Treatment modalities and outcomes of Fanconi anemia patients with head and neck squamous cell carcinoma: Series of 9 cases and review of the literature

Gemcitabine as chemotherapy of head and neck cancer in Fanconi anemia patients

Fanconi anemia (FA) is a rare hereditary disease resulting from an inactivating mutation in the FA/BRCA pathway, critical for the effective repair of DNA interstrand crosslinks (ICLs). The disease is characterized by congenital abnormalities, progressing bone marrow failure, and an increased risk of developing malignancies early in life, in particular head and neck squamous cell carcinoma (HNSCC). While ICL-inducing cisplatin combined with radiotherapy is a mainstay of HNSCC treatment, cisplatin is contra-indicated for FA-HNSCC patients. This dilemma necessitates the identification of novel treatment modalities tolerated by FA-HNSCC patients. To identify druggable targets, an siRNA-based genetic screen was previously performed in HNSCC-derived cell lines from FA and non-FA tumor origin. Here, we report that the Ribonucleotide Reductase (RNR) complex, consisting of the RRM1 and RRM2 subunits, was identified as a therapeutic target for both, FA and non-FA HNSCC. While non-FA HNSCC cells responded differentially to RNR depletion, FA-HNSCC cells were consistently found hypersensitive. This insight was confirmed pharmacologically using 2', 2'-difluoro 2'deoxycytidine (dFdC), also known as gemcitabine, a clinically used nucleotide analog that is a potent inhibitor of the RNR complex. Importantly, while cisplatin exposure displayed severe, long-lasting toxicity on the hematopoietic stem and progenitor compartments in Fancg-/- mice, gemcitabine was well tolerated and had only a mild, transient impact. Taken together, our data implicate that gemcitabine-based chemoradiotherapy could serve as an alternative HNSCC treatment in Fanconi patients, and deserves clinical testing.

Treatment of Fanconi anemia patient with synchronous esophageal and tongue cancer in COVID-19 era: a case report

Although Fanconi anemia patients accompany a high risk of multiple cancers, radiation therapy on these patients has been carried out only in limited cases due to the concern for radiation toxicity that stems from their susceptibility to radiation. We report a case of a 28-year-old female patient diagnosed as synchronous esophageal and tongue cancer, and underwent two cycles of radiation therapy, inevitably in the condition of coronavirus disease 2019 infection. She received radiation therapy of 30 Gy to esophageal mass with neoadjuvant aim in her first-round radiation therapy, and later received 27 Gy to tongue cancer surgical bed with adjuvant aim in her second-round radiation therapy. With no further treatment, she has been maintaining no evidence of disease state for 7 months. Managing Fanconi anemia patients with multiple cancers using radiation therapy is feasible, in which cases a dose de-escalation may be important considering the radiation toxicity and possible future re-treatment.

Exploring the frontiers: tumor immune microenvironment and immunotherapy in head and neck squamous cell carcinoma

The global prevalence of head and neck malignancies positions them as the sixth most common form of cancer, with the head and neck squamous cell carcinoma (HNSCC) representing the predominant histological subtype. Despite advancements in multidisciplinary approaches and molecular targeted therapies, the therapeutic outcomes for HNSCC have only marginally improved, particularly in cases of recurrent or metastatic HNSCC (R/MHNSCC). This situation underscores the critical necessity for the development of innovative therapeutic strategies. Such strategies are essential not only to enhance the efficacy of HNSCC treatment but also to minimize the incidence of associated complications, thus improving overall patient prognosis. Cancer immunotherapy represents a cutting-edge cancer treatment that leverages the immune system for targeting and destroying cancer cells. It's applied to multiple cancers, including melanoma and lung cancer, offering precision, adaptability, and the potential for long-lasting remission through immune memory. It is observed that while HNSCC patients responsive to immunotherapy often experience prolonged therapeutic benefits, only a limited subset demonstrates such responsiveness. Additionally, significant clinical challenges remain, including the development of resistance to immunotherapy. The biological characteristics, dynamic inhibitory changes, and heterogeneity of the tumor microenvironment (TME) in HNSCC play critical roles in its pathogenesis, immune evasion, and therapeutic resistance. This review aims to elucidate the functions and mechanisms of anti-tumor immune cells and extracellular components within the HNSCC TME. It also introduces several immunosuppressive agents commonly utilized in HNSCC immunotherapy, examines factors influencing the effectiveness of these treatments, and provides a comprehensive summary of immunotherapeutic strategies relevant to HNSCC.

Squamous Carcinoma of the Oral Cavity in Patient with Fanconi Anemia: A Challenging Reconstruction with Double-barrel Free Fibula Flap Case Report

Fanconi anemia (FA) is a very rare form of aplastic anemia. Patients with FA have a higher risk of developing solid tumors such as head and neck squamous cell carcinoma, higher risk of local recurrence, and impaired resistance to chemotherapy and radiotherapy treatments than the normal population. In this article, we describe the challenging clinical case of a patient with FA who underwent surgery for the removal of a large squamous cell carcinoma in the oral cavity. Mandibular reconstruction was performed using a biaxial double-barrel fibular flap, with excellent functional aesthetic outcomes.

Extensive Lower Lip Squamous Cell Carcinoma in a Fanconi Anaemia Patient and Treatment Delays during COVID-19 Pandemic

Fanconi anaemia (FA) is an autosomal recessive inherited disease that renders patients susceptible to congenital anomalies, bone marrow failures, leukaemia, and solid malignancies. FA is caused by the loss of function of at least one gene in the FA/BRCA biological pathway, which is involved in DNA repair. Patients with FA have an increased risk of developing head and neck cancer, particularly oral squamous cell carcinoma (SCC). Due to susceptibility of head and neck cancer at a very young age, relatively poor survival rate, low tolerance to oncologic interventions, and complexity of treatments, strict follow-up is mandatory to detect any changes or recurrence of SCC in the head and neck region in FA patients. Surgery is the mainstay of treatment, but adjuvant therapy should be instituted when needed. This short report describes a rare case of lower lip SCC in FA and its management. It also highlights the impact of the COVID-19 pandemic on healthcare practices.

Fanconi anemia: current insights regarding epidemiology, cancer, and DNA repair

Fanconi anemia is a genetic disorder that is characterized by bone marrow failure, as well as a predisposition to malignancies including leukemia and squamous cell carcinoma (SCC). At least 22 genes are associated with Fanconi anemia, constituting the Fanconi anemia DNA repair pathway. This pathway coordinates multiple processes and proteins to facilitate the repair of DNA adducts including interstrand crosslinks (ICLs) that are generated by environmental carcinogens, chemotherapeutic crosslinkers, and metabolic products of alcohol. ICLs can interfere with DNA transactions, including replication and transcription. If not properly removed and repaired, ICLs cause DNA breaks and lead to genomic instability, a hallmark of cancer. In this review, we will discuss the genetic and phenotypic characteristics of Fanconi anemia, the epidemiology of the disease, and associated cancer risk. The sources of ICLs and the role of ICL-inducing chemotherapeutic agents will also be discussed. Finally, we will review the detailed mechanisms of ICL repair via the Fanconi anemia DNA repair pathway, highlighting critical regulatory processes. Together, the information in this review will underscore important contributions to Fanconi anemia research in the past two decades.

A Case of Hypopharyngeal Cancer Associated With Fanconi Anemia: A Helical Tomotherapy Experience

Fanconi anemia (FA) is a disease that could be accompanied by multiple abnormalities, such as growth retardation, bone marrow abnormalities, and cancer susceptibility. Among the FA patients, head and neck squamous cell cancer (HNSCC) is the most observed solid cancer. The life expectancy of patients with FA has increased with recent medical advances. Furthermore, HNSCC is diagnosed in 3% of FA patients, and half of these patients die because of their HNSCC. The median age of HNSCC patients with FA is 31, and according to the literature HNSCC incidence of FA, patients is more than 700-fold of the normal population. Here, we reported the treatment details and challenges we faced during hypopharyngeal cancer treatment in a FA patient.

Fanconi anemia and hematopoietic stem cell transplant as risk factors for oral squamous cell carcinoma: A case report with a 12-year follow-up

Fanconi anemia is a rare disorder resulting from defects in genes responsible for DNA damage responses. It is characterized by congenital anomalies, aplastic anemia, and a predisposition to cancer. Currently, hematopoietic stem cell transplant (HSCT) is the only curative treatment available for bone marrow failure; however, HSCT increases oral squamous cell carcinoma (OSCC) risk. Here we report the case of a patient diagnosed with Fanconi anemia in childhood who was treated with HSCT and later diagnosed with multiple OSCCs during a 12-year follow-up. Despite multiple surgical interventions and radiotherapy regimens, the patient`s health deteriorated. Management of individuals with Fanconi anemia is challenging and must be provided by a multidisciplinary healthcare team to ensure better staging, treatment planning, and coordination.

Three Cases of Esophageal Cancer Related to Fanconi Anemia

The risk of carcinogenesis increases after 20 years old in patients with Fanconi anemia (FA). We herein report three rare cases of FA combined with esophageal cancer in women; all patients were diagnosed with FA in early childhood. Patients 1 and 2 were diagnosed with advanced and superficial esophageal cancer, respectively, at 21 and 30 years old, respectively. Patient 3 was diagnosed with superficial esophageal cancer, underwent curative surgery at 26 years old, and survived for over 5 years without recurrence. Therefore, establishing a protocol for the early detection of esophageal cancer in FA patients over 20 years old is important.

Post-hematopoietic stem cell transplant squamous cell carcinoma in patients with Fanconi anemia: a dreadful enemy

INTRODUCTION

Hematopoietic stem cell transplantation (HSCT) is a curative option for patients with Fanconi anemia (FA) and hematological manifestations but it does not prevent solid tumors, especially squamous cell carcinomas (SCC).

METHODS

Retrospective study in 22 FA patients who had received HSCT and had been followed up beyond 2 years after HSCT.

RESULTS

The median follow-up was 15 years. Six patients developed head-and-neck SCC after transplantation. The cumulative incidence of SCC at 15 and 30 years from the HSCT was 14.2% and 71.2%, respectively. One patient was diagnosed in stage IV and the rest, who were being followed up in cancer screening programs, in stage I. Treatment of SCC consisted of surgery in all patients; radiotherapy and chemotherapy were used in two patients and were poorly tolerated.

CONCLUSION

FA patients have high risk of head-and-neck SCC. Multi-disciplinary programs for early cancer detection are of special relevance in these patients.

Proton Radiotherapy to Reduce Late Complications in Childhood Head and Neck Cancers

In most childhood head and neck cancers, radiotherapy is an essential component of treatment; however, it can be associated with problematic long-term complications. Proton beam therapy is accepted as a preferred radiation modality in pediatric cancers to minimize the late radiation side effects. Given that childhood cancers are a rare and heterogeneous disease, the support for proton therapy comes from risk modeling and a limited number of cohort series. Here, we discuss the role of proton radiotherapy in pediatric head and neck cancers with a focus on reducing radiation toxicities. First, we compare the efficacy and expected toxicities in proton and photon radiotherapy for childhood cancers. Second, we review the benefit of proton radiotherapy in reducing acute and late radiation toxicities, including risks for secondary cancers, craniofacial development, vision, and cognition. Finally, we review the cost effectiveness for proton radiotherapy in pediatric head and neck cancers. This review highlights the benefits of particle radiotherapy for pediatric head and neck cancers to improve the quality of life in cancer survivors, to reduce radiation morbidities, and to maximize efficient health care use.

Treatment of Fanconi Anemia-Associated Head and Neck Cancer: Opportunities to Improve Outcomes

Fanconi anemia, the most frequent genetic cause of bone marrow failure, is characterized by an extreme predilection toward multiple malignancies, including a greater than 500-fold incidence of head and neck squamous cell carcinoma (HNSCC) relative to the general population. Fanconi anemia-associated HNSCC and esophageal SCC (FA-HNSCC) often present at advanced stages with poor survival. Surgical resection remains the primary treatment for FA-HNSCC, and there is often great reluctance to administer systemic agents and/or radiotherapy to these patients given their susceptibility to DNA damage. The paucity of FA-HNSCC case reports limits evidence-based management, and such cases have not been analyzed collectively in detail. We present a systematic review of FA-HNSCC treatments reported from 1966 to 2020, defining a cohort of 119 patients with FA-HNSCC including 16 esophageal SCCs (131 total primary tumors), who were treated with surgery, radiotherapy, systemic therapy (including cytotoxic agents, EGFR inhibitors, or immune checkpoint inhibitors), or a combination of modalities. We summarize the clinical responses and regimen-associated toxicities by treatment modality. The collective evidence suggests that when possible, surgical resection with curative intent should remain the primary treatment modality for FA-HNSCC. Radiation can be administered with acceptable toxicity in the majority of cases, including patients who have undergone stem cell transplantation. Although there is little justification for cytotoxic chemotherapy, EGFR inhibitors and tyrosine kinase inhibitors may be both safe and effective. Immunotherapy may also be considered. Most oncologists have little personal experience with FA-HNSCC. This review is intended as a comprehensive resource for clinicians.

Feasibility of breast radiation therapy in a Fanconi Anemia patient diagnosed with breast cancer: A case report and review of literature

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We present the journey of an FA patient who developed metachronous bilateral breast cancers and was successfully treated with breast conserving therapy with no significant treatment related toxicity.

Fanconi Anemia (FA) is a rare inherited autosomal recessive disease that results in impaired double stranded DNA repair. This leads to both increased susceptibility to various cancers, as well as hypersensitivity to radiotherapy and systemic therapy; thus, increasing the complexity of oncological treatment paradigm.

Here, we present an FA patient who initially developed invasive breast cancer for which she received breast conserving treatment with no significant treatment related toxicity. This was followed by a diagnosis of high-grade ductal carcinoma-in-situ in the contralateral breast, which was managed successfully by surgery and meticulously planned adjuvant radiotherapy, with no treatment interruptions.

Successful use of a therapeutic trial of graduated volume and dose escalation for postoperative head and neck radiotherapy in a Fanconi anemia patient

BACKGROUND

Patients with the heritable disease, Fanconi anemia (FA), have a 500-fold risk of developing head and neck squamous cell carcinomas (HNSCC). However, the use of conventional cytotoxic agents including radiation therapy and cisplatin-based chemotherapy is contraindicated in patients with FA due to underlying DNA repair defects.

METHODS/RESULTS

We present a young FA patient with recurrent HNSCC and high-risk pathologic features treated with a therapeutic trial of chemoradiation. This novel strategy employs a gentle radiation dose and volume escalation with concurrent pembrolizumab. The patient completed the entire course of therapy with no treatment delays or interruptions.

CONCLUSIONS

The FA patient population has a clear need for adjuvant treatment regimens given their predilection for HNSCC. A therapeutic trial may allow FA and other radiosensitive patients to trial radiation with the option to terminate treatment before any severe side effects occur and for some to complete a full course of treatment.

Gingival Bleeding in a Child with Fanconi Anemia: A Case Report and Literature Review

Fanconi anemia (FA) is a rare autosomal recessive disorder characterized by multiple congenital abnormalities, bone marrow failure, and higher susceptibility to malignancies, especially to head and neck carcinomas. Only few reports about the oral manifestations of FA are available. The main reported oral conditions associated with FA are microdontia and advanced periodontitis. The aim of this paper was to report a case of a 10-year-old patient with FA presenting severe spontaneous gingival bleeding, as well as to discuss the role of the dentist in the management and treatment of this condition.

The Implications of Genetic Testing on Radiation Therapy Decisions: A Guide for Radiation Oncologists

The advent of affordable and rapid next-generation DNA sequencing technology, along with the US Supreme Court ruling invalidating gene patents, has led to a deluge of germline and tumor genetic variant tests that are being rapidly incorporated into clinical cancer decision-making. A major concern for clinicians is whether the presence of germline mutations may increase the risk of radiation toxicity or secondary malignancies. Because scarce clinical data exist to inform decisions at this time, the American Society for Radiation Oncology convened a group of radiation science experts and clinicians to summarize potential issues, review relevant data, and provide guidance for adult patients and their care teams regarding the impact, if any, that genetic testing should have on radiation therapy recommendations. During the American Society for Radiation Oncology workshop, several main points emerged, which are discussed in this manuscript: (1) variants of uncertain significance should be considered nondeleterious until functional genomic data emerge to demonstrate otherwise; (2) possession of germline alterations in a single copy of a gene critical for radiation damage responses does not necessarily equate to increased risk of radiation-induced toxicity; (3) deleterious ataxia-telangiesctasia gene mutations may modestly increase second cancer risk after radiation therapy, and thus follow-up for these patients after indicated radiation therapy should include second cancer screening; (4) conveying to patients the difference between relative and absolute risk is critical to decision-making; and (5) more work is needed to assess the impact of tumor somatic alterations on the probability of response to radiation therapy and the potential for individualization of radiation doses. Data on radiosensitivity related to specific genetic mutations is also briefly discussed.