Significance of pretreatment hemoglobin level in patients with T1 glottic cancer

Lack of prognostic effect of carbonic anhydrase-9, hypoxia inducible factor-1α and bcl-2 in 286 patients with early squamous cell carcinoma of the glottic larynx treated with radiotherapy

AIMS

To evaluate the prognostic significance of potential tumour markers of hypoxia and apoptosis in early squamous cell carcinoma of the glottic larynx managed with radiotherapy.

MATERIALS AND METHODS

In total, 382 patients with T1 and T2 squamous cell carcinoma of the glottic larynx (vocal cords) received radical radiotherapy (50-55 Gy, in 16 fractions in 98% of cases). Pre-treatment haemoglobin was available for 328 patients; biopsy samples were available for 286. Immunohistochemistry was carried out for carbonic anhydrase-9 (CA-9), hypoxia inducible factor-1α (HIF-1α) and Bcl-2.

RESULTS

At 5 years, locoregional control was achieved in 88.2%, cancer-specific survival in 95.0% and overall survival in 78.7%. Adverse prognostic factors for locoregional tumour recurrence were pre-treatment haemoglobin <13.0 g/dl (P = 0.035, Log rank test; sensitivity 0.28, specificity 0.84) and stage T2 rather than T1 (P = 0.002). The effect of haemoglobin level on locoregional control was not significant when stratified by the median of 14.2 g/dl (P = 0.43) or as a continuous variable (P = 0.59). High CA-9 (P = 0.11), HIF-1α (P = 0.67) and Bcl-2 (P = 0.77) expression had no prognostic significance.

CONCLUSIONS

High CA-9, HIF-1α and Bcl-2 do not add to the prognostic significance of tumour stage and lower haemoglobin in predicting failure of local control in early glottic larynx squamous cell carcinoma managed with radiotherapy. The effect of haemoglobin was not strong enough to be useful as a prognostic biomarker.

Clinical outcome of T1 glottic carcinoma since the introduction of endoscopic CO2 laser surgery as treatment option

BACKGROUND

Since the introduction of endoscopic laser surgery at our institution in 1996, 189 patients have been treated for T1 glottic carcinoma.

METHODS

Treatment allocation (radiotherapy vs laser surgery) and outcome were evaluated.

RESULTS

Fifty-one percent of T1a lesions were considered suitable for laser surgery. Sixteen percent of T1a patients treated with laser surgery needed additional treatment because of positive resection margins. Overall local control and larynx preservation were 89% and 96%. Both were poorer in T1a patients with larger lesions treated with radiotherapy (local control 75% versus 89%, p = .05, larynx preservation 83% vs 100%, p = .001).

CONCLUSION

Outcome for T1a patients selected for laser surgery is excellent. In patients with larger lesions treated with radiotherapy, outcome is inferior to patients selected for laser surgery, but also to that reported for (unselected) T1a carcinomas treated with radiotherapy in literature. Strategies to improve treatment results in patients deemed unsuitable for laser surgery should be designed.

Outcome of radiotherapy in T1 glottic carcinoma: a population-based study

We evaluated the radiation outcome and prognostic factors in a population-based study of early (T1N0M0) glottic carcinoma. Survival parameters and prognostic factors were evaluated by uni- and multivariate analysis in 316 consecutive irradiated patients with T1 glottic carcinoma in the Comprehensive Cancer Center West region of the western Netherlands. Median follow-up was 70 months (range 1-190 months). Five and ten-year local control was 86 and 84%. Disease specific survival was 97% at 5 and 10 years. In multivariate analysis, pre-existent laryngeal hypertrophic laryngitis was the only predictive factor for local control (relative risk = 3.0, P = 0.02). Comorbidity was prognostic for overall survival. No factor was predictive for disease specific survival. Pre-existent laryngeal hypertrophic laryngitis is a new risk factor associated with reduced local control in T1 glottic carcinoma treated with radiotherapy.

Radiotherapy With or Without Erythropoietin for Anemic Patients With Head and Neck Cancer: A Randomized Trial of the Radiation Therapy Oncology Group (RTOG 99-03)

PURPOSE

To determine whether the addition of recombinant human erythropoietin (Epo) could improve the outcomes of anemic patients receiving definitive radiotherapy for squamous cell carcinoma of the head and neck (SCCHN).

METHODS AND MATERIALS

Eligible patients had SCCHN, with a plan for continuous-course definitive radiotherapy (66-72 Gy) with or without chemotherapy. Patients with Stage III or IV SCCHN were required to undergo concurrent chemoradiotherapy and/or accelerated fractionation radiotherapy. Preradiotherapy hemoglobin was required to be between 9.0 g/dL and 13.5 g/dL (12.5 g/dL for women). Patients randomized to Epo received 40,000 U once weekly, starting 7-10 days before start of radiotherapy.

RESULTS

A total of 148 patients were enrolled; 141 were evaluable. Median pretreatment hemoglobin was 12.1 g/dL. Hemoglobin levels at 4 weeks rose by an average of 1.66 g/dL in the Epo arm, compared with an average 0.24 g/dL decrease in the control arm (p = 0.0001). Median follow-up was 2.5 years (3.1 years for surviving patients). There was no statistically significant difference in the primary endpoint of local-regional failure (LRF) rate between the treatment arms. The 3-year LRF rate was 36% for control and 44% for Epo (p = 0.56). There were also no significant differences in local-regional progression-free survival (LRPFS), patterns of failure, overall survival, or toxicity. The 3-year LRPFS rate was 52% for control and 47% for Epo. The overall survival rate was 57% and 56%, respectively.

CONCLUSIONS

The addition of Epo to definitive radiotherapy for SCCHN did not improve outcomes. The study was not specifically designed to detect a potential negative association between Epo and tumor progression/survival.

Impact of anemia in patients with head and neck cancer treated with radiation therapy

Locoregional recurrence remains a major obstacle to achieving a cure of locally advanced head and neck cancers, despite multimodality therapy. Multiple studies report that a low hemoglobin (Hgb) before or during radiation therapy is an important risk factor for poor locoregional disease control and survival. Anemia is common in the head and neck cancer population and is suspected to contribute to intratumoral hypoxia with resultant radioresistance. Although having a low Hgb level has been shown to be detrimental, it is unclear as to exactly what the threshold should be for low Hgb (studies in this area have used thresholds ranging from 9-14.5 g/dL). Quality-of-life studies suggest that correction of moderately severe anemia may result in significant gains. Optimal Hgb levels for improving outcomes may vary across and within tumor types, and this is an area that requires further evaluation. However, the correction of anemia may be a worthwhile strategy for radiation oncologists to improve local control and survival. This article reviews the impact of anemia on outcomes after radiotherapy of head and neck cancers.

Tissue Microarray Analysis Reveals Prognostic Significance of COX-2 Expression for Local Relapse in T1???2N0 Larynx Cancer Treated with Primary Radiation Therapy

OBJECTIVE

The purpose of this analysis is to determine whether a significant correlation exists between cyclooxygenase-2 (COX-2) expression and local relapse in a large cohort of patients with T1 to 2N0 laryngeal cancer treated with primary radiation therapy.

METHODS AND MATERIALS

Clinical and molecular analyses were conducted on 123 patients with biopsy-proven T1 to 2N0 laryngeal cancer. Clinical prognostic factors included pretreatment hemoglobin, age, sex, race, T stage, tumor subsite, beam energy, biologically equivalent dose, therapy duration, and treatment date. Molecular prognostic factors included COX-2, p53, and Ki-67 expression. Expression levels were determined by immunohistochemistry on paraffin-embedded tissues arrayed on tissue microarrays. Multivariate analysis was done with the Cox proportional hazards model.

RESULTS

Thirty-two patients have locally relapsed, for an actuarial 5-year local relapse-free rate of 70.4%. On multivariate analysis, positive COX-2 expression predicted local relapse after radiation therapy. The relative risk (RR) for local relapse with COX-2 positivity was 2.57 (95% CI, 1.21-5.47; P = .01). Other prognostic factors for local relapse included negative Ki-67 expression (RR = 5.72; 95% CI, 2.04-16.1; P < .001), T2 stage (RR = 2.98; 95% CI, 1.39-6.38; P = .005), and therapy duration greater than 43 days (RR = 6.04; 95% CI, 1.37-26.7; P = .02).

CONCLUSIONS

Positive COX-2 expression predicts for local relapse in T1 to 2N0 larynx cancer in a multivariate model. This relationship may have potential therapeutic implications regarding the use of COX-2 inhibitors during radiation therapy for optimal outcome.

Prognostic significance of pretreatment hemoglobin for local control and overall survival in T1-T2N0 larynx cancer treated with external beam radiotherapy

PURPOSE

To elucidate a relationship between pretreatment hemoglobin and local control in patients with T1-T2N0 larynx cancer treated with radiotherapy.

METHODS AND MATERIALS

A total of 246 patients with T1-T2N0 cancer of the larynx were included in this analysis. Patients were treated using a median daily fraction of 200 cGy to a total median dose of 66 Gy within 47 days. Prognostic factors included pretreatment hemoglobin, age, gender, race, T stage, tumor subsite, beam energy, biologically equivalent dose, and therapy duration.

RESULTS

Fifty patients developed local relapse, for an actuarial 5-year relapse-free rate of 77.3%. The actuarial 5-year survival rate was 69.8%. The pretreatment hemoglobin levels were assessed using the following hemoglobin quartiles: 10.1-13.3, 13.4-14.1, 14.2-14.9, and 15.0-18.3 g/dL. On Cox multivariate analysis, the pretreatment hemoglobin level predicted for local failure and poorer overall survival. The relative risk for 5-year local relapse by hemoglobin quartile was 2.70, 2.33, 1.91, and 1.00 (p = 0.034). The relative risk for poorer 5-year overall survival by hemoglobin quartile was 2.23 1.30, 0.80, and 1.00 (p <0.001).

CONCLUSION

Pretreatment hemoglobin levels predicted for local control and overall survival for larynx cancer in a multivariate model. This relationship has potential therapeutic implications regarding correcting anemia before the initiation of radiotherapy for optimal outcome.

Kinetics of haematopoietic recovery after dose-intensive chemo/radiotherapy in mice: optimized erythroid support with darbepoetin alpha

Despite its frequency and impact on clinical outcomes, anaemia in cancer patients remains poorly understood and suboptimally treated. The definition of optimum treatment schedules with erythropoietic agents requires a suitable model of chemotherapy-induced progressive anaemia. This study investigated novel strategies such as once-per-chemotherapy-cycle dosing, synchronization between erythroid supportive care and chemotherapy, and definition of the optimum timing of erythroid support. A murine model of carboplatin chemotherapy/radiotherapy (CRT)-induced anaemia was used, which caused progressive anaemia across multiple cycles. Weekly administration of recombinant human erythropoietin (rHuEPO) was effective, but the longer-acting darbepoetin alpha resulted in superior responses. In all animals, anaemia became progressive and more refractory across cycles because of accumulated bone marrow damage. Exploiting a specific enzyme-linked immunosorbent assay, which could distinguish between darbepoetin alpha and endogenous erythropoietin, the effect of CRT upon the pharmacokinetics of darbepoetin alpha showed that clearance of darbepoetin alpha, and presumably erythropoietin, was at least partially dependent on a chemotherapy-sensitive pathway. Scheduling data suggested that administration of erythropoietic agents prior to chemotherapy was more effective than administration after chemotherapy. There was no evidence that erythropoietic agents exacerbated anaemia, even when administered immediately prior to CRT in an attempt to "prime" erythroid cells for the effects of CRT.

[Treatment of T1N0 glottis carcinoma with radiotherapy. Results at our center and review of the literature]

OBJECTIVE

To evaluate the results of radiotherapy in the treatment of patients with T1N0 glottic squamous cell carcinoma.

MATERIAL AND METHODS

Retrospective study of a cohort of 338 patients with T1N0 glottic carcinoma treated with radiotherapy at our institution between 1985-1997. A review of the literature published during the last ten years was carried out.

RESULTS

Local control with radiotherapy in our patients was 82%, reaching 97% when salvage surgery was included. The local control with radiotherapy in most of the published series ranges between 81.90%.

CONCLUSIONS

Treatment with radiotherapy achieves local control in early glottic carcinomas (T1N0) in 80-90% of cases. In our centre such treatment achieved local control in 82% of cases.

Analysis of prognostic factors for T(1)N(0)M(0) glottic cancer treated with definitive radiotherapy alone: experience of the cancer hospital of Peking Union Medical College and the Chinese Academy Of Medical Sciences

PURPOSE

To analyze the prognostic factors for early-stage glottic cancer (T(1)N(0)M(0)) treated with radiotherapy alone.

METHODS AND MATERIALS

Between 1958 and 1994, 238 patients (220 male) with T(1)N(0)M(0) (UICC 1997) squamous cell carcinoma of the glottis were treated with 6- or 8 MV X-ray or 60Co radiation in parallel-opposed fields (median size: 22.5 cm(2)) over a median of 52 days to a median dose of 68 Gy. Locoregional control (LC) and overall survival (OS) were estimated by the Kaplan-Meier method. Log-rank and Cox regression analyses were used to identify prognostic factors.

RESULTS

The median follow-up time was 127 months (range: 4-410 months). Five- and 10-year OS rates were 84.0% and 74.9%. The 5-year LC rate was 82.2%. Forty-four patients had recurrent disease (41 locally, 2 in cervical lymph nodes, 1 lost to follow-up); 23 had second malignancies. On multivariate analysis, unfavorable prognostic factors for OS were age >65 years (p < 0.001) and second malignancy (p < 0.001). Unfavorable prognostic factors for LC were bulky tumor (p = 0.023), anterior commissure involvement (p = 0.024), and decrease in hemoglobin during treatment (p = 0.025).

CONCLUSIONS

Radiotherapy alone provides good control of early-stage glottic cancer. Bulky tumor, anterior commissure involvement, and decreasing hemoglobin are negative prognostic factors for LC.

Supraglottic and glottic carcinomas. clinically and biologically distinct entities?

This study aimed to examine the clinical and biological differences in 198 patients with either T1-T2 local glottic or supraglottic squamous cell carcinomas. The patients with supraglottic cancer had a poorer prognosis, as well as more advanced and histologically aggressive tumours than the patients with glottic tumours. They also had lower levels of haemoglobin and a poorer nutritional and performance status. Expression of alpha-catenin, hyaluronan, CD44, p53, p21/WAF1 and bcl-2 in the primary tumour were not associated with the site of the laryngeal carcinoma. In supraglottic tumours, the rate of spontaneous apoptosis and mitotic indices were significantly higher than in glottic tumours. The results suggest that clinical parameters including the haemoglobin level of the patient together with the tumour cell kinetics (mitotic and apoptotic rates) may contribute to the aggressive nature of supraglottic carcinoma.

Anemia is associated with decreased local control of surgically treated squamous cell carcinomas of the glottic larynx

PURPOSE

A strong association between hemoglobin levels and tumor control exists in head and neck cancer treated with radiotherapy. This retrospective study has been performed to determine whether or not this association can also be found in the surgical setting.

METHODS AND MATERIALS

Between January 1970 and December 1990, 258 patients with glottic SCC received conventional surgery only (T1/T2/T3/T4 n = 188/31/37/2, respectively). Locoregional control was calculated by the Kaplan-Meier method. The influence of hemoglobin, T stage, age, gender, performance/nutritional status, and grading was evaluated using a Cox model.

RESULTS

Five-year locoregional control for T1a/T1b/T2/T3/T4 tumors was 91%/85%/76%/62%/0%, respectively (log-rank test, p < 0.0001). Anemia (male < 13, female < 12 g/dL hemoglobin) was present in 27 patients. It was associated with significantly worse 5-year locoregional control, i.e., 60% vs. 85% (log-rank test, p = 0.003). In multivariate analysis stratified for T stage, two variables were of influence: positive margins (relative risk [RR], 3.8; 95% confidence interval [CI], 1.7-8.4), anemia (RR, 3.0; 95% CI, 1.4-6.2). The largest subgroup consisted of 162 patients characterized by male gender, T1, and complete resection. In this subgroup, the significant variables were T stage (T1b vs. T1a; RR, 3.5; 95% CI, 0.96-12.4) and hemoglobin with a RR of 1.4 (95% CI, 1.0-2.1) per g/dL less analyzed as a continuous variable.

CONCLUSION

Anemia is associated with a high risk of treatment failure in surgically treated glottic cancer. Hemoglobin levels might be predictive even within the normal range as indicated by subgroup analysis.