Prognostic factors in head and neck cancer

Predictive value of clinical and radiomic features for radiation therapy response in patients with lymph node-positive head and neck cancer

BACKGROUND

Prediction of survival and radiation therapy response is challenging in head and neck cancer with metastatic lymph nodes (LNs). Here we developed novel radiomics- and clinical-based predictive models.

METHODS

Volumes of interest of LNs were employed for radiomic features extraction. Radiomic and clinical features were investigated for their predictive value relatively to locoregional failure (LRF), progression-free survival (PFS), and overall survival (OS) and used to build multivariate models.

RESULTS

Hundred and six subjects were suitable for final analysis. Univariate analysis identified two radiomic features significantly predictive for LRF, and five radiomic features plus two clinical features significantly predictive for both PFS and OS. The area under the curve of receiver operating characteristic curve combining clinical and radiomic predictors for PFS and OS resulted 0.71 (95%CI: 0.60-0.83) and 0.77 (95%CI: 0.64-0.89).

CONCLUSIONS

Radiomic and clinical features resulted to be independent predictive factors, but external independent validation is mandatory to support these findings.

Improved cancer detection in Waldeyer's tonsillar ring by 68Ga-FAPI PET/CT imaging

Purpose

In cancer of unknown primary (CUP), positron emission tomography/computed tomography (PET/CT) with the glucose analog [¹⁸F]FDG represents the standard imaging approach for localization of the malignant primary. Frequently, however, [¹⁸F]FDG PET/CT cannot precisely distinguish between small occult tumors and chronic inflammation, especially in Waldeyer’s tonsillar ring. To improve the accuracy for detecting primary tumors in the Waldeyer’s tonsillar ring, the novel PET tracer [⁶⁸Ga]Ga-FAPI-4 for specific imaging of fibroblast activation protein (FAP) expression was used as a more specific target for cancer imaging.

Methods

Eight patients with suspicion of a malignant tumor in Waldeyer’s tonsillar ring or a CUP syndrome were examined. PET/CT scans with [¹⁸F]-FDG and [⁶⁸Ga]Ga-FAPI-4 were performed for pre-operative tumor localization. After surgical resection, histopathological and immunohistochemical results were compared to PET/CT findings.

Results

Histopathology revealed a palatine or lingual tonsil carcinoma in all patients. In case of lymph node metastases smaller than 7 mm in size, the [¹⁸F]FDG PET/CT detection rate of cervical lymph node metastases was higher than that of [⁶⁸Ga]FAPI PET/CT, while both tracers identified the primary tumors in all eight cases. The size of the primary and the lymph node metastases was directly correlated to the respective FAP expression, as detected by immunohistochemistry. The mean SUV_max for the primary tumors was 21.29 ± 7.97 for ¹⁸F-FDG and 16.06 ± 6.29 for ⁶⁸Ga-FAPI, respectively (p = 0.2). The mean SUV_max for the healthy contralateral tonsils was 8.38 ± 2.45 for [¹⁸F]FDG and 3.55 ± 0.47 for [⁶⁸Ga]FAPI (p < 0.001). The SUV_max ratio of [⁶⁸Ga]FAPI was significantly different from [¹⁸F] FDG (p = 0.03). Mean TBR_max for the [⁶⁸Ga]Ga-FAPI-4 tracer was markedly higher in comparison to [¹⁸F]FDG (10.90 vs. 4.11).

Conclusion

Non-invasive imaging of FAP expression by [⁶⁸Ga]FAPI PET/CT resulted in a better visual detection of the malignant primary in CUP, as compared to [¹⁸F]FDG imaging. However, the detection rate of lymph node metastases was inferior, presumably due to low FAP expression in small metastases. Nevertheless, by offering a detection method for primary tumors with the potential of lower false positive rates and thus avoiding biopsies, patients with CUP syndrome may benefit from [⁶⁸Ga]FAPI PET/CT imaging.

Pre-treatment radiomic features predict individual lymph node failure for head and neck cancer patients

BACKGROUND AND PURPOSE

To develop and validate a pre-treatment radiomics-based prediction model to identify pathological lymph nodes (pLNs) at risk of failures after definitive radiotherapy in head and neck squamous cell carcinoma patients.

MATERIALS AND METHODS

Training and validation cohorts consisted of 165 patients with 558 pLNs and 112 patients with 467 pLNs, respectively. All patients were primarily treated with definitive radiotherapy, with or without systemic treatment. The endpoint was the cumulative incidence of nodal failure. For each pLN, 82 pre-treatment CT radiomic features and 7 clinical features were included in the Cox proportional-hazard analysis.

RESULTS

There were 68 and 23 nodal failures in the training and validation cohorts, respectively. Multivariable analysis revealed three clinical features (T-stage, gender and WHO Performance-status) and two radiomic features (Least-axis-length representing nodal size and gray level co-occurrence matrix based - Correlation representing nodal heterogeneity) as independent prognostic factors. The model showed good discrimination with a c-index of 0.80 (0.69-0.91) in the validation cohort, significantly better than models based on clinical features (p < 0.001) or radiomics (p = 0.003) alone. High- and low-risk groups were defined by using thresholds of estimated nodal failure risks at 2-year of 60% and 10%, resulting in positive and negative predictive values of 94.4% and 98.7%, respectively.

CONCLUSION

A pre-treatment prediction model was developed and validated, integrating the quantitative radiomic features of individual lymph nodes with generally used clinical features. Using this prediction model, lymph nodes with a high failure risk can be identified prior to treatment, which might be used to select patients for intensified treatment strategies targeted on individual lymph nodes.

Association between high collagenase-3 expression levels and poor prognosis in patients with head and neck cancer

BACKGROUND

Squamous cell carcinoma of the head and neck (HNSCC) is a common cancer type. The ability for curative treatment with surgery and radiotherapy (RT) is usually highly dependent on tumor stage at the time of diagnosis.

METHODS

The purpose of this study was to determine whether the expression of a cancer-specific proteinase, collagenase-3 (matrix metalloproteinase-13 [MMP-13]), is associated with survival parameters in patients with HNSCC. We studied MMP-13 expression in tumors of 81 patients with stage I-IV HNSCC treated with surgery alone or in combination with radiotherapy.

RESULTS

We found a subgroup of patients with high MMP-13 expression level in their tumors (>/=90% MMP-13-positive tumor cells) associated with unfavorable prognosis (median overall survival [OS], 11.8 vs 19.6 months, p = .032). In addition, the median disease-specific survival (DSS) time was markedly reduced in this subgroup (13.8 months vs 40.7 months, p = .062). When the subgroup of patients treated with a curative intent was studied, the same association was found in OS (13.8 vs 24.6 months, p = .023) and DSS (p = .004). In addition, there was a trend for association between >/=90% MMP-13 positivity and a recurrent tumor (p = .078) in curatively treated patients.

CONCLUSIONS

The short survival time associated with high MMP-13 expression levels could not be predicted by tumor size or local lymph node invasion. These results show that a high MMP-13 expression level is associated with aggressiveness of HNSCC and may have prognostic value in patient evaluation.

Versican expression in pharyngeal squamous cell carcinoma: an immunohistochemical study

AIMS

To study the expression of versican, a large proteoglycan involved in repressing adhesion between cells and the extracellular matrix in pharyngeal squamous cell carcinoma (PSCC), and its relation to the expression of p53 and catenins, histological differentiation, clinical data, and prognosis.

METHODS

For the retrospective survey, primary tumours for analyses were obtained from 118 patients diagnosed with PSCC of the oropharynx or hypopharynx. The immunohistochemical expression of versican was studied and was related to the expression pattern of p53 and catenins, in addition to clinical data and survival.

RESULTS

In the primary tumours, strong stromal versican expression was graded as low in 59 (50%) and high in 59 (50%) cases. In addition, intracellular versican staining was seen in nine (8%) tumours. In local lymph node metastases, strong stromal versican staining was significantly more frequent compared with the primary tumours (p = 0.018). Strong stromal versican staining was more frequently seen in less advanced tumours (p = 0.015). There was no association between versican expression and the other investigated variables (p53, catenins, TNM status, and histological grade). Neither stromal nor intracellular versican expression predicted overall survival in these patients.

CONCLUSIONS

Versican was more strongly expressed in the stroma of local metastases and in the earlier stages of disease in PSCC. However, versican expression was not an independent prognostic factor in this entity.

Validation of tissue array technology in head and neck squamous cell carcinoma

BACKGROUND

The recent development of tissue array technology has potentiated large-scale retrospective cohort studies using archival formalin-fixed, paraffin-embedded tissues. This study evaluates the potential for using archival head and neck cancer tissue in such arrays.

METHOD

Tissue array blocks were made from 184 head and neck cancer specimens. Three core tissue biopsies (0.6 mm x 3-4 mm) were taken from individual "donor" paraffin-embedded tumor blocks and arrayed into a new "recipient" paraffin block. Immunohistochemical (IHC) analyses were performed using antibodies recognizing cyclin-D1, Rb, and EGFR. IHC was scored on a 6-point scale for extent and a 3-point scale for intensity. We compared the staining of tissue array disks with staining of full tissue sections.

RESULTS

Seventy-four percent (475 of 640) of samples placed into tissue arrays were confirmed to represent tumor tissue. The remaining samples were lost during processing or contained too few tumor cells. Only 6% of cases were completely lost, whereas 55%, 28%, and 11% of cases were judged on 3, 2, or 1 disk, respectively. Cohen's kappa coefficient was 0.66 for cyclin-D1, 0.40 for EGFR, and 0.41 for Rb.

CONCLUSIONS

Tissue array technology is a rapid and efficient method for retrospective analysis of protein expression and is a promising tool for validation of prognostic markers in large series of head and neck squamous cell carcinomas. The agreement in scoring of the full section and the tissue arrays is reasonable. Discordance is probably due to intraobserver variation and lack of robustness of the scoring inherent of the proteins studied.

Factors Predictive of Local Disease Control after Intra-arterial Concomitant Chemoradiation (RADPLAT)

OBJECTIVES

To determine the relative risk of prognostic factors for local disease control following RADPLAT.

STUDY DESIGN

Prospective study, academic medical center.

METHODS

Analyses of nine categories of risk factors among 240 patients with Stage II-IV carcinoma consecutively treated with RADPLAT (cisplatin 150 mg/m IA and sodium thiosulfate 9 g/m IV, weekly x4; radiotherapy 2 Gy/fraction/d, 5x weekly, 68-74 Gy over 6 to 7 weeks). Median follow-up: 58 months (range, 12-96 mo).

RESULTS

The percentage of patients who had local disease control was 87.5%. Univariant analysis showed T classification (P =.01), laterality of neck disease (P =.026), number of neck levels involved (P =.008), total dose of radiation greater versus less than 60 Gy (P =.027), and presence of pathologically positive lymph nodes following chemoradiation (P =.01) to be significant. Logistic regression analysis showed total dose of radiation (P =.03) and the presence of pathologically positive lymph nodes following chemoradiation (P =.05) to be significant. For Kaplan-Meier estimates of local disease control at 5 years, T classification (P =.038), number of levels with nodal disease (P =.006), and total dose of radiation therapy (P =.0001) were significant. The log-rank test identified as significant the total dose of radiation therapy (P <.0001), the presence of pathologically positive lymph nodes following chemoradiation (P =.005), and the number of neck levels with positive nodes (P =.006). The Cox regression model showed significance for the total dose of radiation (P =.001), the presence of pathologically positive lymph nodes following chemoradiation (P =.007), and the T classification (P =.029).

CONCLUSION

Risk factors significantly associated with local disease control after RADPLAT appears to differ from more traditional therapy and is suggestive of a paradigm shift.