR on MRI and 1 patient showed SD on MRI. Contrast-enhancement of hemiperfused tongue was reported in all evaluable patients. Two patients presented intratumoral necrosis and 5 patients displayed local edema (MRI). One patient had modification of the sternocleidomastoid muscle after IAC.

CONCLUSION

Radiological modifications were observed in the infused area and correlated well with clinical response. This study is ongoing.

[Role and perspectives of sentinel node biopsy in head and neck tumors]

PURPOSE

To evaluate the accuracy of sentinel node biopsy for assessing the neck status for those patients with squamous cell carcinoma T1T2N0 of oral cavity.

PATIENTS AND METHODS

55 patients were included in a prospective study between 2000 and 2003. 53 underwent a sentinel node biopsy (SNB) followed by an elective neck dissection (END). Pathological examination with stepped serial sectioning and immunohistochemistry of sentinel node (SN) has been compared with routine pathology examination of remaining END nodes.

RESULTS

12 patients had a positive SN. No false negative was found. Patient follow up on, at less of 3 years, did not show any node recurrence for those patients with negative SN. After that study, 44 patients had a SNB without END. 7 patients had a positive SN. Follow up showed a node recurrence for 3 patients. In two of these, pathological reexamination showed a micrometastase in SN. SN failure rate is less than 3% for those 99 patients.

CONCLUSION

SNB is a liable procedure. Failure rate is the same as in END. We plan to use this procedure in orophyngeal tumors where it could be possible to reduce irradiation fields and treatment sequels for those patients with negative SN.

Mucoepidermoid carcinoma of salivary glands in the pediatric age group: 18 clinical cases, including 11 second malignant neoplasms

BACKGROUND

Salivary gland tumors represent 1% of head and neck tumors, with only 5% of these occurring in patients younger than 20 years. Mucoepidermoid carcinoma (MEC) is one of the most frequent salivary gland cancers among adults and children.

METHODS

This survey was conducted among 34 French pediatric oncology departments. From 1980 to 2000, 18 cases were reported.

RESULTS

Treatment included surgery or radiotherapy, or both. The 5-year survival rate was 93.7%. Eleven patients had been previously treated by radiotherapy and/or chemotherapy for a first malignant tumor, specifically, lymphoid leukemia (n = 4), lymphoma (n = 3), brain tumor (n = 2), sarcoma (n = 1), and retinoblastoma (n = 1).

CONCLUSIONS

MEC is very rare in the pediatric age group. Treatment involves surgical removal of the tumor plus radiotherapy, according to histologic staging. MEC has a good prognosis in young patients. The survival rate does not differ in the subgroup of patients with MEC as a secondary tumor.

Preoperative sequential chemotherapy in locally advanced squamous cell carcinoma of the head and neck

BACKGROUND

Induction chemotherapy may contribute to decreased local and distant recurrences in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) resectable for cure.

METHODS

Patients with previously untreated locally advanced stage III-IV (N0-2, M0) SCCHN received a dose-dense sequential regimen combining cisplatin/5-fluorouracil followed by bleomycin/methotrexate/hydroxyurea. Induction chemotherapy was followed by locoregional surgery and/or radiation therapy.

RESULTS

Among 37 patients, 23 (62%) had T4 primary tumors. Grade 3 to 4 asymptomatic hematologic toxicity occurred in less than 15% of patients. Nonhematologic toxicities were limited to grade 1 to 2 in less than 20% of patients. In the overall cohort (intent-to-treat; n = 35), 24 (68.5%) of 35 patients had objective clinical responses, including nine complete responses (25.7%). Fifty-seven percent of patients were free of disease at 2.5 years.

CONCLUSIONS

Sequential induction chemotherapy is feasible and active in patients with locally advanced head and neck cancers and may further include recent compounds such as taxanes.

[Locoregional recurrence of ORL cancer: the place of surgery]

Surgery of locoregional failures is mainly represented by salvage surgery after radiotherapy. Due to progress of radiotherapy, especially modification of fractionation and association with chemotherapy, the problem of salvage surgery is nowadays emphasized. Despite the reduction of postoperative mortality and morbidity by the use of myocutaneous flaps the complications are still frequent and the rehabilitation long and difficult. Oncologic results are disappointing too, especially in salvage surgery for oropharyngeal and hypopharyngeal tumors with less than a half of patients being candidates for salvage surgery and 5 year survival rates inferior to 30% in these patients. Laryngeal tumors are more favorable for salvage surgery but in the majority of the cases recurrences after radiotherapy require a total laryngectomy. The poor postoperative, functional and oncologic results after salvage surgery, especially in pharyngeal tumors must be taken into account for the decision of primary treatment. Regarding the important locoregional aggressivity of squamous cell carcinomas of the upper aerodigestive tract, these results must be kept in mind when preservation protocols are in question.

[Larynx preservation: nonsurgical approaches]

The question of larynx preservation is central in the management of patients with a carcinoma of the larynx or hypopharynx, especially to preserve the main functions of the larynx. In early stages (T1-earlyT2) Larynx preservation can generally be obtained with partial surgery or radiotherapy. Some other approaches such as exclusive chemotherapy require further investigations. In locally advanced and infiltrating larynx/hypopharynx carcinomas, (advancedT2-T3), several ways have been used to preserve the larynx including exclusive radiotherapy which can be improved by modified fractionation and acceleration. The efficacy of radiotherapy can be also markedly increased by adding concomitant cisplatin based chemotherapy, as reported recently in a large randomized trial. An alternative approach consisted in using induction chemotherapy (cisplatin-5FU) and followed by a local treatment adapted to the response to chemotherapy. The combined analysis of 3 such randomized trials (GETTEC, Veteran et EORTC) showed that this approach has to be used with caution, and could be safer in good responders to induction chemotherapy. Finally, larynx preservation is generally not proposed in patients with deeply infiltrating tumors and or tumor invading the cartilage or soft tissue in the neck (T4).

[Locoregional recurrences of HNSCC: place of re-irradiations]

Unresectable forms of HNSCC relapses occurring in a previously irradiated area are relatively common and may be difficult to manage from a therapeutic point of view. Full dose re-irradiation with concomitant chemotherapy constitutes an alternative to palliative chemotherapy. Indeed, the feasibility of this approach has been shown, and may be associated with a curative potential in a relatively low proportion of these relapses.

T1-T2 NO oropharyngeal cancers treated with surgery alone. A GETTEC study

The aim of this study is to show that surgical treatment of early-stage squamous cell carcinomas of the oropharynx gives identical, if not better, oncological results than the classic radiotherapy treatment in terms of locoregional control and survival. Fifty-three patients (32 T1, 21 T2, all N0) were operated on during the years 1995-2000. Surgical treatment consisted in a resection by the transoral approach in 43 patients (81.13%); ten patients (18.87%) benefited from a pharyngectomy with (seven) or without (three) mandibular resection. A level I to V selective neck dissection was performed on 35 patients, and 5 patients underwent a level II to V selective neck dissection. The 1-, 3- and 5-year overall survival rates were 100, 94.6 and 73%, respectively. There was no significant difference concerning the tumor stage ( P=0.69), the initial localization ( P=0.64), the macroscopic aspect ( P=0.65) and the management undertaken in the different centers ( P=0.19). The 5-year rate of specific survival was 100%. The 1-, 3- and 5-year locoregional control rates were 96.22, 92.45 and 88.68, respectively. The oncological occurrences observed were 2 persistent diseases, 5 local recurrences, 11 second primary cancers and 0 nodal recurrences. Seven local failures were observed, all of which were controlled after a second treatment. Eleven patients presented second primary cancers; three died, two are alive with an extension of this second localization, and six are alive and free of disease. The locoregional control provided by surgery alone on T1-T2 N0 oropharyngeal cancers is as good as radiotherapy. Moreover surgery alone makes it possible to spare patients the complications and aftereffects of radiotherapy. It also makes it possible during the recurrences to operate on patients in non-irradiated areas with lower morbidity and mortality. It is all the more beneficial since it will be possible to resort to radiotherapy after surgery if need be.

Autofluorescence videoendoscopy for photodiagnosis of head and neck squamous cell carcinoma

The diagnosis of head and neck squamous cell carcinoma is usually made by visual identification. Searching for a non-invasive optical diagnostic method with the ability to detect the precancerous lesions or second primary tumors earlier in high-risk populations led to the development of photodiagnosis by autofluorescence (AF) endoscopy. The aim of the present study was to evaluate and discuss the diagnostic potential of autofluorescence videoendoscopy as a complementary visual aid in the routine endoscopic diagnosis of head and neck cancers. In a prospective study, 48 patients underwent white light (WL) videoendoscopy followed by AF technique at the Institute of Gustave-Roussy from November 2001 to August 2002. Of 48 patients, 30 had suspected precancerous or cancerous laryngeal lesions, 7 presented benign laryngeal lesions, while 8 showed pharyngeal and 3 oral tumors. All detected lesions were evaluated by histological examination. AF was induced by filtered blue light of a xenon short arc lamp and processed by a CCD camera system (D-Light AF System; Storz, Tuttlingen, Germany). Normal laryngeal mucosa displayed a typical green fluorescence signal. Moderate and severe epithelial dysplasia, carcinoma in situ and invasive carcinoma showed a diminished green fluorescence and presented a marked reddish-blue color. In case of hyperkeratosis a bright white color was detected. Some benign lesions, such as granulomas, polyps and papillomas also displayed altered green fluorescence. Autofluorescence videoendoscopy for photodiagnosis of head and neck squamous cell carcinomas has proved to be a method of high specificity and good sensitivity. Two additional precancerous lesions that were invisible at the WL examination but detected with the AF technique show its potential role in the regular screening procedure or follow-up examination in a high-risk population. It was a very helpful complementary visual aid for the intraoperative control of the surgical margins after per oral endoscopic resection.

[Epidermal growth factor receptor and chemoprevention of epithelial tumor: rationale and development methods]

Among the many pathways dysregulated during the carcinogenic process, REGF seems to be one of the most promising pathways to target in order to achieve chemopreventive and anticancer effects. Indeed, chemoprevention, the use of natural or synthetic compounds in order to reverse, suppress or prevent the carcinogenic process, aims at the cellular level at regulating the growth and sensitivity to apoptosis of premalignant and malignant clones. REGF activation leads to uncontrolled cellular proliferation, resistance to apoptosis, angiogenesis and invasion. Furthermore, REGF is frequently overexpressed in many epithelial tumors. This review will focus on the rationale and the ongoing research areas related to chemopreventive approaches targeting REGF.

Cytology vs molecular analysis for the detection of head and neck squamous cell carcinoma in oesopharyngeal brush samples: a prospective study in 56 patients

Oesopharyngeal brush (OPB) sampling with cytological analysis can yield exfoliated cells from asymptomatic tumours of the upper aero-digestive tract and the oesophagus. In this study, we compared cytological evaluation and molecular analysis for the detection of exfoliated cancer cells sampled with an OPB. A total of 56 patients with a known unique head and neck squamous cell carcinoma (HNSCC) and five healthy controls were enrolled prospectively. Exfoliated cells from these 61 patients were collected with an OPB before initial endoscopy. p53 mutations and UT 5085 microsatellite instability (MI) were analysed in the HNSCC tumour, lymphocytes and the corresponding OPB DNA samples. p53 mutations and UT5085 MI were detected in 31 out of 56 and 14 out of 56 HNSCC, respectively, but not in any of the five controls. Direct sequencing of p53 was able to detect mutations in OPB DNA in only two out of 29 patients harbouring a p53-mutated primary tumour. Microsatellite instability was detected in OPB DNA of 11 out of 13 informative (bandshift detected in tumour) patients, whereas cytological analysis detected abnormal cells in only six of the same 13 patients (P=0.03). In informative patients, all positive OPB samples at cytological analysis were also positive at molecular analysis of UT5085, and both analyses confirmed the two negative samples. Molecular analysis of OPB from eight uninformative patients and from five healthy controls were all negative. OPB sampling with MI-based molecular analysis could be efficient for early detection of recurrent HNSCC. This result prompts us to use other microsatellite markers in order to maximise the percentage of informative patients.

Tumour stage, node stage, p53 gene status, and bcl-2 protein expression as predictors of tumour response to platin-fluorouracil chemotherapy in patients with squamous-cell carcinoma of the head and neck

The purpose of this study was to establish the relative contribution of tumour stage, node stage, p53 gene status, p53 expression, and bcl-2 protein expression to tumour response to platin-fluorouracil chemotherapy in 141 patients with squamous-cell carcinomas of the head and neck. Tumour response was measured at the primary site after three cycles of chemotherapy. Exons 2-10 and the coding part of exon 11 were sequenced on both strands. Bcl-2 or p53 expression was detected by immunohistochemistry. Predictor variables of objective response (reduction of at least 50% of tumour size) were tested in univariate and multivariate analyses. P53 mutations were found in 52 patients (37%). Tumour cells expressed p53 in 84 cases (59%) and bcl-2 in 25 cases (18%). T1 or T2 stage (adjusted odds ratio, 3.3; 95% confidence interval 1.3-8.7; P=0.01), N0 node stage (adjusted odds ratio, 2.7; 95% confidence interval 1.1-6.4; P=0.03), p53 wild-type gene (adjusted odds ratio, 4.0; 95% confidence interval 1.7-9.5; P=0.002), and bcl-2 protein expression (adjusted odds ratio, 20; 95% confidence interval 2.3-170; P=0.006), were positively associated with tumour response. P53 protein expression was not predictive of response. In conclusion, tumour stage, node stage, p53 gene status, and bcl-2 expression are independent predictors of tumour response to platin-fluorouracil in patients with squamous-cell carcinomas of the head and neck.

End points for new agents in induction chemotherapy for locally advanced head and neck cancers

More than 60% of patients diagnosed with squamous cell carcinoma of the head and neck present at a locally advanced stage. Although multimodality therapy has improved locoregional control, the 5-year survival rate of this population rarely exceeds 30%. In this review, we analyzed the impact of chemotherapy in the management of locally advanced head and neck cancer and we underline the potential benefit of induction chemotherapy. The Meta-Analysis of Chemotherapy in Head and Neck Cancer collaborative group has suggested a survival advantage of 5% at 5 years for platin-5-fluorouracil induction chemotherapy. We have analyzed cofactors that may affect the survival of head and neck patients and propose new end points for assessment of the efficacy of induction chemotherapy. The detrimental effect of second primary tumors on long-term results is stressed and we have suggested the use of overall 2-year survival as a surrogate end point for induction chemotherapy efficacy. Finally, we have examined the impact of new cytotoxic agents and present the promising results of new taxane-based combinations.

p53 gene status as a predictor of tumor response to induction chemotherapy of patients with locoregionally advanced squamous cell carcinomas of the head and neck

PURPOSE

To determine whether p53 gene status predicts tumor responses to platinum- and fluorouracil-based induction chemotherapy in locoregionally advanced squamous cell carcinomas of the head and neck.

PATIENTS AND METHODS

Tumor responses of 105 patients were measured at the primary tumor site. Objective response and major response were defined by a 50% and 80% reduction in tumor size, respectively. All coding parts of p53 gene were directly sequenced. p53 expression in tumor cells was determined by immunohistochemistry. Human papillomavirus infection was detected by polymerase chain reaction. Odd ratios were adjusted by stepwise logistic regression analysis.

RESULTS

p53 mutations, p53 expression, and tumor stage were sufficient to explain the variation in tumor responses to chemotherapy in multivariate models. p53 mutation was the only variable to significantly predict objective response (odds ratio, 0. 23; 95% confidence interval, 0.10 to 0.57; P =.002) and was the strongest predictor of major response (odds ratio, 0.29; 95% confidence interval, 0.11 to 0.74; P =.006). p53 expression (odds ratio, 0.39; 95% confidence interval, 0.16 to 0.98) and tumor stage (odds ratio, 0.31; 95% confidence interval, 0.10 to 0.96) also predicted major response. Specific mutations (contact mutations) accounted for much of the reduction in the risk of major response associated with overall mutations. In complementary analyses, p53 expression was weakly predictive of major response in the subgroup with wild-type p53, and p53 mutations also predicted histologic response.

CONCLUSION

p53 gene mutations are strongly associated with a poor risk of both objective and major responses to chemotherapy. Contact mutations are associated with the lowest risk of major response to chemotherapy.