Chemotherapy for Recurrent and Metastatic Head and Neck Cancer

Cellulose Mediated Transferrin Nanocages for Enumeration of Circulating Tumor Cells for Head and Neck Cancer

Herein we report a hierarchically organized, water-dispersible 'nanocage' composed of cellulose nanocrystals (CNCs), which are magnetically powered by iron oxide (Fe₃O₄) nanoparticles (NPs) to capture circulating tumor cells (CTCs) in blood for head and neck cancer (HNC) patients. Capturing CTCs from peripheral blood is extremely challenging due to their low abundance and its account is clinically validated in progression-free survival of patients with HNC. Engaging multiple hydroxyl groups along the molecular backbone of CNC, we co-ordinated Fe₃O₄ NPs onto CNC scaffold, which was further modified by conjugation with a protein - transferrin (Tf) for targeted capture of CTCs. Owing to the presence of Fe₃O₄ nanoparticles, these nanocages were magnetic in nature, and CTCs could be captured under the influence of a magnetic field. Tf-CNC-based nanocages were evaluated using HNC patients' blood sample and compared for the CTC capturing efficiency with clinically relevant Oncoviu platform. Conclusively, we observed that CNC-derived nanocages efficiently isolated CTCs from patient's blood at 85% of cell capture efficiency to that of the standard platform. Capture efficiency was found to vary with the concentration of Tf and Fe₃O₄ nanoparticles immobilized onto the CNC scaffold. We envision that, Tf-CNC platform has immense connotation in 'liquid biopsy' for isolation and enumeration of CTCs for early detection of metastasis in cancer.

Therapy Effects of Advanced Hypopharyngeal and Laryngeal Squamous Cell Carcinoma: Evaluated using Dual-Energy CT Quantitative Parameters

The accurate evaluation of the therapeutic effects of advanced laryngeal and hypopharyngeal squamous cell carcinoma (LHSCC) remains challenging. In this study, we determined the value of quantitative parameters derived from dual-energy computed tomography (DECT) for predicting the therapeutic effects of advanced LHSCC and to provide valuable evidence for early judgement of the tumour's response to therapy in clinical practice. We prospectively analysed 41 patients with pathologically confirmed LHSCC. All patients received a DECT scan before therapy. Nineteen of 41 patients showed complete remission (CR), and 22 showed non-complete remission (NCR). The mean of the slope of spectral Hounsfield unit curve (λHU), standardized iodine concentration and effective atomic number in the CR group were significantly lower than the NCR group (P < 0.05). There were no significant differences for T stage, treatment modality and standardized water concentration between two groups (P > 0.05). The best predictor of CR effect was λHU. The 2-year cumulative recurrence rate of patients with higher λHU values was significantly higher than that of patients with lower λHU values (P < 0.05), while the 2-year survival rate of those patients was not significantly different (P > 0.05). DECT could easily identify CR patients and potentially help to choose the appropriate treatment regimen for advanced LHSCC.

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.

Update on role of chemotherapy in head and neck squamous cell cancer

Head and neck squamous cell cancer (HNSCC) is most commonly a tobacco-related disease, affecting nearly 600,000 people worldwide each year. For decades, HNSCC has been treated successfully with multimodality treatments including, surgery, radiation, and chemotherapy, though the 'perfect' treatment paradigm remains elusive. This review will discuss a number of clinical trials, comparing various combinations of chemotherapy and the settings in which they are most successful. Promising research and recent data on the combination of cytotoxic chemotherapy with new biological agents indicate chemotherapy plays a critical role in treatment of HNSCC and will only continue to improve.

Management of unresectable head and neck cancers - a retrospective analysis at a rural medical college of India

OBJECTIVE

To study the natural course of disease in patients of advanced squamous cell carcinoma of head and neck (SCCHN) admitted in a rural tertiary hospital and to formulate an acceptable protocol of management and their prognosis.

STUDY DESIGN

A 5-year retrospective analysis of patients of advanced SCCHN attended in the department of Radiotherapy and admitted at department of ENT at B. S. Medical College, Bankura, West Bengal were analyzed for the present study.

SETTING

B. S. Medical College, Bankura at West Bengal, which is a rural medical college and act as tertiary referral, center for three district of West Bengal namely Midnapur, Purulia, Bankura, part of Burdwan and adjoining area of Jharkhand state.

PATIENTS

We investigated 100 patients in our hospital who presented with advanced and in-operable stage of SCCHN.

ELIGIBILITY CRITERIA

Biopsy proved cases of SCCHN in stage III, stage IVA and stage IVB which is surgically unresectable and without any past history of radiotherapy and chemotherapy were included in this study. KEY DEMOGRAPHIC FEATURES: Eighty-nine men and 11 female with advanced SCCHN were included in this study. Their median age was 48 years (36-78 years) with a median weight of 44 kg and median Karnofsky score 70.

INTERVENTIONS

Different types of palliative surgical intervention like Ryles' tube insertion (16%), feeding jejunostomy (11%), tracheostomy (60%) and arterial ligation (2%) was done to relieve the symptoms. Forty-three patients received chemoradiation and 22 patients received only radiotherapy. Best supportive care was provided to 35 patients.

OUTCOME

Twenty-nine percent of patients had partial response in terms of disease control and none had complete response.

CONCLUSION

Symptomatic relief of respiratory obstruction, dysphagia and pain constitute the mainstay of treatment in the present study. A short course of radiotherapy is found to be effective in control of symptoms and helps to improve the quality-of-life. Complete response to therapy in advanced head and neck squamous cell carcinoma with a poor nutritional status is very difficult to achieve.

A phase II study using vinorelbine and continuous 5-fluorouracil in patients with advanced head and neck cancer

Seventy patients with advanced head and neck cancer were treated with vinorelbine and continuous 5-FU administered in a central venous catheter. Over all response was 36% with 9% complete responses. The most common grade 3 and 4 toxicities were stomatitis (13), infection (5), pain related to vinorelbine infusion (4), skin toxicity (3). Thirty one patients had grade 3 or 4 leukopenia. Treatment was complicated by venous thrombosis in the central venous catheter in one case. A majority of patients experienced dose reduction of one or both drugs or treatment delays due to toxicity. Median time to progression was 4.7 months and overall median survival 6.6 months. We conclude that the regimen is feasible and tolerated with moderate toxicity. Response rates and time to progression are comparable to other studies with multi agent treatment.

Überleben mit hämatogen metastasierten HNO-Tumoren

QUESTIONS

The objective of this retrospective analysis was to investigate parameters with a potential impact on survival in a collective of 114 patients with distant metastatic disease after head and neck cancer.

PATIENTS AND METHODS

The primary endpoint was the survival with distant metastatic disease, the secondary endpoint was overall survival. Primary therapy, local recurrence, second neoplasms, palliative chemotherapy (CHT) and radiotherapy (RT), as well as Karnofsky performance status (KPS) at the time of diagnosis of the metastases were analyzed as potential impact parameters using the log-rank test with subsequent Cox regression analysis.

RESULTS

Palliative CHT (P=0.0020) and KPS (P=0.0011) had a significant positive impact on the median survival probability with metastases (8.2 months) using the log-rank test, KPS at the time of diagnosis of metastases remained as an independent prognostic parameter in the Cox regression (P=0.0013). Primary therapy, local tumor control and KPS had a significant positive influence on the median overall survival probability (18.5 months) univariately (P=0.0139, P=0.0106, P= 0.0096) and multivariately (P=0.0123, and P=0.0063, P=0.0197, respectively).

CONCLUSIONS

KPS at the time of diagnosis of metastases is an independent prognostic parameter for both endpoints. Lacking evidence for life prolongation, palliative therapies should therefore first and foremost focus on the stabilization of the KPS.

Head and Neck Malignancy: Is PET/CT More Accurate than PET or CT Alone?

PURPOSE

To prospectively determine whether combined positron emission tomography (PET) and computed tomography (CT) is more accurate than either PET or CT alone in depicting malignant lesions in the head and neck.

MATERIALS AND METHODS

Study was approved by the institutional review board, and patient informed consent was waived. Sixty-five consecutive patients (42 men, 23 women; age range, 43-83 years) known to have or suspected of having head and neck cancer were examined with combined PET/CT. CT was performed with intravenous administration of a contrast agent, and the CT data were used for attenuation correction. Each examination was interpreted in three ways: PET images in the absence of CT data, CT images in the absence of PET data, and fused PET/CT images. Probability of malignancy of each lesion was assigned a score by using a five-point scale. Receiver operating characteristic (ROC) analyses were performed by using biopsy, imaging, or clinical follow-up as the reference standard. The minimum follow-up was 6 months (range, 6-12 months). The results were additionally analyzed to assess the degree of radiologist confidence.

RESULTS

Follow-up was available for 64 (98%) of 65 patients. ROC analyses demonstrated that PET/CT is significantly superior to PET or CT alone for depiction of malignancy in the head and neck (P < .05). In this series, PET/CT had a sensitivity of 98%, a specificity of 92%, and an accuracy of 94%. Radiologist confidence was substantially higher with the combined modality.

CONCLUSION

Combined PET/CT is more accurate than PET or CT alone for the depiction of malignancy in the head and neck. Radiologist confidence is improved with the combined modality.

Weekly cisplatin paclitaxel and continuous infusion fluorouracil in patients with recurrent and/or metastatic head and neck squamous cell carcinoma: a phase II study

BACKGROUND

Cisplatin, paclitaxel and 5-fluorouracil (5-FU) have demonstrated significant activity in patients with advanced squamous head and neck cancer (HNSCC) despite relevant toxicity. A weekly administration of cisplatin and paclitaxel with continuous infusion of 5-FU could offer a better toxicity profile without affecting dose intensity or treatment outcome. We evaluated the toxicity and the activity of weekly cisplatin/paclitaxel with continuous infusion 5-FU in patients with recurrent and/or metastatic HNSCC.

METHODS

A total of 44 patients were studied. Treatment consisted of two 6-week cycles with weekly cisplatin 20 mg/m2 and paclitaxel 60 mg/m2 and daily continuous infusion 5-FU 200 mg/m2 from day 1 to 42. Patients were evaluated for toxicity and response.

RESULTS

40 out of 44 patients were evaluable for response. After two cycles we observed seven complete responses (16%) and 12 partial responses (27%), with a 43% (95% CI 28-58%) overall response rate. Stable disease was seen in 13 patients (29%) and progressive disease in 12 patients (27%). Toxicity was mild in treated patients: we observed less than 10% of grade 3/4 hematological and gastroenteric toxicity.

CONCLUSIONS

A weekly schedule of cisplatin and paclitaxel associated with continuous infusion 5-FU showed low toxicity in the treatment of advanced HNSCC while significant activity was conserved.

Mutant Nbs1 enhances cisplatin-induced DNA damage and cytotoxicity in head and neck cancer

OBJECTIVE

Enhanced DNA double-strand break (DSB) repair could be a primary cause for development of resistance in tumor cells to cisplatin, which induces crosslinks and DNA DSBs. A protein complex consisting of hMre11, hRad50, and Nbs1 (MRN) has been identified as a critical component in repair of DNA DSBs. The present study investigates whether the expression of a truncated form of Nbs1 interrupts the function of the MRN complex and therefore enhances cisplatin-induced DNA damage and cytotoxicity in human head and neck squamous cell carcinoma (HNSCC).

METHODS AND MEASURES

Two human HNSCC cell lines, JHU006 and JHU029, were used. A dominant negative recombinant adenovirus expressing domains of Nbs1 was constructed. Adenovirus-mediated mutant Nbs1 (Ad-Nbs1) gene transfer was performed with replication-defective virus (DL312) and no treatment as controls. Transgene expression and cell viability were evaluated in transfected cells. Neutral comet assay was performed and the "tail moment," the product of the amount of DNA in the tail and the distance of tail migration, was analyzed for evaluating DNA DSB damage at 24, 48, and 72 hours.

RESULTS

Transgene expression of mutant Nbs1 was confirmed by Western blotting. Ad-Nbs1 gene transfer significantly increased cisplatin-induced cytotoxicity as shown by stunting of 6-day growth curves. Neutral comet analysis revealed that the mean tail moment, indicative of DNA damage, was significantly elevated in cells treated with combined cisplatin and Ad-Nbs1 compared to cisplatin alone in both cell lines.

CONCLUSIONS

Expression of mutant Nbs1 significantly increases cisplatin-induced DNA DSBs and cytotoxicity. The increase in double-strand DNA damage corresponds to the level of cytotoxicity in the different treatment groups and suggests that tumor chemosensitization occurs through augmentation of DNA DSBs.

CLINICAL SIGNIFICANCE

Alteration of DNA repair may provide a novel approach to enhancing sensitivity of HNSCC to chemotherapy. Our study supports the potential application of Ad-Nbs1 in combination with cisplatin for treatment of advanced and metastatic HNSCC.

A phase IB clinical and pharmacokinetic study of the angiogenesis inhibitor SU5416 and paclitaxel in recurrent or metastatic carcinoma of the head and neck

PURPOSE

SU5416 is a novel small organic molecule that non-competitively inhibits the phosphorylation of the VEGF tyrosine kinase receptor, Flk-1. This phase IB study was performed to determine the safety, pharmacokinetics, and preliminary efficacy of the combination of SU5416 and paclitaxel in recurrent or metastatic carcinoma of the head and neck.

METHODS

Enrolled in the study were 12 patients with biopsy-proven recurrent or metastatic carcinoma of the head and neck. Six patients received intravenous SU5416 110 mg/m2 on days 1, 15, 18, 22 and 25, and paclitaxel 70 mg/m2 on days 8, 15 and 22. Since two patients experienced a dose-limiting toxicity (DLT) in cohort 1, the next six patients received identical treatment as above except the paclitaxel dose was reduced to 55 mg/m2 per week.

RESULTS

A total of 42 cycles at two different dose levels were given. In cohort 1 there were two deep venous thromboses that were DLTs. In the second cohort there was a DLT consisting of a transient ischemic attack after receiving SU5416. Most of the other toxicities seen were grade 1 or 2 in nature and consisted of headache, facial flushing, and fatigue. Two patients developed extensive ulcerative cavities at sites of prior radiation. There were no significant changes in the pharmacokinetic parameters of SU5416 given with paclitaxel. Four patients had prolonged freedom from progression of 18, 28, 42, and 60 weeks duration.

CONCLUSIONS

The combination of SU5416 with paclitaxel had a higher than expected incidence of thromboembolic events and prophylactic anticoagulation should be considered for future trials that combine an angiogenesis inhibitor with cytotoxic chemotherapy. Although the future development of SU5416 as a chemotherapeutic agent is unclear, there was a clinical benefit seen with this combination in 36% of the patients. This trial supports the use of developing antiangiogenic combinations, using molecular targeted agents, in head and neck carcinoma.

Systemic chemotherapy for squamous cell head and neck cancer

Squamous cell head and neck cancer is a relatively uncommon malignancy in North America. Nonetheless, it has been of considerable interest to medical oncologists because of its remarkable sensitivity to systemic chemotherapy. Even in patients with relapsed or metastatic disease, meaningful tumour shrinkage can be achieved with systemic therapy. This has led to the performance of carefully conducted clinical trials exploring the role of systemic chemotherapy, not only in the palliative setting, but as part of definitive multi-modality treatment. Chemotherapy has been used as the initial (or induction) treatment, as an adjuvant treatment after definitive surgery and/or radiation, and concurrent with both definitive and adjuvant radiation therapy. Evidence-based conclusions have been drawn from these clinical trials and have led to significant changes in the current standards of care for this disease. In this article, the available data supporting the use of systemic chemotherapy as palliative treatment, and as part of the definitive management for this disease will be reviewed.

Treatment of metastatic head and neck cancer: chemotherapy and novel agents

For more than a decade, the de facto "standard of care" for palliative mangement of recurrent head/neck squamous carcinoma (HNSCC) has been the combination of cisplatin/5-flourouracil. With the advent of new cytotoxins, such as the taxanes, and of the molecularly targeted agents, eg., the EGFR inhibitors, the number of options for treatment in this setting has increased. However, none of these new approaches has yet been proven to be more effective than cisplatin/5-fluorouracil. Further, despite the pallitive intent of therapy in this setting, the palliative effects have been only infrequently assessed, with many studies relying on response as a surrogate for palliation. This chapter will focus on clinical and translational research efforts in the past decade focusing on the patient with incurable locoregionally recurrent or metastatic HNSCC. Ongoing and planned future trails will also be discussed.

A phase II study of paclitaxel and cisplatin combination chemotherapy in recurrent or metastatic head and neck cancer

The taxanes are the most active new agents for squamous-cell carcinoma of the head and neck (SCCHN) since the discovery of cisplatin. Our aim was to define the therapeutic efficacy and toxicity of paclitaxel and cisplatin combination therapy in patients with recurrent SCCHN. Patients with locally recurrent or metastatic SCCHN were enrolled in the study. Patients were required to be chemotherapy-naive, and should have completed radiation therapy at least 6 weeks prior to enrollment. A World Health Organization (WHO) performance status of less than 3 was required. Paclitaxel (Taxol, Bristol Myers Squibb Company, Princeton, NJ) and cisplatin therapy (PC) consisted of prophylaxis with pheniramine 50 mg i.v., ranitidine 150 mg i.v. and dexamethasone 20 mg i.v. given prior to paclitaxel 175 mg/m2 as a 3-hour i.v. infusion, followed by cisplatin 75 mg/m2 as a 1-hour infusion with an additional 3000 cc of saline for hydration. This treatment was repeated every 3 weeks for a maximum of six cycles. Patients were evaluated for response after the third and sixth cycles, or at the time of clinical progression. Fifty patients were enrolled in the study. The overall response rate was 32% with a 10% complete response rate. Forty-eight patients were assessable for toxicity. A total of 221 cycles of chemotherapy was given and the most common toxicity was myelosuppression; 7.7% of cycles had grade III-IV neutropenia. Severe neuropathy, nephropathy, mucositis, and emesis were uncommon (<10 %). At a median follow-up period of 25 months, the median overall survival was 10 months and the 1-year progression-free and overall survival rates were 16.7% and 35.2%, respectively. We conclude that patients with recurrent SCCHN have a moderate response to combination chemotherapy with cisplatin and paclitaxel. Given this moderate response rate, it is unlikely that this combination (PC) might ultimately prove to be superior to standard treatment regimens in terms of significant survival advantage.

Laryngo-pharyngeal carcinoma in childhood

Laryngo-pharyngeal carcinoma is rare in children. We present two cases of squamous cell carcinoma of the laryngopharynx in children less than 15 years of age. Both patients presented with a prolonged history of symptoms and extensive disease at diagnosis. Early visualisation the vocal cords with flexible larygnoscopy is important in children presenting with symptoms suggestive of laryngeal pathology. Long-term complications of definitive local therapy for laryngopharyngeal carcinoma are important in young children. Evidence from studies in adult patients suggests that adjuvant chemotherapy may play a role in laryngeal preservation in a select group of patients.

A phase II study of combined oral uracil and ftorafur with leucovorin for patients with squamous cell carcinoma of the head and neck

BACKGROUND

The objective of this Phase II study was to define the response rate, safety profile, and toxicity of oral uracil and ftorafur (UFT) with leucovorin (UFT/LV) as a palliative treatment for patients with squamous cell carcinoma of the head and neck (SCCHN).

METHODS

Patients with metastatic or recurrent SCCHN with an Eastern Cooperative Oncology Group performance status < 2 and adequate organ function were enrolled in an institutional review board-approved trial. Prior induction or adjuvant chemotherapy was permitted provided 6 months had elapsed since the last chemotherapy. Patients were treated with UFT 300 mg/m(2) per day and leucovorin 90 mg per day administered in three doses daily for 28 days followed by a 7-day break for a 35-day cycle. Planned intrapatient dose modifications were based on individual toxicity. Patients were removed from the study for progression of disease or unacceptable toxicity.

RESULTS

One hundred six cycles of UFT/LV had been administered to 42 patients as of January 1, 2000. The most common toxicities, in descending order of incidence, were anemia, pain, fatigue, diarrhea, nausea, mucositis, and anorexia. Clinically significant toxicities attributable to UFT/ LV were primarily gastrointestinal. On an intent-to-treat basis, three patients (7%) achieved a complete response, and six patients (14%) achieved a partial response. The overall response rate was 21% (95% confidence interval, 10--37%).

CONCLUSIONS

UFT/LV therapy is feasible in this patient population and is generally well tolerated. Response rates are similar to the rates expected with continuous-infusion 5-fluorouracil. UFT/LV should be studied further both alone and in combination therapy for patients with SCCHN.

Chemotherapy in the management of squamous-cell carcinoma of the head and neck

Previously reserved for palliation, chemotherapy is now also a central component of several curative approaches to the management of patients with advanced-stage head and neck cancer. Here we review the results of both induction chemotherapy and chemoradiotherapy trials in patients with curable disease, and chemotherapy trials in patients with recurrent and metastatic disease, and we highlight current areas of investigation. Compared with traditional treatment modalities, chemotherapy given on induction schedules to patients with advanced laryngeal cancer allows greater organ preservation without compromise to survival; when given concomitantly with radiotherapy to patients with resectable or unresectable advanced disease, chemotherapy again improves survival.

Recurrent head and neck cancer: retreatment of previously irradiated areas with combined chemotherapy and radiation therapy-results of a prospective study

PURPOSE

To prospectively test the effectiveness of combined chemotherapy and radiation therapy for recurrent head and neck cancer.

MATERIALS AND METHODS

In 32 patients, external-beam radiation therapy (2 Gy/d) was administered as a 5-day course with simultaneous hydroxyurea (1.5 g/d orally) and 5-fluorouracil (300 mg/m(2)/d bolus), followed by 9 days of rest. This cycle was repeated until a cumulative soft-tissue radiation dose of 110 Gy (including prior radiation therapy) was reached.

RESULTS

At a median follow-up of 18 months, three patients were alive, and 29 had died. The overall 1-year survival rate was 39%. The overall response rate was 41% (13 patients). Acute toxicity was low. According to World Health Organization and Radiation Therapy Oncology Group criteria, there were three cases of grade 3 mucositis or dermatitis and three cases of grade 3 or 4 neutropenia. Three patients had grade 3 late effects: one oral trismus, one jugular venous thrombosis, and one cerebral stroke.

CONCLUSION

The combination of simultaneous 5-fluorouracil and hydroxyurea infusion and local reirradiation is feasible for retreatment of recurrent head and neck tumors. This regimen provides short-term tumor control in most patients and long-term control in a few patients.

A phase II trial of palliative docetaxel plus 5-fluorouracil for squamous-cell cancer of the head and neck

PURPOSE

A phase II study to determine the response rate and toxicity of docetaxel and 5-fluorouracil (5-FU) every four weeks ('TF'), in patients with incurable SCCHN.

PATIENTS AND METHODS

Patients with metastatic or recurrent SCCHN with an ECOG PS < 3 were enrolled in an institutional review board approved trial. Prior induction or adjuvant chemotherapy was permitted provided six months had elapsed. The regimen was docetaxel 70 mg/m2 i.v., day 1 and 5-FU 800 mg/m2/d x 5 days, days 1-5, as a continuous intravenous infusion, repeated every 28 days. Planned intra-patient dose modifications were based on hematological, cutaneous, and gastrointestinal toxicities. Patients were removed from the study for progression of disease or unacceptable toxicity.

RESULTS

Seventeen patients were enrolled. Fourty-six cycles of TF were administered. Reasons for discontinuance of TF included: progressive disease, 12 patients; toxicity, 3 patients; concomitant illness, 1 patient; death, 1 patient. The most common toxicities were neutropenia, mucositis, anemia, fatigue, alopecia, pain, diarrhea and nausea. Evaluation of responses to TF showed that there were four patients of seventeen (24%, 95% exact CI: 6.8-49.9) who achieved a PR or CR. Accrual was terminated after interim analysis of the response rate of the first 17 patients failed to exceed 4 of 17.

CONCLUSIONS

The response rate to TF in patients with SCCHN was lower than expected. Trials of other regimens should take precedence over further exploration of the TF regimen.

Salvage surgery for patients with recurrent squamous cell carcinoma of the upper aerodigestive tract: when do the ends justify the means?

OBJECTIVES/HYPOTHESES

Salvage surgery is widely viewed as a "double-edged sword." It is the best option for many patients with recurrent cancer of the upper aerodigestive tract, especially when original therapy included irradiation, yet it may provide only modest benefit at high personal cost to the patient. The stakes are high because alternatives are of limited value. The primary objective of this study was to fully assess the value of salvage surgical procedures in the treatment of local and regional recurrence. The following hypotheses were developed to focus the study design and data analysis. 1) The efficacy of salvage surgery correlates recurrent stage, recurrent site, and time to presalvage recurrence. 2) The economic and noneconomic costs of salvage surgery increase with higher recurrent stage. 3) Information relating the value of salvage surgery to recurrent stage and recurrent site will be useful to these patients and the physicians who treat them.

STUDY DESIGN

Two complimentary methods of investigation were used: a meta-analysis of the published literature and a prospective observational study of patients undergoing salvage surgery for recurrent cancer of the upper aerodigestive tract.

METHODS

The meta-analysis combined 32 published reports to obtain an estimate of average treatment effect for salvage surgery with regard to survival, disease-free survival, surgical complications, and operative mortality. The prospective observational study included detailed data in 109 patients who underwent salvage surgery. In addition to parameters studied in the meta-analysis, we obtained baseline and interval quality of life data (Functional Living Index for Cancer [FLIC] scores), baseline and interval performance status evaluations (Performance Status Scale for Head and Neck Cancer Patients [PSS head and neck scores]), length of hospital stay, and hospital and physician charges, and related this data primarily to recurrent stage, recurrent site, and time to presalvage recurrence.

RESULTS

The weighted average of 5-year survival in the meta-analysis was 39% in 1,080 patients from 28 different institutions. In the prospective study, median disease-free survival was 17.9 months in 109 patients, and this correlated strongly with recurrent stage, weakly with recurrent site, and not at all with time to presalvage recurrence. Noneconomic costs for patients and economic costs correlated with recurrent stage, but not with site. Baseline FLIC and PSS head and neck scores correlated with recurrent stage, but not with site. After salvage surgery the percentage of patients reaching or exceeding baseline was 51% for FLIC scores, and this differed significantly with recurrent stage. Postoperative interval "success" in PSS head and neck subscale scores for diet and eating in public also correlated with recurrent stage.

CONCLUSIONS

Overall, the expected efficacy for salvage surgery in patients with recurrent head and neck cancer was surprisingly good, but success was limited and costs were great in stage III and, especially, in stage IV recurrences. A strong correlation of efficacy and noneconomic costs with recurrent stage allowed the creation of expectation profiles that may be useful to patients. Additional systematic clinical research is needed to improve results. In the end, the decision to undergo salvage surgery should be a personal choice made by the patient after honest and compassionate discussion with his or her surgeon.

Radiation therapy, cisplatin and hyperthermia in combination in management of patients with recurrent carcinomas of the head and neck with metastatic cervical lymph nodes

Twenty-one patients with recurrent carcinomas of the head and neck with metastatic cervical lymph nodes were treated with radiation therapy, cisplatin and hyperthermia in combination, in an attempt to investigate any potential contribution in terms of safety, response, duration of palliation and quality of life. Patients not initially treated with radiation therapy were treated with a median dose of 70 Gy and patients initially treated with radiation therapy with a median dose of 30Gy. The median number of weekly cisplatin courses was five and the median number of twice weekly local external ultrasound hyperthermia sessions was five. Average T90, Average T50 and Average T10 were 39.9 +/- 1.2 degrees C, 42.4 +/- 1.3 degrees C and 44.5 +/- 0.8 degrees C, respectively, and Average CEM 43 degrees C T90, Average CEM 43 degrees C T50 and Average CEM 43 degrees C T10 were 7.8+/-9.6min, 22.6 +/- 18.8min and 39.3 +/- 25.1min, respectively. Mean follow-up was 1 year. Nodal complete response was achieved in eight patients and palliation of presenting symptoms in 19. Overall survival was 39% at 1 year. Grade 3 acute skin toxicity was observed in one patient and Grade 3 acute haematological toxicity in one. Radiation therapy, cisplatin and hyperthermia in combination appear to be safe and might improve response, prolong duration of palliation and reinstate quality of life in patients with recurrent carcinomas of the head and neck with metastatic cervical lymph nodes.

Induction chemotherapy in head and neck cancer

Induction chemotherapy can produce response rates of 60% to 90%, which are complete in 20% to 50% of previously untreated patients with squamous cell head and neck cancer. It was hoped that this dramatic chemotherapy-induced tumor shrinkage would result in more successful locoregional treatment and prove useful in disease management. Despite many promising phase II studies of neoadjuvant chemotherapy, a large number of well-controlled phase III trials have shown no survival benefit. Distant metastases may be reduced, however, and organ preservation seems more likely with this method of treatment. An understanding of the benefits of chemotherapy in this disease must recognize the multiple reasons why these patients die, and the need for greater sophistication in our endpoint analysis.

Phase II trial of cisplatin and gemcitabine in advanced squamous-cell carcinoma of the head and neck

BACKGROUND

To evaluate the toxicity profile and efficacy of cisplatin combined with gemcitabine in patients with irresectable locally recurrent or metastatic squamous cell carcinoma of the head and neck.

PATIENTS AND METHODS

Gemcitabine was given at a dose of 800 mg/m2 on days 1, 8 and 15, plus cisplatin at a dose of 50 mg/m2 on days 1 and 8; every four weeks.

RESULTS

Twenty-four patients with a median age of 59 years (range 42-74) were included. All patients were evaluable for toxicity and 22 patients were assessable for response. Eleven cases had advanced recurrent locoregional disease while 13 patients had metastatic disease. One CR (4.7%) and four PR (18%) were observed, for an overall response rate of 22.7% (95% CI: 8%-42%). The main toxicity was hematological: neutropenia grade 3-4 in 28% of the cycles and thrombocytopenia grade 3-4 in 16%. The most significant non-hematological toxicity was asthenia grade 2-3 in 24% of the cycles.

CONCLUSIONS

This cisplatin plus gemcitabine combination schedule has a favourable toxicity profile with a discrete activity in patients with locally recurrent or metastatic squamous-cell carcinoma of the head and neck.

An EORTC-ECSG phase II study of vinorelbine in patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck

BACKGROUND

Vinorelbine is an active drug in the treatment of lung and breast cancers and has a favorable toxicity profile. Many clinical trials have demonstrated its antitumor activity in other tumor types including squamous cell carcinoma of the head and neck (SCCHN). We investigated the efficacy and tolerability of vinorelbine in patients with recurrent and/or metastatic SCCHN, previously untreated by chemotherapy.

PATIENTS AND METHODS

Seventy-one patients with locoregional recurrent and/or metastatic SCCHN were treated with vinorelbine at a dose of 30 mg/m2/week i.v. by short-duration infusion on an out-patient basis. Doses were adjusted according to tolerance.

RESULTS

Two complete and seven partial responses were observed among 56 evaluable patients, yielding a response rate of 16% (95% confidence interval (CI): 8%-28%). The overall response rate of all eligible patients (63) was 14%. The responses were seen in recurrent tumors, lymph nodes and in lung metastases, and their median duration was 19 weeks (12-63). The main toxicity, severe and reversible neutropenia (grade 3-4) occurred in 53% of the 69 evaluable (for toxicity) patients. Twelve patients developed severe bronchopulmonary infections, which caused two early deaths. Constipation was observed in 31 patients (45%). Other gastrointestinal toxicities, asthenia, acute pain syndrome and peripheral sensory neuropathy, were mild to moderate. The median number of treatments was seven cycles and the median relative dose intensity of vinorelbine was 85% (25.5 mg/m2/week).

CONCLUSIONS

Vinorelbine is an active drug, with acceptable toxicity, in recurrent and/or metastatic SCCHN, at the dose and schedule administered in the present study. Further evaluation in association with other agents and/or radiotherapy is warranted.

Results and prognostic factors in the retreatment of locally recurrent nasopharyngeal carcinoma

PURPOSE

To review the results and evaluate the prognostic factors in the retreatment of locally recurrent nasopharyngeal carcinoma.

METHODS AND MATERIALS

We reviewed the records of 74 patients with locally recurrent nasopharyngeal carcinoma treated at the University of California, San Francisco between 1957 and 1995. The histologic types included squamous cell carcinoma in 6 (8.1%), nonkeratinizing carcinoma in 48 (64.9%), and undifferentiated carcinoma in 20 (27%) cases. The site of recurrence was in the primary in 46 (62.2%), in the neck nodes in 20 (27%), and in both sites in 8 (10.8%) patients. The recurrent disease was Stage I in 10 (13.5%), Stage II in 16 (21.6%), Stage III in 20 (27%), and Stage IV in 28 (37.9%) patients. Thirty-seven (50%) patients developed recurrence within 2 years and 58 (78.4%) within 5 years after initial treatment. Radiotherapeutic techniques used in the retreatment of primary recurrence consisted of external beam radiotherapy (EBRT), intracavitary brachytherapy, heavy-charged particle beam, and gamma knife, alone or in combination. Reirradiation doses ranged from 18 to 108 Gy, with a median dose of 60 Gy. Treatment of recurrent neck nodes consisted of radical neck dissection (RND) +/- intraoperative radiotherapy (IORT), or EBRT +/- hyperthermia, or chemotherapy +/- hyperthermia. Chemotherapy was used in 22 (30%) patients. Median follow-up was 20 months (range: 2 to 308 months).

RESULTS

The 3-, 5-, and 10-year actuarial overall survival following retreatment were 49, 37, 18%, respectively. Thirty-six patients (49%) were free of further local-regional recurrence after retreatment. The 3-, 5-, and 10-year local-regional progression-free rates were 52, 40, and 38%, respectively. On univariate analysis, histologic type (p < 0.0001), interval to recurrence (p = 0.034), and treatment modality for early-stage disease (p = 0.01) were significant prognostic factors for overall survival, with age being marginally significant (p = 0.053). For local-regional progression-free rate, only histology was significant (p = 0.035). On multivariate analysis, age (p = 0.026), histology (p = 0.015), and interval to recurrence (p = 0.030) were significant for overall survival, and only histology (p = 0.002) and presence of complications (p = 0.016) were significant for local-regional progression-free rate. Of the 64 reirradiated patients, late complications were documented in 29 (45%) patients. The late complications were permanent in 21 (33%) and severe in 15 (23%) patients.

CONCLUSION

Retreatment using radiotherapy alone or in combination with other treatment modalities can achieve long-term local-regional control and survival in a substantial proportion of patients with locally recurrent nasopharyngeal carcinoma. Age, histology, and interval to recurrence were independent prognostic factors for overall survival, but only histology and presence of complications were significant for local-regional progression-free rate.

Concurrent chemoradiotherapy for salvage in relapsed squamous cell head and neck cancer

The results in 9 patients with unresectable recurrent squamous cell cancer of the head and neck who were treated with aggressive concurrent chemoradiotherapy are reported. Treatment consisted of one or two courses of chemotherapy with 5-fluorouracil 1000 mg/m2/day and cisplatin 20 mg/m2/day, both given as 4-day continuous intravenous infusions, concurrent with radiation therapy. Salvage radiation doses between 30 and 70 Gy were administered. Seven patients had previously undergone an attempt at curative surgery, and 7 had been treated with radiation doses between 52 and 72 Gy. The recurrent disease was locally confined in 3, locoregional in 5, and locoregional with metastases in 1 of the 9 patients. Treatment toxicity was significant and included mucositis, nausea/vomiting, and granulocytopenia, but there were no toxic deaths. Complete tumor clearance was possible in 6 of these 9 patients, and 5 patients remain disease-free at 41+, 43+, 45+, 47+, and 50+ months. Of these 5 patients, 4 had previously been treated with both surgery and radiation, while 1 had only undergone surgery. We conclude that aggressive chemotherapy and concurrent (re)irradiation can be given to patients with unresectable, recurrent, squamous cell cancer of the head and neck. Treatment is tolerable, and disease-free long-term survival is possible. Careful patient selection, however, is required.

Bleomycin, epirubicin, carboplatin (BECA) in the treatment of recurrent and/or metastatic squamous cell carcinoma of the head and neck

The aim of this study was to evaluate three active agents, bleomycin (BLM), epirubicin and carboplatin in a new combination (BECA) in terms of feasibility, activity and toxicity in patients with recurrent and metastatic squamous cell carcinoma of the head and neck. From April 1992 to February 1993 15 pts (12M/3F), median age 53 years, all pretreated (6 surgery + radiotherapy; 3 radiotherapy + chemotherapy; 6 radiotherapy), were treated with BLM 15 mg/m2 days 1-14; epirubicin 30 mg/m2 days 1-14 and carboplatin 300 mg/m2 day 1 every 28 days. In the 14 evaluable pts we observed 1 complete response, CR (7.1%), 4 partial responses, PR (28.6%), 5 stable disease, SD and 4 disease progression, PD with an overall response of 35.7%. The treatment was globally well tolerated, 1 pt with grade 3 leukopenia and 1 pt with grade 3 thrombocytopenia, 1 pt with grade 3 emesis and 1 pt with grade 3 mucositis. At the last follow-up the duration of CR was 34 months, the duration of PRs were respectively 22-10-10-7 months, but the SD ranged from 4 to 6 months. The overall median survival was 8 months (3-36), 14 for responders and 4 for non-responders. This final report seems to confirm the activity and efficacy of the BECA regimen, suitable for outpatient administration with an overall response equal to other more aggressive combinations.

Phase I-II trial of recombinant interferon alpha-2b with cisplatin and 5-fluorouracil in recurrent and/or metastatic carcinoma of head and neck

The aims of this study were to establish the feasibility and toxicity of the biochemical modulation of the cisplatin (CDDP)-5FU combination by interferon alpha-2b (INF), and to assess its therapeutic efficacy in recurrent and/or metastatic squamous cell carcinoma of the head and neck (SCCHN). The mandatory eligibility criteria included histologically proven SCCHN; a performance status <2; adequate bone marrow, hepatic, renal, and cardiac functions; and measurable and/or evaluable disease. The protocol was CDDP, 100 mg/m2 i.v. day 1; 5-FU, 1,000 mg/m2 in a c.i.v. infusion over 96 h; and INF 3.10(6) U/day s.c., begun 2 h before cisplatinum for 5 consecutive days, repeated every 3 weeks. Twenty patients were included and received 76 cycles (median number cycles/patient = three). Eighteen patients were evaluable for activity with an overall response rate (RR) of 30% [2 complete responses (CR) + 4 partial responses (PR)], which was 55% (5/9) in previously untreated and 9% (1/11) in previously treated patients. Myelosuppression (50%), mucositis (40%), loss of electrolytes (15%), and asthenia (20%) were the most frequent severe toxic effects. Notwithstanding, the protocol was feasible and well tolerated in this overall population with a poor prognosis. Median duration of response was 8 months, and median survival for the overall population was 8.5 months. This schedule is the test arm of an ongoing international multicentric phase III trial versus standard CDDP-5FU in the same SCCHN population.

Laser photochemotherapy with anthracyclines on cultured human squamous carcinoma cells

A new treatment for cancer has been tested in vitro using light-sensitive anthracyclines followed by laser photoactivation, as described by several investigators. We previously reported 10-fold enhanced laser killing after 2 hours of incubation with daunomycin by cultured human carcinoma cells. This short-term uptake leads to drug localization in cytoplasmic and membrane sites prior to nuclear accumulation and topoisomerase inhibition. In the present study, daunomycin was incubated for 2 or 24 hours with P3 squamous carcinoma cells to directly compare cytoplasmic vs. nuclear drug targeting before and after KTP-532 laser activation. Monolayer cultures of the P3 cells sensitized with daunomycin for 2 hours, then chilled (4 degree C), and exposed to the KTP laser (532 nm, 94.2 J/cm2) had a 2- to 10-fold increased therapeutic response compared with drug or laser alone when measured by MTT tetrazolium assays. After 24 hours of incubation with daunomycin, the chemotherapeutic response of P3 tumor cells was amplified 2-fold by laser exposure. The results suggest that daunomycin and laser treatment can be combined for improved therapy of human cancer.

Chemotherapy of squamous cell carcinoma of head and neck: the future is now

In 1996, there is an established role for chemotherapy in head and neck cancer. Patients with recurrent disease will be offered combination chemotherapy. In this setting, investigations of new drugs or combinations and the pursuit of concomitant chemo-reirradiation are of interest. In patients with locoregionally advanced disease, induction chemotherapy can be used with the goal of larynx preservation. In addition, a role for chemotherapy in nasopharyngeal cancer appears to be emerging with increased survival as therapeutic goal. The combination of cisplatin and 5-FU does not need to be tested further, however, a more definitive evaluation of a biochemically modulated PF regimen might be of interest. Furthermore, induction chemotherapy represents an ideal investigational tool in which to further evaluate the activity of several new drugs in head and neck cancer patients. Finally, concomitant chemoradiotherapy has resulted in increased survival in several randomized clinical studies. Given the poor outcome of standard radiotherapy in patients with unresectable disease, we favor the administration of concomitant chemoradiotherapy in this group of patients as a standard therapy. In our opinion, the use of radiation therapy alone in this group of patients should be restricted to patients with poor performance status or other high medical risks that render the administration of chemotherapy unadvisable. Finally, given the high incidence of second malignancies and general medical complications in cured head and neck cancer patients, studies of chemoprevention and good preventive medical care by a medical oncologist should be made available to all patients.

Laser photochemotherapy: a less invasive approach for treatment of cancer

The effectiveness of combining surgery with chemo- and radiation therapy in treatment of human cancer provides a useful model for further development of new multimodality approaches including laser photochemotherapy. Laser endoscopy often is a useful treatment for obstructive tumors in airways, but interstitial laser fiberoptics is becoming a more precise, minimally invasive alternative for ablation of unresectable or recurrent neoplasms. Combining intratumor chemotherapy with laser energy delivery via interstitial fiberoptics should be most effective using drugs activated by photothermal energy. A number of investigators have shown that anthracyclines and cis-platinum are likely candidates for light or heat activation in cancer cells. An advantage of anthracyclines is their dual role as antitumor drugs and as photosensitizers. Because they are effective chemotherapy agents without photoactivation, two approaches are possible to increase tumor responses. Maximum tolerated dose followed by photoillumination via laser fiberoptics can be used to obtain better tumor palliation. Improved treatment response to lower intratumor drug levels after laser activation also should reduce systemic toxicity. Preclinical studies and recent case reports from several groups suggest photochemotherapy with currently approved drugs and lasers may soon become an attractive alternative for treatment of recurrent tumors in cancer patients.

The use of cisplatin plus 5-fluorouracil chemotherapy in an unselected group of patients with recurrent squamous cell carcinoma of the head and neck

Cisplatin and infusional 5-fluorouracil (5-FU) has become regarded as the standard chemotherapy for squamous cell carcinoma (SCC) of the head and neck. Results of phase II studies vary widely and do not always reflect the activity of regimen in general clinical practice. We have treated 20 consecutive patients with cisplatin 100 mg/m2 and 5-FU given as a 4-day infusion at 1 g/m2 for 24 h. In order to reflect more accurately the activity of this regimen in everyday practice we have followed as many patients as possible to relapse and death and measured the duration of remissions from the end of treatment. 6 patients responded (30%, 95% CI: 10-48%) with 1 patient achieving a complete remission. Partial remission lasted for 3-18 months and the complete remission lasted for 7 months. Median survival of patients from the date of first treatment was 7 months (range 1 week-20.5 months). The regimen was well tolerated but required hospitalisation. We conclude that this regimen is well tolerated, active and a good choice for treating recurrent SCC of the head and neck in an unselected population of patients with recurrent disease in the context of everyday oncological practice.

Electrochemotherapy, a new antitumor treatment. First clinical phase I-II trial

BACKGROUND

Electrochemotherapy is a new antitumor treatment consisting of electrical pulses administered to the tumor several minutes after intravenous injection of bleomycin. In mice, important antitumor effects were observed on subcutaneously transplanted tumors and on spontaneously occurring mammary carcinomas. Cures were obtained after one single treatment combining bleomycin and electric pulses. In humans, permeation nodules seemed an adequate oncologic situation to assay this new procedure. The authors report the first Phase I-II trial of electrochemotherapy.

METHODS

Eight patients with 40 permeation nodules of head and neck squamous cell carcinomas were treated with 10 mg/m2 bleomycin intravenous bolus, followed by four or eight short (100 microseconds) and intense (1300 V/cm) pulses administered through two external electrodes located on each side of the treated nodule.

RESULTS

An instantaneous painless contraction of the underlying muscles was regularly observed. Neither local nor general side effects were observed, and electrochemotherapy was well tolerated. In addition, a clear local antitumor efficacy was found: 23 (57%) nodules were in clinical complete response within a few days.

CONCLUSION

The absence of toxicity, the good tolerance by the patients, and the net antitumor effects observed are encouraging for additional electrochemotherapy developments in clinical oncology.

Simultaneous chemoradiotherapy as salvage treatment in locoregional recurrences of squamous head and neck cancer

This study was designed to determine if long-term palliation could be obtained in pre-irradiated locoregional recurrent squamous head and neck cancer patients, with the administration of simultaneous chemoradiotherapy. Mandatory eligibility criteria were histologically documented squamous head and neck cancer in previously irradiated territory, surgical or brachytherapy salvage unfeasibility, or patient refusal. The protocol consisted of radiotherapy, at a rate of 5 daily fractions of 2 Gy on alternate weeks, with simultaneous continuous intravenous infusion of 5-fluorouracil (5FU) at 800 mg/m2 and oral hydroxyurea (HU) at 1,000-1,500 mg/day for 5 days. Tolerance was good. Acute toxicity was low with no grade > or = III WHO hematologic toxicity observed. Nine patients had grade III mucositis, one had grade IV, three had grade III skin toxicity, and only four patients required a 20% to 30% 5FU dose reduction because of it. Two patients had hand and foot syndrome, and two had asymptomatic 5FU-related cardiac signs (1 ECG, 1 echographic+ECG). Chronic radiotherapy-related effects consisted of Hermitte's sign observed in two patients. Of 34 registered patients, 33 were evaluable for response. An overall rate of 55% (18 patients) of objective responses [complete response (CR) + partial response (PR)] was obtained, with 12 patients (36%) achieving local control of disease. The median survival was 11 months. These data show that palliation could be obtained for the majority of responding patients, and also suggest an improvement in the immediate prognosis with this type of salvage procedure for a selected group of recurrent squamous head and neck cancer patients.

A novel technetium-99m labeled monoclonal antibody (174H.64) for staging head and neck cancer by immuno-SPECT

A novel murine monoclonal antibody (MAb 174H.64) was labeled with 99mTc by a direct method. MAb 174H.64 detects a cytokeratin-associated antigen which is expressed by over 90% of all squamous cell carcinomas. Panendoscopy, sonography and computerized tomography scan were performed in all cases as well as magnetic resonance imaging (in selected patients). Pre-operative immunoscintigraphy was performed in 21 patients with histologically proven primary carcinomas (18 with remaining primary tumors and 3 with lymph node recurrences). Scintigraphic images were obtained 4-6 h after injection of 1.1 GBq of the 99mTc-labeled antibody (2 mg). Late images were acquired 18 to 24 h after injection. Single-Photon-Emission-Computed Tomography (SPECT) of the head and thorax was performed in all patients. The primary tumors were immunoscintigraphically visualized in all 18 patients with remaining primary tumor. Fifteen of 18 loco-regional lymph node metastases were visualized by immunoscintigraphy (the smallest lesions had a diameter of < 1 cm), in one patient lymph node metastases were detected by immunoscan only. Two metastatically involved lymph nodes were identified by histology only (micrometastases). Distant metastases were present in 3 patients, of which two were identified by immunoscintigraphy. Immuno-SPECT according to this method was a sensitive and specific imaging modality for preoperative staging of patients with squamous cell carcinoma of the head and neck and detected lymph node metastases with higher accuracy than conventional clinical and imaging modalities.