Predictive factors for tumor response to preoperative chemotherapy in patients with head and neck squamous carcinoma. The Head and Neck Contracts Program

Do the Conventional Clinicopathologic Parameters Predict for Response and Survival in Head and Neck Cancer Patients Undergoing Neoadjuvant Chemotherapy?

Aims and Background

Neoadjuvant chemotherapy for head and neck carcinoma is still an important treatment modality. The prognostic value of patient and tumor parameters has been extensively evaluated in several trials, yielding mixed results. We report the prognostic factors emerging from a group of patients undergoing neoadjuvant chemotherapy.

Patients and methods

From April 1986 to June 1992, 149 consecutive patients received cisplatin-5-fluorouracil-based neoadjuvant chemotherapy. After four courses of chemotherapy, patients underwent local-regional treatment with surgery, radiation or both. A variety of patient and tumor characteristics were evaluated as predictors for response to chemotherapy and survival.

Results

The complete response, partial response and no response rates to NAC were 52%, 33% and 15%, respectively. No parameters predicted response to chemotherapy. At a maximum follow-up of 87 months, overall survival was 39% and disease-free survival was 49%. Variables shown to be predictors of survival in univariate analyses were age, performance status, histology, site, T, N, stage, and response to chemotherapy. Using the Cox regression analysis, only complete response to induction chemotherapy ( P = 0.0006), performance status ( P = 0.03), stage ( P = 0.01), age ( P = 0.03) and primary tumor site ( P = 0.04) emerged as independent prognostic factors for survival.

Conclusions

Complete response to chemotherapy was confirmed as the strongest prognostic factor influencing survival. However, conventional clinicopathologic factors did not predict response, hence, potential prognostic biologic and molecular factors for response must be sought. At present, much effort must be made for the improvement of the complete response rate, which seems to be a requisite to prolong survival.

Treatment results and prognostic factors for advanced squamous cell carcinoma of the head and neck treated with concurrent chemoradiotherapy

OBJECTIVE

To review our experience in the treatment of concurrent chemoradiotherapy (CCR) for patients with advanced squamous cell carcinoma of the head and neck (SCCHN) and to evaluate the different factors affecting survival and primary organ preservation.

METHODS

We reviewed the records of 101 patients with SCCHN treated with CCR between February 1998 and April 2004. Of 101 patients, 76 were treated with a cisplatin, 5-fluorouracil, methotrexate, and leucovorin (PFML) regimen and 25 were treated with a carboplatin and uracil-tegafur (CBDCA-UFT) regimen. Overall survival (OS), disease-specific survival (DSS) and DSS with primary organ preservation were estimated using Kaplan-Meier methods. The log-rank test and Cox proportional hazards regression were employed to identify significant prognostic factors for OS, DSS, and DSS with primary organ preservation.

RESULTS

The 5-year OS and DSS for all patients were 51.6 and 67.4%, respectively. On multivariate analysis, resectability of the tumor and degree of histological differentiation were significant predictors of survival for patients undergoing CCR; T stage and differentiation were significant prognostic factors for primary organ preservation.

CONCLUSION

In the treatment of CCR for advanced SCCHN, the survival rate of the patients with resectable tumors was excellent and significantly greater compared with the patients with unresectable tumors. T1 to T3 disease in patients with advanced resectable SCCHN is a good predictor of organ preservation. CCR may improve not only primary organ preservation (local control) but also survival in patients with poorly differentiated tumors.

Preliminary results of pre-radiation neck dissection in head and neck cancer patients undergoing organ preservation treatment

CONCLUSION

Pre-RT ND in patients with HNSCC undergoing organ preservation treatment is safe, advantageous, poses no additional morbidity owing to the elective neck dissection, and may possibly improve survival outcomes.

OBJECTIVE

Establish the role of pre-radiation neck dissection (pre-RT ND) in patients with head & neck squamous cell carcinoma (HNSCC) undergoing organ preservation treatment.

MATERIALS AND METHODS

Fourteen patients with histologically confirmed HNSCC in stages III approximately IV with proven regional metastasis were enrolled in the organ preservation approach incorporating pre-RT ND at a tertiary referral center between May 1998 and August 2004. Site matched patients treated with organ preservation intent in the conventional fashion were used as controls. Data were collected for their diagnosis, management, treatment outcome, and follow up.

RESULTS

Disease free survival was significantly better for the pre-RT ND group. There was no significant difference in overall survival, pattern of recurrence, and primary organ preservation rate between the two groups. No significant morbidity owing to neck dissection was noted in patients who underwent neck dissection. Although the delivery of radiation to the primary site was delayed for patients in the pre-RT ND group, it did not influence the major outcomes.

American Society of Clinical Oncology Clinical Practice Guideline for the Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer

Purpose

To develop a clinical practice guideline for treatment of laryngeal cancer with the intent of preserving the larynx (either the organ itself or its function). This guideline is intended for use by oncologists in the care of patients outside of clinical trials.

Methods

A multidisciplinary Expert Panel determined the clinical management questions to be addressed and reviewed the literature available through November 2005, with emphasis given to randomized controlled trials of site-specific disease. Survival, rate of larynx preservation, and toxicities were the principal outcomes assessed. The guideline underwent internal review and approval by the Panel, as well as external review by additional experts, members of the American Society of Clinical Oncology (ASCO) Health Services Committee, and the ASCO Board of Directors.

Results

Evidence supports the use of larynx-preservation approaches for appropriately selected patients without a compromise in survival; however, no larynx-preservation approach offers a survival advantage compared with total laryngectomy and adjuvant therapy with rehabilitation as indicated.

Recommendations

All patients with T1 or T2 laryngeal cancer, with rare exception, should be treated initially with intent to preserve the larynx. For most patients with T3 or T4 disease without tumor invasion through cartilage into soft tissues, a larynx-preservation approach is an appropriate, standard treatment option, and concurrent chemoradiotherapy therapy is the most widely applicable approach. To ensure an optimum outcome, special expertise and a multidisciplinary team are necessary, and the team should fully discuss with the patient the advantages and disadvantages of larynx-preservation options compared with treatments that include total laryngectomy.

Prognostic value of the epidermal growth factor receptor (EGRF) and p53 in advanced head and neck squamous cell carcinoma patients treated with induction chemotherapy

We measured the expression of the p53 nuclear protein and epidermal growth factor receptor (EGFR) in 46 biopsy samples from patients with advanced head and neck cancer treated with induction combination chemotherapy of 5-fluorouracil, cisplatin, and paclitaxel. Tumour expression of p53 protein was analysed with the monoclonal D07 antibody and EGFR with monoclonal H11 antibody. The overall response, defined as complete (CR) and partial response (PR) rates to treatment, was 88%. p53 positive staining was significantly more frequent in patients who did not respond to the induction treatment. EGFR expression failed to show any correlation with the response rate. Multivariate analysis indicated that a tumour location in the oral cavity together with p53 expression combined with moderate-to-high EGFR staining were independent prognostic factors of a shorter disease-free survival (DFS). Location of the tumour in the oral cavity and EGFR expression had independent prognostic value for overall survival (OS). We conclude that the EGFR status and an oral cavity location of the tumour have independent prognostic value in patients with advanced head and neck carcinoma treated with induction chemotherapy. The p53 status appears to be a determinant of the tumour chemo-sensitivity in advanced head and neck squamous cell carcinoma (HNSCC). The presence in the tumour of a p53-positive stain and moderate-to-high staining of EGFR is associated with a shorter DFS and time to treatment failure (TTF) probably reflecting a more aggressive tumour phenotype.

Volumetric and histologic responses to radiotherapy or radiochemotherapy of metastatic cervical lymph nodes of oral squamous cell carcinoma

PURPOSE

The relationship between the volumetric and histologic responses of metastatic cervical nodes to radiotherapy or chemotherapy in the oral and maxillofacial region is unclear. In this study, we evaluated the correlation between the initial volume and regression rate of metastatic nodes with their histologic response to preoperative radiotherapy or radiochemotherapy.

PATIENTS AND METHODS

The volume of 54 metastatic nodes in 32 patients with squamous cell carcinoma in the oral and maxillofacial region was measured by ultrasonography before and after preoperative therapy, and the rate of the volume change was calculated. All surgically removed nodes were histologically classified as poor, good, or complete response according to their histologic features.

RESULTS

There was no significant difference in initial volume among the 3 response groups. Good and complete response nodes showed a significant increase in regression rate compared with poor response nodes. All 11 nodes showing no regression were poor response nodes, and 7 with a regression rate of more than 90% were good or complete response nodes. The remaining 36 nodes (regression rate, 0% to 90%) represented all 3 types of histologic response. Of these, 7 of 9 complete response nodes were found in 5 patients who received combination chemotherapy consisting of 5-fluorouracil, leucovorin, and cisplatin.

CONCLUSIONS

The initial nodal volume before therapy is not a good indicator for the response to radiotherapy and/or chemotherapy. A regression rate of more than 90% may be a useful predictor of the effectiveness of preoperative treatments, but it was difficult to define the cutoff values in regression rates for differentiating types of histologic response.

Analysis of local recurrence in patients with selected T1-3N0M0 squamous cell carcinoma of the true vocal cord managed with a platinum-based chemotherapy-alone regimen for cure

Based on an inception cohort of 35 patients with T1-3N0M0 squamous cell carcinoma of the true vocal cord who had a complete clinical response after a platinum-based induction chemotherapy regimen and a minimum of 3 years of follow-up, the current retrospective study documented the long-term results and consequences of local recurrence following the use of a platinum-based chemotherapy-alone regimen for cure. During the years 1985 to 1996, 231 patients with invasive squamous cell carcinoma of the true vocal cord classified as T1-3N0M0 were managed at our department with a platinum-based induction chemotherapy regimen. A complete clinical response was achieved in 77 patients. Thirty-five of the 77 patients with complete clinical response were managed at our institution with a platinum-based chemotherapy-alone regimen. The statistical analysis of data on survival, local control, nodal control, distant metastasis, and metachronous second primary tumor incidence was based on the Kaplan-Meier product limit method. Univariate analysis was performed for potential statistical relation between local recurrence and various variables. The 3- and 5-year actuarial survival estimates were 91.4% and 88.6%, respectively. Overall, the causes of death were intercurrent disease in 6 patients and metachronous second primary tumor in 4 patients. The 3- and 5-year actuarial local control estimate was 64.8%. No significant statistical relation could be demonstrated between the incidence for local recurrence and the variables under analysis. Salvage treatment in patients with local recurrence yielded a 100% local control rate and laryngeal preservation rate. The 3- and 5-year actuarial lymph node control estimate was 97.1%. The 3- and 5-year actuarial estimate for patients with distant metastasis was 0%. The 5- and 10-year actuarial estimates for patients with metachronous second primary tumor were 9.7% and 28.1%, respectively. Although local recurrence was noted in almost a third of patients with complete clinical response who were managed with a platinum-based chemotherapy-alone regimen, it did not appear to be detrimental, as none of the patients who had local recurrence ultimately died from their disease or lost their larynx.

Chemotherapy alone with curative intent in patients with invasive squamous cell carcinoma of the pharyngolarynx classified as T1-T4N0M0 complete clinical responders

BACKGROUND

The current studies documented the results achieved with chemotherapy alone with curative intent in a series of 67 patients with invasive squamous cell carcinoma of the pharyngolarynx classified as T1-T4N0M0 complete clinical responders after a platin-based induction chemotherapy regimen.

METHODS

Group I consisted of 36 patients with tumors originating from the glottis. Group II consisted of 31 patients with tumors originating from sites within the pharyngolarynx other than the glottis. A minimum of 3 years of follow-up was achieved. Statistical analyses of survival, local control, lymph node control, distant metastasis, and second primary tumor rates were based on the Kaplan-Meier life-table method. Laryngeal preservation rates and local control rates are presented.

RESULTS

The 5-year actuarial survival estimate was 85.1% in Group I patients and 54.8% in Group II patients. Survival was statistically more likely to be reduced in Group II patients compared with Group I patients (P = 0.01). The 5-year actuarial local control estimate was 65.7% in Group I patients and 37.5% in Group II patients. Local failure was statistically more likely to occur in Group II patients compared with Group I patients (P = 0.02). Local control rates after salvage treatment were 100% in Group I patients and 83% in Group II patients. Laryngeal preservation rates after salvage treatment were 100% in Group I patients and 64% in Group II patients. The 5-year actuarial lymph node control estimate was 90% in Group I patients and 73.7% in Group II patients. Lymph node failure was statistically more likely to occur in Group II patients compared with Group I patients (P = 0.04). The 5-year actuarial estimate for patients without distant metastasis was 100% in Group I patients and 90% in Group II patients. Distant metastasis was statistically more likely to occur in Group II patients compared with Group I patients (P = 0.03). The 10-year actuarial estimate for patients without metachronous second primary tumors was 56.4% in Group I and 46.1% in Group II.

CONCLUSIONS

The current report 1) contradicts the old dogma of nonchemocurability for invasive squamous cell carcinoma of the upper aerodigestive tract and 2) suggests that the use of a platin-based chemotherapy-alone regimen with curative intent in patients with invasive squamous cell carcinoma of the pharyngolarynx who are classified as T1-T4N0M0 complete clinical responders after receiving an induction chemotherapy regimen is best indicated when the tumor originates from the glottis.

[Survival rate in epidermoid carcinoma of the oral cavity]

The present study aims to analyse the survival of 94 patients with squamous cell carcinoma of the oral cavity. They were 86 men and 8 women with a mean age of 61. Seventy four percent were smokers and 70% consumed alcohol regularly. Eighty three percent had unhealthy teeth. A great majority of patients (76) were in the advanced stages (III-IV) and 61% showed neck nodules. The overall survival at 5 years was the following: 70% for patients in stage I, 85% in stage II, 58% stage III and only 17% for the patients in stage IV. The most significant prognostic factor that affected the survival was the N stage. For the patients in N0 and N1 we only found significant differences when the lymph nodes were histologically affected by the tumor.

Ultrasonographic assessment for response to radiochemotherapy of metastatic cervical lymph nodes in head and neck cancer: usefulness of grey-scale and color doppler sonography

To predict the response of lymph node metastasis to preoperative radiochemotherapy sonographically, the correlation between ultrasonographs and histologic features was retrospectively examined in 43 metastatic cervical lymph nodes from 24 patients with squamous cell carcinoma in the oral and maxillofacial region. Ultrasonographs were compared among poor-, good-, and complete-response lymph nodes. Before radiochemotherapy, hypoechoic internal echo and intranodal blood perfusion demonstrated many complete-response nodes; in contrast, most poor-response nodes showed peripheral blood perfusion and an avascular pattern, but did not have specific internal echo intensity. Complete-response nodes showed a significant reduction in their maximum and minimum diameters after radiochemotherapy. These results indicate that ultrasonography is useful for predicting the response of cervical lymph node metastasis to radiochemotherapy.

p53 alterations predict tumor response to neoadjuvant chemotherapy in head and neck squamous cell carcinoma: a prospective series

PURPOSE

The tumor suppressor gene p53 plays a crucial role in cell cycle control and apoptosis in response to DNA damages. p53 gene mutations and allelic losses at 17p are one of the most common genetic alterations in primary head and neck squamous cell carcinoma (HNSCC). Alterations of the p53 gene have been shown to contribute to carcinogenesis and drug resistance.

PATIENTS AND METHODS

In this prospective series, patients with HNSCC were treated with cisplatin-fluorouracil neoadjuvant chemotherapy. p53 status was characterized in 106 patients with HNSCC (p53 mutations, allelic losses at p53 locus, and plasma anti-p53 antibodies) to determine the existence of a relationship between p53 gene status and response to neoadjuvant chemotherapy.

RESULTS

Exons 4 to 9 of the p53 gene were analyzed, and mutations were found in 72 of 106 patients with HNSCC. p53 mutations were associated with loss of heterozygosity at chromosome 17p (P <.001). The prevalence of p53-mutated tumors was higher in the group of patients with nonresponse to neoadjuvant chemotherapy than in the group of responders (81% v 61%, respectively; P <.04). When compiling p53 mutations and anti-p53 antibodies in plasma, the correlation between p53 status and response to chemotherapy was significant (87% v 57%, respectively; P =.003). A multivariate analysis showed that p53 status is an independent predictive factor of response to chemotherapy.

CONCLUSION

This prospective study suggests that p53 status may be a useful indicator of response to neoadjuvant chemotherapy in HNSCC.

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.

Larynx preservation in head and neck cancers. A discussion of the National Comprehensive Cancer Network Practice Guidelines

The management of advanced cancers of the larynx and hypopharynx has become increasingly complex as different treatment modalities, including surgery, radiation, and chemotherapy, have been combined with the goal of improving local disease control and disease-specific survival. A union of 17 comprehensive cancer centers in the United States, the National Comprehensive Care Network (NCCN), was formed in 1995 to promote state-of-the-art cancer care. To achieve this goal, multidisciplinary panels of experts from member institutions have created disease-specific practice guidelines for the evaluation and treatment of cancer patients, including those with head and neck cancers. Although detailed analysis of surgical methods and radiation techniques are beyond the scope of this article, the evolving laryngeal preservation strategies for patients with advanced, resectable hypopharyngeal or laryngeal (including supraglottic and glottic) cancers are reviewed using relevant sections of the NCCN practice guidelines as a framework for discussion.

Management of the clinically positive neck in organ preservation for advanced head and neck cancer

BACKGROUND

To investigate clinicopathologic predictive criteria for the optimal management of neck metastases in patients with advanced head and neck cancers treated with combined chemoradiotherapy.

METHODS

Prospective study, 48 patients. Mean length follow-up, 23 months.

RESULTS

Neck stage predicted neck response to chemoradiotherapy; N3 necks showed more partial responses (P = 0.04), and N1 necks showed more complete responses (P = 0.12). Primary tumor site strongly predicted the pathologic response found on neck dissection in patients with a clinical partial response (cPR) following chemoradiotherapy. There was no difference in survival between patients with a clinical complete response (cCR) after chemoradiotherapy, and patients with a pathologic complete response (pCR) after neck dissection (P = 0.20); however, when grouped together, these patients survived longer than did patients with a pPR at neck dissection (P = 0.06).

CONCLUSIONS

Clinical response to induction chemotherapy is a poor predictor of ultimate neck control. Induction chemotherapy followed by chemoradiotherapy, and planned neck dissection for patients with persistent cervical lymphadenopathy, provides good regional control.

Management of the neck in a randomized trial comparing concurrent chemotherapy and radiotherapy with radiotherapy alone in resectable stage III and IV squamous cell head and neck cancer

BACKGROUND

Treating the neck after organ-preservation treatment with radiotherapy or chemoradiotherapy can be problematic.

METHODS

To develop management guidelines, we reviewed the results of a 100-patient phase-3 trial that had compared outcome after radiotherapy alone with outcome after chemoradiotherapy for head and neck cancer. Patients were randomly assigned to receive radiotherapy alone or concurrent chemoradiotherapy. After completing therapy, patients were reassessed, and surgery was recommended for persistent disease at the primary site or neck and for all patients with stage N2-3 neck nodes regardless of clinical response.

RESULTS

Of the 47 patients with stage NO-1, 43 had a complete response (CR); of the 18 N1 patients, all but 4 had a CR. One of these 4, as well as 5 others among the NO-1 patients, underwent neck dissection (n = 6). No disease was found on pathologic examination, and no patient had neck recurrence. Of the remaining 41 N0-1 patients, 3 had disease progression and received no further therapy. Of the 38 others, 4 had neck recurrence, with 3 recurring at the primary site. Of the 53 with stage N2-3, 23 had less than a complete response (<CR), and 30 had a CR. In 35 N2-3 patients, neck dissection was performed as planned. Of these 35, 18 had a CR in the neck; 4 had positive nodes on pathologic examination. The other 17 had a <CR in the neck; 8 had positive nodes on pathologic examination. One patient in this group of 17 had regional recurrence after a pathologically negative neck dissection. Of the 18 N2-3 patients who did not undergo planned neck dissection, 6 had tumor progression and had no further therapy. The other 12, all with a CR in the neck, were followed, and 3 had neck recurrence; none successfully salvaged. Despite a CR in 30 N2-3 patients, 7 had persistent disease or eventual neck recurrence. Adding neck dissection minimized neck recurrence (p = .05). In N2-3 patients, disease-specific survival was significantly better in patients with a CR in the neck (p = .002). Disease-specific survival was not affected by neck dissection (p = .40) but was significantly affected by viable tumor in the specimen (p = .03).

CONCLUSION

Based on these results and the realization that it is difficult to follow patients for recurrent neck cancer, that salvage is often unsuccessful, and that patients dying from uncontrollable neck disease have an extremely poor quality of life, we recommend neck dissection for all N2-3 patients regardless of the neck response and for N1 patients without a CR.

Prognostic significance of computed tomography in tumors of the oral cavity and oropharynx treated with neoadjuvant chemotherapy

BACKGROUND

Despite its high response rate, the use of neoadjuvant chemotherapy remains controversial. Pretherapeutic identification of subgroups of patients who are likely to respond to chemotherapy is of the utmost importance.

PURPOSE

In this study, we have attempted to determine the relationship between specific radiological parameters and the response to neoadjuvant chemotherapy. In addition, we have determined if these parameters could yield prognostic information on recurrence and/or survival.

PATIENTS AND METHODS

Fifty-four patients with a squamous cell carcinoma of the oral cavity or base of tongue who had had a contrast-enhanced CT scan and neoadjuvant chemotherapy were included in this analysis. All clinical, radiological, surgical, histological, and radiotherapeutical parameters as well as the follow-up data were analyzed by a chi-square test. The method of Kaplan-Meyer was used to determine disease-free intervals and crude survival. The log-rank method was used for testing differences in local failures and survival.

RESULTS

Twenty-eight patients were classified as having isodense nodes and 20 patients as having hypodense nodes. Nodal density was not related to tumor size or primary site. N stage was not correlated with the density of the nodes. Patients with hypodense nodes had a significantly lower disease-free interval and survival than patients with isodense nodes. The relation between overall response to chemotherapy and the hypodensity of the nodes didn't reach a significant level.

CONCLUSION

No relation was found between overall response to chemotherapy and N-stage or tumor density. Disease-free interval and crude survival was strongly related to response to chemotherapy.

Correlation between computed tomographic density of lymph node metastases and response to cisplatin-based chemotherapy in patients with head and neck squamous cell carcinoma in an area in which betel quid chewing is prevalent

BACKGROUND

Identifying the factors predicting response to chemotherapy is important for patients with head and neck squamous cell carcinoma (HNSCC). It allows more rational selection of subsets of patients who may benefit from multidisciplinary treatment. Correlation of lymph node density in contrast-enhanced computed tomographic (CT) scans of HNSCC with response to chemotherapy was observed in the recent literature. This prospective study was designed to validate this clinical issue.

METHODS

From January 1992 to March 1995, 71 patients with untreated HNSCC were included in this study in which the following criteria were met: 1) a lymph node > 3 cm by physical examination or > or = 2 cm by scanographic examination; 2) clinically evaluable disease treated by cisplatin-based neoadjuvant chemotherapy; and 3) availability of a pretherapeutic contrast-enhanced CT scan showing the cross-sections of relevant lymph node metastases. The density of the largest lymph node was compared with that of the nuchal muscles by a radiologist blinded to the patient's therapeutic outcome. A lymph node was classified as hypodense if more than 33% of the lymph node surface area was comprised of a hypodense zone, and isodense if less than a third of the lymph node surface area was comprised of a hypodense zone.

RESULTS

Fifty-one patients (72%) had the largest lymph node classified as hypodense, and 63 patients (89%) were found to have extranodal spread (ENS) in the relevant lymph nodes. Fifty-nine patients were betel quid chewers. Lymph node density was not related to T classification, primary site, or histologic differentiation of the primary tumor. There was also no correlation between lymph node density and lymph node N classification. The lymph node chemotherapy response rate was 35% (7 of 20) of the isodense group and 47.1% (24 of 51) of the hypodense group (P = 0.36). ENS was found to have no impact on the chemotherapy response.

CONCLUSIONS

Computed tomographic density of lymph node metastases did predict chemotherapy response in the HNSCC patients in the current study from an area in which betel quid chewing is prevalent.

A clinical trial of continuous cisplatin-fluorouracil induction chemotherapy and supracricoid partial laryngectomy for glottic carcinoma classified as T2

BACKGROUND

Vertical partial laryngectomy (VPL) and radiation therapy (RT) are the recommended conventional conservative options for glottic carcinoma classified as T2. In series presenting more than 100 patients with a minimum 3-year follow-up, however, local recurrence rates were reported as 22-43.5%. The authors' experience with a new strategy based on continuous cisplatin-fluorouracil induction chemotherapy (IC) and supracricoid partial laryngectomy with cricohyoepiglottopexy (CHEP) is presented.

METHODS

A retrospective analysis of 67 patients who presented with untreated moderately to well differentiated invasive glottic carcinoma classified as T2, managed from 1983 to 1991 with IC and CHEP, was conducted. Statistical analysis of survival, local control, nodal control, distant metastasis, and metachronous second primary tumor incidence was based on the Kaplan-Meier actuarial method. Univariate analysis was performed to analyze the relationships between various factors and survival, local recurrence, and nodal recurrence. Clinical response, histologic response, IC toxicity and postoperative course were reported.

RESULTS

The Kaplan-Meier 5-year survival, local recurrence, nodal recurrence, distant metastasis, and metachronous second primary tumor estimate were 92.3%, 5.6%, 1.5%, 1.8%, and 5.6%, respectively. Overall laryngeal preservation was achieved in 65 patients (97%). Ultimate local control was achieved in all patients but one. Nodal recurrence was statistically more likely in patients presenting with a local recurrence. Analysis of the specimens demonstrated complete histologic response to IC in 25 (37.3%) patients. A strong statistical relation (P < 0.0001) was noted between complete clinical response after IC and complete histologic response.

CONCLUSIONS

The change from the prevailing treatment modalities of RT and VPL to a new multimodal strategy (IC+CHEP) did not decrease survival and allowed for an increase in laryngeal preservation rate. The high rate (37.3%) of complete histologic response suggests that IC deserves further consideration in the management of patients with glottic carcinoma classified as T2. The favorable results achieved in this series, when compared with historic controls, should stimulate prospective clinical trials comparing the two surgical procedures (CHEP vs. VPL with or without IC) for resection of Stage II glottic carcinoma.

Does substitution of surgery with induction chemotherapy preserve organ function in inoperable head and neck cancer? A retrospective analysis of 73 cases

From August, 1984 until May, 1991, 154 patients with locally advanced head and neck cancer were treated with 3 cycles of platinum-containing induction chemotherapy followed by definitive radiotherapy. Among them, there were 32 patients with cancer of oropharynx or hypopharynx and 41 patients with cancer of larynx, who were treated with this combined approach with the intention of preserving the involved organ. After the completion of chemotherapy 5 (16%) patients with pharyngeal tumors achieved a complete response (CR) and 14 (44%) a partial response (PR). After the completion of radiotherapy the CR rate was increased to 38%. After induction chemotherapy 7 (17%) of the 41 patients with cancer of the larynx achieved a CR and 25 (61%) a PR. The CR rate was tripled (68%) following radiotherapy and salvage surgery. So far, 8 complete responders with pharyngeal and 6 with laryngeal tumors relapsed mainly locoregionally. With a minimum follow-up of 22 months, median time to progression was 8 months for patients with cancer of the pharynx and 13 months for patients with cancer of the larynx. Median survival for these two groups of patients was 13 and 24 months respectively. In patients with locally advanced cancer of the oropharynx, hypopharynx or larynx induction chemotherapy followed by radiotherapy may delay in many or even omit in a few patients the necessity of radical surgery without compromising survival.

Predictive factors of a complete response to and adverse effects of a CDDP-5FU combination as primary therapy for head and neck squamous carcinomas

Retrospective analysis of detailed patient and tumour factors associated with a complete response to combination inductive chemotherapy with CDDP-5FU (96 or 120 hour continuous infusion) was performed using data from 147 patients with a previously untreated squamous cell carcinoma of the oral cavity, oropharynx or pharyngo-larynx following completion of two (29 patients) or three (118 patients) cycles. Adverse reactions to chemotherapy were documented for all 164 patients included in the study. Eight drug-related deaths occurred due to: acute myocardial infarction (five patients), peptic ulcer disease (two patients) and severe neutropenia with sepsis (one patient). Severe non-lethal complications included marrow depletion (14 patients), peptic ulcer (two patients), thrombophlebitis (seven patients), angina pectoris (two patients), stroke (one patient), pulmonary oedema (one patient) and convulsions (one patient). Six patients refused further treatment because of untoward side effects and tumoral progression was observed in three cases. Separate response rates for the primary site and nodes were determined and analysis of respective predictive factors of response was performed. Complete response was obtained in 31 per cent at the primary site versus 18 per cent for the nodes (p < 0.05). The combined (primary site + nodes) overall complete response rate was 22 per cent. Among 11 factors studied (age, sex, performance status, primary site, tumour differentiation, initial resectability, 5FU dosage per cycle, number of cycles, T, N and TN stages), only performance status, N stage, resectability and number of cycles were associated with a combined complete response. Multivariate analysis showed performance status, N stage, TN stage and resectability to be significant predictive factors of a combined complete response.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation between nodal density in contrasted scans and response to cisplatin-based chemotherapy in head and neck squamous cell cancer: a prospective validation

This prospective study was done to validate an earlier retrospective study demonstrating a relationship between complete response to chemotherapy and nodal density as estimated in contrasted computed tomography (CT scans) in head and neck squamous cell carcinoma (HNSCC). CT scans of 36 patients were evaluated by two radiologists blinded to therapeutic outcome. The density of the largest node (> 2 cm) was compared to that of nuchal muscles. A node was classified as hypodense if more than 33% of the nodal surface area consisted of hypodense zones. Density and nodal staging were related: 67% (10 of 15) of patients with N3 disease but only 29% (six of 21) with N1-N2 exhibited isodensity, p < 0.05. Complete response to chemotherapy was noted in 63% (10 of 16) of the isodense group but only in 15% (three of 20) of the hypodense group, p < 0.01. We believe that nodal density can be used for therapeutic decision-making in high nodal volume HNSCC.

Factors influencing complete response and survival in patients with head and neck cancer treated with platinum-based induction chemotherapy. A Hellenic Co-operative Oncology Group Study

One hundred fifteen consecutive patients with locally advanced carcinoma of the head and neck were treated between August 1984 and August 1989 with three cycles of either of two platinum-based induction chemotherapies, followed by local treatment. After the completion of chemotherapy 26 (23%) patients had complete responses (CR). Several pre-treatment characteristics were analyzed for a possible correlation to CR to induction chemotherapy and to survival. The following variables were closely interrelated: sex, history of smoking, alcohol abuse, histologic type, tumor site and grade. Tumor stage and negative history of smoking were correlated with CR. The variables which were individually correlated with survival were keratinization, CR to chemotherapy, alcohol abuse, histologic type, site and grade of the primary tumor, serum albumin level and tumor stage. A regression analysis after Cox's model to identify a limited set of predictors selected CR, serum albumin, tumor grade, performance status and nodal status as the most significant; when analyzing the data without the time-dependent variable CR, the factors selected by the model were serum albumin, tumor grade, performance status and tumor stage. In conclusion, serum albumin level, tumor grade, performance status and tumor stage prior to treatment can be used to define risk classes in our patient population.

Neoadjuvant chemotherapy consisting of cisplatin and continuous infusions of bleomycin and 5-fluorouracil for advanced head and neck cancer. The need for a new stratification for stage IV (M0) disease

A Phase II study of cisplatin (100 mg/m2 on day 1) and bleomycin (15 mg intravenous push day 1) followed by 5 days of continuous intravenous infusions of 5-fluorouracil (5-FU) (650 mg/m2/d) and bleomycin (16 mg/m2/d) repeated at 21-day intervals was performed in 54 previously untreated patients with nonmetastatic (M0), locoregionally advanced head and neck squamous cell carcinoma (SCC). The aim of this study was to increase the complete response rate to chemotherapy and to identify prognostic factors that may influence local control and disease-free survival. From April 1986 until August 1988, 5 patients with Stage III and 49 with Stage IV (International Union Against Cancer-American Joint Committee on Cancer 1986 [UICC-AJCC]) disease received this regimen. Thirty (61%) patients with Stage IV disease had bulky nodal disease (9 N2c and 21 N3) and 29 (53%) had T4 primary lesions. The response rate was 59% (95% confidence interval, 47% to 71%) and the complete response rate to chemotherapy was 13% (95% confidence interval, 0% to 26%). The response rate was greatly influenced by tumoral volume and performance status (PS). The complete response rate to chemotherapy was 40% for patients with Stage III disease (2 of 5 patients) versus 10% for patients with Stage IV disease (5 of 49 patients; P = 0.02). The response rate for patients with Stage III disease was 100% (5 of 5 patients) versus 55% for patients with Stage IV disease (27 of 49 patients; P = 0.14). For patients with Stage IV bulky nodal disease (N2c-N3), the response rate was 43% (13 of 30 patients) and the complete response rate to chemotherapy was 3% (1 of 30 patients) versus 68% (13 of 19 patients; P = 0.13) and 21% (4 of 19 patients; P = 0.07), respectively, for patients with Stage IV less than N2b disease. The local control rate after definitive therapy was 100% for patients with Stage III disease, 70% (17 of 24 patients) for patients with Stage IV less than N2b disease, and 17% (5 of 30 patients) for patients with bulky nodal disease (P = 0.0005). As of February 1991, with a median follow-up time of 38 months (range, 30 to 53 months), 4 of 5 patients with Stage III disease and 7 of 19 patients with Stage IV less than N2b disease were alive with no evidence of disease (37%) versus 0 of 30 patients with bulky nodal disease (P = 0.001).(ABSTRACT TRUNCATED AT 400 WORDS)

Argyrophilic nucleolar organiser region counts and prognosis in pharyngeal carcinoma

The prognostic significance of argyrophilic nucleolar organiser regions (AgNORs) has been evaluated in biopsy specimens from 61 primary squamous and undifferentiated carcinomas of the pharynx prior to therapy. The univariate Kaplan-Meyer survival analysis showed a significant correlation between 3- and 5-year survival rates and the mean AgNOR number per tumour cell (P less than 0.001). No significant correlation was found between prognosis and patients age and sex, tumour location, clinical stage, histologic grade, extent of lymphocytic infiltration, HMFG-2 positivity of tumour cells and UCHL1, LN2, MB2 positivity of infiltrating lymphocytes. There was no significant association between AgNOR counts and tumour histologic grade or clinical stage. Multivariate survival analysis showed that only two variables were significantly correlated with prognosis: AgNOR counts (P less than 0.001) and the extent of lymphocytic infiltration (P less than 0.027). Our results indicate the prognostic value of AgNOR counts and suggest the use of this method as a significant parameter in the pretherapeutic assessment of the aggressiveness of pharyngeal carcinomas.

Platinum-based induction chemotherapy followed by radiation as definitive treatment for patients with locally advanced cancer of the oral cavity, oropharynx and hypopharynx. A retrospective analysis of 32 cases

Thirty-two patients with locally advanced cancer of oral cavity, oropharynx and hypopharynx were treated with three cycles of platinum-based induction chemotherapy followed by radiation therapy. After completion of the combined treatment 50% of the patients were in complete response (CR) and 28% in partial response (PR). So far, 24 patients have died. Local progression occurred in 20 patients. Survival is 29% at 24 months. Seven (22%) patients remain alive and have been disease-free for 22-59 months. In conclusion, induction chemotherapy followed by radiation therapy may omit radical surgery, without compromising survival, in some patients with locally advanced cancer of the oral cavity, oropharynx and hypopharynx.

Sequential and Synchronous Chemo-Radiotherapy in the Management of Locally Advanced Carcinoma of the Head and Neck

Thirty-nine consecutive patients with stage III-IV squamous cell carcinoma of the head and neck entered a pilot study of sequential and synchronous chemo-radiotherapy. The study was planned as follows: two cycles of induction chemotherapy (MTX, BLM, DDP) followed by radical radiotherapy (66 Gy) with synchronous weekly administration of DDP (20 mg/m2) as a radiosensitizer. Out of the 39 patients evaluable for induction chemotherapy 25 (64%) achieved partial or complete response. Two patients underwent radical surgery after induction chemotherapy and 3 patients died of treatment. Out of the remaining 34 patients, 25 were untreated and 9 presented recurrence after primary surgery. Grade 4 mucositis was the major side effect of concurrent chemo-radiotherapy. Local control after synchronous therapy was obtained In 11 (44%) previously untreated patients and only in 1 (11%) patient of the surgically pretreated group. At the time of the analysis 11 patients were alive, 8 of them free from disease (4 after salvage surgery). Actuarial 2-year survival for previously untreated patients was 33% and 24% for all the patients. This survival is not significantly different (log rank test) from that of a similar group of 24 patients treated at the same institution with radiotherapy alone. The important toxicity of the induction chemotherapy regimen and the poor 2-year survival do not show any benefit from such a combined approach in locally advanced head and neck carcinoma. Nevertheless, despite our disappointing results many data in the literature suggest a role for chemotherapy-based treatments of locally advanced head and neck cancer. Further controlled randomized studies are required to better define the place of chemotherapy in the multi-modality management of stage III-IV head and neck cancer.

A phase III randomised trial of cistplatinum, methotrextate, cisplatinum + methotrexate and cisplatinum + 5-FU in end stage squamous carcinoma of the head and neck. Liverpool Head and Neck Oncology Group

We describe a phase III trial on 200 patients with end stage squamous cell carcinoma of the head and neck. The patients were randomised to one of four treatment arms: cisplatinum alone, methotrexate alone, cisplatinum + 5-FU and cisplatinum + methotrexate. There was no significant difference in the response rates, but the survival of the cisplatinum arm was significantly better than that of the methotrexate arm. The survival of patients receiving cisplatinum as a single agent was longer than that of patients receiving cisplatinum in combination with methotrexate or 5-FU, but not significantly so. Nausea/vomiting and anaemia were significantly more common in the cisplatinum arms than in the methotrexate arm, but the toxicity of combination regimens was not significantly greater than that of cisplatinum used as a single agent.

The correlation of specific variables of tumor differentiation with response rate and survival in patients with advanced head and neck cancer treated with induction chemotherapy

The authors have reported previously that conventionally defined grades of tumor morphology do not correlate with tumor response or survival in advanced squamous cell cancers of the head and neck (SCCHN) treated with cisplatinum combination induction therapy. This lack of correlation may be the result of the imprecision and subjectiveness of the conventional grade determination. To examine this possibility, response and survival were correlated with individual parameters of morphologic differentiation in 136 patients with advanced, untreated SCCHN. A multi-variable analysis of degree of keratinization, number of mitotic figures per high powered field, degree of nuclear differentiation, presence of vascular invasion, intensity of inflammatory response, and invasion pattern of the cancer was performed. The grade of each variable was weighted by assigning a score from 1 to 4, with 1 representing the most differentiated and 4 the least. The cumulative score of each specimen was tallied and assigned to one of three groups, less than 12, 12 to 18, and greater than 18, analogous to the conventional grades of well, moderately, and poorly differentiated, respectively. No correlation between the grade of individual morphologic variables and response to chemotherapy was demonstrated, or between tumor response and cumulative score groups. There was no correlation of the grade of individual morphologic variables or cumulative score groups with survival. Only the survival of patients achieving a complete response to chemotherapy was correlated with the cumulative score groups: 2-year survivals of 84%, 70%, and 46% for less than 12, 12 to 18, and greater than 18, respectively. Multi-parameter analysis of individual features of tumor differentiation is not superior to conventional morphologic analysis in predicting response to chemotherapy or survival in patients with advanced SCCHN.

Induction VBM plus radiotherapy, versus radiotherapy alone for advanced head and neck cancer: long-term results

Between 1978 and 1981, 85 patients with advanced squamous cell carcinoma of the head and neck were randomized to receive induction VBM followed by radiotherapy, or radiotherapy alone. The shortest follow-up is thus 6 years. The median survival of patients receiving induction chemotherapy was 46 weeks, that of the radiotherapy group alone was 75 weeks. As the two groups were not balanced despite randomization, multivariate methods (GLIM) were used to identify significant prognostic factors. These were: response to radiotherapy (P less than 0.001), nodal status (P less than 0.001), age (P less than 0.01), and histological grade (P less than 0.01). Neither treatment with, nor response to, chemotherapy had a significant effect on survival.

Cisplatin and mitoguazone. An induction chemotherapy regimen in advanced head and neck cancer

The combination of cisplatin 100 mg/m2 every 3 weeks and mitoguazone 500 mg/m2 every week with dose escalation was administered as a 9-week induction regimen to 27 patients with previously untreated Stage III or IV squamous cell carcinoma of the head and neck. This was followed by full-course radiation therapy for unresectable patients or surgery and postoperative radiation therapy for those with resectable disease. Sixteen patients had bulky unresectable disease, and ten were candidates for curative resection at study entry. Of 26 patients evaluable for response to chemotherapy, there were seven complete responses (CR) (five of six pathologically confirmed) and ten partial responses (PR) (65% CR + PR). Toxicity was generally mild with Grade 3 or 4 nausea and vomiting occurring in 15% and diarrhea in 12%. Nineteen percent of the patients developed transient nephrotoxicity (serum creatinine greater than 2), 62% anemia (hemoglobin decrease greater than 2 g/dl), 23% leukopenia (leukocyte count less than 3500 cells/microliters) and 8% thrombocytopenia (platelets less than 50,000 cells/microliters). Anorexia, fatigue, and weight loss occurred in nearly all patients. The median survival time of all patients was 17.5 months; complete responders, 43 months; partial responders, 16 months; and nonresponders, 9 months (P = 0.0025). In a multivariate analysis of stage, primary site, resectability status, response to chemotherapy, and local treatment (surgery plus radiation versus radiation), complete response was the only statistically significant covariate for survival. In Phase II single agent trials, mitoguazone has been shown to have a 15% response rate in head and neck cancer and cisplatin, a 30% to 40% response rate (less than 10% CR). Thus, our results, both complete and overall response rates, were higher than would be expected from either drug alone. A possible mechanism for this high response rate may be mitoguazone-induced cell synchronization. In vitro studies demonstrate the accumulation of tumor cells exposed to mitoguazone in S- and G2-phases of the cell cycle. These results would support further evaluation of mitoguazone in combination to explore the theoretical potentiation of antitumor effects by sequencing with cycle-specific agents.

Neoadjuvant chemotherapy in previously untreated patients with advanced head and neck squamous cell cancer

Between May 1981 and January 1986, 130 consecutive patients with advanced untreated head and neck squamous cell cancer (HNSCC) received neoadjuvant chemotherapy (NAC) with two or three courses of the CABO combination (methotrexate 40 mg/m2 intravenously (IV) on days 1 and 15; CDDP 50 mg/m2 IV on day 4; bleomycin 10 mg IV on days 1, 8, and 15; and vincristine 2 mg IV on days 1, 8, and 15 every 3 weeks) prior to surgery and/or radiotherapy. Of the 123 patients evaluable for response to chemotherapy, 19 (15.4%) had a complete remission and 59 (48%) a partial response, yielding a 63.4% overall response rate. Response rate was significantly correlated with the performance status (PS) (P = 0.001), the stage (P = 0.005), and the T class (P = 0.02); 107 patients completed subsequent local treatment (87 with radiotherapy and 20 with surgery +/- radiotherapy). The median survival of the 124 patients evaluable for survival was 14.7 months and the overall survival rate at 3 years was 24%. The median survival and the overall survival at 3 years for the surgical subgroup were 24.7 months and 38% and for the radiotherapy subgroup were 14.3 months and 22%. These results were compared with those obtained in a historical control group of 79 patients treated in our institute with short courses of chemotherapy regimens, which did not include cisplatin, followed by radiotherapy (29 patients) or local treatments alone (26 patients with radiotherapy and 24 patients with surgery +/- radiotherapy) between January 1976 and December 1980. Most of the patient characteristics were evenly distributed (age, sex, and primary sites) except that more advanced lesions were included in the NAC group (Stage IV: 85% versus 62%; T4: 65% versus 42%; N2-3: 48% versus 29%). The overall survival was significantly higher in patients receiving NAC than in the historical control group, comparing both the groups taken as a whole (P less than 0.05) and the surgery +/- radiotherapy (P less than 0.05) and the radiotherapy (P less than 0.02) subgroups. This experience suggests a positive role of NAC on survival. However, this improvement in outcome compared with a historical control group cannot be regarded as definitive evidence for benefit to patients. Randomized studies using active regimens are required to confirm these data.

Acute and late toxicity associated with sequential bleomycin-containing chemotherapy regimens and radiation therapy in the treatment of carcinoma of the nasopharynx

Between 1975 and 1984, 33 patients with squamous cell carcinoma of the nasopharynx received adjuvant chemotherapy before and/or after definitive radiotherapy at UT M. D. Anderson Hospital. The favored chemotherapy regimens during this time were BCMF (bleomycin, cyclophosphamide, methotrexate, and 5-FU) and PMB (cisplatinum, methotrexate, and bleomycin). Total radiation doses to the primary site averaged 65 Gy for T1 and T2 lesions and 70 Gy for T3 and T4 lesions. Neck nodes were given boost treatments to a maximum of 70 Gy, depending on the extent of the disease. The outcome of treatment in these patients was compared to that of a stage-matched group of 71 patients treated during the same time period with radiotherapy alone. However, the groups were not matched with regard to histologic subtypes: 45% of the radiation-only group had prognostically unfavorable keratinizing squamous carcinomas (WHO 1) compared with 18% of the combined modality group. Overall disease-free survival at 5 years was 63% in the combined modality group and 44% in the radiation only group (p = 0.15). Both acute reactions and late treatment complications were much more frequent and severe in patients receiving combined modality treatment. In patients treated with chemotherapy prior to radiation therapy, 10/20 (50%) experienced severe acute toxicity (RTOG Grade 3 or 4) versus 9/71 (13%) in the radiotherapy-only group. Severe late normal tissue injury occurred in 15/33 (45%) of the combined modality group versus 5/71 (7.0%) in the control group. The majority of the late complications in the adjuvant chemotherapy group consisted of severe soft tissue and muscle fibrosis. The average total bleomycin dose in the patients with severe late soft tissue and muscle fibrosis was 336 mg. The actuarial risk of developing a severe late complication by 2 years after treatment was 68% in the combined modality group versus 8% in the radiation-therapy-only group (p = .001). The probability of remaining both disease-free and complication-free at 5 years was 40% in the radiation-only group and 22% in the combined-modality group (p = 0.08). Comparison of these results with other published reports emphasizes the importance of late toxicity data in assessing the ultimate value of combined modality therapy.

Cisplatin and 5-fluorouracil chemotherapy in advanced or recurrent squamous cell carcinoma of the head and neck

Fifty-three patients with advanced or recurrent squamous cell carcinoma of the head and neck (SCCHN) were treated with bolus cisplatin (CDDP) and 96-hour infusion of 5-fluorouracil (5-FU). Twenty-six patients with advanced disease (21 T4 and/or N3) and no prior therapy (NPT) received 2 to 3 cycles of chemotherapy prior to surgery and/or radiation. There were four complete responses (CR) and 12 partial responses (PR) to chemotherapy for an overall response rate of 61%. In 20 patients with locally recurrent or disseminated disease there was one CR and six PR for an overall response rate of 35%. All but one responding patient in both groups showed clear evidence of tumor response after the initial cycle of chemotherapy. Two of the five complete responders required at least three courses to achieve CR. Disease-free survival was poor: only five of 26 patients in the NPT group remain alive and free of disease 8 to 28 months from initial therapy. CDDP and 5-FU is an active combination for SCCHN, but survival benefit remains to be proven.

Regional chemotherapy through a saphenous vein graft for the treatment of head and neck cancers

Regional chemotherapy was given through a vein grafted between the common carotid and external carotid arteries to 20 patients who had a variety of advanced head and neck cancers. The objective response rate was 73.6%, which included 36.8% complete response. The median duration of response was more than 10 months. The toxicity was mild and well tolerated. The complication rate associated with the procedure was low. This form of regional chemotherapy has significant advantages over the conventional form that uses drugs given through the retrograde temporal artery because the catheter-related complications are eliminated, the perfusion of the tumor can be maintained consistently, and, consequently, the response rate is high and the duration of response is increased.

Chemotherapy as a substitute for surgery in the treatment advanced resectable head and neck cancer. A report from the Northern California Oncology Group

This trial determines the feasibility for patients with resectable Stages III/IV head and neck cancer who achieved a complete response to induction chemotherapy of eliminating surgery from their treatment program. Thirty patients were treated with three cycles of cisplatin and 5-fluorouracil (5-FU), followed by reendoscopy and biopsy. Twelve patients achieved a complete pathologic response at the primary and received radiation (interstitial and/or external beam) only. The remainder underwent surgical resection and postoperative radiation. At 2 years, the relapse-free survival was 52%, and the survival was 53% for the entire group. For the 12 complete responders who had surgery eliminated, the relapse-free survival was 60%, and the survival was 70%. This pilot study suggests that for patients with resectable disease who achieve a complete pathologic response to induction chemotherapy at their primary, it is feasible to omit surgery and treat with primary radiation without compromise in survival. This approach warrants further study in a randomized trial.

S-phase fractions and DNA-ploidy of oropharyngeal squamous epithelium carcinomas compared with histologic grade, stage, response to chemotherapy and survival

DNA-ploidy and the percentage of S-phase fractions in 55 primary oropharyngeal squamous epithelium carcinomas were measured by DNA-Flow Cytometry (FCM). The data were compared with the histologic grade, the stage and the response of the tumours to cytostatic chemotherapy. A significant correlation was found between the histologic grade and the mean percentage of S-phase fractions (p less than 0.01). No correlation could be found between the FCM measurement data and the tumour stage. Carcinomas with an amount from 4.0 to 10.4% S-phase fractions responded to chemotherapy by complete remission, and those with 10.0 to 13.3% S-phase fractions by partial remission. The group of non-responders could be subdivided into two subgroups: non-responders with low amounts of S-phase fractions (1.1-3.9%), and non-responders with very high amounts of S-phase fractions (11.6-16.6%). FCM data, histologic and clinical prognostic factors were summed up to a prognostic score. The number of score points showed a significant correlation to the length of survival in months after diagnosis of the tumour (p less than 0.00001). FCM may be used as an additional diagnostic tool for a better biological characterization of the neoplastic tissue, especially as an aid for grading, prediction of the response to chemotherapy and the length of survival.

Adjuvant chemotherapy for advanced head and neck squamous carcinoma. Final report of the Head and Neck Contracts Program

To determine the efficacy of adjuvant chemotherapy in patients with advanced head and neck squamous carcinoma, the National Cancer Institute initiated a multi-institutional, prospective randomized trial termed the Head and Neck Contracts Program. Between 1978 and 1982, 462 patients with resectable Stage III or IV cancers of the oral cavity, larynx, or hypopharynx were randomly assigned to receive one of three treatment options: induction chemotherapy consisting of a single course of cisplatin and bleomycin followed by standard therapy (surgery and postoperative radiotherapy); induction chemotherapy and standard therapy followed by maintenance chemotherapy which consisted of six cycles of monthly cisplatin; or standard therapy alone. Toxicity from the chemotherapy regimens was minimal. Induction therapy resulted in an overall complete response of 3% and a partial response in 34% of patients. With a median follow-up of 61 months, overall survival and disease-free survival were not markedly different among the three groups (P = 0.86 and P = 0.16, respectively). The incidence of distant relapse was reduced in the maintenance group compared to standard or induction groups (P = 0.025 and P = 0.021, respectively) and time to first distant relapse was prolonged (P = 0.032 and P = 0.022, respectively). The results confirm the feasibility of administering chemotherapy prior to surgery or radiation in patients with head and neck cancer but fail to demonstrate a significant impact of one cycle of induction chemotherapy on clinical outcome. The suggestion that distant relapse rates may be reduced with the addition of maintenance chemotherapy supports the need to test traditional adjuvant approaches in patients with advanced head and neck cancer.

Factors predicting response of end stage squamous cell carcinoma of the head and neck to cisplatinum

Cisplatinum significantly prolongs survival in end stage head and neck cancer but only 30-40% of patients respond. Many receive chemotherapy with little or no benefit and it would obviously be advantageous to determine in advance those patients likely to benefit. In 2 phase III trials of chemotherapy in end stage disease, 129 patients have been treated with cisplatinum, either alone or in 2-drug combination with bleomycin, methotrexate or 5-fluorouracil. Factors analysed in the entire group were age, sex, site, previous treatment, performance status and the use of cisplatinum in combination. A high albumen and oro- or nasopharyngeal site were significantly favourable, while a hypopharyngeal, middle ear, skin or paranasal site were all significantly unfavourable. In the separate analysis of the subgroup with recurrent disease, site of recurrence and time to recurrence were analysed in addition to the factors named above. Although similar trends to those in the entire group were observed none reached significant levels. In the subgroup with advanced previously untreated disease, histological grade was analysed in addition to the above factors. Good performance status emerged as significantly favourable. The emerging trends provide some insight regarding outcome but are not sufficiently clearcut to allow a decision to be made on who should and who should not be treated.

Evaluation of size in prognosis of oral cancer

Greatest surface diameter of a cancer, together with suspicion of regional node metastasis, forms the basis for prognosis through the clinical TNM staging system for many cancers. In oral cancer, however, surface size sometimes fails to correlate, or sometimes inversely correlates, with tumor aggressiveness. To shed light on the value of measuring size per se, 155 consecutive oral squamous cancers, treated by surgery, radiation, or a combination, were analyzed to find the degree of correlation between greatest surface measurement and pathologic nodal spread and control of cancer. In tumors less than 2 cm, size correlated with very few nodal metastases and with good prognoses; in tumors greater than 2 cm, increasing size did not show a corresponding increase in pathologic node metastasis or significantly worsening outcomes except for a few very large cancers invading adjacent structures. In conclusion, greatest surface diameter of an oral cancer, when greater than 2 cm, is an unreliable predictor of tumor behavior per se. A small pilot study suggests that tumor thickness may be a better predictor. A formal study of this is planned.