Preoperative hyperfractionated accelerated radiotherapy and radical surgery in advanced head and neck cancer: A prospective phase II study

Epstein-Barr virus and human papillomaviruses as favorable prognostic factors in nasopharyngeal carcinoma: A nationwide study in Finland

Background

Nasopharyngeal carcinoma (NPC) is related to Epstein‐Barr virus (EBV) in endemic areas; however, the role of viruses in nonendemic countries is unclear. Our nationwide study investigated the prevalence and prognostic significance of EBV and human papillomaviruses (HPVs) in Finnish NPC tumors.

Methods

We analyzed samples from 150 patients diagnosed between 1990 and 2009. Viral status was determined using EBV and HPV RNA in situ hybridizations, and p16 immunohistochemistry. Patient and treatment characteristics were obtained from patient records.

Results

In our white patient cohort, 93 of 150 (62%) patients were EBV‐positive and 21/150 (14%) patients were HPV‐positive with no coinfections. Thirty‐six (24%) tumors were negative for both viruses. The 5‐year disease‐specific survival for patients with EBV‐positive, HPV‐positive, and EBV/HPV‐negative tumors was 69%, 63%, and 39%, respectively. In multivariable‐adjusted analysis, overall survival was better among patients with EBV‐positive (P = .005) and HPV‐positive (P = .03) tumors compared to patients with EBV/HPV‐negative tumors.

Conclusions

In our low‐incidence population, EBV and HPV are important prognostic factors for NPC.

Outcome of nasopharyngeal carcinoma in Finland: A nationwide study

BACKGROUND

Nasopharyngeal carcinoma (NPC) is uncommon in western countries and data on the outcome and histological presentation are scarce in nonendemic areas. We report here the outcome on all patients with NPC treated in Finland between 1990 and 2009.

MATERIAL AND METHODS

The Finnish Cancer Registry database was used to identify the patients. Histopathological specimens and clinical records were reviewed to confirm the histological subtypes, prognostic factors, treatment techniques and outcome across different stage groups.

RESULTS

Primary NPC was identified in 207 patients and 42 (20%) had keratinizing squamous cell carcinoma (SCC). The stage distribution was: I, 11%; II, 25%; III, 39%; IV, 25%. Of 191 patients treated with curative intent 85 (44%) received radiotherapy and 106 (56%) chemoradiotherapy. The five-year overall survival for all patients was 57% and for stages I-IV 87%, 69%, 55% and 31%, respectively. The five-year disease-specific and overall survival of all patients treated between 1990 and 1999 were 58% and 49%, and those between 2000 and 2009 66% and 63%, respectively.

CONCLUSIONS

While survival rates are improving and comparable to other western countries they remain inferior to those of endemic countries. This may reflect the different biology of NPC in nonendemic areas, where keratinizing SCC is common.

Emerging insights into head and neck cancer metastasis

The purpose of this review was to provide biological concepts of head and neck cancer metastasis. To attain this goal, we analyzed peer-reviewed articles related to head and neck cancer metastasis obtained though PubMed and archived articles. Articles related to the biologic principles of head and neck cancer metastasis were reviewed and summarized. As locoregional control has improved for patients with head and neck cancer, rates of distant metastasis have not decreased. As patients live longer, many will die of complications related to the development of disease at sites below the clavicles. Emerging evidence now suggests a more complicated framework of metastatic behavior for head and neck cancer. Here, we review the role of regional lymph nodes in containing advanced head and neck cancer, evidence for active as opposed to passive tumor cell metastasis, and clinical implications these concepts have on both treatment of head and neck cancer and future research.

[Combined modality approaches in the treatment of head and neck cancer patients]

The survival rate in patients with head and neck squamous cell cancer (HNSCC) has improved considerably over the past 50 years. This is due not only to changes in anesthetic techniques, but also to the fact that combinations of various therapeutic approaches are more common than they used to be. It is generally accepted that patients with advanced carcinomas require combined modality treatment. It has yet to be established which modality is best to use as the primary treatment. Approaches that begin with radiotherapy or chemotherapy were the most commonly used for a while, but indications are now increasingly being seen that primary surgery leads to good results. Moreover, the use of the epidermal growth factor (EGF) antibody cetuximab has recently been playing an increasingly important role.

Improvement of the breaking strength of wound by combined treatment with recombinant human G-CSF, recombinant human M-CSF, and a TGF-beta1 receptor kinase inhibitor in rat skin

Effective doses of ionizing radiation during preoperative radiotherapy occasionally cause wound complications after subsequent surgery. The authors attempted to accelerate radiation-impaired wound healing in animal models. Recombinant human granulocyte colony-stimulating factor (rhG-CSF), recombinant human macrophage colony-stimulating factor (rhM-CSF), and an inhibitor of transforming growth factor (TGF)-beta1 receptor kinase, SB431542, were injected s.c. into a full-thickness incisional wound site in the dorsal skin of rats after local irradiation of X-ray (30 Gy). Wound healing of irradiated skin was assessed using the breaking strength of the wound and histological analyses. The impaired wound healing in irradiated skin was found to be associated with impaired mobilization of bone marrow-derived cells and enhanced expression of TGF-beta1 mRNA. The breaking strength of the wound in the irradiated skin was approximately one-eighth of that in the non-irradiated skin; however, following combined treatment with the above three compounds the breaking strength increased to approximately one-half of that in the non-irradiated skin. Histological analysis of the wounded skin revealed an increase in formation of collagen fibers and the panniculus carnosus following the combined treatment. Moreover, the increased breaking strength was associated with an increase in a subpopulation of fibrocytes (collagen I/ED1 double positive cells). These findings suggested that a combined treatment with rhG-CSF, rhM-CSF, and SB431542 is promising as a means of improving radiation-impaired wound healing.

Late course accelerated hyperfractionated radiotherapy of nasopharyngeal carcinoma (LCAF)

BACKGROUND AND PURPOSE

To study the efficacy of late course accelerated fractionated (LCAF) radiotherapy in the treatment of nasopharyngeal carcinoma (NPC). The end-points were local control, radiation-induced complications, and factors influencing survival.

PATIENTS AND METHODS

Between December 1995 and April 1998, 178 consecutive NPC patients were admitted for radiation treatment. The radiation beam used was (60)Co gamma or 6 MV X rays. For the first two-thirds of the treatment, two daily fractions of 1.2 Gy were given to the primary lesion, with an interval of > or =6h, 5 days per week to a total dose of 48 Gy/40 fractions, over a period of 4 weeks. For the last third of the treatment, i.e., beginning the 5th week of treatment, an accelerated hyperfractionated schedule was carried out. The dose per fraction was increased to 1.5 Gy, 2 fractions per day with an interval of > or =6h, the total dose for this part of the protocol was 30 Gy/20 fractions over 2 weeks. Thus the total dose was 78 Gy in 60 fractions in 6 weeks.

RESULTS

All patients completed the treatment. Acute mucositis: none in 2 cases, Grade 1 in 43 cases, Grade 2 in 78 cases, Grade 3 in 52 cases, and Grade 4 in 3 cases. Local control rate: the 5 year nasopharyngeal local control rate was 87.7%, and the cervical lymph nodes local control rate was 85.7%. The 5-year distant metastasis rate was 26.1%, and 5 year survivals were 67.9%, 16 (9%) patients had radiation-induced cranial nerve palsy, 7(4%) patients had temporal lobe or brainstem damage.

CONCLUSIONS

With this treatment schedule, patients' tolerance was good, local control and 5 year survivals were better than conventional fractionation schedules, and radiation-related late complications did not increase, as 5-year survival rates of conventional fractionation radiotherapy were only 58%. Randomized clinical trials are being carried out to further confirm the efficacy of LCAF for nasopharyngeal carcinoma.