Analysis of Prognostic Factors in Squamous Cell Carcinomas of the Head and Neck

Association between severity of dysphagia and survival in patients with head and neck cancer

BACKGROUND

This study examined risk factors for dysphagia, a common and serious condition in patients with head and neck cancer, and the association between severity of dysphagia and survival.

METHODS

Chart reviews were performed on patients diagnosed with head and neck cancer between January 2001 and April 2003, who had dysphagia diagnoses or swallowing evaluations. Regression analyses determined factors associated with dysphagia and the association between observed survival and severity of dysphagia.

RESULTS

Almost 50% of the 407 patients had dysphagia. Risk factors included advanced stage, older age, female sex, and hypopharyngeal tumors. The most severe dysphagia ([L.] nil per os or "nothing by mouth" status), which was associated with lower survival rates, was the strongest independent predictor of survival.

CONCLUSIONS

Swallowing problems should be considered when determining appropriate cancer-directed treatment and posttreatment care. Because of dysphagia's high incidence rate and association with survival, a speech-language pathologist should be involved to ensure routine diagnostic and therapeutic swallowing interventions.

Radical Radiotherapy in Head and Neck Squamous Cell Carcinoma: An Analysis of Prognostic and Therapeutic Factors

AIMS

Head and neck squamous cell carcinoma (HNSCC) continues to be a leading cancer in developing countries. Definitive radiation therapy either primary or as postoperative adjuvant is offered to most patients. We aimed to identify prognostic and therapeutic factors that affect locoregional control and survival in patients undergoing radical radiotherapy for head and neck squamous cell cancers.

MATERIALS AND METHODS

A retrospective analysis of 568 previously untreated patients with squamous head and neck cancers, who received radical radiotherapy between 1990 and 1996, using local control, locoregional control and disease-free survival (DFS) as outcome measures.

RESULTS

With a median follow-up of 18 months for living patients, the 5-year local control, locoregional control and DFS for all 568 patients were 53%, 45% and 41%, respectively, for all stages combined. The 5-year local control, locoregional control and DFS as per the American Joint Committee on Cancer stage grouping were 78%, 70% and 70%; 64%, 59% and 57%; 51%, 42% and 37%; and 40%, 27% and 22% from stages I to IV, respectively, with highly significant P values. Patients receiving higher doses (> or = 66 Gy) had a significantly better outcome compared with lower doses. The 5-year local control (59% vs 48%, P = 0.0015), locoregional control (47% vs 41%; P = 0.0043) and DFS (44% vs 37%; P = 0.0099) were significantly better in patients receiving > or = 66 Gy. Site of primary also affected outcome significantly, with oral cavity lesions faring badly.

CONCLUSION

Tumour stage remains the most important factor affecting outcome in radical radiotherapy of HNSCC. A definite dose-response relationship exists with higher total doses, leading to better local control, locoregional control and DFS in all stages. Site of primary affects outcome too, with laryngeal primaries doing well and oral cavity cancers faring the worst.

Prediction of TP53 status for primary cisplatin, fluorouracil, and leucovorin chemotherapy in ethmoid sinus intestinal-type adenocarcinoma

PURPOSE

To assess the role of TP53 status in predicting pathologic complete remission after primary chemotherapy in patients with ethmoidal intestinal-type adenocarcinoma (ITAC).

PATIENTS AND METHODS

Thirty patients with ethmoidal ITAC enrolled onto a phase II study received chemotherapy with cisplatin, fluorouracil, and leucovorin (PFL) followed by surgery and radiation. On surgical specimens, absence of viable tumor cells was defined as pathologic complete remission (pCR). TP53 status/p53 function, analyzed on pretreatment biopsies, were retrospectively correlated with pathologic results and patient outcome.

RESULTS

Twelve patients achieved a pCR; 18 patients did not (overall response rate, 40%). In patients with wild-type (wt) TP53 or functional p53 protein, the pCRs were 83% and 80%, respectively; in patients with mutated TP53 or impaired p53 protein, pCRs were 11% and 0%, respectively (P < or = .0001). At a median 55-month follow-up, all pCR patients were disease-free; 44% of nonresponding patients experienced relapse (P = .0061).

CONCLUSION

The results indicate the existence of two genetic ITAC subgroups, defined by differences in TP53 mutational status or protein functionality, that strongly influence pathologic response to primary chemotherapy and, ultimately, prognosis. PFL seems to be highly effective in terms of pCR and disease-free survival in the presence of a wt or a still-efficient p53 protein, even when encoded by a mutated TP53 gene (eg, early-stop codon mutation), but ineffective in ITACs carrying a disabled p53 protein. Whether this model is extensible to other head and neck cancers needs appropriate investigation.

Prognostic implications of loss of heterozygosity at 8p21 and 9p21 in head and neck squamous cell carcinoma

Loss of heterozygosity (LOH) in chromosomal regions that harbor tumor suppressor genes from tumor tissue may lead to decreased survival time in cancer patients with squamous cell carcinoma of the head and neck (HNSCC). We studied 8 regions frequently lost in HNSCC in 150 patients having a primary diagnosis of HNSCC. Tumor and normal tissue DNA were genotyped for microsatellite repeat markers in 8 unlinked chromosomal regions. The association between LOH and death from HNSCC was investigated, weighted by number of informative markers per region and adjusted for age at diagnosis, self-reported race, tumor stage and current smoking status. LOH at 3 chromosomal regions were independently associated with reduced survival. A greater risk for cancer mortality was observed for LOH at chromosomal regions 3p24.3-p14.3 (p = 0.02), 8p21.3-p11.21 (p = 0.02) and 9p24.2-p21.2 (p = 0.03). In these regions, LOH at one or more markers was observed in 66.9%, 43.3% and 60.6% of patients, respectively. Survival times were significantly shorter for those with LOH at marker NEFL on 8p21.2 (relative risk = 6.15; p = 0.0002) and at D9S126 on 9p21.2 (relative risk = 5.96; p = 0.0003). Our results indicate that LOH at several chromosomal sites may offer additional independent prognostic information beyond traditional indicators such as tumor stage and age.

Recurrent neck disease in oral cancer

PURPOSE

The goals were to examine the clinical and pathologic features of patients who developed metastatic squamous cell carcinoma in the cervical lymph nodes after initial treatment and to identify any common patterns.

PATIENTS AND METHODS

A retrospective analysis of 35 patients of varying initial tumor stage was performed. There were 18 patients who had an initial neck dissection and 17 patients whose neck was managed by a "watch and wait" policy.

RESULTS

Recurrence frequently involved level II nodes, and extracapsular spread was invariably present. The time taken for recurrence to develop was the same in both groups of patients (15 months, P =.35), and the overall median survival time after recurrence was 18 months (12 to 25 months, 95% confidence interval). In 27 of 29 patients (93%) who had the primary tumor resected, the thickness of tumor was greater than 5 mm.

CONCLUSION

Neck recurrence may represent residual disease; it has histologically unfavorable features and consequently a poor prognosis. The frequency of recurrence at level II emphasizes the need for meticulous dissection in this region, and tumor thickness needs to be considered in planning treatment of the clinically negative neck.

Improved prediction of metastasis in tongue carcinomas, combining vascular and nuclear tumor parameters

BACKGROUND

Predicting the presence of metastasis, based on tumor or tumor-related characteristics is of utmost importance. The authors studied the significance of tumor DNA features and tumor-related angiogenesis to predict the occurrence of metastasis in squamous cell carcinomas (SCCs) of the tongue.

METHODS

Paraplast blocks from resection specimens of 20 metastasized and 20 nonmetastasized SCCs of the tongue with a minimum follow-up of 24 months were used. Tissue sections were stained with anti-CD34 monoclonal antibodies for vessel visualization, and according to Feulgen to stain DNA. Using image analysis, data from both stainings were computed for each of the 40 carcinomas. A logistic regression model to predict the presence of metastasis, based on vascular and nuclear morphology features, was developed.

RESULTS

The intratumor variation of chromatin condensation and the percentage vessels smaller than 5 microm in diameter were selected for the model. The model correctly predicted metastasis in 90% of patients and excluded metastasis correctly in 75% of nonmetastasized tumors. Taking into account the prevalence of metastasis in SCC of the tongue of between 30% and 60%, this means a predictive value for a negative outcome of between 95% and 83%.

CONCLUSIONS

The proposed model shows an improvement of predictive values compared with previous models with single parameters. Therefore, a multiparameter model appears to predict the multiparameter process of metastasis better.

Prognostic factors and relative risk for survival in N1-3 oral squamous cell carcinoma: a multivariate analysis using Cox's hazard model

The records of 136 patients with N1-3 oral squamous cell carcinoma treated by surgery were investigated retrospectively, with the aim of finding out which factors were predictive of survival on multivariate analysis. Four independent factors significantly influenced survival in the following order: pN stage; T stage; histological grade; and N stage. The most significant was pN stage, the five-year survival for patients with pN0 being 91% and for patients with pN1-3 41%. A further study was carried out on the 80 patients with pN1-3 to find out their prognostic factors for survival and the independent factors identified by multivariate analysis were T stage and presence or absence of extracapsular spread to metastatic lymph nodes.

Pretreatment pathologic prognostic factors in head and neck squamous cell carcinoma

Squamous carcinomas of the head and neck region are a common problem for the otolaryngologist; surgeons are obliged to draw together disparate lines of evidence-from physical examination, pathology, and radiology-to plan optimal therapy for their patients. This article explores some of the ways in which pathologic analysis of a biopsy specimen in the past (determination of extent of invasion and degree of differentiation), present (including an analysis of the pattern of infiltration and the tumor' s DNA content), and, perhaps, the future (possibilities including cytogenetics and analysis of discrete steps in the cell cycle) plays a role in this process.

[Immunocytochemical venous blood studies in patients with manifest oral cavity carcinomas, oral precancerous conditions, benign tumors and in chronic alcoholic patients]

In a prospective pilot study we investigated the percentage of immunocompetent cells in the peripheral blood in 146 patients (lymphocytes, leucocytes, monocytes, T cells, B cells, NK cells, T-helper cells, T-suppressor cells, ratio T-helper/T-suppressor cells, activated T cells HLA-DR) by flow cytometry. The immunologic parameters were derived from patients with oral and oropharyngeal squamous cell carcinomas, precancerous lesions and benign tumours and from a group of heavy smokers and alcoholics. Carcinoma patients (n = 46) were compared with risk groups and a reference group consisting of patients with inflammatory disease. Within the collective of carcinoma patients we measured the immune status before and after chemo-, radio- and operative therapy. We also analysed the immune parameters in relation to clinical and histomorphological parameters (TNM status, grading). The univariate analysis of monocytes showed significant relationships between on the one hand carcinoma patients and on the other alcoholics and those with benign tumours and precancerous lesions. In precancerous lesions NK cells were significantly increased compared with alcoholics and the reference group. A significant decrease in B cells in carcinoma patients may show incipient insufficiency of the humoral immunity. The immune parameters showed a different reaction depending on therapy. After irradiation we found a significant increase of T-suppressor cytotoxic cells and decreases in B and T-helper cells. Chemotherapy showed an increase in T and T-helper cells and a decrease in B cells. Surgical therapy alone yielded an increase in B cells. The comparison of all pre- and posttherapeutic parameters showed significant changes only in activated T cells HLA-DR. We found no correlation between prognostic clinico-pathological factors and immune parameters. No changes were found in a multivariate analysis.

Head and neck carcinoma--stage at presentation

A prospective study was performed during a 2-year-period. A total of 127 patients presenting with a squamous cell carcinoma of the head, neck and upper aerodigestive tract were entered into the study. Patients were classified according to the primary site, namely: larynx (n = 44), oropharynx (n = 28), hypopharynx (n = 17) and oral cavity (n = 19) and others (n = 19). Patients were staged according to the UICC TNM classification (1987) and the nature and duration of their symptoms were recorded. Sixty-one per cent of patients were found to be presenting with advanced disease (stages 3 and 4): oropharynx--71%; hypopharynx--77%; oral cavity--50%; larynx--34%. No relationship could be established between stage at presentation and duration of symptoms and 53% of patients with advanced disease had been symptomatic for less than 3 months at the time of diagnosis. Only 28% of patients presenting with stage 3 or 4 disease had symptoms for 3 months or longer. Earlier diagnosis will not make a significant impact on the overall prognosis in head and neck cancer.

Evaluation of sensitivity in DNA aneuploidy detection using a mathematical model

Detection of DNA aneuploid populations in samples analyzed by flow cytometry generally requires recognition of more than a single G0/G1 peak on the resulting DNA histogram. This assessment is critical in clinical samples if diagnosis or subsequent patient treatment are influenced. In this paper we evaluate three major distribution parameters that contribute to recognition or obscuration of closely spaced peaks on a DNA histogram. These parameters are (1) coefficient of variation (CV), (2) proportion of cells within each peak, and (3) separation of peaks (DNA index, DI). Through the analysis of computer-synthesized DNA histograms, we produced a single chart illustrating the minimum CV required for two peaks (representing DNA diploid and DNA aneuploid cells) in mixtures of various proportions (1:99 to 99:1) and DI values (1.01 to 1.20) to be resolved. This information can be utilized to provide insight into the ability of flow cytometry to resolve a DNA aneuploid population in a histogram.

Frequent amplification of 11q13 DNA markers is associated with lymph node involvement in human head and neck squamous cell carcinomas

Amplification of 11q13 DNA markers, particularly hst-1/FGF4 oncogene and the bcl-1 locus, was evaluated in 178 head and neck squamous cell carcinomas (SCCs) by Southern blot and slot blot hybridisation. Coamplification of hst-1/FGF4 and bcl-1 genes was found in 57% of primary tumours and in 60% of the 89 metastatic lymph nodes tested. The pattern of amplification was significantly similar in matched sets of primary SCCs and metastatic lymph nodes. Levels of amplification, quantified by densitometric analysis of slot blots, ranged from 2 to 18-fold normal gene dosage. Also, c-myc oncogene (8q24) was found amplified less frequently, since 7% of 169 SCCs tested contained amplification of this gene, the level of which ranged from 2 to 8-fold. Hst-1/bcl-1 gene amplification was observed more frequently in the tumours arising from the hypopharynx. Coamplification of hst-1 and bcl-1 genes was significantly positively associated with tumours with nodal involvement (P = 0.001). Incidence of hst-1/bcl-1 gene amplification is higher in the tumours with a clinical stage III or IV. Hst-1/bcl-1 gene amplification was not related to tumour differentiation or local invasiveness. This prospective study shows that amplification of 11q13 DNA markers is a prominent event occurring in head and neck SCC and may contribute to the pathogenesis and evolution of a subset of patients bearing this type of cancer.

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.