Chemoradiation therapy using radiotherapy, systemic chemotherapy with 5-fluorouracil and nedaplatin, and intra-arterial infusion using carboplatin for locally advanced head and neck cancer – Phase II study

Concurrent chemoradiotherapy using gemcitabine and nedaplatin in recurrent or locally advanced head and neck squamous cell carcinoma

BACKGROUND

Patients with recurrent or locally advanced head and neck squamous cell carcinoma (HNSCC) typically have limited treatment options and poor prognosis.

AIM

To evaluate the efficacy and safety of two drugs with potent radio-sensitization properties including gemcitabine and nedaplatin as concurrent chemoradiotherapy regimens in treating HNSCC.

METHODS

This single-arm prospective study enrolled patients with HNSCC to receive gemcitabine on days 1 and 8 and nedaplatin on days 1 to 3 for 21 days. Intensity-modulated radiation therapy with a conventional fraction was delivered 5 days per week. Objective response rate (ORR), disease control rate, and toxicity were observed as primary endpoints. Overall survival (OS) and progression free survival were recorded and analyzed as secondary endpoints.

RESULTS

A total of 24 patients with HNSCC were enrolled. During the median 22.4-mo follow-up, both ORR and disease control rate were 100%. The one-year OS was 75%, and one-year progression-free survival (PFS) was 66.7% (median PFS was 15.1 mo). Recurrent HNSCC patients had a poorer prognosis than the treatment-naïve patients, and patients who achieved complete response had better survival than those in the PR group (all P < 0.05). The most common grade 1-4 (100%) or grade 3-4 toxicities (75%) were hematological, and the most common grade 3-4 non-hematological toxicity was mucositis in 17 (71%) patients.

CONCLUSION

Gemcitabine plus nedaplatin with concurrent chemoradiotherapy is a therapeutic option for HNSCC with predictable tolerability. Considering the high adverse event rate, the optimized dose and schedule must be further explored.

Experience in Intra-arterial Chemotherapy using Two Protocols for the Treatment of OSCC over Two Decades at the University Hospital Vienna

OBJECTIVES

This retrospective study performed a comprehensive analysis of the usage of intra-arterial chemotherapy (iaCh) for locally recurrent UICC stage IV oral squamous cell carcinoma (OSCC) over two decades at the Department of Cranio-Maxillofacial and Oral Surgery at the University Hospital Vienna to assess the utility of its future use.

METHODS

Between 1994 and 2014, iaCh was indicated in 48 OSCC cases. In these, the two most frequent iaCh schemes, cisplatin/5-fluorouracil (Cis/5-FU) and methotrexate/bleomycin (MTX/Bleo), were chosen for further analysis. The effect on survival of two distinct intra-arterial protocols and their covariates were analyzed with the Kaplan-Meier method as well as univariate and multivariate Cox proportional hazard regression models.

RESULTS

The mean follow-up period was 29.91 months. The two intra-arterial chemotherapy groups did not differ significantly in sample size, demographic data or therapeutic covariates. The Cis/5-FU iaCh regimen was associated with significantly better overall survival (median OS 2.6 years vs. 1.3 years; p=0.002) and had a beneficial effect on survival (HR=3.62, p=0.015). Side effects occurred at a frequency similar to that described in the literature for intravenous chemotherapy (ivCh).

CONCLUSIONS

These results suggest a preference for administering Cis/5-FU for iaCh. Nevertheless, due to economic considerations in healthcare expenditures, there is no future for iaCh in the treatment of head and neck carcinomas because ivCh is known to be equivalent.

A Novel External Carotid Arterial Sheath System for Intra-arterial Infusion Chemotherapy of Head and Neck Cancer

PURPOSE

The purpose of this study was to describe a novel system for treating advanced head and neck cancer consisting of an external carotid arterial sheath (ECAS) and a microcatheter to inject drugs retrogradely into multiple feeding arteries through the superficial temporal artery (STA).

MATERIALS AND METHODS

Four consecutive patients with head and neck cancer that had more than one feeding artery were enrolled in this study. The ECAS was made of polyurethane and surface-coated with heparin resin to prevent thrombus formation, allowing it to remain in place for a prolonged period of time. The ECAS was inserted through the STA, and its tip was placed between the maxillary artery and facial artery. The tumor-feeding arteries were selected using a hooked-shaped microcatheter through the ECAS.

RESULTS

A total of 13 target arteries were selected in the four patients. The microcatheter inserted via the ECAS was used to catheterize ten arteries (five lingual arteries and five facial arteries). The remaining three lingual arteries were directly selected by the catheter without ECAS. All of the target arteries were able to be catheterized superselectively. The technical success rate was 100%. Vascular occlusion, which might have been caused by the ECAS, was observed in one patient. No neurologic toxicities occurred.

CONCLUSION

This ECAS system is a new approach for retrograde superselective intra-arterial chemotherapy that covers the entire tumor with anticancer drugs. It has the potential to increase the effectiveness of therapy for advanced head and neck cancer.

LEVEL OF EVIDENCE

Level 4, Case Series.

Selection of recipient vessels for free flap following intra-arterial chemoradiotherapy

OBJECTIVE

This study aims at selecting recipient vessels for free flap following intra-arterial chemoradiotherapy. At present, many centers combine intra-arterial chemotherapy and concomitant radiotherapy for treating head and neck cancer with favorable results. However, some patients develop recurrent, residual disease/complications after completing treatment protocols and thus require free-flap surgery. The feasibility of microsurgery following intra-arterial chemoradiotherapy remains unclear.

STUDY DESIGN AND METHODS

We retrospectively analyzed 730 patients who underwent free-flap surgery for managing treatment-related complications/defects following head and neck surgery from January 1999 to February 2012. All patients were categorized into two groups according to the presence (group A)/absence (group B) of a history of intra-arterial chemotherapy. Microvascular revision rates were compared between the groups. In group A, the correlation between catheterization sites and recipient vessels used for microsurgery was assessed.

RESULTS

A total of 769 free flaps were created in 730 patients and comprised 36 and 733 flaps in groups A and B, respectively. Microvascular revision rates were 2.8% (1/36) and 4.2% (31/733) in groups A and B, respectively, with no significant difference observed between the groups. No statistically significant difference was observed when only cases of arterial thrombosis were included. Vessels used for recipient anastomoses were not directly exposed to intra-arterially injected agents.

CONCLUSION

Preoperative intra-arterial chemoradiotherapy does not significantly increase the risk of microvascular revisions, particularly artery-related revisions, if vessels selectively catheterized and perfused with chemotherapeutic agents during intra-arterial chemotherapy are avoided as recipient vessels.

Expression of mutant p53 in oral squamous cell carcinoma is correlated with the effectiveness of intra-arterial chemotherapy

The aim of the present study was to evaluate the correlation between the positive expression rate of mutant p53 and the clinical characteristics of patients with oral squamous cell carcinoma (OSCC), as well as the effectiveness of intra-arterial chemotherapy. Expression of mutant p53 in tumor tissues was determined by immunohistochemical analysis of 51 OSCC patients, prior to and following intra-arterial chemotherapy. Prior to intra-arterial chemotherapy, mutant p53 positive rates in patients with higher pathological grades were significantly higher than those of the patients with lower pathological grades. The mutant p53 positive rate in patients with lymph node metastasis was 73% (19/26), which was significantly higher than that of the patients without lymph node metastasis (20%, 5/25). Mutant p53 was expressed in 17% (3/18) of clinical phase II patients, while 64% (21/33) of clinical phase III and IV patients exhibited positive expression of mutant p53 (P<0.05). The mutant p53 positive rate in chemotherapy non-responsive patients was 69% (11/16), which was significantly higher than that in the chemotherapy-responsive patients (37%, 13/35). Mutant p53 positive rates were not significantly correlated with age, gender or the location of the tumor. The mutant p53 positive rate prior to chemotherapy was 47% (24/51), and decreased to 18% (9/51) following chemotherapy. Expression of mutant p53 was decreased in all 13 (100%) chemotherapy-responsive patients, while only 5 (45%) chemotherapy non-responsive patients exhibited reduced expression levels of mutant p53 (P<0.05). In conclusion, mutant p53 has a significant role in the differentiation, development and treatment guidance of OSCC. Intra-arterial chemotherapy with 5-fluorourcil and carboplatin potentially exerts a therapeutic effect by reducing the expression of mutant p53.

Clinical usefulness of [18F] fluoro-2-deoxy-D-glucose uptake in 178 head-and-neck cancer patients with nodal metastasis treated with definitive chemoradiotherapy: consideration of its prognostic value and ability to provide guidance for optimal selection of patients for planned neck dissection

PURPOSE

To evaluate the clinical effectiveness of pretreatment [18F] fluoro-2-deoxy-D-glucose-positron emission tomography for head-and-neck squamous cell carcinoma patients with nodal metastasis treated with chemoradiotherapy.

METHODS AND MATERIALS

Between March 2002 and December 2006, 178 patients with head-and-neck squamous cell carcinoma and nodal metastasis underwent fluoro-2-deoxy-D-glucose positron emission tomography before chemoradiotherapy. Fluoro-2-deoxy-D-glucose uptake by both the primary lesion and the neck node was measured using the standard uptake value (SUV). The overall survival, disease-free survival, local control, nodal progression-free survival, and distant metastasis-free survival rates were calculated, and several prognostic factors were evaluated.

RESULTS

The patients with a nodal SUV≥6.00 had a significantly lower 3-year disease-free survival rate than those with a lower SUV (44% vs. 69%, p=.004). On multivariate analysis, a high SUV of nodal disease also proved to be a significantly unfavorable factor for disease-free survival (p=.04, 95% confidence interval [CI], 1.02-3.23), nodal progression-free survival (p=.05; 95% CI, 1.00-4.15), and distant metastasis-free survival (p=.016; 95% CI, 1.25-8.92). Among the patients with a greater nodal SUV (≥6.00), those treated with planned neck dissection had better nodal progression-free survival than those in the observation group (p=.04, hazard ratio, 2.36; 95% CI, 1.00-5.85).

CONCLUSION

Among head-and-neck squamous cell carcinoma patients treated with chemoradiotherapy, the pretreatment SUV of nodal disease was one of the strongest prognostic factors and also provided important information for the selection of patients suitable for planned neck dissection.

Determinants of outcome following surgery for oral squamous cell carcinoma

The recent changes in incidence and prevalence of oral squamous cell carcinoma in relation to gender and age mirror the changing patterns of exposure to tobacco and alcohol, the main etiological agents. Most cases of oral cancer are managed by surgery, often combined with radiotherapy. Histopathological assessment of the resection specimen provides information vital for postoperative management and prognosis. This review considers the full range of histological determinants of outcome in relation to the primary oral tumor and any metastatic involvement of the cervical lymphatic system, together with an outline of more general patient factors that may also impact on morbidity and mortality rates.

A new method of selective intra-arterial infusion therapy via the superficial temporal artery for head and neck cancer

OBJECTIVE

We proposed a new selective intra-arterial infusion method via the superficial temporal artery for preventing dislocation of the catheter.

STUDY DESIGN

This study included 92 patients who were treated by this combination therapy between May 1999 and December 2004. Primary tumor sites included the tongue in 73 patients, base of the tongue in 6 patients, floor of mouth in 4 patients, buccal mucosa in 4 patients, and other sites in 5 patients. Seventy-three patients had untreated lesions and 19 patients had recurrent lesions. Under fluoroscopy, a catheter was inserted into the target artery through the superficial temporal artery using a catheter exchange method.

RESULTS

In 76 (83%) of 92 patients, a catheter was successfully inserted into the target artery. In 4 patients, the catheter fell out of the selected artery during treatment.

CONCLUSION

This selective intra-arterial method will be an important modality for advanced tongue cancer.

Intra-arterial chemoradiotherapy for locally advanced oral cavity cancer: analysis of therapeutic results in 134 cases

The objective of this study was to investigate the therapeutic results of arterial injection therapy via the superficial temporal artery for 134 cases of stages III and IV (M0) oral cavity cancer retrospectively, and to clarify the prognostic factors. We administered intra-arterial chemoradiotherapy by continuous infusion of carboplatin in 65 cases from January 1993 to July 2002. Systemic chemotherapy was performed on 26 cases at the same time. We administered intra-arterial chemoradiotherapy by cisplatin with sodium thiosulphate in 69 cases from October 2002 to December 2006. Systemic chemotherapy was performed on 48 cases at the same time. The 3-year local control rate was 68.6% (T2-3: 77.9%; T4: 51.3%), and the 3-year survival rate was 53.9% (stage III: 62.9%; stage IV: 45.3%). Regarding the results of multivariate analysis of survival rates, age (<65), selective intra-arterial infusion, and the use of cisplatin as an agent for intra-arterial infusion were significant factors. The therapeutic results of intra-arterial chemoradiotherapy via the superficial temporal artery were not inferior to the results of surgery. In particular, the results of arterial injection therapy by cisplatin with sodium thiosulphate were excellent, so we believe that it will be a new therapy for advanced oral cavity cancer.