Pretreatment prognostic factors of survival in patients with locally advanced nonmetastatic squamous cell carcinoma of the head and neck treated with radiation therapy with or without concurrent chemotherapy

Prognostic Factors for the Therapeutic Performance of Cisplatin in Head and Neck Malignancies

Introduction

For squamous cell carcinoma of the head and neck (HNSCC), cisplatin is used as primary or adjuvant (radio)chemotherapy. In terms of dosage, two main regimens are used, weekly 40mg/m² or 3-weekly 100mg/m². For an optimal outcome, the highest possible cumulative total dose of cisplatin is aimed for. The selection of the scheme is patient-specific, but the factors for the selection of the optimal scheme have not yet been conclusively researched. The aim of this study was to find correlations between initial laboratory values and the cumulative total dose of cisplatin, as well as any correlations between early laboratory values or their dynamics and later laboratory values or their dynamics to provide support in the selection of the chemo regimen.

Material and Methods

In this retrospective study, the clinical data and laboratory values, namely glomerular filtration rate (GFR), hemoglobin, albumin, leucocyte, erythrocyte and platelet count, over the course of time of 79 patients with HNSCC who had received chemotherapy with cisplatin in our clinic between 2018 and 2021 were evaluated.

Results

Patients on 3-weekly regimens achieved a higher mean cumulative total dose of cisplatin than patients on weekly regimens (214.18 ± 65.95 vs 183.33 ± 65.2 mg/m²). Significant positive correlations were seen for total cumulative dose of cisplatin with initial GFR (p=0.001, Pearson's r=0.364), initial hemoglobin (p=0.035, r=0.237), initial erythrocyte (p=0.002, r=0.337), and initial albumin (p=0.002, r=0.337). There were no significant correlations for initial leucocyte or platelets. Regarding the dynamics of the laboratory values under the first chemo administration, no correlation was found with later laboratory values or dynamics.

Discussion and Conclusion

As in other prospective studies, our retrospective analysis found a higher cumulative total dose in the 3-weekly regimen. As this seems to correlate positively with patient outcome, superiority of the 3-weekly regimen over the weekly regimen can be assumed. Functioning organ systems, especially of the bone marrow and kidneys, are associated with an increased cumulative total dose and can therefore be regarded as predictive factors. Regular monitoring of laboratory values is nevertheless essential throughout the entire course of chemotherapy.

Chemoradiotherapy as Definitive Treatment for Elderly Patients with Head and Neck Cancer

Background

With the aging population and a rising incidence of squamous cell carcinoma of the head and neck (SCCHN), there is an emerging need for developing strategies to treat elderly patients.

Patients and Methods

We retrospectively analyzed 158 patients treated with definitive, concurrent chemoradiotherapy (CRT) for SCCHN. Clinicopathological characteristics, acute toxicities, and oncological outcomes were compared between patients younger and older than (or of age equal to) 65, 70, and 75 years.

Results

RT dose, chemotherapy regimen, and total chemotherapy dose were balanced between the groups. After a median follow-up of 29 months, overall survival (OS), progression-free survival (PFS), local control rate, and distant metastasis-free survival stratified by age of ≥65, ≥70, or ≥75 years revealed no differences. The rate of acute toxicities was also not higher for older patients. Worse ECOG performance score (ECOG 2-3) was associated with impaired OS (p = 0.004) and PFS (p = 0.048).

Conclusion

Definitive treatment with CRT for SCCHN is feasible and effective; even in advanced age treatment decisions should be made according to general condition and comorbidity, rather than calendar age alone.

Nuclear expression of p65 (RelA) in patients receiving post-operative radiotherapy for locally advanced squamous cell carcinoma of the head and neck

Background

This study investigated the prognostic role of nuclear expression of p65 in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) receiving post-operative radio(chemo)therapy.

Methods

Nuclear p65-expression (H-score ≤50 versus >50) plus twelve characteristics were analyzed in 151 patients for overall survival (OS), metastases-free survival (MFS) and loco-regional control (LRC). Additional characteristics included age, gender, Karnofsky performance score (KPS), pre-radiotherapy hemoglobin levels, tumor site, histological grading, human papilloma virus (HPV)-status, T-classification, N-classification, American Joint Committee on Cancer (AJCC)-stage, extent of resection and concurrent chemotherapy. Univariate analyses were performed with Kaplan-Meier method and log-rank test, multivariate analyses with Cox proportional hazards model.

Results

On univariate analyses, p65-expression had a significant impact on OS (p < 0.001) and LRC (p < 0.001) but not on MFS (p = 0.29). On multivariate analysis, KPS ≥80 (risk ratio [RR] 2.23; p = 0.012), HPV-positivity (RR 5.83; p = 0.020), T1-T2 (RR 1.38; p = 0.048), N0-N2a (RR 2.72; p = 0.005) and complete resection (RR 2.02; p = 0.049) were positively associated with OS; p65-negativity achieved borderline significance (RR 3.02; p = 0.052). Better MFS was associated with KPS ≥80 (RR 2.49; p = 0.015), T1-T2 (RR: 1.74; p = 0.005), N0-N2a (RR: 6.22; p < 0.001) and complete resection (RR 3.43; p = 0.003). Positive associations with LRC were found for p65-negativity (RR 5.06; p = 0.008), T1-T2 (RR: 1.49; p = 0.022), N0-N2a (RR: 2.97; p = 0.004) and favorable tumor site (RR 1.28; p = 0.025).

Conclusions

P65-negativity was significantly associated with improved LRC and achieved borderline significance with respect to improved OS. Thus, p65-expression may be an additional target for novel agents in the treatment of locally advanced SCCHN.

The impact of HPV infection, smoking history, age and operability of the patient on disease-specific survival in a geographically defined cohort of patients with oropharyngeal squamous cell carcinoma

CONCLUSIONS

Patients with human papillomavirus (HPV)-positive tumours had better 5-year disease-specific survival (DSS) than HPV-negative patients. TNM score only predicted prognosis among HPV-negative patients. A previous history of smoking and age at diagnosis predicted DSS among HPV-positive patients whereas operability at diagnosis predicted DSS among both HPV-positive and HPV-negative patients.

OBJECTIVES

HPV is a risk factor for oropharyngeal squamous cell carcinoma (OPSCC). The extent to which smoking, age and operability could play a role in HPV-positive surgically treated head and neck SCCs has not been extensively addressed previously and this study aimed to evaluate these factors.

METHODS

We identified 232 patients with OPSCC, of which 186 from the tonsil or base of the tongue region were treated in the period 1992-2008 in Western Norway. The 5-year DSS was recorded. Details on smoking history and whether the lesion was operable or not, as well as clinical information, were obtained retrospectively from the hospital records.

RESULTS

TNM stage predicted survival only among HPV-negative patients. A previous smoking affected prognosis only among HPV-positive patients (relative risk (RR) = 2.5; confidence interval (CI) = 1.0-6.2; p = 0.05). Increasing age of the patient had a negative effect on survival in HPV-positive patients only, especially among the oldest quartile (RR = 4.4; CI = 2.0-9.0; p < 0.001). Whether the tumour was operable or not uniquely predicted DSS both among HPV-positive (RR = 0.34; CI = 0.13-0.93; p < 0.05) and HPV-negative (RR = 0.25; CI = 0.10-0.66; p < 0.01) patients with tonsil/base of the tongue SCC.

Evaluation of the prognostic role of tumor cell podoplanin expression in locally advanced squamous cell carcinoma of the head and neck

BACKGROUND AND PURPOSE

To investigate the potential prognostic role of tumor cell podoplanin expression in patients treated with resection followed by irradiation or chemoradiotherapy for locally advanced squamous cell carcinoma of the head and neck (SCCHN).

MATERIALS AND METHODS

Podoplanin expression (≤10 % versus > 10 %) and 12 other factors were evaluated in 160 patients for their association with locoregional control (LRC), metastases-free (MFS) and overall survival (OS). Other factors were age, gender, Eastern Cooperative Oncology Group (ECOG) performance status, preradiotherapy (pre-RT) hemoglobin level, tumor site, histological grading, T category, N category, American Joint Committee on Cancer (AJCC) stage, human papillomavirus (HPV) status, extent of resection and concurrent chemotherapy.

RESULTS

In multivariate analysis, ECOG performance status 0-1 (risk ratio, RR: 3.01; 95 % confidence interval, CI: 1.42-7.14; p = 0.003), pre-RT hemoglobin levels ≥ 7.45 mmol/l (12 g/dl; RR: 2.03; 95 % CI: 1.04-3.94; p = 0.038), oropharyngeal cancer (RR: 1.25; 95 % CI: 1.01-1.55; p = 0.038) and T category T1-2 (RR: 1.81; 95 % CI: 1.24-2.79; p = 0.002) were significantly associated with improved LRC. T category T1-2 (RR: 1.90; 95 % CI: 1.25-3.06; p = 0.002) and N category N0-2a (RR: 5.22; 95 % CI: 1.96-18.09; p < 0.001) were significantly associated with better MFS. Pre-RT hemoglobin levels ≥ 7.45 mmol/l (RR: 2.44; 95 % CI: 1.27-4.74; p = 0.007), T category T1-2 (RR: 1.97; 95 % CI: 1.36-3.04; p < 0.001) and N category N0-2a (RR: 2.87; 95 % CI: 1.37-6.61; p = 0.005) were significantly associated with improved OS. Podoplanin expression ≤ 10 % showed a trend towards improved OS on both univariate (p = 0.050) and multivariate analysis (RR: 1.86; 95 % CI: 0.96-3.59; p = 0.07).

CONCLUSION

Treatment outcomes were significantly associated with performance status, pre-RT hemoglobin level, tumor site and tumor stage. Tumor cell expression of podoplanin ≤ 10 % showed a trend towards improved OS when compared to podoplanin expression of > 10 %.

Concomitant chemoradiotherapy versus induction chemotherapy followed by chemoradiotherapy as definitive, first line treatment of squamous cell carcinoma of the head and neck. A retrospective single center analysis

PURPOSE

Despite the lack of evidence to support its implementation in the clinical practice, induction chemotherapy (IC) before chemoradiotherapy (CRT) is often used in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN). We retrospectively examined the tolerability, feasibility, and clinical outcome of both concepts in a single center analysis.

PATIENTS AND METHODS

In all, 83 patients were treated between 2007 and 2010 with IC + CRT (n = 42) or CRT alone (n = 41). IC consisted of docetaxel, cisplatin and 5-fluorouracil (TPF), or cisplatin and 5-fluorouracil (PF). All patients were scheduled to receive 2 cycles of PF during concurrent CRT. Adverse events were assessed according to the common toxicity criteria of adverse events (CTCAE v. 3.0). Associations were tested using the χ² test, and survival estimates were calculated according to Kaplan-Meier.

RESULTS

The median follow-up was 30.35 months (range 2.66-61.25 months). At 2 years, the overall survival rate was significantly higher for primary CRT compared to IC + CRT group (74.8 % vs. 54 %, respectively; p = 0.041). Significantly more treatment-related overall grade 4 toxicities were documented in the IC + CRT group compared to the CRT group (42.9% vs. 9.8%; p = 0.001). Renal toxicity ≥ grade 2 occurred in 52.4 % vs. 7.3 % (p < 0.001), respectively. In all, 93 % of the patients with primary CRT compared to 71 % with IC + CRT received the planned full radiotherapy dose (p = 0.012).

CONCLUSION

This is, to our knowledge, the largest retrospective study to compare IC + CRT with primary CRT. IC showed high acute toxicity, compromised the feasibility of concurrent CRT, and was associated with reduced overall survival rates compared to primary CRT. The lack of clinical benefit in conjunction with the increased toxicity does not support implementation of IC.

Androgen receptor expression: prognostic value in locally advanced squamous cell carcinoma of the head and neck

BACKGROUND AND PURPOSE

This study investigated the prognostic value of androgen receptor (AR) expression of tumor cells in patients treated with surgery and subsequent radio(chemo)therapy for locally advanced squamous cell carcinoma of the head and neck (SCCHN).

MATERIAL AND METHODS

The impact of AR and 11 additional factors on locoregional control (LRC), metastases-free survival (MFS), and overall survival (OS) was retrospectively studied in 163 patients with nonmetastatic stage III/IV SCCHN. Additional factors included age, gender, ECOG performance status, pre-radiotherapy (pre-RT) hemoglobin levels, tumor site, histologic grade, T category, N category, HPV status, extent of resection, and concurrent chemotherapy.

RESULTS

On multivariate analysis, improved LRC was significantly associated with pre-RT hemoglobin levels≥12 g/dl (risk ratio [RR] 2.22; 95% confidence interval [CI] 1.19–4.13; p=0.013), tumor site (RR 1.39; 95% CI 1.14–1.70; p=0.001), lower T category (RR 1.67; 95% CI 1.18–2.44; p=0.003), and lower N category (RR 4.18; 95% CI 1.90–10.55; p<0.001). Improved MFS was associated with AR expression (RR 2.21; 95% CI 1.01–5.41; p=0.048), better ECOG performance status (RR 3.19; 95% CI 1.50–7.14; p=0.003), lower T category (RR 2.24; 95% CI 1.47–3.65; p<0.001), and lower N category (RR 5.33; 95% CI 2.07–16.63; p<0.001). OS was positively associated with AR expression (RR 1.99; 95% CI 1.06–4.00; p=0.032), better ECOG performance status (RR 2.20; 95% CI 1.20–4.09; p=0.010), pre-RT hemoglobin levels≥12 g/dl (RR 2.13; 95% CI 1.19–3.82; p=0.012), lower T category (RR 1.81; 95% CI 1.30–2.62; p<0.001), and lower N category (RR 3.41; 95% CI: 1.65–7.80; p<0.001).

CONCLUSION

Tumor cell expression of AR was an independent prognostic factor for MFS and OS and should be considered in future prospective trials.

Basics of tumor development and importance of human papilloma virus (HPV) for head and neck cancer

Head and Neck Squamous Cell Carcinomas (HNSCC) are the 6(th) most common cancers worldwide. While incidence rates for cancer of the hypopharynx and larynx are decreasing, a significant increase in cancer of the oropharynx (OSCC) is observed. Classical risk factors for HNSCC are smoking and alcohol. It has been shown for 25 to 60% of OSCC to be associated with an infection by oncogenic human papilloma viruses (HPV). The development of "common" cancer of the head and neck is substantially enhanced by an accumulation of genetic changes, which lead to an inactivation of tumor suppressor genes or activation of proto-oncogenes. A more or less uniform sequence of different DNA-damages leads to genetic instability. In this context, an early and frequent event is deletion on the short arm of chromosome 9, which results in inactivation of the p16-gene. In contrast, for HPV-induced carcinogenesis, expression of the viral proteins E6 and E7 is most important, since they lead to inactivation of the cellular tumor-suppressor-proteins p53 and Rb. The natural route of transoral infection is a matter of debate; peroral HPV-infections might be frequent and disappear uneventfully in most cases. Smoking seems to increase the probability for developing an HPV-associated OSCC. The association of HNSCC with HPV can be proven with established methods in clinical diagnostics. In addition to classical prognostic factors, diagnosis of HPV-association may become important for selection of future therapies. Prognostic relevance of HPV probably surmounts many known risk-factors, for example regional metastasis. Until now, no other molecular markers are established in clinical routine. Future therapy concepts may vary for the two subgroups of patients, particularly patients with HPV-associated OSCC may take advantage of less aggressive treatments. Finally, an outlook will be given on possible targeted therapies.

Survival of patients with head and neck cancer. Impact of physical status and comorbidities

BACKGROUND

Prognostic factors (e.g., gender, tumor stage, and hypoxia) have an impact on survival in patients with head and neck cancer. Thus, the impact of physical status and comorbidities on treatment decision and survival were evaluated.

PATIENTS AND METHODS

A total of 169 primary, inoperable patients with squamous cell cancer of the head and neck were retrospectively investigated. Patients were treated with hyperfractionated accelerated radio(chemo)therapy (HARcT) or hypofractionated radio(chemo)therapy (HypoRcT). Depending on the individual patient's situation (Karnofsky Performance Index, KPI), treatment for patients with a KPI of 80-100% was generally radiochemotherapy and for patients with a KPI ≤ 70% treatment was radiotherapy alone. In addition, all comorbidities were evaluated. Uni- and multivariate proportional hazards model were used, and overall survival (OS) was estimated by the Kaplan-Meier method.

RESULTS

Treatment consisted of HARcT for 76 patients (45%), HART for 28 patients (17%), HypoRcT for 14 patients(8%), and HypoRT for 51 patients (30%). Of the patients, 107 patients (63%) presented with a KPI of 80-100%. OS (20%) was significantly better for patients with a KPI of 80-100%, while the OS for patients with a KPI ≤ 70% was 8% (p < 0.001). Good KPI, total irradiation dose (> 70 Gy), and chemotherapy were significant prognostic factors for better OS.

CONCLUSION

Our retrospective analysis shows that performance status with dependency on comorbidities was an independent risk factor for OS.

Comparison of radiochemotherapy alone to surgery plus radio(chemo)therapy for non-metastatic stage III/IV squamous cell carcinoma of the head and neck: A matched-pair analysis

BACKGROUND AND PURPOSE

The standard treatment for non-metastatic stage III/IV squamous cell carcinoma of the head and neck varies worldwide. This study compared the outcomes of radiochemotherapy alone to surgery followed by radio(chemo)therapy (radiotherapy plus/minus concurrent chemotherapy).

PATIENTS AND METHODS

Data from 148 patients treated with radiochemotherapy alone were matched to 148 patients treated with surgery plus radio(chemo)therapy. Groups were matched 1:1 for nine potential prognostic factors including age, gender, performance status, tumor site, histologic grade, T category, N category, AJCC stage, and hemoglobin level before radiotherapy, and compared for locoregional control, metastases-free survival, and overall survival.

RESULTS

Locoregional control rates at 1, 2, and 3 years were 81%, 73%, and 67% after surgery plus radio(chemo)therapy and 81%, 74%, and 65% after radiochemotherapy alone (p = 0.89). Metastases-free survival rates were 86%, 80%, and 75% after surgery plus radio(chemotherapy) versus 87%, 80%, and 72% after radiochemotherapy alone (p = 0.57). Overall survival rates were 80%, 64%, and 63% after surgery plus radio(chemo)therapy versus 83%, 68%, and 60% after radiochemotherapy alone (p = 0.96). On multivariate analyses, T category (p < 0.001), N category (p = 0.004), and hemoglobin level prior to radiotherapy (p < 0.001) were associated with locoregional control. Histologic grade (p = 0.045), T category (p < 0.001), N category (p = 0.003), and hemoglobin level prior to radiotherapy (p < 0.001) were associated with metastases-free survival. Histologic grade (p = 0.030), ECOG performance status (p = 0.033), T category (p = 0.007), N category (p = 0.024) and hemoglobin level before radiotherapy (p < 0.001) were associated with overall survival.

CONCLUSION

Outcomes of radiochemotherapy alone appeared similar to those of surgery plus radio(chemo)therapy. Randomized trials comparing both treatments for different tumor sites are warranted.

Perfusion CT in squamous cell carcinoma of the upper aerodigestive tract: long-term predictive value of baseline perfusion CT measurements

BACKGROUND AND PURPOSE

PCT studies hold short-term predictive value in patients treated with chemoradiotherapy. Our aim was to examine the long-term predictive value of baseline PCT studies for local tumor control and overall survival in SCCA of the upper aerodigestive tract treated with chemoradiotherapy.

MATERIALS AND METHODS

Eighty-four patients with advanced SCCA underwent PCT followed by concomitant chemoradiation. The acquired perfusion maps represented BF, BV, MTT, and PS. Visual analysis of the parametric maps for identification of tumor perfusion patterns was conducted. ROC curves, t tests, and Kaplan-Meier survival curves were plotted for local disease control and overall survival.

RESULTS

The median time of local tumor control was 24 months. The BF and PS values were significantly higher in patients who had no recurrence than in those with local failure (P < or = .02). The BF and PS were predictive (P < or = .0006) but BV and MTT held no significant predictive values for local tumor control. The patients with high BF and PS had a longer local tumor control than the patients with hypoperfused tumors (P = .0007). A visually detected BF-BV mismatch had a sensitivity/specificity of 63%/66% (P = .03) and 59%/69% (P = .03) for local tumor control and OS, respectively. Patients without mismatch lived significantly longer than patients with mismatch (P = .01).

CONCLUSIONS

BF, PS, and mismatch of BF-BV are significant predictors of local tumor control after chemoradiation in SCCA of the upper aerodigestive tract.