Effect of multimodality treatment on overall survival for patients with metastatic or recurrent HPV-positive head and neck squamous cell carcinoma

Sexual history of patients with human papillomavirus positive and negative oropharyngeal cancer: A systematic review and meta-analysis

BACKGROUND

Increased sexual activity is associated with higher human papillomavirus (HPV) rates; however, there is a lack of analysis comparing the sexual history of patients with HPV positive and HPV negative oropharyngeal cancer (OPC).

METHODS

In this meta-analysis, PubMed, Scopus, and CINAHL were searched for articles that included patients with OPC and reported information regarding HPV status and either history of oral sex, number of sexual partners, or sexually transmitted infections (STI).

RESULTS

A total of 11 studies were included with 3296 patients with OPC. Patients with HPV positive OPC were more likely than patients with HPV negative OPC to report a history of oral sex (92%, 95% CI: 87.0-97.0 vs. 74.5%, 95% CI: 50.6-98.4, p < 0.0001), higher mean number of sexual partners (18.4 partners, 95% CI: 1.5-35.4 vs. 7.2 partners, 95% CI: 1.0-13.4, p < 0.0001), and more frequent history of STI (23.7%, 95% CI: 18.4-29.0 vs. 8.8%, 95% CI: 4.7-12.8, p = 0.0001).

CONCLUSIONS

Compared to patients with HPV negative OPC, our analysis shows a larger proportion of patients with HPV positive OPC had participated in oral sex, had a higher number of sexual partners, and had a higher proportion of STI history.

Survival Benefit from Cancer-Directed Surgery for Metastatic Head and Neck Cancer

OBJECTIVES

This study aimed to gather evidence for the survival benefit of cancer-directed surgery (CDS) in metastatic head and neck cancer (M1 HNC) and identify which patients will benefit most from CDS.

METHODS

Patients with M1 HNC were identified within the SEER database. According to whether received CDS, patients were divided into the CDS and non-CDS groups. The bias between the two groups was minimized using Propensity Score Matching (PSM), and the prognostic role of CDS was investigated using Kaplan-Meier analysis, log-rank test, and Cox proportional hazard models. The primary endpoint was overall survival (OS), and the secondary endpoint was cancer-specific survival (CSS).

RESULTS

A total of 3215 patients with M1 HNC were extracted, including 566 patients who received CDS that were 1:1 propensity score-matched with patients who did not receive CDS. In the matched dataset, the median OS and CSS in CDS groups were significantly higher than in non-CDS groups (OS: 19.0 vs. 9.0 months, p < 0.001; CSS: 21.0 vs. 9.0 months, p < 0.001). Meanwhile, multivariable Cox regression analysis also revealed that CDS was a favorable prognostic factor for both OS and CSS. Furthermore, subgroups of patients with M1 HNC (younger age, being married, grade I-II, oropharynx site, earlier T/N stage, radiotherapy) were inclined to benefit from CDS, while those patients who received chemotherapy failed to benefit from CDS.

CONCLUSIONS

This study indicated that CDS was associated with improved survival in M1 HNC, especially for those subpopulations that benefit more from CDS treatment.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1288-1298, 2024.

Retreatment of Recurrent or Second Primary Head and Neck Cancer After Prior Radiation: Executive Summary of the American Radium Society® (ARS) Appropriate Use Criteria (AUC): Expert Panel on Radiation Oncology - Head and Neck Cancer

BACKGROUND

Re-treatment of recurrent or second primary head and neck cancers occurring in a previously irradiated field is complex. Few guidelines exist to support practice.

METHODS

We performed an updated literature search of peer-reviewed journals in a systematic fashion. Search terms, key questions, and associated clinical case variants were formed by panel consensus. The literature search informed the committee during a blinded vote on the appropriateness of treatment options via the modified Delphi method.

RESULTS

The final number of citations retained for review was 274. These informed five key questions, which focused on patient selection, adjuvant re-irradiation, definitive re-irradiation, stereotactic body radiation (SBRT), and re-irradiation to treat non-squamous cancer. Results of the consensus voting are presented along with discussion of the most current evidence.

CONCLUSIONS

This provides updated evidence-based recommendations and guidelines for the re-treatment of recurrent or second primary cancer of the head and neck.

Prognostic factors for bone metastases from head and neck squamous cell carcinoma: A case series of 97 patients

Although bone is the second-most frequent site of distant metastases of head and neck squamous cell carcinoma (HNSCC), variable prognostic factors in patients with bone metastases from HNSCC have not been fully investigated. The aim of the present study was to assess the prognostic factors affecting overall survival (OS) in these patients. The medical records of 97 patients at two institutions who developed bone metastases from HNSCC between January 2010 and December 2020 were retrospectively reviewed. A multivariate analysis using a Cox proportional hazards model was performed to identify potential clinical predictive factors for longer OS. The median OS was 7 months, and the 1- and 2-year OS rates for all patients were 35.4 and 19.2%, respectively. The independent predictive factors for longer OS were single bone metastasis, good performance status and administration of systemic chemotherapy. The median OS with each predictor was 10, 10 and 10.5 months, respectively. In a selected group of patients with these three factors, the OS was 14.5 months. In conclusion, single bone metastasis, a good performance status and systemic chemotherapy were independent predictors of longer OS in patients with HNSCC, but their contributions were limited.

Outcomes after salvage for HPV-positive recurrent oropharyngeal cancer treated with primary radiation

PURPOSE

HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) carries a favorable prognosis for patients, yet nearly 30% of patients will experience disease relapse. We sought to detail patterns of failure, associated salvage therapy, and outcomes for patients with recurrent HPV-positive OPSCC.

METHODS AND MATERIALS

This is a single institution retrospective study of patients with recurrent HPV-positive OPSCC irradiated from 2002 to 2014. The primary study outcome was overall survival (OS, calculated using the Kaplan-Meier method). Secondary aims included patterns of first failure with descriptive details of salvage therapy. Solitary recurrences were defined as initial presentation of recurrence in a single site (primary, neck or oligometastatic), and multi-site was defined as local and regional and/or multiple sites of distant recurrence. Survival outcomes were compared using the log-rank test.

RESULTS

The cohort consisted of 132 patients. The median follow-up was 59 months for surviving patients. Estimated 2-year and 5-year OS rates were 47% and 32%, respectively. Comparative 2-year and 5-year OS rates were 65% and 46% versus 19% and 9% for the solitary group and multi-site group, respectively (p < .001).

CONCLUSIONS

Patients with recurrent HPV-positive OPSCC experience 5-year survival of approximately 32%. However, patients with a "solitary" recurrence including disease at the primary site, neck or oligometastatic site have more favorable long-term outcomes.

The emergence of long-term survivors in recurrent and metastatic squamous cell head and neck cancer

PURPOSE OF REVIEW

The systemic therapies available in recurrent and metastatic head and neck squamous cell carcinoma to date are palliative-intent treatments in most cases. However, a small subgroup of patients derives unconventional benefit and become long-term survivors, achieving cure in some cases. This review focusses on this group of patients, discusses recent literature and suggests plausible molecular hypothesis.

RECENT FINDINGS

Human papillomavirus-related disease is known to confer a better prognosis in metastatic patients, probably because of its greater sensitivity to systemic therapies. This group of patients seems to have a greater immune activation, which could partly explain this fact. Moreover, the use of antiepidermal growth factor receptor therapies in the metastatic setting has doubled the prevalence of long-term survivors. One of the most plausible explanations is the immune-modulatory effect of cetuximab mediated by antibody-dependent cell-mediated cytotoxicity.These facts, along with the recent encouraging results of checkpoint inhibitors in this disease, give hope that these therapies will not only improve survival but also increase the prevalence of long-term survivors.

SUMMARY

Long-term survivors merit our utmost attention as an in-depth study of these patients could help us to better understand the tumour biology and allow us to develop robust biomarkers and effective targeted therapies, which could in turn lead to a true paradigm shift.

NRF2, p53, and p16: Predictive biomarkers to stratify human papillomavirus associated head and neck cancer patients for de-escalation of cancer therapy

Patients with HPV associated (HPV^+ve) head and neck squamous cell carcinoma (HNSCC), particularly oropharyngeal cancer, show better treatment response, higher survival rates, and lower risks of recurrence as compared to HPV^-ve HNSCC patients. Despite increased sensitivity to treatment modality, HPV^+ve HNSCC patients are subjected to the same intensive anti-cancer therapy as HPV^-ve HNSCC patients and thus subjecting them to unwarranted long-term toxicity. To identify predictive biomarkers for risk-stratification, we have analyzed the mutational spectrum, and the evidence suggests that gain-of-function mutations in the NRF2 pathway are highly prevalent in HPV^-ve HNSCC. At the same time, it is rare in HPV^+ve HNSCC tumors. We have reviewed the importance of gain-of-NRF2 function and loss of p53 in the prognosis of HNSCC patients and discussed a predictive scoring system using a combination of HPV status (p16), NRF2 pathway and p53 to stratify HPV^+ve HNSCC into good versus poor responders, which could immensely help in guiding future de-escalation treatment approaches in patients with HPV^+ve HNSCC.

Exploring Radiation Response in Two Head and Neck Squamous Carcinoma Cell Lines Through Metabolic Profiling

Head and neck squamous cell carcinoma (HNSCC) is the sixth most common form of cancer worldwide. Radiotherapy, with or without surgery, represents the major approach to curative treatment. However, not all tumors are equally sensitive to irradiation. It is therefore of interest to apply newer system biology approaches (e.g., metabolic profiling) in squamous cancer cells with different radiosensitivities in order to provide new insights on the mechanisms of radiation response. In this study, two cultured HNSCC cell lines from the same donor, UM-SCC-74A and UM-SCC-74B, were first genotyped using Short Tandem Repeat (STR), and assessed for radiation response by the means of clonogenic survival and growth inhibition assays. Thereafter, cells were cultured, irradiated and collected for subsequent metabolic profiling analyses using liquid chromatography-mass spectrometry (LC-MS). STR verified the similarity of UM-SCC-74A and UM-SCC-74B cells, and three independent assays proved UM-SCC-74B to be clearly more radioresistant than UM-SCC-74A. The LC-MS metabolic profiling demonstrated significant differences in the intracellular metabolome of the two cell lines before irradiation, as well as significant alterations after irradiation. The most important differences between the two cell lines before irradiation were connected to nicotinic acid and nicotinamide metabolism and purine metabolism. In the more radiosensitive UM-SCC-74A cells, the most significant alterations after irradiation were linked to tryptophan metabolism. In the more radioresistant UM-SCC-74B cells, the major alterations after irradiation were connected to nicotinic acid and nicotinamide metabolism, purine metabolism, the methionine cycle as well as the serine, and glycine metabolism. The data suggest that the more radioresistant cell line UM-SCC-74B altered the metabolism to control redox-status, manage DNA-repair, and change DNA methylation after irradiation. This provides new insights on the mechanisms of radiation response, which may aid future identification of biomarkers associated with radioresistance of cancer cells.

Is pulmonary metastasectomy beneficial in head and neck squamous cell carcinoma? A review of literature

Metastatic head and neck squamous cell carcinoma (HNSCC) has traditionally carried a dismal prognosis; however with advances in care, it has been shown that pulmonary metastasectomy is a viable therapeutic option in selected patients, palliating symptoms and improving survival. With the increasing incidence of human papilloma virus-related HNSCC and better availability of minimal access surgery, there is a need to better understand the role of pulmonary metastasectomy in the treatment of HNSCC. This article summarizes the literature on indications, results, surgical options and approaches, clinical dilemmas, and controversies associated with pulmonary metastasectomy in HNSCC, to identify suitable candidates and optimize outcomes.

Oligometastatic status as predictor of survival in metastatic human papillomavirus-positive oropharyngeal carcinoma

BACKGROUND

Oligometastasis is a good prognostic indicator when compared to widely metastatic disease in malignancies of other organ systems. We hypothesized that oligometastasis in human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (SCC) would be associated with better overall survival.

METHODS

This is a retrospective review of all HPV-positive oropharyngeal SCC treated at one center with at least 1-year of follow-up. Patients were stratified into 2 cohorts: oligometastasis (1-2 metastases, confined to 1 organ system) or polymetastasis (>2 metastases or multiple organ involvement) with cohorts compared for time to distant metastasis and overall survival after metastasis.

RESULTS

Thirty-eight of 506 patients (7.5%) developed metachronous distant metastasis; 12 developed oligometastasis and 26 developed polymetastasis. Median overall survival after oligometastasis was significantly longer than polymetastasis at 45 months (95% confidence interval [CI] 19 months - not reached) and 10 months (95% CI 5-24 months; P = .00028).

CONCLUSION

Oligometastasis in metastatic HPV-positive oropharyngeal SCC portends a better prognosis than polymetastasis.

John M, Chen AM. Prognostic significance of HPV status in the re-irradiation of recurrent and second primary cancers of the head and neck

PURPOSE

To evaluate the prognostic significance of human papillomavirus (HPV) status among patients treated by salvage radiation therapy for local-regional recurrences and second primary cancers of the head and neck arising in a previously irradiated field.

METHODS AND MATERIALS

The medical records of 54 consecutive patients who underwent re-irradiation for squamous cell carcinoma of the head and neck occurring in a previously irradiated field were reviewed. Only patients with biopsy-proven evidence of recurrent disease that had previously been treated with doses of radiation therapy of at least 60 Gy were included. Determination of HPV status at the time of recurrence was performed by p16 immunohistochemistry. The median age at re-irradiation was 58.5 years (range, 27.9 to 81.5 years). Thirty patients (55.5%) were lifelong never-smokers. The Kaplan Meier method was used to calculate overall survival, progression-free survival, and local-regional control, and distant metastasis-free survival with comparisons between groups performed using the log-rank test.

RESULTS

HPV status among tumors that were re-irradiated was as follows: 16 positive (29.7%); 7 negative (12.9%); 31 unknown (57.4%). The median overall survival in the entire cohort was 11.7 months (range, 8 to 27 months), with the 1-year and 2-year estimates of overall survival being 47.2% and 38.4%, respectively. A statistical trend was identified favoring patients with HPV-positive cancers with respect to the endpoints of overall survival (p = 0.06) and progression-free survival (p = 0.08) after re-irradiation when compared to the HPV-negative/unknown population. There was no significant difference in distant control between the two cohorts (p = 0.40).

CONCLUSIONS

The favorable prognostic significance of HPV seemingly extends to patients treated by re-irradiation suggesting that this biomarker may be useful in risk stratification in this setting.

Volume, Dose, and Fractionation Considerations for IMRT-based Reirradiation in Head and Neck Cancer: A Multi-institution Analysis

PURPOSE

Limited data exist to guide the treatment technique for reirradiation of recurrent or second primary squamous carcinoma of the head and neck. We performed a multi-institution retrospective cohort study to investigate the effect of the elective treatment volume, dose, and fractionation on outcomes and toxicity.

METHODS AND MATERIALS

Patients with recurrent or second primary squamous carcinoma originating in a previously irradiated field (≥40 Gy) who had undergone reirradiation with intensity modulated radiation therapy (IMRT); (≥40 Gy re-IMRT) were included. The effect of elective nodal treatment, dose, and fractionation on overall survival (OS), locoregional control, and acute and late toxicity were assessed. The Kaplan-Meier and Gray's competing risks methods were used for actuarial endpoints.

RESULTS

From 8 institutions, 505 patients were included in the present updated analysis. The elective neck was not treated in 56.4% of patients. The median dose of re-IMRT was 60 Gy (range 39.6-79.2). Hyperfractionation was used in 20.2%. Systemic therapy was integrated for 77.4% of patients. Elective nodal radiation therapy did not appear to decrease the risk of locoregional failure (LRF) or improve the OS rate. Doses of ≥66 Gy were associated with improvements in both LRF and OS in the definitive re-IMRT setting. However, dose did not obviously affect LRF or OS in the postoperative re-IMRT setting. Hyperfractionation was not associated with improved LRF or OS. The rate of acute grade ≥3 toxicity was 22.1% overall. On multivariable logistic regression, elective neck irradiation was associated with increased acute toxicity in the postoperative setting. The rate of overall late grade ≥3 toxicity was 16.7%, with patients treated postoperatively with hyperfractionation experiencing the highest rates.

CONCLUSIONS

Doses of ≥66 Gy might be associated with improved outcomes in high-performance patients undergoing definitive re-IMRT. Postoperatively, doses of 50 to 66 Gy appear adequate after removal of gross disease. Hyperfractionation and elective neck irradiation were not associated with an obvious benefit and might increase toxicity.

Systemic Treatment in HPV-Induced Recurrent or Metastatic HNSCC

Recurrent or metastatic head and neck cancer describes tumor deposits that arise locally, regionally, or at distant sites after treatment or distant metastases at the time of primary diagnosis. Prognosis for R/M squamous cell carcinomas of the head and neck (HNSCC) is poor and treatment options are limited in this situation. Human papillomavirus (HPV) is an important risk factor for HNSCC. About 40 % of all HNSCC have been attributed to HPV in Europe. HPV positivity at initial diagnosis is the single best prognostic factor for survival. However, data for the prognostic and predictive value of HPV in the R/M situation are still scarce. Due to the rising incidence of HPV-associated cancers, the number of R/M HPV+ carcinomas is also expected to rise. This chapter therefore aims to give an overview of the current knowledge concerning the role of HPV as a prognostic and predictive marker in recurrent or metastatic HNSCC.

The rationale for HPV-related oropharyngeal cancer de-escalation treatment strategies

The treatment paradigms for head and neck squamous cell cancer (HNSCC) are changing due to the emergence of human papillomavirus-associated tumors (HPV-related), possessing distinct molecular profiles and responses to therapy. Retrospective studies have suggested that HPV-related HNSCCs are more frequently cured than those caused by tobacco. Current clinical trials focus on the reduction of treatment-related toxicity and the development of HPV-targeted therapies. New treatment strategies include: 1) dose reduction of radiotherapy, 2) the use of cetuximab instead of cisplatin for chemo-radiation 3) less invasive surgical options, i.e. trans-oral robotic surgery and trans-oral laser microlaryngoscopy, and 4) more specific treatment attempts, including immunotherapeutic strategies, thanks to increasing comprehension of the molecular background of HPV-related HNSCC. Whereas recently published data shed light on immune mechanisms, other studies have focused on specific vaccination against HPV-related HNSCC. A crucial problem is patient selection to the chosen bias. Truly HPV-related cancers (p16-positive and HPV DNA-positive) with biomarkers for good response to therapy could be included in randomized trials aiming for less severe and better tailored therapy.

Carboplatin-pemetrexed in treatment of patients with recurrent/metastatic cancers of the head and neck; superior outcomes in oropharyngeal primaries

Background: Platinum-based therapy in combination with 5-fluorouracil with cetuximab has shown the best survival in pts with recurrent/metastatic squamous cell carcinoma of the head and neck (R/M SCCHN). The purpose of this study is to evaluate the efficacy and tolerability of carboplatin, pemetrexed and to assess differential outcomes in patients with oropharyngeal primary and HPV related disease.

Patients and Methods: The charts of consecutive patients with R/M SCCHN were reviewed. All patients receiving at least one cycle of the two-drug regimen (pemetrexed 500 mg/m², carboplatin area under the curve of five intravenously), were included for assessment of response, safety, toxicity, and survival.

Results: A total of 86 patients received this regimen between January 2008 and December 2012, of which, 63 were included in this analysis. Forty-one percent (26) of the patients had cancers of the oropharynx, and of those, 50% had HPV-positive disease, 32% (20) had cancers of the larynx, and 24% (15) of the oral cavity. Median number of cycles administered was 4 (range 1–14 cycles) with 50% of the patients receiving four or more cycles. Half the patients achieved stable disease as their best response, 8% (5) attained a partial response, 24% progressed on therapy, and the remaining patients (12) could not have their response assessed. On the basis of Kaplan–Meier analysis, median progression-free survival (PFS) was 5.1 months (95% CI 3.2, 6.2) and median overall survival (OS) was 9.4 months (95% CI 4.3, 13.1). Among pts with oropharyngeal primary (n = 26), median PFS was 6.4 months (95% CI 2.8, 7.9) and median OS was 16.6 months (95% CI 9.6, 19.5). Among HPV+ pts (n = 13), median PFS was 7.0 months (95% CI 4.8, ne) and median OS was 17.1 months (95% CI 11.2, 21.7).

Conclusion: Combination carboplatin-pemetrexed is an effective and well-tolerated treatment, associated with a median PFS of 5.1 months and a clinical benefit in at least 57% of the patients treated.